Sex-Specific Gaps in Cardiovascular Psychosocial Research: An Analysis of Studies Cited in the American Heart Association's 2021 Statement on Psychological Health and Cardiovascular Disease.

BACKGROUND: The American Heart Association's 2021 Scientific Statement on Psychological Health, Well-Being, and the Mind-Heart-Body Connection affirms the critical role contributed by psychosocial factors in cardiovascular disease outcomes, yet the cited resource continues to lack the sex-specific rigor necessary for equitable clinical guidance. METHODS: We conducted a review of 206 research articles cited in the statement to assess whether studies reported participant sex, reported the percentage of women enrolled, tested for sex differences, and performed sex-disaggregated analyses. RESULTS: Although 71% of studies disclosed participant sex, only 29% examined results by sex, drew sex-inclusive conclusions (27%), or performed appropriate subgroup analyses (25%). These practices varied significantly by study design: randomized controlled trials, the gold standard of clinical evidence and most relied upon for clinical practice guidelines, had the lowest rates of female-majority (≥50%) enrollment, while cohort and cross-sectional designs were more inclusive. In pooled meta-analytic data comprising 899 studies, male-only trials exceeded female-only ones, and 16% failed to report sex. Temporal trends revealed no meaningful improvement in sex reporting from 1987 to 2021, despite decades of policy reforms intended to close these gaps. While slight gains in female enrollment and analytic rigor were observed, they remain insufficient to meet the needs of sex-responsive research. CONCLUSIONS: Our findings reveal a critical disconnect between the clinical importance of psychosocial factors and the sex representation in the evidence used to guide practice. Deliberate reforms in study design and analytic expectations are needed to ensure that future guidelines rest on an equitable foundation.