Looking beyond the male default: why cardiovascular research needs to change
A new viewpoint article by a group of heart health experts is calling for major changes to cardiovascular research after a systematic review found that only 26% of New Zealand cardiovascular studies that included both men and women considered sex or gender differences as a primary focus.
The authors warn that these evidence gaps are contributing to inequitable heart health outcomes, particularly for Māori and Pacific women.
The viewpoint article emerged from Restoring the Balance, a research programme funded by Pūtahi Manawa | Healthy Hearts for Aotearoa New Zealand Centre of Research Excellence, which is working to improve heart health equity for Māori, Pacific peoples and women.
The accompanying review found that while many New Zealand cardiovascular studies included both women and men, relatively few analysed differences between them. Even when differences were identified, researchers rarely explored why they existed or what they meant for prevention, diagnosis or treatment.
The team hopes to raise awareness of these research gaps and provide researchers with practical tools to take a more balanced approach to sex, gender and ethnicity in cardiovascular research.
The authors argue these gaps are not simply academic. Research shapes clinical guidelines, informs health policy and influences where health resources are directed.
“When research neglects gender, health systems learn to do the same,” says co-author Dr Julia Shanks.
When the evidence changes, care can change
The importance of taking sex differences seriously is reflected in a major change to how heart attacks are defined and diagnosed.
In August 2026, the world’s leading cardiovascular organisations agreed on a new global definition of heart attack, clinically known as myocardial infarction (MI). The new definition introduces clearer sex-specific diagnostic criteria and gives greater recognition to different causes of heart attack, including several that are more common in women.
The definition reinforces the use of sex-specific thresholds for cardiac troponin, a key blood test used to detect heart muscle injury. It also recognises coronary artery spasm, coronary embolism and spontaneous coronary artery dissection (SCAD) as forms of primary myocardial infarction. SCAD, which involves a tear in a coronary artery, occurs in women in around 80% of cases and can occur during or soon after pregnancy.
For the Restoring the Balance researchers, the development illustrates why sex differences need to be considered from the beginning of the research process.
It is a reminder that when research asks different questions, it can change what we know about heart disease and importantly, how it is recognised and treated.
The consequences are particularly significant for Māori and Pacific women. A 2025 national Cardiac Impact Report found that Māori and Pacific people are hospitalised or die from heart disease more than a decade earlier, on average, than European and other New Zealanders.
“For Māori and Pacific women, gender inequities often intersect with the impacts of colonisation, racism and wider social inequities. If research doesn't examine those intersections, health systems have little evidence to guide meaningful change,” says Dr Shanks.
The review also found that none of the studies examined the experiences or impacts of cardiovascular disease for gender-diverse people, highlighting an important gap in understanding heart health across diverse populations.
Without evidence that reflects their experiences, opportunities to improve care and reduce inequities can continue to be missed.
“This is not a new issue, and meaningful change is long overdue,” says Dr Shanks.
“Cardiovascular research has historically neglected sex and gender due to the false assumption that female physiology was biologically identical to males, aside from reproductive organs, leading to men being treated as the medical default. But now we know that women are not just little men.”
A call to action
The authors have outlined practical recommendations to improve future research. They are calling for researchers to incorporate sex, gender and ethnicity into study design from the outset, analyse and report findings separately where appropriate, investigate observed differences, and adopt culturally responsive approaches that uphold Te Tiriti o Waitangi while supporting Māori and Pacific leadership in research.
The work is continuing. Over the next three years, researchers will investigate menopausal heart disease risk in communities while beginning foundational work towards Aotearoa New Zealand's first transgender heart disease risk database.
Ultimately, the programme aims to build a more complete understanding of cardiovascular health across diverse populations, ensuring the evidence used to shape healthcare better reflects the realities of all people in Aotearoa.
Read the viewpoint article in the NZMJ here