1
|
Patel N, Mittal N, Wilkinson MJ, Taub PR. Unique features of dyslipidemia in women across a lifetime and a tailored approach to management. Am J Prev Cardiol 2024; 18:100666. [PMID: 38634109 PMCID: PMC11021917 DOI: 10.1016/j.ajpc.2024.100666] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2023] [Revised: 03/26/2024] [Accepted: 04/04/2024] [Indexed: 04/19/2024] Open
Abstract
Purpose of Review Cardiovascular disease is a leading cause of death worldwide. Dyslipidemia is a critical modifiable risk factor for the prevention of cardiovascular disease. Dyslipidemia affects a large population of women and is especially pervasive within racial/ethnic minorities. Recent Findings Dyslipidemia in pregnancy leads to worse outcomes for patients and creates increased cardiovascular risk for women at an older age. However, women remain underscreened and undertreated compared to men. Females also comprise a small portion of clinical trial participants for lipid lowering agents with increased disease prevalence compared to trial representation. However, recent lipid trials have shown different efficacies of therapies such as ezetimibe, inclisiran, and bempedoic acid with a greater relative benefit for women. Summary Pathophysiology of dyslipidemia varies between men and women and across a woman's lifetime. While increased lipid levels or lipid imbalances are more common in postmenopausal women over age 50, conditions such as PCOS and FH produce higher cardiovascular risk for young women.Best practices for management of women with dyslipidemia include early screening with lifestyle intervention and pharmacotherapy with statin and non-statin agents to achieve guideline directed LDL-C thresholds.
Collapse
Affiliation(s)
- Neeja Patel
- University of California, Los Angeles, United States
| | | | | | - Pam R. Taub
- University of California, San Diego, United States
| |
Collapse
|
2
|
Holm KE, Sandhaus RA, Allison S, Strange C. Clinical trial attitudes among individuals with Alpha-1 antitrypsin deficiency. Respir Med 2024; 229:107676. [PMID: 38795925 DOI: 10.1016/j.rmed.2024.107676] [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: 02/02/2024] [Revised: 05/01/2024] [Accepted: 05/21/2024] [Indexed: 05/28/2024]
Abstract
PURPOSE This study examined characteristics of clinical trials that influence interest in participation among individuals with alpha-1 antitrypsin deficiency (AATD). PROCEDURES A cross-sectional survey was completed by individuals with AATD. Thirty-four items described characteristics of clinical trials, which were rated from 1 (would not participate) to 5 (highly interested in participating). Logistic regression was used to compare participants with high interest in trials (defined as scores of 4 or 5 on ≥50 % of responses) to all remaining participants. RESULTS Data were provided by 1664 participants (91.6 % with lung disease, 16.3 % with liver disease, 14.9 % with lung and liver disease). Nearly one-third (31.8 %) indicated that they would not participate in a trial if there was a chance of getting a placebo. If the trial included three liver biopsies, 53.3 % would not participate. More than two-thirds (69.8 %) of participants who were using augmentation therapy would not participate in a trial that required twelve months off therapy. Individuals with two or more exacerbations in the prior year were more likely to have high interest in trials (OR = 1.4, 95 % CI = 1.1-1.7, p = 0.009). In addition, individuals with a score of 10 or higher on the COPD Assessment Test were more likely to have high interest (OR = 1.4, 95 % CI = 1.1-1.8, p = 0.010). CONCLUSIONS A sizeable percentage of participants indicated that they would not participate in clinical trials that include a placebo, involve multiple liver biopsies, or involve discontinuing augmentation therapy. Individuals who are more affected by AATD have more interest in trial participation than individuals who are less affected.
