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Zhang J, Peng M, Li J, Li L, Bai X, Thabane L, Yh Lip G, Van Spall HG, Li G. Enrollment of Black, Indigenous and People of Color (BIPOC) and female participants in the US diabetes trials spanning 2000 to 2020: A chronological survey. Diabetes Metab Syndr 2024; 18:103074. [PMID: 39033649 DOI: 10.1016/j.dsx.2024.103074] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/14/2023] [Revised: 07/11/2024] [Accepted: 07/14/2024] [Indexed: 07/23/2024]
Abstract
AIMS Little is known about the enrollment practice of both Black, Indigenous and People of Color (BIPOC) and females in the US diabetes trials. We aimed to perform a chronological survey to evaluate the enrollment of BIPOC and female participants in the US diabetes randomized controlled trials (RCTs) over the past two decades. METHODS We searched databases to systematically include the US diabetes RCTs from 2000 January 1st to 2020 December 31st. Primary outcome was the adequate enrollment of both BIPOC and females, defined by the participation to prevalence ratio (PPR) > 0.8. We tested the temporal trend in adequate enrollment over time and used logistic regression analysis to explore the relationship between adequate enrollment and trial characteristics. RESULTS A total of 69 US diabetes trials were included for analyses, with a median BIPOC and female enrollment percentage of 29.0 % and 45.4 % respectively. There were 22 (31.9 %) trials with adequate enrollment of both BIPOC and females. No significant trend of adequate enrollment percentage of BIPOC and females over time was observed (P = 0.16). Of trial types, those with medication interventions were significantly related to decreased odds of adequate enrollment, when compared to trials with non-drug interventions (odds ratio = 0.29, 95 % confidence interval: 0.11-0.84). CONCLUSIONS Less than one third of the US diabetes trials adequately enrolled both BIPOC and females over the past two decades, and no temporal improvement in BIPOC and female participant enrollment was observed. These results highlight the need for more endeavors to mitigate inadequate representation regarding BIPOC and female enrollment in diabetes trials.
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Affiliation(s)
- Jingyi Zhang
- Center for Clinical Epidemiology and Methodology (CCEM), The Affiliated Guangdong Second Provincial General Hospital of Jinan University, Guangzhou, China
| | - Miaoguan Peng
- Department of Endocrinology, Guangdong Provincial Key Laboratory of Major Obstetric Diseases, Guangdong Provincial Clinical Research Center for Obstetrics and Gynecology, Guangdong-Hong Kong-Macao Greater Bay Area Higher Education Joint Laboratory of Maternal-Fetal Medicine, The Third Affiliated Hospital of Guangzhou Medical University, Guangzhou, 510150, China
| | - Jianfeng Li
- Department of Epidemiology and Health Statistics, School of Public Health, Guangdong Medical University, Dongguan, China
| | - Likang Li
- Center for Clinical Epidemiology and Methodology (CCEM), The Affiliated Guangdong Second Provincial General Hospital of Jinan University, Guangzhou, China
| | - Xuerui Bai
- Department of Public Health and Preventive Medicine, School of Medicine, Jinan University, Guangzhou, China
| | - Lehana Thabane
- Father Sean O'Sullivan Research Centre, St Joseph's Healthcare Hamilton, Hamilton, ON, Canada; Faculty of Health Sciences, University of Johannesburg, Johannesburg, South Africa; Department of Health Research Methods, Evidence, and Impact (HEI), McMaster University, Hamilton, ON, Canada
| | - Gregory Yh Lip
- Liverpool Centre for Cardiovascular Science at University of Liverpool, Liverpool John Moores University and Liverpool Heart & Chest Hospital, Liverpool, United Kingdom; Danish Center for Health Services Research, Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
| | - Harriette Gc Van Spall
- Department of Health Research Methods, Evidence, and Impact (HEI), McMaster University, Hamilton, ON, Canada; Department of Medicine, McMaster University, Hamilton, ON, Canada
| | - Guowei Li
- Center for Clinical Epidemiology and Methodology (CCEM), The Affiliated Guangdong Second Provincial General Hospital of Jinan University, Guangzhou, China; Father Sean O'Sullivan Research Centre, St Joseph's Healthcare Hamilton, Hamilton, ON, Canada.
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Silvestre J, Benn L, Chen AF, Lieberman JR, Peters CL, Nelson CL. Diversity of Backgrounds and Academic Accomplishments for Presidents Elected to Hip and Knee Arthroplasty Societies in the United States. J Arthroplasty 2024; 39:1856-1862. [PMID: 38309637 DOI: 10.1016/j.arth.2024.01.042] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/17/2023] [Revised: 01/19/2024] [Accepted: 01/24/2024] [Indexed: 02/05/2024] Open
Abstract
BACKGROUND Academic accomplishments and demographics for presidents of hip and knee arthroplasty societies are poorly understood. This study compares the characteristics of presidents nominated to serve the Hip Society, Knee Society, and American Association of Hip and Knee Surgeons. METHODS This was a cross-sectional study of arthroplasty presidents in the United States (1990 to 2022). Curriculum vitae and academic websites were analyzed for demographic, training, bibliometric, and National Institutes of Health (NIH) funding data. Comparisons were made between organizations and time periods (1990 to 2005 versus 2006 to 2022). RESULTS There were 97 appointments of 78 unique arthroplasty presidents (80%). Most presidents were male (99%) and Caucasian (95%). There was 1 woman (1%) and 5 non-Caucasian presidents (2% Asian, 3% Hispanic). There were no differences in demographics between the 3 arthroplasty organizations and the 2 time periods (P > .05). Presidents were appointed at 55 ± 10 years old, which was on average 24 years after completion of residency training. Most presidents had arthroplasty fellowship training (68%), and the most common were the Hospital for Special Surgery (21%) and Massachusetts General Hospital (8%). The median h-index was 53 resulting from 191 peer-reviewed publications, which was similar between the 3 organizations (P > .05). There were 2 presidents who had NIH funding (2%), and there were no differences in NIH funding between the 3 organizations (P > .05). CONCLUSIONS Arthroplasty society presidents have diverse training pedigrees, high levels of scholarly output, and similar demographics. There may be future opportunities to promote diversity and inclusion among the highest levels of leadership in total joint arthroplasty.
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Affiliation(s)
- Jason Silvestre
- Medical University of South Carolina, Charleston, South Carolina
| | - Lancelot Benn
- Howard University College of Medicine, Washington, District of Columbia
| | | | - Jay R Lieberman
- Keck School of Medicine of University of Southern California, Los Angeles, California
| | | | - Charles L Nelson
- Perelman School of Medicine at University of Pennsylvania, Philadelphia, Pennsylvania
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Wu D, Ono R, Wang S, Kobayashi Y, Sughimoto K, Liu H. Pulse wave signal-driven machine learning for identifying left ventricular enlargement in heart failure patients. Biomed Eng Online 2024; 23:60. [PMID: 38909231 PMCID: PMC11193305 DOI: 10.1186/s12938-024-01257-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/25/2023] [Accepted: 06/12/2024] [Indexed: 06/24/2024] Open
Abstract
BACKGROUND Left ventricular enlargement (LVE) is a common manifestation of cardiac remodeling that is closely associated with cardiac dysfunction, heart failure (HF), and arrhythmias. This study aimed to propose a machine learning (ML)-based strategy to identify LVE in HF patients by means of pulse wave signals. METHOD We constructed two high-quality pulse wave datasets comprising a non-LVE group and an LVE group based on the 264 HF patients. Fourier series calculations were employed to determine if significant frequency differences existed between the two datasets, thereby ensuring their validity. Then, the ML-based identification was undertaken by means of classification and regression models: a weighted random forest model was employed for binary classification of the datasets, and a densely connected convolutional network was utilized to directly estimate the left ventricular diastolic diameter index (LVDdI) through regression. Finally, the accuracy of the two models was validated by comparing their results with clinical measurements, using accuracy and the area under the receiver operating characteristic curve (AUC-ROC) to assess their capability for identifying LVE patients. RESULTS The classification model exhibited superior performance with an accuracy of 0.91 and an AUC-ROC of 0.93. The regression model achieved an accuracy of 0.88 and an AUC-ROC of 0.89, indicating that both models can quickly and accurately identify LVE in HF patients. CONCLUSION The proposed ML methods are verified to achieve effective classification and regression with good performance for identifying LVE in HF patients based on pulse wave signals. This study thus demonstrates the feasibility and potential of the ML-based strategy for clinical practice while offering an effective and robust tool for diagnosing and intervening ventricular remodeling.
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Affiliation(s)
- Dandan Wu
- Graduate School of Science and Engineering, Chiba University, Chiba, Japan
| | - Ryohei Ono
- Department of Cardiovascular Medicine, Chiba University Graduate School of Medicine, Chiba, Japan
| | - Sirui Wang
- Graduate School of Science and Engineering, Chiba University, Chiba, Japan
| | - Yoshio Kobayashi
- Department of Cardiovascular Medicine, Chiba University Graduate School of Medicine, Chiba, Japan
| | - Koichi Sughimoto
- Graduate School of Science and Engineering, Chiba University, Chiba, Japan
| | - Hao Liu
- Graduate School of Science and Engineering, Chiba University, Chiba, Japan.
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Breathett K, Lewsey S, Brownell NK, Enright K, Evangelista LS, Ibrahim NE, Iturrizaga J, Matlock DD, Ogunniyi MO, Sterling MR, Van Spall HGC. Implementation Science to Achieve Equity in Heart Failure Care: A Scientific Statement From the American Heart Association. Circulation 2024; 149:e1143-e1163. [PMID: 38567497 DOI: 10.1161/cir.0000000000001231] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/04/2024]
Abstract
Guideline-directed medical therapies and guideline-directed nonpharmacological therapies improve quality of life and survival in patients with heart failure (HF), but eligible patients, particularly women and individuals from underrepresented racial and ethnic groups, are often not treated with these therapies. Implementation science uses evidence-based theories and frameworks to identify strategies that facilitate uptake of evidence to improve health. In this scientific statement, we provide an overview of implementation trials in HF, assess their use of conceptual frameworks and health equity principles, and provide pragmatic guidance for equity in HF. Overall, behavioral nudges, multidisciplinary care, and digital health strategies increased uptake of therapies in HF effectively but did not include equity goals. Few HF studies focused on achieving equity in HF by engaging stakeholders, quantifying barriers and facilitators to HF therapies, developing strategies for equity informed by theory or frameworks, evaluating implementation measures for equity, and titrating strategies for equity. Among these HF equity studies, feasibility was established in using various educational strategies to promote organizational change and equitable care. A couple include ongoing randomized controlled pragmatic trials for HF equity. There is great need for additional HF implementation trials designed to promote delivery of equitable guideline-directed therapy.
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Prichard R, Maneze D, Straiton N, Inglis SC, McDonagh J. Strategies for improving diversity, equity, and inclusion in cardiovascular research: a primer. Eur J Cardiovasc Nurs 2024; 23:313-322. [PMID: 38190724 DOI: 10.1093/eurjcn/zvae002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/30/2023] [Accepted: 01/02/2024] [Indexed: 01/10/2024]
Abstract
This paper aims to empower cardiovascular (CV) researchers by promoting diversity, equity, and inclusion (DE&I) principles throughout the research cycle. It defines DE&I and introduces practical strategies for implementation in recruitment, retention, and team dynamics within CV research. Evidence-based approaches supporting underrepresented populations' participation are outlined for each research phase. Emphasizing the significance of inclusive research environments, the paper offers guidance and resources. We invite CV researchers to actively embrace DE&I principles, enhancing research relevance and addressing longstanding CV health disparities.
