Gender Gaps Persist in CV Research, Editorships, and Training

A series of studies published this week in Circulation highlight the ever-present gender divide among cardiology trial participants, journal editors, and training programs.

The papers are part of the journal’s fourth annual Go Red for Women issue, published online Monday. Senior associate editor Biykem Bozkurt, MD, PhD (Michael E. DeBakey VA Medical Center, Houston, TX), said the issue is intended to highlight and disseminate important CVD research in women.

“This focused platform allows us to accelerate recognition and innovation, explore unique mechanisms, new epidemiological trends, novel diagnostic and therapeutic approaches, and strategies to close the gaps and eliminate disparities in the care of women with CVD,” she told TCTMD in an email.

Commenting to TCTMD on the importance of these particular studies, Gina Lundberg, MD (Emory University School of Medicine, Atlanta, GA), Stressed that the aim is to raise awareness of these kinds of disparities. “We talk about actionable items and we talk about gaps, and I think that these studies point out that [one] actionable item is we need to intentionally recruit and try to increase the numbers of women in cardiology and also [increase] diversity [across] ethnic, racial, cultural, religious, and even different socioeconomic backgrounds.”

Women in Cardiovascular Research

In the first paper, Xurui Jin, MD (Duke Kunshan University, China), and colleagues show that while the participation of women in cardiovascular clinical trials has improved over the past decade, enrollment of women still lags far behind.

Among 740 cardiovascular trials completed between 2010 and 2017 and registered on ClinicalTrials.gov, 38.2% of 862,652 participants were women, they found. The overall male-to-female ratio in these trials was 0.51, but this was smaller with older age (1.02 for ≤ 55 years vs 0.40 for 61-65 years) and differed by intervention type (0.44 for procedure trials vs 0.78 for lifestyle intervention trials), disease type (0.34 for ACS vs 3.20 for pulmonary hypertension), region (0.45 for Western-Pacific vs 0.55 for the Americas), nature of sponsorship (0.14 for government-sponsored and 0.73 for multi-sponsored), and trial size (0.56 for smaller vs 0.49 for larger trials).

The participation prevalence ratio (PPR)—a measurement calculated by dividing the percentage of female trial participants by the percentage of women in the disease population—was higher for hypertension (0.82) and pulmonary hypertension trials (1.33) and low for arrhythmia (0.78), coronary heart disease (0.67), stroke (0.73), ACS (0.66), and heart failure trials (0.48). Additionally, the younger than 55 age group had a higher PPR than all other age groups (P < 0.0083), and drug trials had higher PPR than device trials (P = 0.0009).

We talk about actionable items and we talk about gaps, and I think that these studies point out that [one] actionable item is we need to intentionally recruit and try to increase the numbers of women in cardiology. Gina Lundberg

Between 2013 and 2017, the researchers found significant increases in PPRs for stroke (P < 0.001) and heart failure trials (P = 0.01) compared with earlier time periods.

“These findings provide key insights into factors impacting women’s representation in cardiovascular trials, including both success factors as well as areas where women remain under-represented,” the authors write. “Future efforts should build on prior successes and target key areas for improvement with multifactorial approaches to enhance recruitment of women.”

As for why women might participate less in clinical trials compared with men, Jin and colleagues say that there are multiple patient- and trial site-related opportunities for a patient to fall out of the enrollment pathway.

“First, a patient must be made aware of the opportunity to participate, which requires that either the patients identify the opportunity via consumer channels or that study sites approach adequate numbers of female patients for participation,” they write. “Women must also have access to centers participating in trials in order to enroll, which can require both that referrals are appropriately made and that patients can support participation logistics such as transportation and child care. Finally, women must understand and be comfortable with the clinical trial process, with the process of informed consent, and with the overall clinical trial experience.”

Women make decisions differently than men, say the authors, “which means that the same enrollment process may yield different enrollment rates by sex.”

Because of all of this, “increasing the number of women who choose to enroll in clinical trials requires novel approaches to the recruitment and enrollment process,” Jin and colleagues write. “These strategies should consider multiple factors included in this study as well as practical and innovative psychological, cultural, and gender-specific measurements.

Fewer Women Journal Editors

For the second study, Sowmya Balasubramanian, MD (Congenital Heart Center, Ann Arbor, MI), and colleagues examined the contemporary representation of women on editorial boards of general cardiology and subspecialty-specific cardiology journals.

Notably, they found that for general cardiology journals between 1998 and 2018 there were no women editors-in-chief of US publications and only one in Europe. Women were less represented as deputy/associate editors in European general cardiology journals compared with US ones (9% vs 20.7%; P = 0.02), although editorial board membership was similar (11.8% vs 12.8%; P = 0.60).

Over 20 years, the American Journal of Cardiology saw no changes in the gender make-up of its editors,  Circulation increased representation of women on both its editorial board and in deputy/associate editor roles, while the Journal of the American College of Cardiology only saw increases the former. Women serving on the editorial boards of all three journals cumulatively doubled between 1998 and 2018 (6.3% to 12.9%; P < 0.0001).