Collapse
Affiliation(s)
| | | | | | - Charlie Strange
- AlphaNet, Inc., USA; Medical University of South Carolina, USA
| |
Collapse
|
3
|
Gosselin M, Baroud ML, Denis OR, Gagnon ME, Sirois C. Evidence-based data for newly approved medications' use in older adults: An analysis from clinical trials to monographs. J Am Geriatr Soc 2024; 72:1252-1262. [PMID: 38270204 DOI: 10.1111/jgs.18772] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2023] [Revised: 12/05/2023] [Accepted: 12/20/2023] [Indexed: 01/26/2024]
Abstract
BACKGROUND Older adults have historically been excluded from clinical trials, limiting evidence-based data. An updated picture of the situation with newly marketed medications is needed. We aimed to describe (1) the recommendations specific to older adults in monographs of newly marketed medications; (2) the representation of older adults in clinical trials of those medications. METHODS In November 2020, we listed all medications that received a notice of compliance from Health Canada between January 2006 and September 2020, excluding those with indications irrelevant to community-dwelling older adults and locally acting medications. We assessed the availability and clarity of recommendations in monographs regarding older adults. Using Clinicaltrials.gov, we identified randomized controlled double-blind Phase III-IV trials led in Canada/United States of a sample of 30 commonly used medications among those previously listed. We extracted information on study design, participants, and efficacy/safety analysis specific to older patients. We used simple linear regression and Chi-square/Fisher's exact tests to analyze time trends in the representation of older adults over different periods. RESULTS A total of 195 monographs were included. Of the 130 monographs reporting a dosing recommendation in older adults, 53 (41%) also reported limited/insufficient data in this population or its subgroups. Of the 373 trials included, 217 (58%) did not integrate a maximum age as an inclusion criterion. However, only 113 (30%) reported including a proportion of older adults representative (or over-representative) of the Canadian older population. Most trials (n = 289; 78%) did not provide efficacy or safety data specific to older adults. In our sample, the number/proportion of older adults in trials seemed to be increasingly reported over time, either explicitly or implicitly (e.g., inclusion criterion specifies <65 years old). CONCLUSIONS Newly marketed medications still appear to under-represent older adults. The resulting lack of clear recommendations in monographs compromises evidence-based practice, thereby perpetuating the risk to older adults' health.
Collapse
Affiliation(s)
- Maude Gosselin
- Department of Social and Preventive Medicine, Faculty of Medicine, Université Laval, Quebec, Quebec, Canada
| | | | | | - Marie-Eve Gagnon
- Faculty of Pharmacy, Université Laval, Quebec, Quebec, Canada
- Department of Health Sciences, Université du Québec à Rimouski, Rimouski, Quebec, Canada
| | - Caroline Sirois
- Faculty of Pharmacy, Université Laval, Quebec, Quebec, Canada
- Centre d'excellence sur le vieillissement de Québec, Quebec, Quebec, Canada
- VITAM, Sustainable Health Research Centre, Quebec, Quebec, Canada
- CHU de Québec-Université Laval Research Centre, Quebec, Quebec, Canada
| |
Collapse
|
4
|
Ahmed R, de Souza RJ, Li V, Banfield L, Anand SS. Twenty years of participation of racialised groups in type 2 diabetes randomised clinical trials: a meta-epidemiological review. Diabetologia 2024; 67:443-458. [PMID: 38177564 PMCID: PMC10844363 DOI: 10.1007/s00125-023-06052-w] [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: 07/27/2023] [Accepted: 10/16/2023] [Indexed: 01/06/2024]
Abstract
