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Granton D, Rodrigues M, Raparelli V, Honarmand K, Agarwal A, Friedrich JO, Perna B, Spaggiari R, Fortunato V, Risdonne G, Kho M, VanderKaay S, Chaudhuri D, Gomez-Builes C, D'Aragon F, Wiseman D, Lau VI, Lin C, Reid J, Trivedi V, Prakash V, Belley-Cote E, Al Mandhari M, Thabane L, Pilote L, Burns KEA. Sex and gender-based analysis and diversity metric reporting in acute care trials published in high-impact journals: a systematic review. BMJ Open 2024; 14:e081118. [PMID: 38719297 PMCID: PMC11103199 DOI: 10.1136/bmjopen-2023-081118] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/18/2023] [Accepted: 02/23/2024] [Indexed: 05/22/2024] Open
Abstract
OBJECTIVE To characterise sex and gender-based analysis (SGBA) and diversity metric reporting, representation of female/women participants in acute care trials and temporal changes in reporting before and after publication of the 2016 Sex and Gender Equity in Research guideline. DESIGN Systematic review. DATA SOURCES We searched MEDLINE for trials published in five leading medical journals in 2014, 2018 and 2020. STUDY SELECTION Trials that enrolled acutely ill adults, compared two or more interventions and reported at least one clinical outcome. DATA ABSTRACTION AND SYNTHESIS 4 reviewers screened citations and 22 reviewers abstracted data, in duplicate. We compared reporting differences between intensive care unit (ICU) and cardiology trials. RESULTS We included 88 trials (75 (85.2%) ICU and 13 (14.8%) cardiology) (n=111 428; 38 140 (34.2%) females/women). Of 23 (26.1%) trials that reported an SGBA, most used a forest plot (22 (95.7%)), were prespecified (21 (91.3%)) and reported a sex-by-intervention interaction with a significance test (19 (82.6%)). Discordant sex and gender terminology were found between headings and subheadings within baseline characteristics tables (17/32 (53.1%)) and between baseline characteristics tables and SGBA (4/23 (17.4%)). Only 25 acute care trials (28.4%) reported race or ethnicity. Participants were predominantly white (78.8%) and male/men (65.8%). No trial reported gendered-social factors. SGBA reporting and female/women representation did not improve temporally. Compared with ICU trials, cardiology trials reported significantly more SGBA (15/75 (20%) vs 8/13 (61.5%) p=0.005). CONCLUSIONS Acute care trials in leading medical journals infrequently included SGBA, female/women and non-white trial participants, reported race or ethnicity and never reported gender-related factors. Substantial opportunity exists to improve SGBA and diversity metric reporting and recruitment of female/women participants in acute care trials. PROSPERO REGISTRATION NUMBER CRD42022282565.
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Affiliation(s)
- David Granton
- Department of Medicine and Interdepartmental Division of Critical Care, University of Toronto, Toronto, Ontario, Canada
| | - Myanca Rodrigues
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Ontario, Canada
| | - Valeria Raparelli
- Department of Translational Medicine, University of Ferrara, Ferrara, Italy
- University Center for Studies on Gender Medicine, University of Ferrara, Ferrara, Italy
| | - Kimia Honarmand
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Ontario, Canada
- Division of Critical Care, Mackenzie Health, Vaughan, Ontario, Canada
| | - Arnav Agarwal
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Ontario, Canada
- Division of General Internal Medicine, Department of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Jan O Friedrich
- Department of Medicine and Interdepartmental Division of Critical Care, University of Toronto, Toronto, Ontario, Canada
- Critical Care and Medicine Departments, Unity Health Toronto, Toronto, Ontario, Canada
| | - Benedetta Perna
- Department of Translational Medicine, University of Ferrara, Ferrara, Italy
| | - Riccardo Spaggiari
- Department of Translational Medicine, University of Ferrara, Ferrara, Italy
| | - Valeria Fortunato
- Department of Translational Medicine, University of Ferrara, Ferrara, Italy
| | - Gianluca Risdonne
- Department of Translational Medicine, University of Ferrara, Ferrara, Italy
| | - Michelle Kho
- School of Rehabilitation Science, McMaster University, Hamilton, Ontario, Canada
- Physiotherapy Department, Research Institute of St. Joe's Hamilton, St Joseph's Healthcare Hamilton, Hamilton, Ontario, Canada
