Skip to main page content
Access keys NCBI Homepage MyNCBI Homepage Main Content Main Navigation
Randomized Controlled Trial
. 2017 Nov 29;6(12):e006872.
doi: 10.1161/JAHA.117.006872.

Implicit Gender Bias and the Use of Cardiovascular Tests Among Cardiologists

Free PMC article
Randomized Controlled Trial

Implicit Gender Bias and the Use of Cardiovascular Tests Among Cardiologists

Stacie L Daugherty et al. J Am Heart Assoc. .
Free PMC article


Background: Physicians' gender bias may contribute to gender disparities in cardiovascular testing. We used the Implicit Association Test to examine the association of implicit gender biases with decisions to use cardiovascular tests.

Methods and results: In 2014, cardiologists completed Implicit Association Tests and a clinical vignette with patient gender randomly assigned. The Implicit Association Tests measured implicit gender bias for the characteristics of strength and risk taking. The vignette represented an intermediate likelihood of coronary artery disease regardless of patient gender: chest pain (part 1) followed by an abnormal exercise treadmill test (part 2). Cardiologists rated the likelihood of coronary artery disease and the usefulness of stress testing and angiography for the assigned patient. Of the 503 respondents (9.3% of eligible; 87% male, median age of 45 years, 58% in private practice), the majority associated strength or risk taking implicitly with male more than female patients. The estimated likelihood of coronary artery disease for both parts of the vignette was similar by patient gender. The utility of secondary stress testing after an abnormal exercise treadmill test was rated as "high" more often for female than male patients (32.8% versus 24.3%, P=0.04); this difference did not vary with implicit bias. Angiography was more consistently rated as having "high" utility for male versus female patients (part 1: 19.7% versus 9.8%; part 2: 73.7% versus 64.3%; P<0.05 for both); this difference was larger for cardiologists with higher implicit gender bias on risk taking (P=0.01).

Conclusions: Cardiologists have varying degrees of implicit gender bias. This bias explained some, but not all, of the gender variability in simulated clinical decision-making for suspected coronary artery disease.

Keywords: angiography; gender disparities; implicit bias; stress testing.


Figure 1
Figure 1
Flowchart of the study population. IAT indicates Implicit Association Test.
Figure 2
Figure 2
Cardiology physicians' gender bias regarding risk taking and strength. IAT indicates Implicit Association Test.
Figure 3
Figure 3
The strength of angiography rating varied according to case patient gender and physician implicit gender bias. The x‐axis represents physician gender bias based on Implicit Association Test scores, and the y‐axis represents the extent to which angiography was rated as useful for the case vignette by the physician. The relationship between gender bias and angiography rating is indicated when the case patient was male (blue line) and female (red line). In unadjusted analysis, significant interactions were seen between gender bias and case gender; those with higher implicit gender bias on risk taking (A) or strength (B) rated angiography as less useful in women than men (unadjusted P<0.05 for interaction for both). After adjustment for perceived likelihood of coronary artery disease and physician specialty, the interaction between risk‐taking bias and patient gender on angiography usefulness remained significant (adjusted P=0.01 for interaction in panel A); however, the interaction with strength bias was no longer significant (adjusted P=0.12 in panel B).