AIMS/HYPOTHESIS Type 2 diabetes mellitus prevalence is increasing globally and the greatest burden is borne by racialised people. However, there are concerns that the enrolment of racialised people into RCTs is limited, resulting in a lack of ethnic and racial diversity. This may differ depending whether an RCT is government funded or industry funded. The aim of this study was to review the proportions of racialised and white participants included in large RCTs of type 2 diabetes pharmacotherapies relative to the disease burden of type 2 diabetes in these groups. METHODS The Ovid MEDLINE database was searched from 1 January 2000 to 31 December 2020. English language reports of RCTs of type 2 diabetes pharmacotherapies published in select medical journals were included. Studies were included in this review if they had a sample size of at least 100 participants and all participants were adults with type 2 diabetes. Industry-funded trials must have recruited participants from at least two countries. Government-funded trials were not held to the same standard because they are typically conducted in a single country. Data including the numbers and proportions of participants by ethnicity and race were extracted from trial reports. The participation-to-prevalence ratio (PPR) was calculated for each trial by dividing the percentage of white and racialised participants in each trial by the percentage of white and racialised participants with type 2 diabetes, respectively, for the regions of recruitment. A random-effects meta-analysis was used to generate the pooled PPRs and 95% CIs across study types. A PPR <0.80 indicates under-representation and a PPR >1.20 indicates over-representation. Risk of bias assessments were not conducted for this study as the objective was to examine recruitment of racialised and white participants rather than evaluate the trustworthiness of clinical trial outcomes. RESULTS A total of 83 trials were included, involving 283,122 participants, of which 15 were government-funded and 68 were industry-funded trials. In government-funded trials, the PPR for white participants was 1.11 (95% CI 0.99, 1.24) and the PPR for racialised participants was 0.72 (95% CI 0.60, 0.86). In industry-funded trials, the PPR for white participants was 1.95 (95% CI 1.74, 2.18) and the PPR for racialised participants was 0.36 (95% CI 0.32, 0.42). The limitations of this study include the reliance on investigator-reported ethnicity and race to classify participants as 'white' or 'racialised', the use of estimates for type 2 diabetes prevalence and demographic data, and the high levels of heterogeneity of pooled estimates. However, despite these limitations, the results were consistent with respect to direction. CONCLUSIONS/INTERPRETATION Racialised participants are under-represented in government- and industry-funded type 2 diabetes trials. Strategies to improve recruitment and enrolment of racialised participants into RCTs should be developed. REGISTRATION Open Science Framework registration no. f59mk ( https://osf.io/f59mk ) FUNDING: The authors received no financial support for this research or authorship of the article.
Collapse
Affiliation(s)
- Rabeeyah Ahmed
- Department of Medicine, Faculty of Health Sciences, McMaster University, Hamilton, ON, Canada
- Chanchlani Research Centre, McMaster University, Hamilton, ON, Canada
| | - Russell J de Souza
- Chanchlani Research Centre, McMaster University, Hamilton, ON, Canada
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, ON, Canada
| | - Vincent Li
- Department of Medicine, Faculty of Health Sciences, McMaster University, Hamilton, ON, Canada
| | - Laura Banfield
- Health Sciences Library, McMaster University, Hamilton, ON, Canada
| | - Sonia S Anand
- Department of Medicine, Faculty of Health Sciences, McMaster University, Hamilton, ON, Canada.
- Chanchlani Research Centre, McMaster University, Hamilton, ON, Canada.
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, ON, Canada.
| |
Collapse
|
5
|
Zhang AD, Anderson TS, Hastings SN. Demographic characteristics of participants in clinical trials to treat Alzheimer disease, 2008-2023. J Am Geriatr Soc 2024; 72:942-945. [PMID: 37916640 PMCID: PMC10949061 DOI: 10.1111/jgs.18645] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2023] [Accepted: 10/04/2023] [Indexed: 11/03/2023]
Affiliation(s)
- Audrey D. Zhang
- Department of Medicine, Duke University School of Medicine,
Durham, NC
| | - Timothy S. Anderson
- Division of General Internal Medicine, University of
Pittsburgh School of Medicine, Pittsburgh, PA
| | - S. Nicole Hastings
- Department of Medicine, Duke University School of Medicine,
Durham, NC
- Center of Innovation to Accelerate Discovery and Practice
Transformation, Durham Veterans Affairs Health Care System, Durham, NC
| |
Collapse
|
6
|
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).