| | - Sandra VanderKaay
- School of Rehabilitation Science, McMaster University, Hamilton, Ontario, Canada
| | - Dipayan Chaudhuri
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Ontario, Canada
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Carolina Gomez-Builes
- Department of Anesthesiology and Pain Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Frédérick D'Aragon
- Department of Anesthesiology, Universite de Sherbrooke, Sherbrooke, Quebec, Canada
- Centre de Recherche du Centre Hospitalier, Universite de Sherbrooke, Sherbrooke, Quebec, Canada
| | - Daniel Wiseman
- Departments of Medicine and Critical Care Medicine, McGill University, Montreal, Quebec, Canada
| | - Vincent Issac Lau
- Department of Critical Care Medicine, University of Alberta Faculty of Medicine & Dentistry, Edmonton, Alberta, Canada
| | - Celina Lin
- Department of Medicine, Division of Physical Medicine & Rehabilitation, McMaster University, Hamilton, Ontario, Canada
| | - Julie Reid
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Ontario, Canada
| | - Vatsal Trivedi
- Department of Medicine and Interdepartmental Division of Critical Care, University of Toronto, Toronto, Ontario, Canada
- Department of Anesthesiology and Pain Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Varuna Prakash
- Department of Medicine and Interdepartmental Division of Critical Care, University of Toronto, Toronto, Ontario, Canada
| | - Emilie Belley-Cote
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Ontario, Canada
- Department of Medicine, Divisions of Cardiology and Critical Care, McMaster University, Hamilton, Ontario, Canada
| | - Maha Al Mandhari
- Department of Anesthesiology and Pain Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Lehana Thabane
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Ontario, Canada
| | - Louise Pilote
- Department of Medicine, McGill University, Montreal, Quebec, Canada
- Department of Medicine, Research Institute of the McGill University Health Centre, Montreal, Ontario, Canada
| | - Karen E A Burns
- Department of Medicine and Interdepartmental Division of Critical Care, University of Toronto, Toronto, Ontario, Canada
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Ontario, Canada
- Critical Care and Medicine Departments, Unity Health Toronto, Toronto, Ontario, Canada
- Department of Medicine, University of Toronto, Toronto, Ontario, Canada
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Lindsey ML, Usselman CW, Ripplinger CM, Carter JR, DeLeon-Pennell KY. Sex as a biological variable for cardiovascular physiology. Am J Physiol Heart Circ Physiol 2024; 326:H459-H469. [PMID: 38099847 DOI: 10.1152/ajpheart.00727.2023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/20/2023] [Revised: 12/08/2023] [Accepted: 12/10/2023] [Indexed: 02/03/2024]
Abstract
There have been ongoing efforts by federal agencies and scientific communities since the early 1990s to incorporate sex and/or gender in all aspects of cardiovascular research. Scientific journals provide a critical function as change agents to influence transformation by encouraging submissions for topic areas, and by setting standards and expectations for articles submitted to the journal. As part of ongoing efforts to advance sex and gender in cardiovascular physiology research, the American Journal of Physiology-Heart and Circulatory Physiology recently launched a call for papers on Considering Sex as a Biological Variable. This call was an overwhelming success, resulting in 78 articles published in this collection. This review summarizes the major themes of the collection, including Sex as a Biological Variable Within: Endothelial Cell and Vascular Physiology, Cardiovascular Immunity and Inflammation, Metabolism and Mitochondrial Energy, Extracellular Matrix Turnover and Fibrosis, Neurohormonal Signaling, and Cardiovascular Clinical and Epidemiology Assessments. Several articles also focused on establishing rigor and reproducibility of key physiological measurements involved in cardiovascular health and disease, as well as recommendations and considerations for study design. Combined, these articles summarize our current understanding of sex and gender influences on cardiovascular physiology and pathophysiology and provide insight into future directions needed to further expand our knowledge.