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Affiliation(s)
- Roslyn Prichard
- Faculty of Health, University of the Sunshine Coast, 90 Sippy Downs Drive, Sippy Downs, 4556 Queensland, Australia
| | - Della Maneze
- School of Nursing, Faculty of Science, Medicine, and Health, University of Wollongong, Wollongong, New South Wales, Australia
| | - Nicola Straiton
- St Vincent's Health Network, Nursing Research Institute, Australian Catholic University, Sydney, New South Wales, Australia
| | - Sally C Inglis
- IMPACCT, Faculty of Health, University of Technology Sydney, Sydney, New South Wales, Australia
| | - Julee McDonagh
- School of Nursing, Faculty of Science, Medicine, and Health, University of Wollongong, Wollongong, New South Wales, Australia
- Centre for Chronic and Complex Care Research, Blacktown Hospital, Blacktown, New South Wales, Australia
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Breathett K. Why diversity is needed at every level of clinical trials, from participants to leaders. Nat Med 2024; 30:929. [PMID: 38605167 DOI: 10.1038/s41591-024-02914-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/13/2024]
Affiliation(s)
- Khadijah Breathett
- Division of Cardiovascular Medicine, Krannert Cardiovascular Research Center, Indiana University, Indianapolis, IN, USA.
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Mendieta G, Zannad F. Strategies for rejuvenating clinical trialists' leadership. Eur Heart J 2024; 45:864-866. [PMID: 38190316 DOI: 10.1093/eurheartj/ehad851] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/10/2024] Open
Affiliation(s)
- Guiomar Mendieta
- Servei de Cardiologia, Institut Clínic Cardiovascular, Hospital Clínic de Barcelona, c/Villarroel 170, 08036 Barcelona, Spain
- Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), c/del Rosselló 149, 08036 Barcelona, Spain
| | - Faiez Zannad
- Centre d'Investigation Clinique-Plurithématique Inserm 1433, Centre Hospitalier Regional Universitaire, Université de Lorraine, 4, rue du Morvan 54500 Vandoeuvre les Nancy, Nancy Brabois, France
- Inserm U1116, CHRU Nancy Brabois, F-CRIN INI-CRCT (Cardiovascular and Renal Clinical Trialists), 4, rue du Morvan 54500 Vandoeuvre les Nancy, Nancy, France
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Averbuch T, Lee SF, Zagorski B, Mebazaa A, Fonarow GC, Thabane L, Van Spall HGC. Effect of a transitional care model following hospitalization for heart failure: 3-year outcomes of the Patient-Centered Care Transitions in Heart Failure (PACT-HF) randomized controlled trial. Eur J Heart Fail 2024; 26:652-660. [PMID: 38303550 DOI: 10.1002/ejhf.3134] [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: 09/30/2023] [Revised: 11/17/2023] [Accepted: 12/25/2023] [Indexed: 02/03/2024] Open
Abstract
AIMS Patients are at high risk of death or readmission following hospitalization for heart failure (HF). We tested the effect of a transitional care model that included month-long nurse-led home visits and long-term heart function clinic visits - with services titrated to estimated risk of clinical events - on 3-year outcomes following hospitalization. METHODS AND RESULTS In a pragmatic, stepped-wedge cluster randomized trial, 10 hospitals were randomized to the intervention versus usual care. The primary outcome was a composite of all-cause death, readmission, or emergency department (ED) visit. Secondary outcomes included components of the primary composite outcomes, HF readmissions and healthcare resource utilization. There were 2494 patients (50.4% female) with mean age of 77.7 years. The primary outcome was reached in 1040 (94.2%) patients in the intervention and 1314 (94.5%) in the usual care group at 3 years. The intervention did not reduce the risk of the primary composite outcome (hazard ratio [HR] 0.92, 95% confidence interval [CI] 0.81-1.05) nor the component outcomes overall, although numerically reduced the risk of ED visits in women but not men (HR 0.79, 95% CI 0.63-1.00 vs. HR 0.98, 95% CI 0.80-1.19; sex-treatment interaction p = 0.23). The uptake of guideline-directed medical therapy was no different with the intervention than with usual care, with the exception of sacubitril/valsartan, which increased with the intervention (3.3% vs 1.5%; relative risk 6.2, 95% CI 1.92-20.06). CONCLUSIONS More than 9 of 10 patients hospitalized for HF experienced all-cause death, readmission, or ED visit at 3 years. A transitional care model with services titrated to risk did not improve the composite of these endpoints, likely because there were no major differences in uptake of medical therapies between the groups. CLINICAL TRIAL REGISTRATION ClinicalTrials.gov Identifier NCT02112227.
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Affiliation(s)
- Tauben Averbuch
- Department of Cardiology, University of Calgary, Calgary, AB, Canada
| | - Shun Fu Lee
- Population Health Research Institute, Hamilton, ON, Canada
| | - Brandon Zagorski
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada
| | - Alexandre Mebazaa
- Department of Anesthesia and Critical Care-APHP, AM: Université Paris Cité; MASCOT Inserm, Paris, France
| | - Gregg C Fonarow
- Division of Cardiology, Ahmanson-UCLA Cardiomyopathy Center, University of California Los Angeles Medical Center, Los Angeles, CA, USA
| | - Lehana Thabane
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada
- The Research Institute of St. Joe's, Hamilton, ON, Canada
| | - Harriette G C Van Spall
- Population Health Research Institute, Hamilton, ON, Canada
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada
- Department of Medicine, McMaster University, Hamilton, ON, Canada
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Pelton M, Ssentongo P, Sun A, Groff D, Dalessio S, Clarke K. Race and Ethnic Representation in Crohn's Disease Trials of Biologic and Small Molecule Medications: A Systematic Review and Meta-analysis. J Crohns Colitis 2024; 18:204-211. [PMID: 37586091 DOI: 10.1093/ecco-jcc/jjad138] [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: 02/08/2023] [Indexed: 08/18/2023]
Abstract
BACKGROUND AND AIMS Randomised controlled trials historically under-represent marginalised racial and ethnic populations. As incidence and prevalence of Crohn's disease in these groups rise, it is important to characterise their inclusion in randomised controlled trials on first-line and pipe-line medications. METHODS PubMed was searched systematically for randomised controlled trials of biologic and small molecule inhibitor [SMI] medications, with a primary outcome related to efficacy following PRISMA guidelines. We used descriptive statistics to summarise demographic variables and meta-regression analyses to estimate temporal trends in racial inclusion. RESULTS More than a half of trials did not report any racial/ethnic demographics [53.7%] and several reported racial demographics for only one race [20.9%]. When racial data were reported, Whites made up 90.2% of participants. Percentages of Black, Asian, Native American/Pacific Islander, and participants considered 'Other' averaged 2.9%, 11.6%, 0.5%, and 1.6% out of the total sample sizes of 3901, 3742, 828 and 4027, respectively. Proportional representation of White participants decreased over time [p <0.01] and proportional representation of Asian participants increased over time [p = 0.047]. In ordinal logistic regression, mean year of trial enrolment significantly increased the number of racial groups reported [p <0.001]. CONCLUSIONS Half of published randomised controlled trials in Crohn's disease contain no racial or ethnic demographics, and the remaining often only have limited inclusion of Black, Native American/Pacific Islander, and Hispanic patients. Further work should characterise representation in observational and prospective trials. Researchers should work to: 1] increase reporting of racial and ethnic demographics; and 2] improve recruitment and retention of marginalised populations.
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Affiliation(s)
- Matt Pelton
- Department of Internal Medicine, Rutgers Robert Wood Johnson Medical School, New Brunswick, New Jersey, USA
| | - Paddy Ssentongo
- Department of Internal Medicine, Penn State College of Medicine, Hershey, Pennsylvania, USA
| | - Ashley Sun
- Penn State College of Medicine, Hershey, Pennsylvania, USA
| | - Destin Groff
- Penn State College of Medicine, Hershey, Pennsylvania, USA
| | - Shannon Dalessio
- Department of Gastroenterology, Penn State College of Medicine, Hershey, Pennsylvania, USA
| | - Kofi Clarke
- Department of Gastroenterology, Penn State College of Medicine, Hershey, Pennsylvania, USA
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Long C, Williams AO, McGovern AM, Jacobsen CM, Hargens LM, Duval S, Jaff MR. Diversity in randomized clinical trials for peripheral artery disease: a systematic review. Int J Equity Health 2024; 23:29. [PMID: 38350973 PMCID: PMC10865563 DOI: 10.1186/s12939-024-02104-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2023] [Accepted: 01/13/2024] [Indexed: 02/15/2024] Open
Abstract
BACKGROUND Significant race and sex disparities exist in the prevalence, diagnosis, and outcomes of peripheral artery disease (PAD). However, clinical trials evaluating treatments for PAD often lack representative patient populations. This systematic review aims to summarize the demographic representation and enrollment strategies in clinical trials of lower-extremity endovascular interventions for PAD. METHODS Following the 2020 Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, we searched multiple sources (Medline, EMBASE, Cochrane, Clinicaltrials.gov, WHO clinical trial registry) for randomized controlled trials (RCTs), RCT protocols, and peer-reviewed journal publications of RCTs conducted between January 2012 and December 2022. Descriptive analysis was used to summarize trial characteristics, publication or study protocol characteristics, and the reporting of demographic characteristics. Meta-regression was used to explore associations between demographic characteristics and certain trial characteristics. RESULTS A total of 2,374 records were identified. Of these, 59 met the inclusion criteria, consisting of 35 trials, 14 publications, and 10 protocols. Information regarding demographic representation was frequently missing. While all 14 trial publications reported age and sex, only 4 reported race/ethnicity, and none reported socioeconomic or marital status. Additionally, only 4 publications reported clinical outcomes by demographic characteristics. Meta-regression analysis revealed that 6% more women were enrolled in non-European trials (36%) than in European trials (30%). CONCLUSIONS The findings of this review highlight potential issues that may compromise the reliability and external validity of study findings in lower-extremity PAD RCTs when applied to the real-world population. Addressing these issues is crucial to enhance the generalizability and impact of clinical trial results in the field of PAD, ultimately leading to improved clinical outcomes for patients in underrepresented populations. REGISTRATION The systematic review methodology was published in the International Prospective Register of Systematic Reviews (PROSPERO: CRD42022378304).
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Affiliation(s)
- Chandler Long
- Duke Vascular and Endovascular Surgery, Duke University Medical Center, Duke University, Durham, NC, 27707, USA
| | - Abimbola O Williams
- Health Economics & Market Access, Boston Scientific, Marlborough, MA, 01752, USA.
| | - Alysha M McGovern
- Health Economics & Market Access, Boston Scientific, Marlborough, MA, 01752, USA
| | - Caroline M Jacobsen
- Health Economics & Market Access, Boston Scientific, Marlborough, MA, 01752, USA
| | - Liesl M Hargens
- Health Economics & Market Access, Boston Scientific, Marlborough, MA, 01752, USA
| | - Sue Duval
- Health Economics & Market Access, Boston Scientific, Marlborough, MA, 01752, USA
- Division of Cardiology, Department of Medicine, University of Minnesota, Minneapolis, MN, 55455, USA
| | - Michael R Jaff
- Health Economics & Market Access, Boston Scientific, Marlborough, MA, 01752, USA
- Peripheral Interventions, Boston Scientific, Maple Grove, MN, 55133, USA
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Rao BR, Dickert NW, Morris AA. Ethical Complexity of Medical Treatment Affordability and Clinical Trial Diversity in Heart Failure. Circ Cardiovasc Qual Outcomes 2024; 17:e010227. [PMID: 38377226 DOI: 10.1161/circoutcomes.123.010227] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/22/2024]
Affiliation(s)
- Birju R Rao
- Division of Cardiology, Emory University School of Medicine, Atlanta, GA (B.R.R., N.W.D., A.A.M.)
| | - Neal W Dickert
- Division of Cardiology, Emory University School of Medicine, Atlanta, GA (B.R.R., N.W.D., A.A.M.)
