Pacemaker therapy through a sex-specific lens: a narrative review of clinical and procedural disparities

Pacemaker therapy is a cornerstone in the management of bradyarrhythmias, yet accumulating data highlight important sex-based disparities across indications, procedural care and long-term outcomes. Women are consistently under-represented among pacemaker recipients, tend to be older at implantation, and are more frequently admitted via emergency pathways despite substantial symptom burden from sinus node dysfunction. Men more often receive pacemakers for atrioventricular conduction disease, at younger ages and with greater cumulative exposure to long-term pacing and device-related procedures. Procedurally, women have higher rates of acute complications, particularly pneumothorax, pocket haematoma and lead perforation, reflecting differences in body size, venous anatomy and myocardial vulnerability. At the same time, men appear to carry a higher long-term risk of device infection. Historical inequities in device selection, with lower use of dual-chamber systems in women, are narrowing but remain a concern in some cohorts. Long-term outcomes suggest that although women experience more early procedural risk, their survival after pacemaker implantation is at least comparable to, and sometimes better than, that of men, with distinct profiles of heart failure, pacing-induced cardiomyopathy and quality-of-life trajectories. Emerging technologies such as leadless pacemakers and conduction system pacing may mitigate several of these disparities by avoiding leads and pockets, reducing dyssynchrony and lowering complication rates in high-risk subgroups. However, women remain under-enrolled in device trials, mechanistic explanations for many sex differences are incomplete, and systematic sex-specific reporting is often lacking. Addressing these gaps is essential to deliver equitable, evidence-based and personalised pacemaker therapy for both women and men. However, most available evidence derives from high-income countries and selected national registries, with limited representation from low and middle-income regions, which may constrain the generalisability of these findings across diverse healthcare settings.