Similar articles

See all similar articles

Cited by 6 articles

  • Cardiovascular Disease in Women Across the Lifespan: The Importance of Sleep.
    Daugherty SL, Carter JR, Bourjeily G. Daugherty SL, et al. J Womens Health (Larchmt). 2020 Mar;29(3):452-460. doi: 10.1089/jwh.2020.8331. Epub 2020 Feb 25. J Womens Health (Larchmt). 2020. PMID: 32096682
  • Do Sex Differences Exist in the Establishment of "Do Not Attempt Resuscitation" Orders and Survival in Patients Successfully Resuscitated From In-Hospital Cardiac Arrest?
    Perman SM, Beaty BL, Daugherty SL, Havranek EP, Haukoos JS, Juarez-Colunga E, Bradley SM, Fendler TJ, Chan PS; American Heart Association Get With The Guidelines‐Resuscitation Investigators †. Perman SM, et al. J Am Heart Assoc. 2020 Feb 18;9(4):e014200. doi: 10.1161/JAHA.119.014200. Epub 2020 Feb 17. J Am Heart Assoc. 2020. PMID: 32063126 Free PMC article.
  • Sex Differences in Symptom Phenotypes Among Patients With Acute Myocardial Infarction.
    Brush JE Jr, Krumholz HM, Greene EJ, Dreyer RP. Brush JE Jr, et al. Circ Cardiovasc Qual Outcomes. 2020 Feb;13(2):e005948. doi: 10.1161/CIRCOUTCOMES.119.005948. Epub 2020 Feb 17. Circ Cardiovasc Qual Outcomes. 2020. PMID: 32063049
  • Identification of Racial Inequities in Access to Specialized Inpatient Heart Failure Care at an Academic Medical Center.
    Eberly LA, Richterman A, Beckett AG, Wispelwey B, Marsh RH, Cleveland Manchanda EC, Chang CY, Glynn RJ, Brooks KC, Boxer R, Kakoza R, Goldsmith J, Loscalzo J, Morse M, Lewis EF, Abel S, Adams A, Anaya J, Andrews EH, Atkinson B, Avutu V, Bachorik A, Badri O, Bailey M, Baird K, Bakshi S, Balaban D, Barshop K, Baumrin E, Bayomy O, Beamesderfer J, Becker N, Berg DD, Berman AN, Blum SM, Boardman AP, Boden K, Bonacci RA, Brown S, Campbell K, Case S, Cetrone E, Charrow A, Chiang D, Clark D, Cohen AJ, Cooper A, Cordova T, Cuneo CN, de Feria AA, Deffenbacher K, DeFilippis EM, DeGregorio G, Deutsch AJ, Diephuis B, Divakaran S, Dorschner P, Downing N, Drescher C, D'Silva KM, Dunbar P, Duong D, Earp S, Eckhardt C, Elman SA, England R, Everett K, Fedotova N, Feingold-Link T, Ferreira M, Fisher H, Foo P, Foote M, Franco I, Gilliland T, Greb J, Greco K, Grewal S, Grin B, Growdon ME, Guercio B, Hahn CK, Hasselfeld B, Haydu EJ, Hermes Z, Hildick-Smith G, Holcomb Z, Holroyd K, Horton L, Huang G, Jablonski S, Jacobs D, Jain N, Japa S, Joseph R, Kalashnikova M, Kalwani N, Kang D, Karan A, Katz JT, Kellner D, Kidia K, Kim JH, Knowles SM, Kolbe L, Kore I, Koullias Y, Kuye I, Lang J, Lawlor M, Lechner MG, Lee K, Lee S, Lee Z, Limaye N, Lin-Beckford S, Lipsyc M, Little J, Loewenthal J, Logaraj R, Lopez DM, Loriaux D, Lu Y, Ma K, Marukian N, Matias W, Mayers JR, McConnell I, McLaughlin M, Meade C, Meador C, Mehta A, Messenger E, Michaelidis C, Mirsky J, Mitten E, Mueller A, Mullur J, Munir A, Murphy E, Nagami E, Natarajan A, Nsahlai M, Nze C, Okwara N, Olds P, Paez R, Pardo M, Patel S, Petersen A, Phelan L, Pimenta E, Pipilas D, Plovanich M, Pong D, Powers BW, Rao A, Ramirez Batlle H, Ramsis M, Reichardt A, Reiger S, Rengarajan M, Rico S, Rome BN, Rosales R, Rotenstein L, Roy A, Royston S, Rozansky H, Rudder M, Ryan CE, Salgado S, Sanchez P, Schulte J, Sekar A, Semenkovich N, Shannon E, Shaw N, Shorten AB, Shrauner W, Sinnenberg L, Smithy JW, Snyder G, Sreekrishnan A, Stabenau H, Stavrou E, Stergachis A, Stern R, Stone A, Tabrizi S, Tanyos S, Thomas C, Thun H, Torres-Lockhart K, Tran A, Treasure C, Tsai FD, Tsaur S, Tschirhart E, Tuwatananurak J, Venkateswaran RV, Vishnevetsky A, Wahl L, Wall A, Wallace F, Walsh E, Wang P, Ward HB, Warner LN, Weeks LD, Weiskopf K, Wengrod J, Williams JN, Winkler M, Wong JL, Worster D, Wright A, Wunsch C, Wynter JS, Yarbrough C, Yau WY, Yazdi D, Yeh J, Yialamas MA, Yozamp N, Zambrotta M, Zon R. Eberly LA, et al. Circ Heart Fail. 2019 Nov;12(11):e006214. doi: 10.1161/CIRCHEARTFAILURE.119.006214. Epub 2019 Oct 29. Circ Heart Fail. 2019. PMID: 31658831
  • Sex-Specific Thresholds of High-Sensitivity Troponin in Patients With Suspected Acute Coronary Syndrome.
    Lee KK, Ferry AV, Anand A, Strachan FE, Chapman AR, Kimenai DM, Meex SJR, Berry C, Findlay I, Reid A, Cruickshank A, Gray A, Collinson PO, Apple FS, McAllister DA, Maguire D, Fox KAA, Newby DE, Tuck C, Keerie C, Weir CJ, Shah ASV, Mills NL; High-STEACS Investigators. Lee KK, et al. J Am Coll Cardiol. 2019 Oct 22;74(16):2032-2043. doi: 10.1016/j.jacc.2019.07.082. J Am Coll Cardiol. 2019. PMID: 31623760 Free PMC article.
See all "Cited by" articles


    1. Tobin JN, Wasserthiel‐Smoller S, Wexler JP, Steingart RM, Budner N, Lense L. Sex bias in considering coronary bypass surgery. Ann Intern Med. 1987;107:19–25. - PubMed
    1. Steingart R, Packer M, Hamm P, Coglianese M, Gersh B, Geltman E, Sollano J, Katz S, Moye L, Basta L, Lewis S, Gottlieb S, Bernstein V, McEwan P, Jacobson K, Brown E, Kukin M, Kantrowitz N, Pfeffer MA. Sex differences in the management of coronary artery disease. Survival and Ventricular Enlargement Investigators. N Engl J Med. 1991;325:226–230. - PubMed
    1. Ayanian JZ, Epstein AM. Differences in the use of procedures between women and men hospitalized for coronary heart disease. N Engl J Med. 1991;325:221–225. - PubMed
    1. Shaw LJ, Miller DD, Romeis JC, Kargl D, Younis LT, Chaitman BR. Gender differences in the noninvasive evaluation and management of patients with suspected coronary artery disease. Ann Intern Med. 1994;120:559–566. - PubMed
    1. Blomkalns AL, Chen AY, Hochman JS, Peterson ED, Trynosky K, Diercks DB, Brogan JGX, Boden WE, Roe MT. Gender disparities in the diagnosis and treatment of non‐ST‐segment elevation acute coronary syndromes: large‐scale observations from the CRUSADE (Can Rapid Risk Stratification of Unstable Angina Patients Suppress Adverse Outcomes With Early Implementation of the American College of Cardiology/American Heart Association Guidelines) National Quality Improvement Initiative. J Am Coll Cardiol. 2005;45:832–837. - PubMed

Publication types