Advancing cardiovascular imaging in Iraq: infrastructure, gender diversity, and future perspectives

Abstract

Cardiovascular imaging (CVI) provides an essential and accurate assessment of cardiac anatomy, function, and prognosis, thereby guiding management planning in long-term illnesses. It plays an essential role in modern cardiology in Iraq, where the adoption of advanced CVI technologies has enhanced diagnostic precision and patient care. However, there are some limitations that may interrupt the specialized improvement process, including a shortage of specialized personnel, limited infrastructure, and economic barriers. To address these challenges, the Iraqi Council of Cardiology established a nationally accredited CVI fellowship program in 2019. The key feature to initiate the program is the deliberate integration of diversity, particularly gender and geographic representation, into the training framework. This approach yielded a significantly high participation of women in CVI compared to other cardiology subspecialties in Iraq, which eventually reflected a special regional trend and productive response to workforce gaps. Also, geographic diversity has widened access to expertise across governorates, supporting equitable healthcare delivery. Regardless of these advances, marked progress needs continued investment in infrastructure and alignment with international standards. Furthermore, expanding and strengthening research capacity and fostering international collaborations will be critical to advance the whole process. The Iraqi CVI program has illustrated the framework of policy, training, and workforce planning that will overcome systemic limitations and contribute to the advancement of equitable cardiovascular care in resource-limited settings.

Plain language summary

This article describes the need of diversity as a vital role in the cardiovascular imaging program in Iraq and not just an addition to the cardiology specialty

In this review, we have showed the requirements and the methods to improve the Cardiovascular Imaging (CVI) program diversity and progression in Iraq. Also, the review highlights the growing importance of CVI in diagnosing, treating, and managing cardiovascular diseases (CVD), especially in Iraq, where limited resources and infrastructure pose challenges. It focuses on the role of CVI in improving healthcare efficiency, guiding interventions, and reducing unnecessary procedures while addressing gender and geographic diversity in the field. Efforts to enhance training, international collaboration, and infrastructure are crucial for advancing CVI in Iraq. The review also discusses barriers faced by women in cardiology globally and highlights Iraq’s progress in empowering women through CVI fellowship programs. Future directions focus on expanding access, education, and research to optimize cardiac care.

Introduction

In recent years, cardiovascular diseases (CVD) have become more prevalent and complex. Different therapies are emerging to target various pathophysiological aspects of CVDs, necessitating a better understanding and more precise tools for diagnosing these CVDs. All of this has led to the development of advanced cardiac imaging tools that are not only used for diagnosis but also for guiding treatment and prognosis of different CVDs (see Figure 1).

Figure 1.

Role of cardiovascular imaging in modern cardiology. This schematic outlines the applications of CVI in diagnosis, prognosis, treatment guidance, and post-intervention assessment. CVI enables visualization of cardiac anatomy and function, providing crucial insights for clinical decision-making and risk stratification.

CVI, cardiovascular imaging.

The healthcare system in Iraq faces challenges, including limited resources and infrastructure, which can impact the prevention and management of CVDs. Therefore, enhancing access to advanced cardiovascular imaging (CVI) technology and training healthcare professionals can significantly improve the management of CVDs, bridge gaps in the healthcare system, provide better care, and reduce the burden of CVDs in the population. CVI techniques enable detailed visualization of the heart, which provides valuable insights into disease severity and potential outcomes, helping clinicians predict disease prognosis and tailor interventions to improve long-term health. CV imaging modalities are essential for diagnosing congenital heart diseases in children and predicting future cardiac events. ¹ They play a crucial role in assessing cardiac perfusion capabilities and are instrumental in diagnosing coronary artery disorders, particularly when clinical signs and laboratory results are nonspecific. ² Furthermore, international guidelines recommend employing noninvasive cardiac imaging as an initial measure prior to evaluating the need for interventional cardiac revascularization.^3,4 Therefore, it is used to assess the specific need for and plan interventional procedures. This helps avoid unnecessary invasive techniques and improves patient safety. ⁵ It also helps reduce the need for more expensive treatments or emergency interventions later on, contributing to more efficient use of healthcare resources. It is essential for evaluating post-intervention success and identifying any complications or areas requiring further treatment. CVI accounts for approximately 61.5% of all cardiac examinations, with echocardiography making up about two-thirds of these evaluations. ⁶ Hence, there is a growing need for specialized training and education for healthcare professionals in Iraq to ensure that local practitioners are up to date with the latest technologies and techniques. Limited CVI data from Iraq can affect health policy decisions and resource allocation, limiting the ability to address the specific needs and challenges faced in Iraq’s healthcare system. By estimating these data, they can be used for research purposes, providing statistics on the prevalence, causes, and treatment of CVDs, which can contribute to the development of more effective public health strategies.