On the editorial boards of European journals, early-career female faculty were better represented than in the US (42.9% vs 15.6%; P = 0.02).

Looking at subspecialty journals, only Circulation Heart Failure had a female editor-in-chief, and women were similarly represented in US and European journals as deputy editors and editorial board members.

“This study highlights the need for continued attention to barriers in career advancement for women in cardiology,” the authors write. “Engagement of women faculty at early career stages as ad hoc reviewers would help create a robust pipeline of future women editors. Diversity in editorial boards can not only improve the societal relevance and quality of the journal, but also provide women role models for future generations. A more gender-balanced and diverse editorial team adds value by decreasing publication bias against women, providing a favorable impression of the journal and increasing likelihood of competitive submissions.”

Disparity Among Trainees

Finally, researchers led by Muhammad Khan, MD (John H. Stroger Jr. Hospital of Cook County, Chicago, IL), looked at trends in the representation of women among cardiology trainees over the past decade, using data from the Association of American Medical Colleges.

In 2017-2018, 21.4% of cardiology trainees were women, which shows a modest but significant increase since 2007-2008 (15.9%; P < 0.01). Among cardiology subspecialties, the lowest proportions of women were seen in interventional cardiology (10.2%) and electrophysiology (11.6%), whereas advanced heart failure/transplant (31.2%) and adult congenital heart disease (46.7%) had the greatest degree of female representation.

Interestingly, about half (51.9%) of pediatric cardiology trainees were women in 2017-2018, which is a substantial increase over 2007-2008 (39%). Within all internal medicine specialties, cardiology, critical care medicine, and pulmonary disease were the most male-dominated. Outside internal medicine, only orthopedic surgery had a greater gender disparity (84.7% men), whereas the highest number of women trainees were in obstetrics/gynecology (83%).

Interestingly, Lundberg commented, even though fields like OB/GYN are now predominantly made up of women, “at one time, all the OB-GYNs were men.”

She referenced articles published in JAMA Cardiology in 2018 that specified some of the main concerns female trainees had about pursuing a career in cardiology. “They said that they felt that cardiology was a difficult environment, . . . that it was not female friendly, and it was not family friendly,” she recalled. “Those things are still the biggest hurdles to why we're not attracting more women to cardiology. I think too often we don't really encourage women” or are unknowingly discouraging women from entering the field, Lundberg added.

“Underrepresentation of women in surgery has been attributed to several factors such as implicit biases which lead to associations of ‘men with surgery,’ micro-aggressions which impact the climate of women in surgical specialties, concerns about lifestyle/family factors, and lack of women role models in the field,” according to Khan and colleagues. “Since the two most commonly identified factors guiding trainees’ subspecialty selection are supportive role models and positive encouragement, efforts for change will effectively be initiated around these two factors.”

Some specific recommendations they make include establishing focused mentoring and volunteer programs for female medical students which “may serve to ignite interest in cardiology and reduce misconceptions” and providing travel grants to attend cardiology conferences for networking opportunities and sponsoring visiting rotations in order to “increase exposure of early trainees to the cardiology field and to women role models.”

Khan and colleagues also call for improvement in professional development of women cardiologists at all stages, more transparent family medical leave policies, flexible training pathways, nongender biased funding opportunities, greater gender balance on journal editorial boards, and more invited women speakers at cardiology conferences.

‘Interrelated Issues’

The different types of gender gaps highlighted in the three papers are connected, Lundberg noted.

“I particularly think the article about the lack of women in cardiology has everything to do with all the other results,” Lundberg said. “If you don't have women in cardiology positions, you're not going to have women in editor positions, and if you don't have women in cardiology with a lot of diverse backgrounds, you're not going to take care of women as well as we take care of men. . . . I really think they're all interrelated issues.”

Bozkurt agreed. “Studies that have women PIs have higher recruitment of women,” she said. “There is lack of recognition that heart disease is the leading cause of death of women and both women as patients and clinicians still lack this awareness.”

In order to increase the proportion of women in cardiovascular trials, Bozkurt said “there needs to be a minimum expected or a required ratio for recruitment of women in clinical trials. Specific [requests for applications] or studies should be developed for addressing efficacy and outcomes in women. There needs to be a widespread campaign for increasing awareness and screening for women and cardiovascular disease. This may entail better coordination of care between different providers such as obstetricians, who may be the first clinician a woman sees, internists, and cardiologists.”

Acknowledging that there has been an improvement in awareness of cardiovascular disease among women, Bozkurt said that “significant gaps persist and adverse trends are emerging in cardiovascular disease in women. Sex-specific trends in acute myocardial infarction reflect a slowing of the decline in hospitalization rates for acute myocardial infarction in women compared with men. Also, we are recognizing that pregnancy-related complications such as preeclampsia or premature birth with low birth weight are significant risk factors for cardiovascular disease in women in addition to traditional risk factors such as diabetes, hypertension, smoking, hyperlipidemia, and family history.”

Both of these topics are tackled in other papers in the Go Red For Women issue.

Ultimately, according to Lundberg, increased female representation in trials, editorial boards, and trainees “has to become the standard and the norm if we're going to see a change.