HFpEF Often Missed in Women Due to Diagnostic Bias: Martha Gulati, MD

Women have been significantly underrepresented in clinical trials for heart failure when compared with men.¹ At the American Heart Association Scientific Sessions 2025, The American Journal of Managed Care^® spoke with Martha Gulati, MD, director of the Davis Women's Heart Center at the Cedars-Houston Methodist DeBakey Heart and Vascular Center, about how women are often misdiagnosed for heart failure with preserved ejection fractions (HFpEF).

This transcript has been lightly edited; captions are auto-generated.

Transcript

Heart failure, particularly HFpEF, is often underdiagnosed or misdiagnosed in women. What clinical or systemic biases must be addressed to ensure women’s symptoms are identified and they receive the same specialized care as men?

That's a great question because I do think that women, particularly, are underdiagnosed because their symptoms are discounted, and this is particularly true for HFpEF. The symptoms for HFpEF can be simple things like shortness of breath, sometimes chest discomfort, or leg swelling. Again, all of these things can be caused by other things. I will say, though, women are often told, "Oh, are you anxious? Are you stressed?" There's always an excuse for a woman's symptom. When men have those symptoms, they are taken far more seriously and get the diagnosis a lot sooner.

And for women, because we are disproportionately affected by HFpEF rather than HFrEF, I think there are delays, like the physical exam is not as easy to fully appreciate. When we do an echocardiogram, we see a normal ejection fraction, and we think, "Okay, it's normal." And unless you really look at the echo yourself and really make sure that there are no measures of diastolic dysfunction or other measures that can tell us that the heart is not working normally, often it gets dismissed.

I think it starts with listening to our patients. I think that women's symptoms, just in general, in the cardiology world are discounted. There's always some other reason. “Oh, you're out of shape,” or “Oh, you've gained weight; that's why you're short of breath." They may have done all of those things, but it may be because of the fact that they're living with heart failure. And I always use this hashtag when I'm talking about my female patients because I see them after—I’m probably like the 4th or 5th cardiologist they visited—but my expression is, "Listen to women.” Women don't have time to come to the doctor. If they’re at the doctor, it’s because something is wrong. And we need to be better at thinking that there's something wrong with the patient rather than thinking they’re anxious, depressed, or whatever other excuse we give. And I also think that when we use our wonderful cardiac imaging tools and biomarkers we have, we should be using them on the entire population, not excluding 51% of the population.

Part of the reason that we are where we are right now is that we've excluded women from research for years, and we're just catching up, and we're finding whether [the drugs] work as effectively in women—but that's not the problem for us; it's missing making the diagnosis. And I will say we actually have some good news about heart failure in general, and it's not specific to HFpEF or HFrEF, but more recently, we did an analysis of all the trials on ClinicalTrials.gov, and our group found, actually, that finally we are enrolling more women into heart failure trials, which is exciting because before it was heart failure that had the lowest enrollment of women in really any of our cardiovascular trials, and now they have significantly improved. And that’s great news, but we have to make the diagnosis of women to get those women on those life-saving drugs.

References

1. Rivera FB, Magalong JV, Bantayan NRB, et al. Participation of women in cardiovascular trials from 2017 to 2023: a systematic review. JAMA Netw Open. 2025;8(8):e2529104. doi:10.1001/jamanetworkopen.2025.29104