Impacts of cardiac imaging technology on the healthcare system in Iraq

The high prevalence of CVDs in high-, low-, and middle-income countries (HIC, LIC, and MIC) can be attributed to a variety of risk factors that vary across regions. Understanding the prevalence rates and their implications helps illustrate the global burden of CVDs and the influence of different risk factors.

CVI significantly influences multiple facets of healthcare in Iraq, including emergency care, patient management, research, and healthcare policy.

Global guidelines have recommended CVI techniques to investigate patients with suspected CV disorders carefully, with structured evaluation, and to categorize those patients based on their specific risk profiles to arrange their clinical workup. ⁷ This will invest in medical infrastructure and imaging technologies, which can improve access and affordability to overcome limited resources in Iraq. Arranging patient risk profiles will offer a “personalized approach” based on each case, and this will further provide accurate chronic management and reduce hospital readmission. CVI plays a crucial role in the early detection of cardiac conditions in the emergency department, ⁷ and this will offer a better triage process and provide an improved level of care and treatment for patients earlier. All these CVI utilities can provide a bulk of data that can support research findings in Iraq. They will enhance the understanding of disease mechanisms, treatment planning, and provide access for patients to participate in research and clinical trials. These data can inform healthcare system policy to prioritize and effectively improve cardiac care unit services, strategic planning, and the development of new implementations in the cardiac care program. This collaboration between clinicians and patients will form the cornerstone of healthcare empowerment. Globally, collaborations and partnerships with international organizations will improve the local healthcare system and provide better expertise in the future. At the beginning, CVI techniques may require high costs, but in the long term, they may reduce the need for other diagnostic workups and hence are cost-effective. Enhancing the accessibility of CVI, allocating resources to healthcare, and fostering collaborative efforts are crucial approaches for Iraq to fully expand the benefits of CVI.

• Method: The data on gender and geographic distribution were extracted from the Iraqi Council of Cardiology from 2020 to 2024. The data are freely accessible through direct access from the Iraqi Scientific Council of Cardiology Department. There was a lack of gender and geographic diversity. During the start of the CVI program recruitment in Iraq in 2020, 75% of recruited candidates were women. This support and encouragement of women to be recruited and retained in the program has continued so far, and currently, 83.3% of CVI fellows are women. See Table 1, which provides the distribution of cardiology fellows in Iraq per year based on gender classification.

Table 1.

Gender distribution of cardiovascular imaging fellows in Iraq (2020–2024).

Items	2020	2021	2022	2023	2024	Total
Men	2	0	2	1	1	6
Women	6	5	5	6	8	30
Total	8	5	7	7	9	36

The figure highlights a progressive increase in female participation, reaching 83.3% in 2024. This stands in contrast to global benchmarks, where female representation in cardiology training remains below 25%. ⁸ The program demonstrates a unique regional trend of women outnumbering men in this subspecialty, unlike patterns reported in the US, UK, Australia, and the Middle East countries.

Gender diversity in the cardiac imaging field in Iraq

Cardiology is a competitive career and is considered a male-dominated specialty, with a neglected proportion of women in this field over the years. ⁹ In Iraq, the gender gap in cardiology has exceeded that seen in other specialties such as surgery. ¹⁰ Gender and geographic diversity in academic cardiology workforces are evident in prior research. ¹¹

The Iraqi female population forms about half of the total population (data: IMOPCSO), and Iraqi female medical students constitute a large percentage of medical graduates, with a gradual increase over the years. ¹⁰ Women represent a small proportion of internal medicine fellowships and are almost absent in cardiology fellowship programs.^10,12 By contrast, a gradual improvement has been seen in gender diversity in echocardiography careers. ¹⁰ These differences are attributed to reasons related to better work–life balance. One way to empower women in the cardiovascular workforce is to enhance their recruitment in the crucial and vital subspecialty of cardiology, which is CVI.