Collapse
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
| |
Collapse
|
7
|
Andersson NW, Corn G, Dohlmann TL, Melbye M, Wohlfahrt J, Lund M. Effectiveness of low-density lipoprotein cholesterol reduction with lipid lowering therapy for secondary prevention amongst older individuals: a nationwide cohort study. Age Ageing 2024; 53:afad241. [PMID: 38219226 DOI: 10.1093/ageing/afad241] [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: 07/11/2023] [Indexed: 01/16/2024] Open
Abstract
BACKGROUND Data about the clinical benefit from initial low-density lipoprotein cholesterol (LDL-C) reduction with lipid lowering treatment for secondary prevention and risk of major vascular events amongst older as compared with younger individuals treated during routine clinical care are limited. We investigated this in a nationwide cohort. METHODS Individuals aged ≥ 50 years with a first-time hospitalisation for a cardiovascular event (index event, including acute coronary syndrome, non-haemorrhagic stroke, transient ischaemic attack and coronary revascularisation), 1 January 2008 to 31 October 2018, who subsequently used lipid lowering treatment, and had an LDL-C measurement before and after the event were included. Hazard ratios (HRs) for major vascular events per 1 mmol/L reduction in LDL-C were estimated for the included 21,751 older and 22,681 younger individuals (≥/<70 years old) using Cox regression. RESULTS LDL-C lowering was associated with a 12% lower risk of major vascular events in older individuals per 1 mmol/L reduction in LDL-C (HR 0.88, 95% confidence interval [CI] 0.84-0.93), with no significant difference compared with the risk reduction amongst younger individuals (HR 0.88, 95% CI 0.83-0.93; P-value for difference between age groups: 0.86). The risk reduction was more pronounced when post hoc restricting, as a proxy for compliance, to new users with an LDL-C reduction above the lowest decile for both older (0.81, 95% CI 0.73-0.90) and younger (0.81, 95% CI 0.72-0.91) individuals. CONCLUSIONS This study strongly supports a similar relative clinical benefit of LDL-C reduction with lipid lowering treatment for secondary prevention of major vascular events amongst individuals aged ≥70 and <70 years.
Collapse
Affiliation(s)
- Niklas W Andersson
- Department of Epidemiology Research, Statens Serum Institut, Copenhagen, Denmark
| | - Giulia Corn
- Department of Epidemiology Research, Statens Serum Institut, Copenhagen, Denmark
- Statistics and Data Analysis, Danish Cancer Institute, Copenhagen, Denmark
| | - Tine L Dohlmann
- Department of Epidemiology Research, Statens Serum Institut, Copenhagen, Denmark
| | - Mads Melbye
- Danish Cancer Institute, Copenhagen, Denmark
- HUNT Center for Molecular and Genetic Epidemiology, Norwegian University of Science and Technology, Trondheim, Norway
- Department of Genetics, Stanford University School of Medicine, Stanford, CA, USA
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Jan Wohlfahrt
- Department of Epidemiology Research, Statens Serum Institut, Copenhagen, Denmark
- Cancer Epidemiology and Surveillance, Danish Cancer Institute, Copenhagen, Denmark
| | - Marie Lund
- Department of Epidemiology Research, Statens Serum Institut, Copenhagen, Denmark
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
- Department of Clinical Pharmacology, Copenhagen University Hospital - Bispebjerg and Frederiksberg, Copenhagen, Denmark
| |
Collapse
|
8
|
Goldstein KM, Kung LCY, Dailey SA, Kroll-Desrosiers A, Burke C, Shepherd-Banigan M, Lumsden R, Sims C, Schexnayder J, Patel D, Cantrell S, Sheahan KL, Gierisch JM. Strategies for enhancing the representation of women in clinical trials: an evidence map. Syst Rev 2024; 13:2. [PMID: 38166994 PMCID: PMC10759390 DOI: 10.1186/s13643-023-02408-w] [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: 04/21/2023] [Accepted: 12/03/2023] [Indexed: 01/05/2024] Open
Abstract