- Department of Epidemiology, Emory University Rollins School of Public Health, Atlanta, GA (N.W.D.)
| | - Alanna A Morris
- Division of Cardiology, Emory University School of Medicine, Atlanta, GA (B.R.R., N.W.D., A.A.M.)
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Clavel MA, Van Spall HG, Mantella LE, Foulds H, Randhawa V, Parry M, Liblik K, Kirkham AA, Cotie L, Jaffer S, Bruneau J, Colella TJ, Ahmed S, Dhukai A, Gomes Z, Adreak N, Keeping-Burke L, Limbachia J, Liu S, Jacques KE, Mullen KA, Mulvagh SL, Norris CM. The Canadian Women's Heart Health Alliance ATLAS on the Epidemiology, Diagnosis, and Management of Cardiovascular Disease in Women - Chapter 8: Knowledge Gaps and Status of Existing Research Programs in Canada. CJC Open 2024; 6:220-257. [PMID: 38487042 PMCID: PMC10935691 DOI: 10.1016/j.cjco.2023.11.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2023] [Accepted: 11/14/2023] [Indexed: 03/17/2024] Open
Abstract
Despite significant progress in medical research and public health efforts, gaps in knowledge of women's heart health remain across epidemiology, presentation, management, outcomes, education, research, and publications. Historically, heart disease was viewed primarily as a condition in men and male individuals, leading to limited understanding of the unique risks and symptoms that women experience. These knowledge gaps are particularly problematic because globally heart disease is the leading cause of death for women. Until recently, sex and gender have not been addressed in cardiovascular research, including in preclinical and clinical research. Recruitment was often limited to male participants and individuals identifying as men, and data analysis according to sex or gender was not conducted, leading to a lack of data on how treatments and interventions might affect female patients and individuals who identify as women differently. This lack of data has led to suboptimal treatment and limitations in our understanding of the underlying mechanisms of heart disease in women, and is directly related to limited awareness and knowledge gaps in professional training and public education. Women are often unaware of their risk factors for heart disease or symptoms they might experience, leading to delays in diagnosis and treatments. Additionally, health care providers might not receive adequate training to diagnose and treat heart disease in women, leading to misdiagnosis or undertreatment. Addressing these knowledge gaps requires a multipronged approach, including education and policy change, built on evidence-based research. In this chapter we review the current state of existing cardiovascular research in Canada with a specific focus on women.
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Affiliation(s)
- Marie-Annick Clavel
- Institut Universitaire de Cardiologie et de Pneumologie de Québec, Université Laval, Québec, Québec, Canada
| | - Harriette G.C. Van Spall
- Department of Medicine, Department of Health Research Methods, Evidence, and Impact, McMaster University, Toronto, Ontario, Canada
| | - Laura E. Mantella
- Department of Biomedical and Molecular Sciences, Queen’s University, Kingston, Ontario, Canada
| | - Heather Foulds
- College of Kinesiology, University of Saskatchewan, Saskatoon, Saskatchewan, Canada
| | - Varinder Randhawa
- Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada
| | - Monica Parry
- Lawrence S. Bloomberg Faculty of Nursing, University of Toronto, Toronto, Ontario, Canada
| | - Kiera Liblik
- Department of Medicine, Kingston Health Science Center, Kingston, Ontario, Canada
| | - Amy A. Kirkham
- Faculty of Kinesiology and Physical Education, University of Toronto, Toronto, Ontario, Canada
- Toronto Rehabilitation Institute (KITE), University Health Network, Toronto, Ontario, Canada
| | - Lisa Cotie
- Toronto Rehabilitation Institute (KITE), University Health Network, Toronto, Ontario, Canada
| | - Shahin Jaffer
- General Internal Medicine, University of British Columbia, Vancouver, British Columbia, Canada
| | - Jill Bruneau
- Faculty of Nursing, Memorial University of Newfoundland and Labrador, St John, Newfoundland and Labrador, Canada
| | - Tracey J.F. Colella
- Toronto Rehabilitation Institute (KITE), University Health Network, Toronto, Ontario, Canada
| | - Sofia Ahmed
- Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Abida Dhukai
- Lawrence S. Bloomberg Faculty of Nursing, University of Toronto, Toronto, Ontario, Canada
| | - Zoya Gomes
- Faculty of Medicine, Division of Cardiology, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Najah Adreak
- Department of Surgery, University of British Columbia, Vancouver, British Columbia, Canada
| | - Lisa Keeping-Burke
- Department of Nursing and Health Sciences, University of New Brunswick, Saint John, New Brunswick, Canada
| | - Jayneel Limbachia
- Schulich School of Medicine, Western University, London, Ontario, Canada
| | - Shuangbo Liu
- Section of Cardiology, Department of Medicine, Max Rady College of Medicine, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Karen E. Jacques
- Person with lived experience, Canadian Women’s Heart Health Alliance, Ottawa, Ontario, Canada
| | - Kerri A. Mullen
- University of Ottawa Heart Institute, Ottawa, Ontario, Canada
| | - Sharon L. Mulvagh
- Faculty of Medicine, Division of Cardiology, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Colleen M. Norris
- Faculty of Nursing, University of Alberta, Edmonton, Alberta, Canada
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13
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Yogeswaran V, Hidano D, Diaz AE, Van Spall HGC, Mamas MA, Roth GA, Cheng RK. Regional variations in heart failure: a global perspective. Heart 2023; 110:11-18. [PMID: 37353316 DOI: 10.1136/heartjnl-2022-321295] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/27/2022] [Accepted: 06/06/2023] [Indexed: 06/25/2023] Open
Abstract
Heart failure (HF) is a global public health concern that affects millions of people worldwide. While there have been significant therapeutic advancements in HF over the last few decades, there remain major disparities in risk factors, treatment patterns and outcomes across race, ethnicity, socioeconomic status, country and region. Recent research has provided insight into many of these disparities, but there remain large gaps in our understanding of worldwide variations in HF care. Although the majority of the global population resides across Asia, Africa and South America, these regions remain poorly represented in epidemiological studies and HF trials. Recent efforts and registries have provided insight into the clinical profiles and outcomes across HF patterns globally. The prevalence of HF and associated risk factors has been reported and varies by country and region ranges, with minimal data on regional variations in treatment patterns and long-term outcomes. It is critical to improve our understanding of the different factors that contribute to global disparities in HF care so we can build interventions that improve our general cardiovascular health and mitigate the social and economic cost of HF. In this narrative review, we hope to provide an overview of the global and regional variations in HF care and outcomes.
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Affiliation(s)
| | - Danelle Hidano
- Division of Cardiology, University of Washington, Seattle, Washington, USA
| | - Andrea E Diaz
- Department of Medicine, University of Washington, Seattle, Washington, USA
| | - Harriette G C Van Spall
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada
| | - Mamas A Mamas
- Keele Cardiovascular Research Group, Keele University, Newcastle, UK
| | - Gregory A Roth
- Division of Cardiology, University of Washington, Seattle, Washington, USA
| | - Richard K Cheng
- Division of Cardiology, University of Washington, Seattle, Washington, USA
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14
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Amin K, Bethel G, Jackson LR, Essien UR, Sloan CE. Eliminating Health Disparities in Atrial Fibrillation, Heart Failure, and Dyslipidemia: A Path Toward Achieving Pharmacoequity. Curr Atheroscler Rep 2023; 25:1113-1127. [PMID: 38108997 PMCID: PMC11044811 DOI: 10.1007/s11883-023-01180-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/25/2023] [Indexed: 12/19/2023]
Abstract
PURPOSE OF REVIEW Pharmacoequity refers to the goal of ensuring that all patients have access to high-quality medications, regardless of their race, ethnicity, gender, or other characteristics. The goal of this article is to review current evidence on disparities in access to cardiovascular drug therapies across sociodemographic subgroups, with a focus on heart failure, atrial fibrillation, and dyslipidemia. RECENT FINDINGS Considerable and consistent disparities to life-prolonging heart failure, atrial fibrillation, and dyslipidemia medications exist in clinical trial representation, access to specialist care, prescription of guideline-based therapy, drug affordability, and pharmacy accessibility across racial, ethnic, gender, and other sociodemographic subgroups. Researchers, health systems, and policy makers can take steps to improve pharmacoequity by diversifying clinical trial enrollment, increasing access to inpatient and outpatient cardiology care, nudging clinicians to increase prescription of guideline-directed medical therapy, and pursuing system-level reforms to improve drug access and affordability.
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Affiliation(s)
- Krunal Amin
- Department of Medicine, Duke University School of Medicine, Durham, NC, USA
| | - Garrett Bethel
- Department of Medicine, Duke University School of Medicine, Durham, NC, USA
| | - Larry R Jackson
- Department of Medicine, Duke University School of Medicine, Durham, NC, USA
- Duke Clinical Research Institute, Durham, NC, USA
| | - Utibe R Essien
- Department of Medicine, David Geffen School of Medicine at the University of California, Los Angeles, CA, USA
- Division of General Internal Medicine and Health Services Research, David Geffen School of Medicine at the University of California, Los Angeles, CA, USA
- Center for the Study of Healthcare Innovation, Implementation & Policy, Greater Los Angeles VA Healthcare System, Los Angeles, CA, USA
| | - Caroline E Sloan
- Department of Medicine, Duke University School of Medicine, Durham, NC, USA.
- Department of Population Health Sciences, Duke University School of Medicine, Durham, NC, USA.
- Duke-Margolis Center for Health Policy, Duke University, Durham, NC, USA.
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15
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Vo AK, Cerdeña JP, Loree JM, Cairns BE, Conklin AI, Kaseweter K, Chondoma L, Cragg JJ, Kramer JLK. Race-based reporting and participation of Black individuals in registered pain clinical trials, United States, 2000 to 2019. Pain 2023; 164:1976-1984. [PMID: 37068160 DOI: 10.1097/j.pain.0000000000002893] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2022] [Accepted: 01/10/2023] [Indexed: 04/19/2023]
Abstract
ABSTRACT There are numerous, well-established racial disparities in the management of pain. The degree to which these are evident at the stage of conducting clinical trials is unknown. To address this knowledge gap, we examined race-based reporting, participation of Black individuals, and the factors associated with reporting and participation in pain clinical trials in the United States. Data were extracted from Clinicaltrials.gov and published articles. One thousand two hundred trials met our inclusion criteria; 482 (40.2%) reported participant race. More recent, publicly funded, and larger trials were more likely to report race. Of 82,468 participants included in pain clinical trials that reported race, 15,101 were Black individuals (18.3%). Participation of Black individuals was significantly associated with pain type (ß = +27% in cardiovascular disease pain compared with acute pain, P < 0.05), study population (ß = +33% and +7% in pain in minoritized populations and women, respectively, compared with general population, P < 0.05), pain intervention (ß = +7.5% for trials of opioid interventions compared with nonopioid interventions, P < 0.05), and a diverse team of investigators (ß = +8.0% for studies incorporating a visible non-White investigator compared with those that did not, P < 0.05). Our results indicate that representation of Black participants in pain clinical trials generally aligns with national demographics in the United States. Increased representation corresponds with health conditions more prevalent among Black individuals (eg, cardiovascular disease) and with a diverse study team composition. Despite these encouraging results, less than half of pain trials reported race, which introduces potential publication bias and limits external validity.