To bridge the gaps in healthcare systems, meet the need for CVI, and empower the female workforce in cardiology, the Iraqi Council of Cardiology have established a well-structured, accredited CVI fellowship program in Iraq at the end of 2019. Decision-makers in the cardiology fellowship program noticed the lack of diversity, especially in terms of gender, in previously established cardiology fellowships. Accordingly, gender and geographic diversity in the CVI workforce were enhanced.

It was found that the perspectives of women and men cardiologists differ regarding their careers. ¹³ Women report many factors, such as low work satisfaction, low income, family needs, low career progress, and maternity leave inequity. Women tend to choose cardiac imaging over clinical cardiology as a career due to these factors. These factors may also affect the career choice for women in Iraq, but the listed reasons above have strongly shifted men away from this field in Iraq, leaving women with a higher proportion. Women as medical graduates form half of the total, though they are still underrepresented in the field of cardiac imaging as cardiologists, fellows, ¹⁴ and in leadership roles, and most notably in guideline authorship.^15,16 Some studies have explained the inequity in sex diversity in this field. In a global survey estimating women’s underrepresentation, half of the women reported imposter syndrome—feeling inadequate regardless of having the required ability and qualifications as men—in addition to other factors such as depression, anxiety, and lack of motivation. ¹⁴

On the opposite side, in Iraq, the current high demand for plastic surgery, dermatology, and general surgery has attracted men to choose these specialties, which open more opportunities for them to make their own private practices, personal projects, and gain specialization and recognition through public perception and media influence. Also, these specialties have less exposure to radiation and are seen as having a more direct impact on patients, as they are considered more hands-on compared to other specialties. In general, men prefer specialties that develop their educational professionalism and clinical skills, along with financial considerations, while the infrastructure in Iraq and the fewer established professionals in cardiac imaging have limited this career as a preferred choice for men.

Geographic distribution of CVI fellows in Iraq

As Baghdad is the capital city, the population size is much higher than in other cities, as well as the number of medical graduates and fellows. Therefore, it creates the need for more cardiology teaching centers and fellows to be offered.

The interesting part is that the cardiac fellows in the teaching program are from 12 governorates—among 18 governorates (26.0%)—in Iraq, which represents considerable geographic diversity in the CVI program (Figure 2).

Figure 2.

Geographic distribution of cardiovascular imaging fellows in Iraq. Fellows were recruited from 12 out of 18 governorates (66.7%) between 2020 and 2024, indicating substantial geographic diversity in the program. This distribution supports equitable capacity-building in cardiac imaging services beyond Baghdad and addresses workforce gaps across underserved regions. Comparable geographic workforce diversification strategies have been recommended internationally to strengthen equitable healthcare delivery. ¹⁷

Research output by CVI fellows

In Iraq, the prevalence of cardiac CT topics in fellowship theses may be affected by local factors related to the healthcare system and training programs that offer this modality more than others. The clinical relevance of the demand for CT in most cases is higher than for other techniques, due to the local risk factors for CVD in Iraq compared to other countries. Not to mention the high and emerging role of CT in contemporary guidelines for guiding different CVD management strategies. Furthermore, the available funding for cardiac CT equipment makes it the most useful technique supported by the government, and because it has more funding and policy initiatives, this can impact research priorities due to the higher patient volume that increases data availability.

The second most prevalent CVI topic in research theses is 2D echocardiography. The first reason is its widespread use and accessibility in many centers and private clinics. It forms the basis and plays a fundamental role among CVI techniques in many settings, and hence has the most clinical relevance to cardiac fellowship and research protocols. It is cost-effective for most of the population and is often used in combination with other imaging modalities, thus providing valuable integration that improves overall diagnostic accuracy.