BACKGROUND Equitable sex- and gender-based representation in clinical trials is an essential step to ensuring evidence-based care for women. While multi-institutional actions have led to significant improvements in the inclusion of women in trials, inequity persists in areas like sex-neutral cancers and cardiovascular disease. We sought to identify strategies described or evaluated to boost the inclusion of women in clinical trials. METHODS We used evidence mapping methodology to examine the breadth of relevant literature. We developed an a priori protocol and followed reporting guidance from the Preferred Reporting Items for Systematic Reviews and Meta-Analysis where applicable. We searched MEDLINE® (via PubMed) and EMBASE (via Elsevier) databases from inception through April 4, 2023, and used standardized procedures incorporating duplication and data verification. We included articles that described strategies to improve the recruitment and retention of women in clinical trials. RESULTS We identified 122 articles describing recruitment and retention strategies for 136 trials (377,595 women). Only one article distinguished between the sex and gender identity of participants, and none defined their use of the terms such as "women" or "female". The majority of articles (95%) described recruitment for only women, and 64% were conducted in the USA. Ninety-two articles (75%) described strategies in the context of sex-specific conditions (e.g., gynecologic diagnosis). The majority of included articles evaluated a behavioral intervention (52%), with 23% evaluating pharmacologic interventions and 4% invasive interventions. The most common trial phase for reported strategies was during outreach to potential participants (116 articles), followed by intervention delivery (76), enrollment (40), outcomes assessment (21), analysis and interpretation (3), and dissemination (4). We describe specific types of strategies within each of these phases. CONCLUSIONS Most of the existing literature describing strategies to improve the inclusion of women draws from trials for sex-specific conditions and is largely related to outreach to potential participants. There is little information about how and if studies have attempted to proportionally increase the inclusion of women in trials with both men and women or those focused on invasive and pharmacologic interventions. Future work in this area should focus on how to increase the participation of women in mixed-sex studies and on those areas with remaining inequities in trial participation.
Collapse
Affiliation(s)
- Karen M Goldstein
- Center of Innovation to Accelerate Discovery and Practice Transformation, Durham Veterans Affairs Health Care System, 508 Fulton Street, Durham, NC, 27705, USA.
- Division of General Internal Medicine, Duke University School of Medicine, 40 Duke Medicine Circle, Durham, NC, 27710, USA.
| | - Lindsay Chi Yan Kung
- Health Management & Policy, Graduate School of Public Health, San Diego State University, 5500 Campanile Drive, San Diego, CA, 92182-4162, USA
| | - Susan Alton Dailey
- Center of Innovation to Accelerate Discovery and Practice Transformation, Durham Veterans Affairs Health Care System, 508 Fulton Street, Durham, NC, 27705, USA
| | - Aimee Kroll-Desrosiers
- VA Central Western Massachusetts Healthcare System, 421 North Main Street, Leeds, MA, 01053, USA
- UMass Chan Medical School, 55 Lake Ave. N, Worcester, MA, 01655, USA
| | - Colleen Burke
- Department of Population Health Sciences, Duke University School of Medicine, 215 Morris Street, Durham, NC, 27701, USA
| | - Megan Shepherd-Banigan
- Center of Innovation to Accelerate Discovery and Practice Transformation, Durham Veterans Affairs Health Care System, 508 Fulton Street, Durham, NC, 27705, USA
- Department of Population Health Sciences, Duke University School of Medicine, 215 Morris Street, Durham, NC, 27701, USA
- Duke-Margolis Center for Health Policy, 100 Fuqua Drive, Box 90120, Durham, NC, 27708, USA
| | - Rebecca Lumsden
- Division of General Internal Medicine, Duke University School of Medicine, 40 Duke Medicine Circle, Durham, NC, 27710, USA
| | - Catherine Sims
- Center of Innovation to Accelerate Discovery and Practice Transformation, Durham Veterans Affairs Health Care System, 508 Fulton Street, Durham, NC, 27705, USA