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Affiliation(s)
- Anh Khoa Vo
- Facutly of Pharmaceutical Sciences, University of British Columbia, Vancouver, BC, Canada
- International Collaboration on Repair Discoveries (ICORD), University of British Columbia, Vancouver, BC, Canada
| | - Jessica P Cerdeña
- Yale School of Medicine, Yale University, New Haven, CT, United States
| | | | - Brian E Cairns
- Facutly of Pharmaceutical Sciences, University of British Columbia, Vancouver, BC, Canada
| | - Annalijn I Conklin
- Facutly of Pharmaceutical Sciences, University of British Columbia, Vancouver, BC, Canada
- Centre for Health Evaluation and Outcome Sciences, Providence Health Care Research Institute, St. Paul's Hospital, Vancouver, BC, Canada
| | - Kimberley Kaseweter
- Bill Nelems Pain Research Centre, University of British Columbia, Okanagan Campus, Kelowna, BC, Canada
| | - Lerato Chondoma
- Indigenous Research Support Initiative, VP Research and Innovation, University of British Columbia, Vancouver, BC, Canada
| | - Jacquelyn J Cragg
- Facutly of Pharmaceutical Sciences, University of British Columbia, Vancouver, BC, Canada
- International Collaboration on Repair Discoveries (ICORD), University of British Columbia, Vancouver, BC, Canada
| | - John L K Kramer
- Department of Anesthesiology, Pharmacology, and Therapeutics, Faculty of Medicine, University of British Columbia, Vancouver, BC, Canada
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16
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Hill L, Baruah R, Beattie JM, Bistola V, Castiello T, Celutkienė J, Di Stolfo G, Geller TP, Lambrinou E, Mindham R, McIlfatrick S, Strömberg A, Jaarsma T. Culture, ethnicity, and socio-economic status as determinants of the management of patients with advanced heart failure who need palliative care: A clinical consensus statement from the Heart Failure Association (HFA) of the ESC, the ESC Patient Forum, and the European Association of Palliative Care. Eur J Heart Fail 2023; 25:1481-1492. [PMID: 37477052 DOI: 10.1002/ejhf.2973] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/13/2022] [Revised: 06/29/2023] [Accepted: 07/09/2023] [Indexed: 07/22/2023] Open
Abstract
The delivery of effective healthcare entails the configuration and resourcing of health economies to address the burden of disease, including acute and chronic heart failure, that affects local populations. Increasing migration is leading to more multicultural and ethnically diverse societies worldwide, with migration research suggesting that minority populations are often subject to discrimination, socio-economic disadvantage, and inequity of access to optimal clinical support. Within these contexts, the provision of person-centred care requires medical and nursing staff to be aware of and become adept in navigating the nuances of cultural diversity, and how that can impact some individuals and families entrusted to their care. This paper will examine current evidence, provide practical guidance, and signpost professionals on developing cultural competence within the setting of patients with advanced heart failure who may benefit from palliative care.
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Affiliation(s)
- Loreena Hill
- School of Nursing and Midwifery, Queen's University Belfast, Belfast, UK
- College of Nursing and Midwifery, Mohammed Bin Rashid University, Dubai, United Arab Emirates
| | - Resham Baruah
- Chelsea and Westminster NHS Foundation Trust, London, UK
| | - James M Beattie
- Cicely Saunders Institute, King's College London, London, UK
| | - Vasiliki Bistola
- National and Kapodistrian University of Athens, Department of Cardiology, Heart Failure Unit, Attikon University Hospital, Athens, Greece
| | - Teresa Castiello
- Department of Cardiovascular Imaging, King's College London, Croydon Health Service London, London, UK
| | - Jelena Celutkienė
- Clinic of Cardiac and Vascular Diseases, Institute of Clinical Medicine, Faculty of Medicine, Vilnius University, Vilnius, Lithuania
| | - Giuseppe Di Stolfo
- Cardiovascular Department, Fondazione IRCCS Casa Sollievo della Sofferenza, San Giovanni Rotondo, Italy
| | - Tal Prager Geller
- Palliative care centre DOROT medical centre Netanya, Netanya, Israel
| | | | - Richard Mindham
- United Kingdom European Society of Cardiology Patient Forum, Sophia Antipolis, France
| | - Sonja McIlfatrick
- Institute of Nursing and Health Research, Ulster University, Belfast, UK
| | - Anna Strömberg
- Department of Health, Medicine and Health Sciences, Linköping University, Linköping, Sweden
- Department of Cardiology, Linköping University, Linköping, Sweden
| | - Tiny Jaarsma
- Department of Health, Medicine and Health Sciences, Linköping University, Linköping, Sweden
- Julius Center, University Medical Center Utrecht, Utrecht, The Netherlands
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17
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Reddy KP, Faggioni M, Eberly LA, Halaby R, Sanghavi M, Lewey J, Mehran R, Coylewright M, Herrmann HC, Giri J, Fanaroff AC, Nathan AS. Enrollment of Older Patients, Women, and Racial and Ethnic Minority Individuals in Valvular Heart Disease Clinical Trials: A Systematic Review. JAMA Cardiol 2023; 8:871-878. [PMID: 37494015 DOI: 10.1001/jamacardio.2023.2098] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 07/27/2023]
Abstract
Importance Inadequate representation of older patients, women, and racial minority individuals in cardiovascular clinical trials limits both the generalizability of trial findings and inclusivity in access to novel therapies and therapeutic strategies. Objective To report on temporal trends in the representation of older patients, women, and racial and ethnic minority individuals in clinical trials studying treatments for valvular heart disease. Evidence Review All published clinical trials enrolling more than 100 adults with any valvular heart disease published between 2005 and 2020 were included after searches with PubMed and ClinicalTrials.gov. Data on age, sex, race, and ethnicity reported in the included studies were collected. Trials were assigned to 4 time periods based on the publication date, and temporal trends were analyzed in the representation of older patients, women, and racial and ethnic minority individuals. Findings A total of 139 clinical trials with 51 527 participants were identified. Of these trials, 103 (74%) investigated aortic valve disease and the remainder mitral valve disease. Overall, 63 trials (45.3%) enrolled patients only in Europe, 24 (17.3%) only in North America, and 19 (13.7%) in multiple geographical regions. The weighted mean (SD) age of enrolled patients was 68.4 (11.4) years, increasing nonsignificantly from 61.9 (5.9) years in 2005-2008 to 72.8 (9.6) years in 2017-2020 (P = .09 for trend). The overall proportion of women enrolled in valvular heart disease trials was 41.1%, with no significant changes over time. Data on race and ethnicity of trial participants were reported in 13 trials (9.4%), in which trial-level representation of American Indian/Alaska Native, Asian, Black/African American, Hispanic, and Native Hawaiian/Pacific Islander patients ranged from 0.27% to 43.9%. There were no significant temporal trends noted in the enrollment of racial and ethnic minority populations. The representation of women in clinical trials was positively associated with enrollment rates of older patients and underrepresented racial and ethnic groups. Conclusions and Relevance This review found that over the past 2 decades, women and racial and ethnic minority individuals have remained underrepresented in North American valvular heart disease clinical trials. Further work is needed to improve the reporting of race and ethnicity data and address barriers to trial enrollment for older patients, women, and racial and ethnic minority individuals.
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Affiliation(s)
- Kriyana P Reddy
- Penn Cardiovascular Outcomes, Quality, and Evaluative Research Center, University of Pennsylvania, Philadelphia
| | - Michela Faggioni
- Division of Cardiology, Hospital of the University of Pennsylvania, Philadelphia
| | - Lauren A Eberly
- Penn Cardiovascular Outcomes, Quality, and Evaluative Research Center, University of Pennsylvania, Philadelphia
- Division of Cardiology, Hospital of the University of Pennsylvania, Philadelphia
| | - Rim Halaby
- Division of Cardiology, Hospital of the University of Pennsylvania, Philadelphia
| | - Monika Sanghavi
- Division of Cardiology, Hospital of the University of Pennsylvania, Philadelphia
| | - Jennifer Lewey
- Division of Cardiology, Hospital of the University of Pennsylvania, Philadelphia
| | - Roxana Mehran
- Icahn School of Medicine at Mount Sinai, New York, New York
- Associate Editor, JAMA Cardiology
| | | | - Howard C Herrmann
- Division of Cardiology, Hospital of the University of Pennsylvania, Philadelphia
| | - Jay Giri
- Penn Cardiovascular Outcomes, Quality, and Evaluative Research Center, University of Pennsylvania, Philadelphia
- Division of Cardiology, Hospital of the University of Pennsylvania, Philadelphia
- Corporal Michael J. Crescenz VA Medical Center, Philadelphia, Pennsylvania
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Alexander C Fanaroff
- Penn Cardiovascular Outcomes, Quality, and Evaluative Research Center, University of Pennsylvania, Philadelphia
- Division of Cardiology, Hospital of the University of Pennsylvania, Philadelphia
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Ashwin S Nathan
- Penn Cardiovascular Outcomes, Quality, and Evaluative Research Center, University of Pennsylvania, Philadelphia
- Division of Cardiology, Hospital of the University of Pennsylvania, Philadelphia
- Corporal Michael J. Crescenz VA Medical Center, Philadelphia, Pennsylvania
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, Pennsylvania
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18
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Jalloh MB, Averbuch T, Kulkarni P, Granger CB, Januzzi JL, Zannad F, Yeh RW, Yancy CW, Fonarow GC, Breathett K, Gibson CM, Van Spall HGC. Bridging Treatment Implementation Gaps in Patients With Heart Failure: JACC Focus Seminar 2/3. J Am Coll Cardiol 2023; 82:544-558. [PMID: 37532425 PMCID: PMC10614026 DOI: 10.1016/j.jacc.2023.05.050] [Citation(s) in RCA: 10] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/11/2023] [Revised: 05/19/2023] [Accepted: 05/25/2023] [Indexed: 08/04/2023]
Abstract
Heart failure (HF) is a leading cause of death and disability in older adults. Despite decades of high-quality evidence to support their use, guideline-directed medical therapies (GDMTs) that reduce death and disease burden in HF have been suboptimally implemented. Approaches to closing care gaps have focused largely on strategies proven to be ineffective, whilst effective interventions shown to improve GDMT uptake have not been instituted. This review synthesizes implementation interventions that increase the uptake of GDMT, discusses barriers and facilitators of implementation, summarizes conceptual frameworks in implementation science that could improve knowledge uptake, and offers suggestions for trial design that could better facilitate end-of-trial implementation. We propose an evidence-to-care conceptual model that could foster the simultaneous generation of evidence and long-term implementation. By adopting principles of implementation science, policymakers, researchers, and clinicians can help reduce the burden of HF on patients and health care systems worldwide.
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Affiliation(s)
- Mohamed B Jalloh
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Tauben Averbuch
- Department of Cardiology, University of Calgary, Calgary Alberta, Canada
| | | | - Christopher B Granger
- Division of Cardiology, Duke University School of Medicine, Durham, North Carolina, USA
| | - James L Januzzi
- Baim Institute for Clinical Research, Boston, Massachusetts, USA; Cardiology Division, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Faiez Zannad
- Université de Lorraine, INSERM and Centre Hospitalier Régional Universitaire, Nancy, France
| | - Robert W Yeh
- Baim Institute for Clinical Research, Boston, Massachusetts, USA; Smith Center for Outcomes Research, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
| | - Clyde W Yancy
- Baim Institute for Clinical Research, Boston, Massachusetts, USA; Northwestern University, Feinberg School of Medicine, Chicago, Illinois, USA
| | - Gregg C Fonarow
- Ahmanson-UCLA Cardiomyopathy Center, David Geffen School of Medicine, University of California-Los Angeles, Los Angeles, California, USA
| | - Khadijah Breathett
- Division of Cardiovascular Medicine, Indiana University, Indianapolis, Indiana, USA
| | - C Michael Gibson
- Baim Institute for Clinical Research, Boston, Massachusetts, USA
| | - Harriette G C Van Spall
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada; Baim Institute for Clinical Research, Boston, Massachusetts, USA; Research Institute of St Joseph's, Hamilton, Ontario, Canada; Population Health Research Institute, Hamilton, Ontario, Canada.