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Affiliation(s)
- Merry L Lindsey
- School of Graduate Studies, Meharry Medical College, Nashville, Tennessee, United States
- Research Service, Nashville Veterans Affairs Medical Center, Nashville, Tennessee, United States
| | - Charlotte W Usselman
- Cardiovascular Health and Autonomic Regulation Laboratory, Department of Kinesiology and Physical Education, McGill University, Montreal, Quebec, Canada
| | - Crystal M Ripplinger
- Department of Pharmacology, UC Davis School of Medicine, Davis, California, United States
| | - Jason R Carter
- Robbins College of Health and Human Sciences, Baylor University, Waco, Texas, United States
| | - Kristine Y DeLeon-Pennell
- Division of Cardiology, Department of Medicine, School of Medicine, Medical University of South Carolina, Charleston, South Carolina, United States
- Research Service, Ralph H. Johnson Veterans Affairs Medical Center, Charleston, South Carolina, United States
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Usselman CW, Lindsey ML, Robinson AT, Habecker BA, Taylor CE, Merryman WD, Kimmerly D, Bender JR, Regensteiner JG, Moreau KL, Pilote L, Wenner MM, O'Brien M, Yarovinsky TO, Stachenfeld NS, Charkoudian N, Denfeld QE, Moreira-Bouchard JD, Pyle WG, DeLeon-Pennell KY. Guidelines on the use of sex and gender in cardiovascular research. Am J Physiol Heart Circ Physiol 2024; 326:H238-H255. [PMID: 37999647 DOI: 10.1152/ajpheart.00535.2023] [Citation(s) in RCA: 9] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/31/2023] [Revised: 11/02/2023] [Accepted: 11/21/2023] [Indexed: 11/25/2023]
Abstract
In cardiovascular research, sex and gender have not typically been considered in research design and reporting until recently. This has resulted in clinical research findings from which not only all women, but also gender-diverse individuals have been excluded. The resulting dearth of data has led to a lack of sex- and gender-specific clinical guidelines and raises serious questions about evidence-based care. Basic research has also excluded considerations of sex. Including sex and/or gender as research variables not only has the potential to improve the health of society overall now, but it also provides a foundation of knowledge on which to build future advances. The goal of this guidelines article is to provide advice on best practices to include sex and gender considerations in study design, as well as data collection, analysis, and interpretation to optimally establish rigor and reproducibility needed to inform clinical decision-making and improve outcomes. In cardiovascular physiology, incorporating sex and gender is a necessary component when optimally designing and executing research plans. The guidelines serve as the first guidance on how to include sex and gender in cardiovascular research. We provide here a beginning path toward achieving this goal and improve the ability of the research community to interpret results through a sex and gender lens to enable comparison across studies and laboratories, resulting in better health for all.
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Affiliation(s)
- Charlotte W Usselman
- Cardiovascular Health and Autonomic Regulation Laboratory, Department of Kinesiology and Physical Education, McGill University, Montreal, Quebec, Canada
| | - Merry L Lindsey
- School of Graduate Studies, Meharry Medical College, Nashville, Tennessee, United States
- Research Service, Nashville Veterans Affairs Medical Center, Nashville, Tennessee, United States
| | - Austin T Robinson
- Neurovascular Physiology Laboratory, School of Kinesiology, Auburn University, Auburn, Alabama, United States
| | - Beth A Habecker
- Department of Chemical Physiology and Biochemistry and Knight Cardiovascular Institute, Oregon Health and Science University, Portland, Oregon, United States
| | - Chloe E Taylor
- School of Health Sciences, Western Sydney University, Sydney, New South Wales, Australia
| | - W David Merryman
- Department of Biomedical Engineering, Vanderbilt University, Nashville, Tennessee, United States
| | - Derek Kimmerly
- Autonomic Cardiovascular Control and Exercise Laboratory, Division of Kinesiology, School of Health and Human Performance, Faculty of Health, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Jeffrey R Bender
- Section of Cardiovascular Medicine, Department of Internal Medicine, Yale Cardiovascular Research Center, New Haven, Connecticut, United States
- Department of Immunobiology, Yale University School of Medicine, New Haven, Connecticut, United States
| | - Judith G Regensteiner
- Divisions of General Internal Medicine and Cardiology, Department of Medicine, Ludeman Family Center for Women's Health Research, University of Colorado Anschutz Medical Campus, Aurora, Colorado, United States
| | - Kerrie L Moreau
- Division of Geriatrics, Department of Medicine, University of Colorado Anschutz Medical Campus, Aurora, Colorado, United States