- Duke Rheumatology Division, 40 Duke Medicine Circle Clinic 1j, Durham, NC, 27710, USA
| | - Julie Schexnayder
- University of Alabama at Birmingham School of Nursing, NB545 1720 2nd, Ave S, Birmingham, AL, 35294, USA
| | - Dhara Patel
- Center of Innovation to Accelerate Discovery and Practice Transformation, Durham Veterans Affairs Health Care System, 508 Fulton Street, Durham, NC, 27705, USA
| | - Sarah Cantrell
- Duke University Medical Center Library & Archives, Duke University School of Medicine 10 Searle Drive, Durham, NC, 27710, USA
| | | | - Jennifer M Gierisch
- Center of Innovation to Accelerate Discovery and Practice Transformation, Durham Veterans Affairs Health Care System, 508 Fulton Street, Durham, NC, 27705, USA
- Division of General Internal Medicine, Duke University School of Medicine, 40 Duke Medicine Circle, Durham, NC, 27710, USA
- Department of Population Health Sciences, Duke University School of Medicine, 215 Morris Street, Durham, NC, 27701, USA
| |
Collapse
|
9
|
Fogacci F, Yerlitaş Sİ, Giovannini M, Zararsız G, Lido P, Borghi C, Cicero AFG. Sex X Time Interactions in Lp(a) and LDL-C Response to Evolocumab. Biomedicines 2023; 11:3271. [PMID: 38137492 PMCID: PMC10741148 DOI: 10.3390/biomedicines11123271] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2023] [Revised: 12/05/2023] [Accepted: 12/07/2023] [Indexed: 12/24/2023] Open
Abstract
The aim of this study was to evaluate whether there were significant sex x time interactions in lipoprotein(a) (Lp(a)) and low-density lipoprotein cholesterol (LDL-C) response to treatment with the Proprotein Convertase Subtilisin/Kexin type 9 inhibitor (PCSK9i) Evolocumab, in a real-life clinical setting. For this purpose, we pooled data from 176 outpatients (Men: 93; Women: 83) clinically evaluated at baseline and every six months after starting Evolocumab. Individuals who had been on PCSK9i for less than 30 months and nonadherent patients were excluded from the analysis. Over time, absolute values of Lp(a) plasma concentrations significantly decreased in the entire cohort (p-value < 0.001) and by sex (p-value < 0.001 in men and p-value = 0.002 in and women). However, there were no sex-related significant differences. Absolute plasma concentrations of LDL-C significantly decreased over time in the entire cohort and by sex (p-value < 0.001 always), with greater improvements in men compared to women. The sex x time interaction was statistically significant in LDL-C (all p-values < 0.05), while absolute changes in Lp(a) were not influenced by either sex or time (all p-value > 0.05). Our data partially reinforce the presence of differences in response to treatment to PCSK9i between men and women and are essential to gain a better understanding of the relationship between LDL-C and Lp(a) lowering in response to PCSK9i. Further research will clarify whether these sex-related significant differences translate into a meaningful difference in the long-term risk of ASCVD.
Collapse
Affiliation(s)
- Federica Fogacci
- Hypertension and Cardiovascular Risk Research Center, Medical and Surgical Sciences Department, Alma Mater Studiorum University of Bologna, 40100 Bologna, Italy; (F.F.); (M.G.); (C.B.)
| | - Serra İlayda Yerlitaş
- Department of Biostatistics, Erciyes University School of Medicine, 38039 Kayseri, Turkey; (S.İ.Y.); (G.Z.)
- Drug Application and Research Center (ERFARMA), Erciyes University, 38280 Kayseri, Turkey
| | - Marina Giovannini
- Hypertension and Cardiovascular Risk Research Center, Medical and Surgical Sciences Department, Alma Mater Studiorum University of Bologna, 40100 Bologna, Italy; (F.F.); (M.G.); (C.B.)
| | - Gökmen Zararsız
- Department of Biostatistics, Erciyes University School of Medicine, 38039 Kayseri, Turkey; (S.İ.Y.); (G.Z.)
- Drug Application and Research Center (ERFARMA), Erciyes University, 38280 Kayseri, Turkey
| | - Paolo Lido
- Italian Medicines Agency (AIFA), 00187 Rome, Italy;
| | - Claudio Borghi
- Hypertension and Cardiovascular Risk Research Center, Medical and Surgical Sciences Department, Alma Mater Studiorum University of Bologna, 40100 Bologna, Italy; (F.F.); (M.G.); (C.B.)