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19
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Marrie RA, Chataway J, Bierer BE, Finlayson M, Martinez-Lapiscina EH, Panagoulias J, Sormani MP, Williams MJ, Amezcua L. Enhancing diversity of clinical trial populations in multiple sclerosis. Mult Scler 2023; 29:1174-1185. [PMID: 37555490 PMCID: PMC10413791 DOI: 10.1177/13524585231189677] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2023] [Revised: 04/19/2023] [Accepted: 05/02/2023] [Indexed: 08/10/2023]
Abstract
BACKGROUND Demographic characteristics, social determinants of health (SDoH), health inequities, and health disparities substantially influence the general and disease-specific health outcomes of people with multiple sclerosis (MS). Participants in clinical trials do not represent all people with MS treated in practice. OBJECTIVE To provide recommendations for enhancing diversity and inclusion in clinical trials in MS. METHODS We held an international workshop under the Auspices of the International Advisory Committee on Clinical Trials in MS (the "Committee") to develop recommendations regarding diversity and inclusivity of participants of clinical trials in MS. Workshop attendees included members of the Committee as well as external participants. External participants were selected based on expertise in trials, SDoH, health equity and regulatory science, and diversity with respect to gender, race, ethnicity, and geography. RESULTS Recommendations include use of diversity plans, community engagement and education, cultural competency training, biologically justified rather than templated eligibility criteria, adaptive designs that allow broadening of eligibility criteria over the course of a trial, and logistical and practical adjustments to reduce study participant burden. Investigators should report demographic and SDoH characteristics of participants. CONCLUSION These recommendations provide sponsors and investigators with methods of improving diversity and inclusivity of clinical trial populations in MS.
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Affiliation(s)
- Ruth Ann Marrie
- Departments of Internal Medicine and Community Health Sciences, Max Rady College of Medicine, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, MB, Canada
| | - Jeremy Chataway
- Queen Square Multiple Sclerosis Centre, Department of Neuroinflammation, UCL Queen Square Institute of Neurology, Faculty of Brain Sciences, University College London, London, UK/National Institute for Health Research, University College London Hospitals, Biomedical Research Centre, London, UK/Medical Research Council Clinical Trials Unit at UCL, Institute of Clinical Trials and Methodology, University College London, London, UK
| | - Barbara E Bierer
- The Multi-Regional Clinical Trials Center of Brigham and Women’s Hospital and Harvard, Cambridge, MA, USA/Harvard Medical School, Boston, MA, USA
| | - Marcia Finlayson
- School of Rehabilitation Therapy, Faculty of Health Sciences, Queen’s University, Kingston, ON, Canada
| | - Elena H Martinez-Lapiscina
- Center of Neuroimmunology, Laboratory of Advanced Imaging in Neuroimmunological Diseases, Hospital Clinic Barcelona, Institut d’Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Universitat de Barcelona, Barcelona, Spain/Office of Therapies for Neurological and Psychiatric Disorders, Human Medicines Division, European Medicines Agency, Amsterdam, The Netherlands
| | | | | | | | - Lilyana Amezcua
- Department of Neurology, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
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20
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Gupta P, Sandy LC, Glorioso TJ, Khanna A, Khazanie P, Allen LA, Peterson PN, Bull S, Ho PJM. Secondary analysis of electronic opt-out consent in pragmatic research: A study design method to diversify clinical trials? Am Heart J 2023; 261:104-108. [PMID: 36966921 DOI: 10.1016/j.ahj.2023.03.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/17/2023] [Revised: 03/06/2023] [Accepted: 03/22/2023] [Indexed: 05/26/2023]
Abstract
We conducted a multi-center pragmatic trial of a low-risk intervention focused on medication adherence using an opt-out consent approach, where patients could opt out by letter and then electronically. We focus on the cohort after opt-out by mail. Here, we describe that 8% of patients opted out electronically, resulting in a 92% participation rate. Patients who self-identify as Black or Hispanic were less likely to opt out in the study, and half the study cohort was female. This demographic data is useful for planning future trials employing this approach.
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Affiliation(s)
- Prerna Gupta
- Anschutz Medical Center, Division of Cardiology, University of Colorado, Aurora, CO.
| | - Lisa C Sandy
- Anschutz Medical Center, Division of General Internal Medicine, University of Colorado, Aurora, CO
| | - Thomas J Glorioso
- Rocky Mountain Regional Veteran Affairs Medical Center, Cardiology Section, Aurora, CO
| | - Amber Khanna
- Anschutz Medical Center, Division of Cardiology, University of Colorado, Aurora, CO
| | - Prateeti Khazanie
- Anschutz Medical Center, Division of Cardiology, University of Colorado, Aurora, CO
| | - Larry A Allen
- Anschutz Medical Center, Division of Cardiology, University of Colorado, Aurora, CO
| | - Pamela N Peterson
- Anschutz Medical Center, Division of Cardiology, University of Colorado, Aurora, CO; Department of Cardiology, Denver Health, Denver, CO
| | - Sheana Bull
- Colorado School of Public Health, Aurora, CO
| | - Pei Jai Michael Ho
- Anschutz Medical Center, Division of Cardiology, University of Colorado, Aurora, CO; Rocky Mountain Regional Veteran Affairs Medical Center, Cardiology Section, Aurora, CO
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21
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Filbey L, Zhu JW, D'Angelo F, Thabane L, Khan MS, Lewis E, Patel MR, Powell-Wiley T, Miranda JJ, Zuhlke L, Butler J, Zannad F, Van Spall HGC. Improving representativeness in trials: a call to action from the Global Cardiovascular Clinical Trialists Forum. Eur Heart J 2023; 44:921-930. [PMID: 36702610 DOI: 10.1093/eurheartj/ehac810] [Citation(s) in RCA: 18] [Impact Index Per Article: 18.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/29/2022] [Revised: 11/24/2022] [Accepted: 12/20/2022] [Indexed: 01/28/2023] Open
Abstract
Participants enrolled in cardiovascular disease (CVD) randomized controlled trials are not often representative of the population living with the disease. Older adults, children, women, Black, Indigenous and People of Color, and people living in low- and middle-income countries are typically under-enrolled in trials relative to disease distribution. Treatment effect estimates of CVD therapies have been largely derived from trial evidence generated in White men without complex comorbidities, limiting the generalizability of evidence. This review highlights barriers and facilitators of trial enrollment, temporal trends, and the rationale for representativeness. It proposes strategies to increase representativeness in CVD trials, including trial designs that minimize the research burden on participants, inclusive recruitment practices and eligibility criteria, diversification of clinical trial leadership, and research capacity-building in under-represented regions. Implementation of such strategies could generate better and more generalizable evidence to reduce knowledge gaps and position the cardiovascular trial enterprise as a vehicle to counter existing healthcare inequalities.
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Affiliation(s)
- Lynaea Filbey
- Department of Medicine, McMaster University, 20 Copeland Avenue, David Braley Research Building, Suite C3-117, Hamilton, ON L8L 0A3, Canada
| | - Jie Wei Zhu
- Department of Medicine, McMaster University, 20 Copeland Avenue, David Braley Research Building, Suite C3-117, Hamilton, ON L8L 0A3, Canada
| | - Francesca D'Angelo
- Department of Medicine, McMaster University, 20 Copeland Avenue, David Braley Research Building, Suite C3-117, Hamilton, ON L8L 0A3, Canada
| | - Lehana Thabane
- Research Institute of St. Josephs, St. Joseph's Healthcare Hamilton, 50 Charlton Ave E, Hamilton, ON L8N 4A6, Canada.,Population Health Research Institute, 237 Barton St E, Hamilton ON L8L 2X2, Canada.,Faculty of Health Sciences, University of Johannesburg, 1 Bunting Road, FADA Building, Johannesburg, Gauteng 2092, South Africa.,Department of Health Research Methods, Evidence, and Impact, McMaster University, 1280 Main St W, McMaster University Medical Centre, 2C Area, Hamilton, ON L8S 4K1, Canada
| | - Muhammad Shahzeb Khan
- Division of Cardiology, Duke Clinical Research Institute, 300 W Morgan Street, Duke University School of Medicine, Durham, NC 27701, USA
| | - Eldrin Lewis
- Cardiovascular Division, Stanford University School of Medicine, 291 Campus Drive, Li Ka Shing Building, Stanford, CA 94305-5101, USA
| | - Manesh R Patel
- Division of Cardiology, Duke Clinical Research Institute, 300 W Morgan Street, Duke University School of Medicine, Durham, NC 27701, USA
| | - Tiffany Powell-Wiley
- Social Determinants of Obesity and Cardiovascular Risk Laboratory, Cardiovascular Branch, Division of Intramural Research, National Heart, Lung, and Blood Institute, National Institutes of Health, 31 Center Drive, Building 31, Bethesda, MD 20892, USA.,Intramural Research Program, National Institute on Minority Health and Health Disparities, National Institutes of Health, 6707 Democracy Boulevard, Suite 800, Bethesda, MD 20892-5465, USA
| | - J Jaime Miranda
- CRONICAS Center of Excellence in Chronic Diseases, Av. Armendariz, 2nd floor, Miraflores 15074, Lima, Peru
| | - Liesl Zuhlke
- South African Medical Research Council and Division of Paediatric Cardiology, University of Cape Town and Red Cross Memorial Children's Hospital, Klipfontein Road, Rondebosch, Cape Town, Western Cape 7700, South Africa
| | - Javed Butler
- Department of Medicine, University of Mississippi Medical Center, 2500 North State Street, Jackson, MS 39216, USA.,Baylor Scott and White Research Insistute, 3434 Live Oak St, Suite 501, Dallas, TX 75204, USA
| | - Faiez Zannad
- Centre d'Investigations Cliniques Plurithématique 1433, Université de Lorraine, 4 rue du Morvan, ILM, ground floor, Vandoeuvre-des-Nancy, Meurthe-et-Moselle 54500, France.,Institut National de la Santé et de la Recherche Médicale 1116, Centre Hospitalier Régional, 18 av Mozart, Marseille, Bouches-du-Rhône 13276, France.,Investigation Network Initiative-Cardiovascular and Renal Clinical Trialists, Universitaire de Nancy, French Clinical Research Infrastructure Network, 4 rue de Morvan, Vandoeuvre-des-Nancy, Meurthe-et-Moselle 54500, France
| | - Harriette G C Van Spall
- Department of Medicine, McMaster University, 20 Copeland Avenue, David Braley Research Building, Suite C3-117, Hamilton, ON L8L 0A3, Canada.,Research Institute of St. Josephs, St. Joseph's Healthcare Hamilton, 50 Charlton Ave E, Hamilton, ON L8N 4A6, Canada.,Population Health Research Institute, 237 Barton St E, Hamilton ON L8L 2X2, Canada.,Department of Health Research Methods, Evidence, and Impact, McMaster University, 1280 Main St W, McMaster University Medical Centre, 2C Area, Hamilton, ON L8S 4K1, Canada
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22
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Rawlley B, Marchina S, Cappucci SP, Gogia B, Wang JY, Stillman A, Kumar S. Investigation on Gender Differences in Leadership of Stroke-Related Clinical Trials. Stroke 2023; 54:295-303. [PMID: 36300372 DOI: 10.1161/strokeaha.122.039173] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
BACKGROUND Gender disparities among principal investigators of clinical trials (CT) can have implications regarding the areas of investigation, methods, conduct, trial enrollment, and interpretation of results. An estimation of the gender gap in the leadership of stroke-related CTs from North America has to date not been undertaken. METHODS We extracted information about stroke-related CTs between 2011 and 2020 from www. CLINICALTRIALS gov and PubMed. We examined the gender distribution according to the academic credentials and the trial type. The gender of PIs and authors was determined using gender package in R, which identifies gender using historical data from the United States. Additionally, we obtained information from Association of American Medical Colleges and the Accreditation Council for Graduate Medical Education data resource books on the gender composition of full-time neurology faculty, neurology residents and vascular neurology fellows. RESULTS In these analyses of 821 CTs registered on Clinicaltrials.gov and 110 trials published on PubMed, we found that gender disparity among the PIs, first and last authors have persisted over the last decade without any significant trend toward parity (P>0.05). On examining the gender distribution according to academic credentials and trial type, we found that men were over-represented in the sub-group of PIs with an MD degree (78.11% versus 21.87%; P<0.01) and those leading acute stroke trials (86.04% versus 13.89%; P<0.01). We also found that a lower proportion of women neurology residents pursued a vascular neurology fellowship during this period (33.5% versus 42.5%; P<0.05). CONCLUSIONS Our results show that the favorable trend toward gender parity seen in Neurology faculty over the last decade has not translated to the same in the leadership of CTs. Our findings merit further investigation and a re-examination of efforts toward inclusion of women as leaders of stroke-related CTs.