- Eastern Colorado Health Care System, Geriatric Research Education and Clinical Center, Aurora, Colorado, United States
| | - Louise Pilote
- Centre for Outcomes Research and Evaluation, Research Institute of the McGill University Health Centre, McGill University, Montreal, Quebec, Canada
| | - Megan M Wenner
- Department of Kinesiology and Applied Physiology, University of Delaware, Newark, Delaware, United States
| | - Myles O'Brien
- School of Physiotherapy and Department of Medicine, Faculty of Health, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Timur O Yarovinsky
- Section of Cardiovascular Medicine, Department of Internal Medicine, Yale Cardiovascular Research Center, New Haven, Connecticut, United States
- Department of Immunobiology, Yale University School of Medicine, New Haven, Connecticut, United States
| | - Nina S Stachenfeld
- John B. Pierce Laboratory, New Haven, Connecticut, United States
- Department of Obstetrics, Gynecology and Reproductive Sciences, Yale School of Medicine, New Haven, Connecticut, United States
| | - Nisha Charkoudian
- Thermal and Mountain Medicine Division, United States Army Research Institute of Environmental Medicine, Natick, Massachusetts, United States
| | - Quin E Denfeld
- School of Nursing and Knight Cardiovascular Institute, Oregon Health and Science University, Portland, Oregon, United States
| | - Jesse D Moreira-Bouchard
- Q.U.E.E.R. Lab, Programs in Human Physiology, Department of Health Sciences, Boston University College of Health and Rehabilitation Sciences: Sargent College, Boston, Massachusetts, United States
| | - W Glen Pyle
- IMPART Team Canada Network, Dalhousie Medicine, Saint John, New Brunswick, Canada
- Department of Biomedical Sciences, University of Guelph, Guelph, Ontario, Canada
| | - Kristine Y DeLeon-Pennell
- School of Medicine, Division of Cardiology, Department of Medicine, Medical University of South Carolina, Charleston, South Carolina, United States
- Research Service, Ralph H. Johnson Veterans Affairs Medical Center, Charleston, South Carolina, United States
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Sohani ZN, Behlouli H, de Moura CS, Abrahamowicz M, Pilote L. Sex Differences in the Effectiveness of Angiotensin-Converting Enzyme Inhibitors, Angiotensin II Receptor Blockers, and Sacubitril-Valsartan for the Treatment of Heart Failure. J Am Heart Assoc 2023; 12:e028865. [PMID: 37421275 PMCID: PMC10382087 DOI: 10.1161/jaha.122.028865] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/18/2023] [Accepted: 05/23/2023] [Indexed: 07/10/2023]
Abstract
Background PARAGON-HF (Efficacy and Safety of LCZ696 Compared to Valsartan, on Morbidity and Mortality in Heart Failure Patients With Preserved Ejection Fraction) suggested a potential benefit of sacubitril-valsartan in women with preserved ejection fraction. Among patients with heart failure previously treated with angiotensin-converting enzyme inhibitors (ACEIs) or angiotensin II receptor blockers (ARBs), we studied whether effectiveness of treatment with sacubitril-valsartan compared with ACEI/ARB monotherapy differed between men and women for both preserved and reduced ejection fraction. Methods and Results Data were derived from the Truven Health MarketScan Databases between January 1, 2011, and December 31, 2018. We included patients with a primary diagnosis of heart failure on treatment with ACEIs, ARBs, or sacubitril-valsartan on the basis of the first prescription after diagnosis. A total of 7181 patients treated with sacubitril-valsartan, 25 408 patients using an ACEI, and 16 177 patients treated with ARBs were included. A total of 790 readmissions or deaths occurred among 7181 patients in the sacubitril-valsartan group and 11 901 events in 41 585 patients treated with an ACEI/ARB. Adjusted for covariates, the hazard ratio (HR) for treatment with sacubitril-valsartan compared with an ACEI or ARB was 0.74 (95% CI, 0.68-0.80). The protective effect of sacubitril-valsartan was evident for men and women (women: HR, 0.75 [95% CI, 0.66-0.86]; P<0.01; men: HR, 0.71 [95% CI, 0.64-0.79]; P<0.01; P interaction 0.03). A protective effect for both sexes was seen only among those with systolic dysfunction. Conclusions Treatment with sacubitril-valsartan is more effective at reducing death and admission to the hospital for heart failure compared with ACEIs/ARBs similarly among men and women with systolic dysfunction; sex differences in the effectiveness of sacubitril-valsartan in diastolic dysfunction requires further investigation.
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Affiliation(s)
| | - Hassan Behlouli
- The Research Institute of the McGill University Health CentreMontrealQuebecCanada
| | | | - Michal Abrahamowicz
- The Research Institute of the McGill University Health CentreMontrealQuebecCanada
| | - Louise Pilote
- The Research Institute of the McGill University Health CentreMontrealQuebecCanada
- Department of Epidemiology, Occupational Health, and BiostatisticsMcGill UniversityMontréalCanada
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