In comparison, Cardiac Magnetic Resonance (CMR) is high-cost, less accessible, and not widely available. Therefore, CMR is not covered as often as other topics, due to limited data, fewer training opportunities, and fewer professionals with expertise in this field. CMR involves complex procedures and preparation, which may be challenging to provide within Iraq’s healthcare system. Although it requires integration with other imaging techniques, CMR can often be replaced by other modalities where demand is higher and patient needs are simpler (Figure 3).

Figure 3.

Percentages of topics covered by the thesis output from the Cardiovascular Imaging Fellowship.

Cardiac imaging disparities between Iraq and HIC, LIC, and MIC

The uneven spread of heart disease and its associated risk factors results in diverse cardiovascular outcomes worldwide. The dissimilar access to advanced imaging techniques in HIC, LIC, and MIC can delay diagnosis and worsen disease prognosis. In HIC, there is greater access to cardiac imaging and precise diagnostic capabilities, while LIC and MIC face significant barriers to accessing advanced imaging technologies due to high costs and limited infrastructure. This eventually leads to less diagnostic detail, lower imaging quality, and reduced decision-making accuracy.

This access disparity increased after the COVID-19 pandemic from March 2019 to April 2020, during which a considerable reduction in diagnostic procedures was reported globally—a 64% decrease. This later returned to previous levels in upper-middle and HICs, but remained low (30%) in LICs. ¹⁸

In our study, females represent 83.3% compared to males at 16.6% over the 5 years since the opening of this specialty in 2020. Several steps were taken to enhance women’s recruitment in Iraq. During the fellowship, two candidates had three pregnancies. The program director decided to de-route these women, relocating them from their predetermined allocation in cardiac CT to other cardiac services and training in areas with less exposure to radiation, such as echocardiography modalities. The program director ensured flexible rescheduling and reallocation of their training blocks without impacting the robustness or validity of the training program.

Furthermore, women cardiologists in the United States constitute 21.5% in cardiology and 9.8% in interventional cardiology, respectively. ¹⁹ Another study ²⁰ shows women consultants forming 13% and fellows forming 28% in the UK.

In Australia, they form 14%, ²¹ while in other studies, women represent less than 15% of cardiologists and less than 5% of interventional cardiologists.^16,21 These data are similar to each other but differ from our results. These proportions indicate that men represent the higher prevalence of cardiology fellows in high-income and highly educated countries, which is the opposite of our findings.

A previous survey in the United States revealed that 63% of women cardiologists experienced discrimination. ²² Many HICs face this type of barrier due to the competition with men in this male-dominated specialty. In Iraq, this specialty is not a preferred or competitive choice for men compared to other specialties, and women represent a higher proportion.

In Europe, specifically in Switzerland, 26% of cardiologists were women over 5 years, and in Belgium, they were 16.4%.^22,23

In the Middle East, women cardiologists form less than 5%, in Oman 7%, and in Lebanon 3%.^24,25

In general, the establishment of the CVI fellowship program in Iraq and the Middle East has shown that clinical and workforce needs have limited resource settings. By advancing geographic and gender diversity, it will align with international efforts to strengthen features in LIC and MIC. In India and Brazil, there were some comparable challenges, such as limited infrastructure, unequal workforce diversity, and under-representation of women in cardiology sub-speciality.^26,27 On the other side, Iraq’s representation of women have distinctive percentage (83.3%), which is higher than other Low-Middle Income Countries (LMIC), forming less than 25% of women cardiology trainees. ²⁸

Furthermore, other studies also suggested that gender diversity enhances patient-centered care clinical diagnosis, and provides greater communication.^8,29 Despite the entry rate, the gender and geographic diversity require addressing the limitations of women’s access to leadership opportunities, disparities in academic promotion, and lower representation in guideline authorship.^16,30

Integrating AI into CVI clinical practice could optimize the efficacy of automated image acquisition, segmentation, and interpretation, as well as reduce inter-observer variability. ³¹ It could expand access to high-quality imaging in resource-constrained settings such as Iraq.