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Affiliation(s)
- Bharat Rawlley
- Department of Internal Medicine, State University of New York Upstate Medical University, Syracuse, New York (B.R.)
| | - Sarah Marchina
- Department of Neurology, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, Massachusetts (S.M., S.P.C., B.G., J.-Y.W., A.S., S.K.)
| | - Stefanie P Cappucci
- Department of Neurology, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, Massachusetts (S.M., S.P.C., B.G., J.-Y.W., A.S., S.K.)
| | - Bhanu Gogia
- Department of Neurology, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, Massachusetts (S.M., S.P.C., B.G., J.-Y.W., A.S., S.K.)
| | - Jia-Yi Wang
- Department of Neurology, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, Massachusetts (S.M., S.P.C., B.G., J.-Y.W., A.S., S.K.)
| | - Alexandra Stillman
- Department of Neurology, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, Massachusetts (S.M., S.P.C., B.G., J.-Y.W., A.S., S.K.)
| | - Sandeep Kumar
- Department of Neurology, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, Massachusetts (S.M., S.P.C., B.G., J.-Y.W., A.S., S.K.)
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23
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Mastoris I, DeFilippis EM, Martyn T, Morris AA, Van Spall HG, Sauer AJ, J Sauer A. Remote Patient Monitoring for Patients with Heart Failure: Sex- and Race-based Disparities and Opportunities. Card Fail Rev 2023; 9:e02. [PMID: 36891178 PMCID: PMC9987513 DOI: 10.15420/cfr.2022.22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/22/2022] [Accepted: 09/16/2022] [Indexed: 02/05/2023] Open
Abstract
Remote patient monitoring (RPM), within the larger context of telehealth expansion, has been established as an effective and safe means of care for patients with heart failure (HF) during the recent pandemic. Of the demographic groups, female patients and black patients are underenrolled relative to disease distribution in clinical trials and are under-referred for RPM, including remote haemodynamic monitoring, cardiac implantable electronic devices (CIEDs), wearables and telehealth interventions. The sex- and race-based disparities are multifactorial: stringent clinical trial inclusion criteria, distrust of the medical establishment, poor access to healthcare, socioeconomic inequities, and lack of diversity in clinical trial leadership. Notwithstanding addressing the above factors, RPM has the unique potential to reduce disparities through a combination of implicit bias mitigation and earlier detection and intervention for HF disease progression in disadvantaged groups. This review describes the uptake of remote haemodynamic monitoring, CIEDs and telehealth in female patients and black patients with HF, and discusses aetiologies that may contribute to inequities and strategies to promote health equity.
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Affiliation(s)
- Ioannis Mastoris
- Cardiology Division, Department of Medicine, Massachusetts General Hospital Boston, Massachusetts, US
| | | | - Trejeeve Martyn
- Department of Cardiovascular Medicine, Heart, Vascular, and Thoracic Institute, Kaufman Center for Heart Failure Treatment and Recovery, Cleveland Clinic Ohio, US
| | - Alanna A Morris
- Department of Medicine, Emory University School of Medicine Georgia, US
| | - Harriette Gc Van Spall
- Department of Medicine, Department of Health Research Methods, Evidence and Impact, McMaster University Hamilton, Canada.,Population Health Research Institute and Research Institute of St Joseph's Hamilton, Canada
| | - Andrew J Sauer
- Saint Luke's Mid America Heart Institute and University of Missouri-Kansas City Kansas City, Missouri, US
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24
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Rawlley B, Khan AP, Chopra S, Bansal K, Anamika FNU, Khan AM. Gender differences in first authorship of randomized controlled trials from India. Contemp Clin Trials 2023; 125:107081. [PMID: 36626965 DOI: 10.1016/j.cct.2023.107081] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2022] [Revised: 01/05/2023] [Accepted: 01/05/2023] [Indexed: 01/09/2023]
Abstract
BACKGROUND It has been established that identity of the trial leadership plays a role in the conduct of the trial. An estimation of the gender composition of RCT leadership in India has not been undertaken. We performed this study to quantify the gender composition of first authors of RCTs published from India for the years 2011 to 2020. METHODS PubMed database was searched using the keyword "randomized controlled trial". We included studies that were classified as a RCT, had a first author affiliation that belonged to India and were published online between 1st January 2011 to 31st December 2020. The gender of the first authors was determined using Gender-API and manually. RESULTS Out of the total 4136 RCTs included in our study, the gender of 4056 (98%) first authors were identified. Of the 4056 first authors, 1198 (30%) were women and 2858 (70%) were men. The mean (SD) percentage of yearly distribution of women and men as first authors was 29.53(2.23) and 70.46(2.23), respectively. We did not find any significant change in gender distribution of first authors over the course of ten years [P = 0.78]. CONCLUSION The persistence of gender disparity in the leadership of RCTs from India demands greater efforts towards inclusion of women as leaders of clinical trials.
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Affiliation(s)
- Bharat Rawlley
- Department of Internal Medicine, State University of New York Upstate Medical University, Syracuse, NY, United States of America
| | - Afzal Parvez Khan
- Department of Community Medicine, University College of Medical Sciences and Guru Teg Bahadur Hospital, New Delhi 110095, India
| | - Shrey Chopra
- Department of Community Medicine, University College of Medical Sciences and Guru Teg Bahadur Hospital, New Delhi 110095, India
| | - Kamakshi Bansal
- Department of Community Medicine, University College of Medical Sciences and Guru Teg Bahadur Hospital, New Delhi 110095, India
| | - F N U Anamika
- Department of Community Medicine, University College of Medical Sciences and Guru Teg Bahadur Hospital, New Delhi 110095, India
| | - Amir Maroof Khan
- Department of Community Medicine, University College of Medical Sciences and Guru Teg Bahadur Hospital, New Delhi 110095, India.
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25
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Mentz RJ, Anstrom KJ, Eisenstein EL, Sapp S, Greene SJ, Morgan S, Testani JM, Harrington AH, Sachdev V, Ketema F, Kim DY, Desvigne-Nickens P, Pitt B, Velazquez EJ. Effect of Torsemide vs Furosemide After Discharge on All-Cause Mortality in Patients Hospitalized With Heart Failure: The TRANSFORM-HF Randomized Clinical Trial. JAMA 2023; 329:214-223. [PMID: 36648467 PMCID: PMC9857435 DOI: 10.1001/jama.2022.23924] [Citation(s) in RCA: 65] [Impact Index Per Article: 65.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
Abstract
IMPORTANCE Although furosemide is the most commonly used loop diuretic in patients with heart failure, some studies suggest a potential benefit for torsemide. OBJECTIVE To determine whether torsemide results in decreased mortality compared with furosemide among patients hospitalized for heart failure. DESIGN, SETTING, AND PARTICIPANTS TRANSFORM-HF was an open-label, pragmatic randomized trial that recruited 2859 participants hospitalized with heart failure (regardless of ejection fraction) at 60 hospitals in the United States. Recruitment occurred from June 2018 through March 2022, with follow-up through 30 months for death and 12 months for hospitalizations. The final date for follow-up data collection was July 2022. INTERVENTIONS Loop diuretic strategy of torsemide (n = 1431) or furosemide (n = 1428) with investigator-selected dosage. MAIN OUTCOMES AND MEASURES The primary outcome was all-cause mortality in a time-to-event analysis. There were 5 secondary outcomes with all-cause mortality or all-cause hospitalization and total hospitalizations assessed over 12 months being highest in the hierarchy. The prespecified primary hypothesis was that torsemide would reduce all-cause mortality by 20% compared with furosemide. RESULTS TRANSFORM-HF randomized 2859 participants with a median age of 65 years (IQR, 56-75), 36.9% were women, and 33.9% were Black. Over a median follow-up of 17.4 months, a total of 113 patients (53 [3.7%] in the torsemide group and 60 [4.2%] in the furosemide group) withdrew consent from the trial prior to completion. Death occurred in 373 of 1431 patients (26.1%) in the torsemide group and 374 of 1428 patients (26.2%) in the furosemide group (hazard ratio, 1.02 [95% CI, 0.89-1.18]). Over 12 months following randomization, all-cause mortality or all-cause hospitalization occurred in 677 patients (47.3%) in the torsemide group and 704 patients (49.3%) in the furosemide group (hazard ratio, 0.92 [95% CI, 0.83-1.02]). There were 940 total hospitalizations among 536 participants in the torsemide group and 987 total hospitalizations among 577 participants in the furosemide group (rate ratio, 0.94 [95% CI, 0.84-1.07]). Results were similar across prespecified subgroups, including among patients with reduced, mildly reduced, or preserved ejection fraction. CONCLUSIONS AND RELEVANCE Among patients discharged after hospitalization for heart failure, torsemide compared with furosemide did not result in a significant difference in all-cause mortality over 12 months. However, interpretation of these findings is limited by loss to follow-up and participant crossover and nonadherence. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT03296813.
