Abstract Despite growing recognition of sex disparities in cardiovascular disease (CVD), contemporary, harmonized analyses of sex-specific burden in the European region that could inform targeted prevention strategies, remain limited. Sex-specific patterns in CVD burden and risk factor exposure across 55 European Society of Cardiology (ESC) member countries were examined using data from the 2023 Global Burden of Disease study. Risk factor exposure was quantified using age–sex-standardized summary exposure values for 10 established cardiovascular risk factors. Disease incidence and mortality for major CVD categories, including maternal hypertensive disorders, were estimated by calculating age–sex-standardized rates per 100 000 person-years using the 2013 European Standard Population. Analyses were performed by sex at country, regional, and ESC-wide levels and over time (1990–2023). In 2023, in the ESC region, the overall CVD burden was broadly similar in men and women, with women accounting for 55% (6.0 million) of cases and 50% of deaths (1.5 million). This apparent parity, however, concealed marked sex differences in disease composition, risk exposure, and geographic disparities. Compared with men, women had a lower proportion of CVD due to ischaemic heart disease (21% vs 38%) and a higher contribution from peripheral arterial disease (23% vs 19%). Major differences were also apparent in risk profiles, particularly for behavioural risk factors—with summary exposure values of tobacco and alcohol being 10%–20% points higher in men than women; contrasting with cardiometabolic factors, such as high body mass index and low physical activity, that were often 5%–15% points higher in women than men, and more modest differences in environmental and biological risks, including air pollution, fasting glucose, or cholesterol. Cardiovascular disease burden further varied widely across countries and disparities affected women more strongly than men, with an approximately three-fold difference between the lowest- and highest-incidence countries in women, compared with a two-fold difference in men, and even larger disparities in mortality and premature mortality (up to 25-fold in women). Maternal hypertensive disorders substantially shaped both the scale and composition of CVD burden in women, accounting for 25% of incident CVD in women and exhibiting substantial geographic variation, with up to 18-fold differences in incidence across countries. These findings challenge conventional approaches that treat CVD as a homogeneous condition. In particular, the substantial contribution of non-ischaemic conditions and maternal hypertensive disorders to the burden in women, alongside distinct patterns of risk exposure and wider geographic disparities, underscore the importance of adopting a life-course and sex- and gender-informed approach to cardiovascular prevention and policy.