- Unit of Cardiovascular Internal Medicine, Department of Cardiac, Thoracic, Vascular Pathology, IRCCS Azienda Ospedaliero-Universitaria di Bologna, 40100 Bologna, Italy
| | - Arrigo F. G. Cicero
- Hypertension and Cardiovascular Risk Research Center, Medical and Surgical Sciences Department, Alma Mater Studiorum University of Bologna, 40100 Bologna, Italy; (F.F.); (M.G.); (C.B.)
- Unit of Cardiovascular Internal Medicine, Department of Cardiac, Thoracic, Vascular Pathology, IRCCS Azienda Ospedaliero-Universitaria di Bologna, 40100 Bologna, Italy
| |
Collapse
|
10
|
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.
Collapse
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.
| |
Collapse
|
11
|
Albosta M, Grant JK, Michos ED. Bempedoic Acid: Lipid Lowering for Cardiovascular Disease Prevention. Heart Int 2023; 17:27-34. [PMID: 38419721 PMCID: PMC10900064 DOI: 10.17925/hi.2023.17.2.1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2023] [Accepted: 08/22/2023] [Indexed: 03/02/2024] Open
Abstract
The management of low-density lipoprotein cholesterol (LDL-C) levels is a central strategy for the prevention of atherosclerotic cardiovascular disease. Current United States (2018 American Heart Association/American College of Cardiology/Multisociety) and European (2019 European Society of Cardiology/European Atherosclerosis Society) guidelines endorse statin therapy as the first-line therapy for pharmacologic LDL-C lowering. However, in clinical practice up to 30% of patients report partial or complete intolerance to statin therapy. While the nocebo effect with statins is well described, perceived statin intolerance prevents many patients from achieving LDL-C thresholds associated with clinical benefit. Bempedoic acid is a novel, oral, non-statin lipid-l owering therapy that works by inhibiting adenosine triphosphate-citrate lyase, an enzymatic reaction upstream of 3-hydroxy-3-methylglutaryl coenzyme A reductase in the hepatic cholesterol synthesis pathway. Bempedoic acid confers reduction in LDL-C of ~18% on background statin therapy,~21% in patients with statin intolerance, and ~38% when given in fixed-dose combination with ezetimibe. The CLEAR Outcomes trial, which enrolled high-risk primary and secondary prevention patients with reported statin intolerance and LDL-C levels ≥100 mg/dL, showed that bempedoic acid compared with placebo reduced 4-component major adverse cardiovascular events (MACE) by 13% (hazard ratio 0.87, 95% confidence interval 0.79-0.96). Bempedoic acid also reduced 3-component MACE by 15%, myocardial infarction by 23% and coronary revascularization by 19%. The benefit was even greater in the primary prevention cohort (hazard ratio 0.70, 95% confidence interval 0.55-0.89) for 4-component MACE. Bempedoic acid was associated with increases in uric acid levels and cholelithiasis, but numerically fewer events of myalgia and new-onset diabetes. These findings confirm that bempedoic acid is an effective approach to reduce cardiovascular outcomes in high-risk patients with statin intolerance who require further reduction in LDL-C.