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Affiliation(s)
- Robert J. Mentz
- Duke Clinical Research Institute, Durham, North Carolina
- Department of Medicine, Division of Cardiology, Duke University School of Medicine, Durham, North Carolina
| | - Kevin J. Anstrom
- Gillings School of Global Public Health, University of North Carolina at Chapel Hill
| | | | - Shelly Sapp
- Duke Clinical Research Institute, Durham, North Carolina
| | - Stephen J. Greene
- Duke Clinical Research Institute, Durham, North Carolina
- Department of Medicine, Division of Cardiology, Duke University School of Medicine, Durham, North Carolina
| | - Shelby Morgan
- Duke Clinical Research Institute, Durham, North Carolina
| | - Jeffrey M. Testani
- Department of Internal Medicine, Section of Cardiovascular Medicine, Yale School of Medicine, New Haven, Connecticut
| | | | - Vandana Sachdev
- Division of Cardiovascular Sciences, National Heart, Lung, and Blood Institute, Bethesda, Maryland
| | - Fassil Ketema
- Division of Cardiovascular Sciences, National Heart, Lung, and Blood Institute, Bethesda, Maryland
| | - Dong-Yun Kim
- Division of Cardiovascular Sciences, National Heart, Lung, and Blood Institute, Bethesda, Maryland
| | - Patrice Desvigne-Nickens
- Division of Cardiovascular Sciences, National Heart, Lung, and Blood Institute, Bethesda, Maryland
| | - Bertram Pitt
- Division of Cardiology, Department of Medicine, University of Michigan, Ann Arbor
| | - Eric J. Velazquez
- Department of Internal Medicine, Section of Cardiovascular Medicine, Yale School of Medicine, New Haven, Connecticut
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26
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Van Spall HGC, Mehran R, Januzzi JL. Dear colleagues: enough with the men-only author panels. Eur Heart J Suppl 2022; 24:L53-L56. [PMID: 36545226 PMCID: PMC9762874 DOI: 10.1093/eurheartjsupp/suac118] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
Graphical Abstract.
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Affiliation(s)
| | - Roxana Mehran
- Icahn School of Medicine, Mount Sinai Hospital, New York, NY, USA
| | - James L Januzzi
- Cardiology Division, Massachusetts General Hospital, Baim Institute for Clinical Research and Harvard Medical School, 55 Fruit Street, Boston, MA 02114, USA
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27
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Social Media and Cardiovascular Health: Implications for Women. Curr Atheroscler Rep 2022; 24:901-913. [PMID: 36441421 PMCID: PMC10017051 DOI: 10.1007/s11883-022-01069-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/03/2022] [Indexed: 11/29/2022]
Abstract
PURPOSE OF REVIEW Cardiovascular disease (CVD) is the leading cause of mortality in adult women in the USA, yet CVD is underrecognized in women. Disparities in care are further pronounced in women of racial/ethnic minority backgrounds. In this review, we discuss the role of social media (SoMe) as a tool to (i) promote women's cardiovascular (CV) health and (ii) address and potentially reduce gaps in care, particularly in general cardiology (targeting atherosclerotic cardiovascular disease), cardio-oncology, and cardio-obstetrics. We also briefly discuss women's CV health as a common, although not unique, focus of women in cardiology on SoMe. RECENT FINDINGS Studies have suggested the utility of social media to help advance subspecialties of cardiology. Leaders within general cardiology, cardio-oncology, and cardio-obstetrics have curated social media strategies to advance their respective fields and call attention to cardiovascular health disparities in female populations and racial/ethnic minorities. In addition to these types of uses, women in cardiology also frequently use SoMe to encourage a career in cardiology and to share experiences, challenges, and resources for support and career advancement as healthcare professionals; men in cardiology and especially those who are allies for sex and racial/ethnic minorities also use SoMe for these means. Herein, we highlight the role and myriad applications of social media in the promotion of women's cardiovascular health. We discuss five primary roles of social media: increasing public awareness, disseminating medical literature in a rapid and accessible fashion, facilitating professional networking, serving as a platform for medical conferences, and empowering patients. These core strategies are discussed through the lens of general cardiology, cardio-oncology, and cardio-obstetrics. We also demonstrate how these applications can be leveraged to increase representation of women in cardiology, also supporting an increased focus on women's cardiovascular health.
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28
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Zhang X, Zhao Y, Zhou Y, Lv J, Peng J, Zhu H, Liu R. Trends in research on sick sinus syndrome: A bibliometric analysis from 2000 to 2022. Front Cardiovasc Med 2022; 9:991503. [DOI: 10.3389/fcvm.2022.991503] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2022] [Accepted: 10/19/2022] [Indexed: 11/11/2022] Open
Abstract
Sick sinus syndrome (SSS) is a refractory arrhythmia disease caused by the pathological changes of sinoatrial node and its adjacent tissues. 2,251 publications related to SSS were retrieved from Web of Science database from 2000 to 2022 and analyzed by using VOS viewer and CiteSpace software. The results showed the United States dominated the field, followed by Japan, Germany, and China. SSS was closely related to risk factors such as atrial fibrillation and aging. Sick sinus syndrome, atrial fibrillation and sinus node dysfunction were the top three keywords that had the strongest correlation with the study. Pacemaker implantation, differentiation and mutation are research hotspots currently. Clinical studies on SSS found that sick sinus syndrome, atrial fibrillation, and pacemakers were the top three keywords that had the largest nodes and the highest frequency. In the field of basic applied research and basic research, atrial fibrillation and pacemaker cells were the focus of research. In conclusion, bibliometric analysis provided valuable information for the prevention, treatment and future research trends of SSS.
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29
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Zhang J, Van Spall HGC, Wang Y, Thabane L, Wang R, Li G. Twenty-year trends in racial and ethnic enrollment in large diabetes randomized controlled trials. BMC Med 2022; 20:294. [PMID: 36109742 PMCID: PMC9479279 DOI: 10.1186/s12916-022-02501-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/15/2022] [Accepted: 07/27/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Lack of representativeness in Black, Indigenous, and People of Colour (BIPOC) enrollment could compromise the generalizability of study results and health equity. This study aimed to examine trends in BIPOC groups enrollment in diabetes randomized controlled trials (RCTs) and to explore the association between trial factors and high-enrollment of BIPOC groups. METHODS We systematically searched the literature on large diabetes RCTs with a sample size of ≥ 400 participants published between 2000 and 2020. We assessed temporal trends in enrollment of racial and ethnic groups in the included trials. Logistic and linear regression analyses were used to explore the relationship between trial factors and the high-enrollment defined by median enrollment rate. RESULTS A total of 405 RCTs were included for analyses. The median enrollment rate of BIPOC groups was 24.0%, with 6.4% for the Black group, 11.2% for Hispanic, 8.5% for Asian, and 3.0% for other BIPOC groups respectively. Over the past 20 years, the BIPOC enrollment showed an increased trend in the diabetes RCTs, ranging from 20.1 to 28.4% (P for trend = 0.041). A significant trend towards increased enrollment for Asian group was observed. We found that weekly or daily intervention frequency (OR = 0.48, 95% CI: 0.26, 0.91) and duration of intervention > 6.5 month (OR = 0.59, 95% CI: 0.37, 0.95) were significantly related to decreased odds of high-enrollment, while type 2 diabetes (OR = 1.44, 95% CI: 1.04, 1.99) was associated with high-enrollment of BIPOC groups. CONCLUSIONS The enrollment of BIPOC was found to increase in large diabetes RCTs over the past two decades; some trial factors may be significantly associated with BIPOC enrollment. These findings may highlight the importance of enrollment of BIPOC groups and provide insights into the design and implementation of future clinical trials in diabetes.
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Affiliation(s)
- Jingyi Zhang
- Center for Clinical Epidemiology and Methodology (CCEM), Guangdong Second Provincial General Hospital, Guangzhou, China
| | - Harriette G C Van Spall
- Department of Health Research Methods, Evidence, and Impact (HEI), McMaster University, Hamilton, ON, Canada.,Department of Medicine, McMaster University, Hamilton, ON, Canada
| | - Yaoyao Wang
- Department of Epidemiology, School of Medicine, Jinan University, Guangzhou, China
| | - Lehana Thabane
- Department of Health Research Methods, Evidence, and Impact (HEI), McMaster University, Hamilton, ON, Canada.,St Joseph's Healthcare Hamilton, ON, Hamilton, Canada.,Faculty of Health Sciences, University of Johannesburg, Johannesburg, South Africa
| | - Ruoting Wang
- Center for Clinical Epidemiology and Methodology (CCEM), Guangdong Second Provincial General Hospital, Guangzhou, China
| | - Guowei Li
- Center for Clinical Epidemiology and Methodology (CCEM), Guangdong Second Provincial General Hospital, Guangzhou, China. .,Department of Health Research Methods, Evidence, and Impact (HEI), McMaster University, Hamilton, ON, Canada.
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30
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Li G, Zhang J, Van Spall HGC, Douglas PS, Wang Y, Sun X, Thabane L. Exploring ethnic representativeness in diabetes clinical trial enrolment from 2000 to 2020: a chronological survey. Diabetologia 2022; 65:1461-1472. [PMID: 35705796 PMCID: PMC9200441 DOI: 10.1007/s00125-022-05736-z] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/12/2021] [Accepted: 04/07/2022] [Indexed: 02/05/2023]
Abstract
AIMS/HYPOTHESIS Ethnic representativeness of participant enrolment in diabetes RCTs involving multiple ethnicities remains unknown. The aims of this study were to evaluate the status and temporal trend of ethnic representativeness in enrolment to diabetes RCTs, and to assess under-enrolment of non-white ethnic groups and explore trial characteristics associated with under-enrolment. METHODS We conducted a chronological survey by systematically searching the literature to include eligible RCTs published between January 2000 and December 2020. We assessed temporal trends in enrolment of ethnic groups in the included trials. Univariable logistic regression was used to explore the association between trial characteristics and under-enrolment of non-white groups, using a participant to prevalence ratio of <0.8 to define under-enrolment. This study was registered in PROSPERO (CRD42021229100). RESULTS We included 405 RCTs for analysis (327 multi-country trials, 69 conducted in the USA and nine conducted in the UK). The median enrolment rate of all non-white groups was 24.0% in the overall RCTs. Trials conducted in the USA and the UK had median enrolment rates of 29.0% and 12.0% for all non-white groups, respectively. There was a temporal trend towards increased participation of non-white ethnic groups in the overall RCTs; however, no significant improvement over time was found in the US or UK trials. Non-white groups were under-enrolled in most included trials: 62.3% (43/69) in US trials and 77.8% (7/9) in UK trials. The US trials with a high female proportion were associated with lower odds of under-enrolment of all non-white groups (OR 0.22; 95% CI 0.07, 0.65), while trials receiving funding from industry showed increased odds of under-enrolment (OR 4.64; 95% CI 1.50, 14.35). Outpatient enrolment and intervention duration were significantly associated with under-enrolment of Black participants. Only a small proportion of trials reported subgroup results or explored the effect modification by ethnicity. CONCLUSIONS/INTERPRETATION A temporal trend towards increased non-white ethnic enrolment was found in diabetes RCTs globally, but not in the USA or the UK. Non-white ethnic groups were under-represented in the majority of diabetes trials conducted in the USA and the UK. Some trial characteristics may be associated with non-white under-enrolment in diabetes trials. These findings provide some evidence for non-white ethnic representativeness in diabetes trials over the past two decades, and highlight the need for more effective strategies and endeavours to alleviate under-enrolment of non-white ethnic groups.
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Affiliation(s)
- Guowei Li
- Center for Clinical Epidemiology and Methodology, Guangdong Second Provincial General Hospital, Guangzhou, China.