Also, in the United States, in 2017–2018, the women represented 21.4% among cardiology trainees, with only 10.2% and 11.6% in interventional cardiology and electrophysiology, respectively. ³²

In France, female cardiology trainees represented 23.9%, and in the United Kingdom 29%, while across North America, Australia, and UK, female represented 15% of cardiology trainees compared to 43% of all internal medicine programs.^33,34

Some facilities and barriers have contributed to these differences and led to these results. First, the Iraqi CVI program was designed with diversity as a core principle, which makes the program different from other Western programs and thus the percentage of women was higher. Second, one of the most important and commonly shared barriers is family issues, which represent a major reason for the small proportion of women in this specialty. Pregnancy planning and uncompensated maternity leave have contributed to these biased percentages. Even in HICs and LMICs, women face the same social barriers, and both developed and developing countries often fail to provide special funding to help women balance their careers with family responsibilities.

Global and Iraq evidence: What increased gender diversity changes for patients?

Various large analyses showed that increased gender diversity can enhance patient outcomes, reduce in-hospital mortality rates, and decrease readmission. Patient–gender concordance has also been shown to enhance outcomes for female cardiovascular patients. ³⁵ Previous systematic reviews demonstrated that female physicians adhere more closely to guidelines, which results in better diagnostic pathways, improved risk factor control, and more appropriate use of imaging. ³⁶ However, the under-representation of women in clinical trial leadership, research authorship, and imaging studies has created a sex gap in diagnosing atypical disease presentations, such as atypical ischemia, which often show different sensitivity and specificity in women. ³⁷ Increasing female representation in these areas would help reduce such gaps and create a better diagnostic approach.

Hospital and surgical team studies have also found that diverse teams can deliver better recovery rates and safer approaches for patients. ³⁸ Therefore, diverse cardiovascular teams could achieve greater diagnostic accuracy.

In the context of Iraq, these factors are closely related to cultural and regional epidemiology. For example, many previous results and publications ³⁹ show that women with cardiac symptoms are less likely to seek primary care unless there are female cardiac physicians available or female-friendly clinics. These cultural differences highlight the importance of a gender-diverse CVI team in Iraq. Moreover, the low percentage of women represented in CVI in Iraq ⁴⁰ not only limits female patients’ presentation in research studies but also affects outcomes and reduces the diversity of roles and participation.

Conclusion

Enhancing a well-structured and diverse CVI fellowship program in Iraq will strengthen the country’s cardiovascular clinical care quality. Achievement of this milestone requires long-term strategies and action-oriented priorities, which include advanced training across governorates, continued investment in imaging infrastructures, and institutionalization of diversity policies to ensure equitable participation. Future research should assess the long term impact of this diversity on patient care and clinical improvement, and then refine the national curricula based on it. Moreover, fostering collaborations with international cardiovascular societies and academic institutions will offer great opportunities and knowledge exchange with alignment to global development. Through strategic policy, investment, and research, Iraq has the opportunity to establish a model of equitable and resilient CVI training that may serve as an example for other LIC and MIC.

Future directions

Enhancing cardiac imaging in Iraq includes addressing both infrastructural and educational challenges to improve diagnostic accuracy and patient outcomes. This involves increasing investment and funding in healthcare infrastructure to upgrade advanced cardiac imaging facilities and technology. In addition, partnerships with international organizations and private sector entities support and enhance cardiac imaging capabilities. CVI program should implement specialized training programs for radiologists, cardiologists, and technicians to ensure they are proficient with the latest imaging technologies and techniques.

Also, the program should encourage ongoing professional development through workshops, conferences, and online courses. It should implement quality control systems to regularly assess and improve imaging practices and outcomes. The CVI program should support research initiatives focused on cardiac imaging to foster innovation and collaborate with international experts to stay updated with global advancements and integrate best practices. The number of cardiac imaging centers, especially in underserved regions, should increase to improve accessibility for patients. Electronic health record systems should enhance to improve patient information sharing and support better diagnostic accuracy. Finally, the program should spread public awareness about the importance of cardiac health and the role of imaging in diagnosing and managing heart diseases.