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, ON, Canada.
| | - Jingyi Zhang
- Center for Clinical Epidemiology and Methodology, Guangdong Second Provincial General Hospital, Guangzhou, China
| | - Harriette G C Van Spall
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, ON, Canada
- Department of Medicine, McMaster University, Hamilton, ON, Canada
| | - Pamela S Douglas
- Duke University Clinical Research Institute, Duke University, Durham, NC, USA
| | - Yaoyao Wang
- Department of Epidemiology, School of Medicine, Jinan University, Guangzhou, China
| | - Xin Sun
- Chinese Evidence-Based Medicine Center and Cochrane China Center, West China Hospital, Sichuan University, Chengdu, China.
| | - Lehana Thabane
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, ON, Canada
- St Joseph's Healthcare Hamilton, Hamilton, ON, Canada
- Faculty of Health Sciences, University of Johannesburg, Johannesburg, South Africa
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31
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Racial Disparities in Cardiovascular Risk and Cardiovascular Care in Women. Curr Cardiol Rep 2022; 24:1197-1208. [PMID: 35802234 DOI: 10.1007/s11886-022-01738-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/09/2022] [Indexed: 11/03/2022]
Abstract
PURPOSE OF REVIEW Research on sex and gender aspects cardiovascular disease has contributed to a reduction in cardiovascular mortality in women. However, cardiovascular disease remains the leading cause of death of women in the United States. Disparities in cardiovascular risk and outcomes among women overall persist and are amplified for women of certain ethnic and racial subgroups. We review the evidence of racial and ethnic differences in cardiovascular risk and care among women and describe a path forward to achieve equitable cardiovascular care for women of racial and ethnic minority groups. RECENT FINDINGS There is a disproportionate effect on cardiovascular outcomes in women and certain racial and ethnic groups in part due to disparities in triage, diagnosis, treatment, which lead to amplification of inequalities in women of minority racial and ethnic background. Data suggest gender and racial bias, underappreciation of nontraditional risk factors, underrepresentation of women in clinical trials and undertreatment of disease contributes to persistent differences in cardiovascular disease outcomes in women of color. Understanding the myriad of factors that contribute to increased cardiovascular risk, and disparities in treatment and outcomes among women from racial/ethnic minority backgrounds is imperative to improving cardiovascular care for this patient population.
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32
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Ilonze O, Free K, Breathett K. Unequitable Heart Failure Therapy for Black, Hispanic and American-Indian Patients. Card Fail Rev 2022; 8:e25. [PMID: 35865458 PMCID: PMC9295006 DOI: 10.15420/cfr.2022.02] [Citation(s) in RCA: 15] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/07/2022] [Accepted: 03/03/2022] [Indexed: 12/02/2022] Open
Abstract
Despite the high prevalence of heart failure among Black and Hispanic populations, patients of colour are frequently under-prescribed guideline-directed medical therapy (GDMT) and American-Indian populations are not well characterised. Clinical inertia, financial toxicity, underrepresentation in trials, non-trustworthy medical systems, bias and structural racism are contributing factors. There is an urgent need to develop evidence-based strategies to increase the uptake of GDMT for heart failure in patients of colour. Postulated strategies include prescribing all GDMT upon first encounter, aggressive outpatient uptitration of GDMT, intervening upon social determinants of health, addressing bias and racism through changing processes or policies that unfairly disadvantage patients of colour, engagement of stakeholders and implementation of national quality improvement programmes.
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Affiliation(s)
- Onyedika Ilonze
- Division of Cardiovascular Medicine, Krannert Cardiovascular Institute, Indiana University, Indianapolis, IN, US
| | - Kendall Free
- Department of Biofunction Research, Tokyo Medical and Dental University, Tokyo, Japan
| | - Khadijah Breathett
- Division of Cardiovascular Medicine, Krannert Cardiovascular Institute, Indiana University, Indianapolis, IN, US
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Zhu JW, D'Angelo F, Miranda JJ, Yancy CW, Cupido B, Zannad F, Van Spall HGC. Incorporating Cultural Competence and Cultural Humility in Cardiovascular Clinical Trials to Increase Diversity Among Participants. J Am Coll Cardiol 2022; 80:89-92. [PMID: 35772919 DOI: 10.1016/j.jacc.2022.05.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/11/2022] [Revised: 04/28/2022] [Accepted: 05/02/2022] [Indexed: 11/18/2022]
Affiliation(s)
- Jie Wei Zhu
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada
| | | | - J Jaime Miranda
- CRONICAS Center of Excellence in Chronic Diseases, Universidad Peruana Cayetano Heredia, Lima, Peru; Department of Medicine, School of Medicine, Universidad Peruana Cayetano Heredia, Lima, Peru
| | - Clyde W Yancy
- Department of Internal Medicine, Division of Cardiology, Northwestern University, Feinberg School of Medicine, Chicago, Illinois, USA
| | - Blanche Cupido
- Department of Medicine, Division of Cardiology, University of Cape Town, Cape Town, South Africa
| | - Faiez Zannad
- Centre d'Investigations Cliniques Plurithématique 1433, Université de Lorraine, Institut National de la Santé et de la Recherche Médicale 1116, Centre Hospitalier Régional, Nancy, France; Universitaire de Nancy, French Clinical Research Infrastructure Network, Investigation Network Initiative-Cardiovascular and Renal Clinical Trialists, Nancy, France
| | - Harriette G C Van Spall
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada; Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada; Population Health Research Institute, Hamilton, Ontario, Canada; Research Institute of St. Joseph's, Hamilton, Ontario, Canada.
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Abstract
The majority of cardiovascular randomized controlled trials (RCTs) test interventions in selected patient populations under explicitly protocol-defined settings. Although these ‘explanatory’ trial designs optimize conditions to test the efficacy and safety of an intervention, they limit the generalizability of trial findings in broader clinical settings. The concept of ‘pragmatism’ in RCTs addresses this concern by providing counterbalance to the more idealized situation underpinning explanatory RCTs and optimizing effectiveness over efficacy. The central tenets of pragmatism in RCTs are to test interventions in routine clinical settings, with patients who are representative of broad clinical practice, and to reduce the burden on investigators and participants by minimizing the number of trial visits and the intensity of trial-based testing. Pragmatic evaluation of interventions is particularly important in cardiovascular diseases, where the risk of death among patients has remained fairly stable over the past few decades despite the development of new therapeutic interventions. Pragmatic RCTs can help to reveal the ‘real-world’ effectiveness of therapeutic interventions and elucidate barriers to their implementation. In this Review, we discuss the attributes of pragmatism in RCT design, conduct and interpretation as well as the general need for increased pragmatism in cardiovascular RCTs. We also summarize current challenges and potential solutions to the implementation of pragmatism in RCTs and highlight selected ongoing and completed cardiovascular RCTs with pragmatic trial designs. In this Review, Khan and colleagues discuss the benefits and challenges of including pragmatism in the design, conduct and interpretation of randomized controlled trials (RCTs) for cardiovascular disease and highlight selected ongoing and completed cardiovascular RCTs that incorporate a pragmatic design. Most cardiovascular randomized controlled trials (RCTs) conducted to date have been ‘explanatory’, that is, designed to study the intervention in optimized conditions with selected patient populations and frequent protocolized assessments. Although explanatory RCT designs increase validity, they limit the generalizability of trial findings, whereas a ‘pragmatic’ approach to RCTs yields findings more relevant to real-world practice. In pragmatic RCTs, interventions are tested in patients who are broadly representative of the condition being studied, and the study is aligned with routine clinical care to reduce costs and organizational burden. Although pragmatic RCTs tend to attenuate estimates of treatment effects, they do provide a more realistic understanding of population-level effectiveness and costs than explanatory trials. Pragmatic trials can highlight barriers to the implementation of therapies and are better suited than explanatory RCTs to assessing the effects of implementation strategies and health-care policies at the population level. Widespread implementation of pragmatic trials would require the development of technological infrastructure to collect and share data as well as regulatory guidelines amenable to findings derived from routinely collected data.
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Under-utilization of Guideline-Directed Medical Therapy in Heart Failure: Can Digital Health Technologies PROMPT Change? J Am Coll Cardiol 2022; 79:2214-2218. [DOI: 10.1016/j.jacc.2022.03.351] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/23/2022] [Accepted: 03/23/2022] [Indexed: 11/17/2022]
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Gender Diversity in Cardiovascular Clinical Trial Research Begins at the Top. J Am Coll Cardiol 2022; 79:929-932. [PMID: 35241227 DOI: 10.1016/j.jacc.2022.01.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/15/2021] [Revised: 01/03/2022] [Accepted: 01/04/2022] [Indexed: 01/14/2023]
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Gevaert AB, Kataria R, Zannad F, Sauer AJ, Damman K, Sharma K, Shah SJ, Van Spall HGC. Heart failure with preserved ejection fraction: recent concepts in diagnosis, mechanisms and management. Heart 2022; 108:1342-1350. [PMID: 35022210 DOI: 10.1136/heartjnl-2021-319605] [Citation(s) in RCA: 67] [Impact Index Per Article: 33.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/14/2021] [Accepted: 11/29/2021] [Indexed: 12/31/2022] Open
Abstract
It is estimated that half of all patients with heart failure (HF) have HF with preserved ejection fraction (HFpEF). Yet this form of HF remains a diagnostic and therapeutic challenge. Differentiating HFpEF from other causes of dyspnoea may require advanced diagnostic methods, such as exercise echocardiography, invasive haemodynamics and investigations for 'HFpEF mimickers'. While the classification of HF has relied heavily on cut-points in left ventricular ejection fraction (LVEF), recent evidence points towards a gradual shift in underlying mechanisms, phenotypes and response to therapies as LVEF increases. For example, among patients with HF, the proportion of hospitalisations and deaths due to cardiac causes decreases as LVEF increases. Medication classes that are efficacious in HF with reduced ejection fraction (HFrEF) have been less so at higher LVEF ranges, decreasing the risk of HF hospitalisation but not cardiovascular or all-cause death in HFpEF. These observations reflect the burden of non-cardiac comorbidities as LVEF increases and highlight the complex pathophysiological mechanisms, both cardiac and non-cardiac, underpinning HFpEF. Treatment with sodium-glucose cotransporter 2 inhibitors reduces the risk of composite cardiovascular events, driven by a reduction in HF hospitalisations; renin-angiotensin-aldosterone blockers and angiotensin-neprilysin inhibitors result in smaller reductions in HF hospitalisations among patients with HFpEF. Comprehensive management of HFpEF includes exercise as well as treatment of risk factors and comorbidities. Classification based on phenotypes may facilitate a more targeted approach to treatment than LVEF categorisation, which sets arbitrary cut-points when LVEF is a continuum. This narrative review summarises the pathophysiology, diagnosis, classification and management of patients with HFpEF.
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Affiliation(s)
- Andreas B Gevaert
- Research Group Cardiovascular Diseases, GENCOR Department, University of Antwerp, Antwerp, Belgium.,Department of Cardiology, University Medical Centre Groningen, Groningen, The Netherlands.,Department of Cardiology, Antwerp University Hospital (UZA), Edegem, Belgium
| | - Rachna Kataria
- Department of Cardiology-Advanced Heart Failure and Cardiac Transplantation, Corrigan Minehan Heart Center, Massachusetts General Hospital/Harvard Medical School, Boston, Massachusetts, USA
| | - Faiez Zannad
- Université de Lorraine, INSERM, Centre d'Investigations Cliniques-1433 and INSERM U1116, Centre Hospitalier Regional Universitaire de Nancy, Nancy, France.,Investigation Network Initiative-Cardiovascular and Renal Clinical Trialists, French Clinical Research Infrastructure Network, Nancy, France
| | - Andrew J Sauer
- Center for Advanced Heart Failure and Heart Transplantation, The University of Kansas Health System, Kansas City, Kansas, USA
| | - Kevin Damman
- Department of Cardiology, University Medical Centre Groningen, Groningen, The Netherlands
| | - Kavita Sharma
- Division of Cardiology, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Sanjiv J Shah
- Division of Cardiology, Department of Medicine and Bluhm Cardiovascular Institute, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Harriette G C Van Spall
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Ontario, Canada .,Research Institute of St. Joe's and Population Health Research Institute, Hamilton, Ontario, Canada.,Department of Medicine, McMaster University, Hamilton, Ontario, Canada
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