Collapse
Affiliation(s)
- Michael Albosta
- Internal Medicine Department, University of Miami Miller School of Medicine/Jackson Memorial Hospital, Miami, FL, USA
| | - Jelani K Grant
- Ciccarone Center for the Prevention of Cardiovascular Disease, Division of Cardiology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Erin D Michos
- Ciccarone Center for the Prevention of Cardiovascular Disease, Division of Cardiology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| |
Collapse
|
12
|
Galema-Boers AMH, Mulder JWCM, Steward K, Roeters van Lennep JE. Sex differences in efficacy and safety of PCSK9 monoclonal antibodies: A real-world registry. Atherosclerosis 2023; 384:117108. [PMID: 37059655 DOI: 10.1016/j.atherosclerosis.2023.03.013] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/31/2022] [Revised: 02/16/2023] [Accepted: 03/16/2023] [Indexed: 04/16/2023]
Abstract
BACKGROUND AND AIMS Proprotein convertase subtilisin/kexin 9 monoclonal antibodies (PCSK9 mAbs) reduce low-density lipoprotein (LDL-c) with a favourable safety profile. Available data from PCSK9 antibody trials suggest LDL-c reduction is lower in women compared to men. Data in real-world setting is scarce. The aim of this study was to assess sex differences in efficacy and safety of PCSK9 antibodies in clinical care. METHODS All patients starting with evolocumab or alirocumab in our lipid clinic were included in a prospective registry. We collected clinical information, including baseline and follow-up mean LDL-C levels after initiation of PCSK9 mAbs treatment. In addition, side effects and PCSK9 mAbs discontinuation were recorded. RESULTS We analysed 436 patients (209 women), mean age 58 ± 11 years. Women had higher baseline LDL-c levels compared to men (4.7 ± 1.6 mmol/L vs 4.1 ± 1.4 mmol/L, p < 0.01). PCSK9 mAbs resulted in less relative LDL-c reduction in women compared to men (50% vs 61% p<0.01), but equal absolute LDL-c reduction (respectively 2.3 ± 1.3 mmol/L vs 2.5 ± 1.1 mmol/L, p = 0.087). Women less often reached LDL-c target levels than men (50% vs 72%). No sex differences were observed in reporting of side effects (women 32% vs men 27% p = 0.26) or PCSK9 mAbs discontinuation (women 13% vs men 10%, p = 0.46). CONCLUSIONS In clinical practice, PCSK9 mAbs are less effective in reducing LDL-c levels in women compared to men and equally safe, implying the importance of sex differences in PCSK9 metabolism.
Collapse
Affiliation(s)
| | - Janneke W C M Mulder
- Department of Internal Medicine, Erasmus University Medical Center, Rotterdam, the Netherlands
| | - Kim Steward
- Department of Internal Medicine, Erasmus University Medical Center, Rotterdam, the Netherlands
| | | |
Collapse
|
13
|
Venditti V, Bleve E, Morano S, Filardi T. Gender-Related Factors in Medication Adherence for Metabolic and Cardiovascular Health. Metabolites 2023; 13:1087. [PMID: 37887412 PMCID: PMC10609002 DOI: 10.3390/metabo13101087] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2023] [Revised: 10/05/2023] [Accepted: 10/12/2023] [Indexed: 10/28/2023] Open
Abstract
This review explores the impact of gender on medication adherence in the context of metabolic and cardiovascular diseases. Optimal adherence to medication is crucial for achieving treatment goals and preventing adverse outcomes in chronic diseases. The review examines specific conditions such as type 2 diabetes, hypercholesterolemia, arterial hypertension, cardiovascular diseases, and heart failure. In type 2 diabetes, female sex, younger age, new drug prescription, non-white ethnicity, low education level, and low income were identified as predictors of non-adherence. Depressive disorders were also found to influence adherence. In hypercholesterolemia, women exhibited poorer adherence to statin therapy compared to men, with statin-related side effects and patient perception being significant factors. Adherence to anti-hypertensive therapy showed conflicting results, with studies reporting both higher and lower adherence in women. Limited evidence suggests that women may have poorer adherence after acute myocardial infarction and stroke. Regarding heart failure, adherence studies have shown inconsistent findings. The reasons for gender differences in medication adherence are multifactorial and include sociodemographic, disease-related, treatment-related, and psychological factors. This review emphasizes the need for further research to better understand these differences and develop gender-customized interventions that can improve medication adherence and reduce the burden of metabolic and cardiovascular diseases.
Collapse
Affiliation(s)
- Vittorio Venditti
- Department of Experimental Medicine, “Sapienza” University of Rome, Viale Regina Elena 324, 00161 Rome, Italy; (V.V.); (E.B.); (S.M.)
| | - Enrico Bleve
- Department of Experimental Medicine, “Sapienza” University of Rome, Viale Regina Elena 324, 00161 Rome, Italy; (V.V.); (E.B.); (S.M.)
| | - Susanna Morano
- Department of Experimental Medicine, “Sapienza” University of Rome, Viale Regina Elena 324, 00161 Rome, Italy; (V.V.); (E.B.); (S.M.)
| | - Tiziana Filardi
- Department of Human Sciences and Promotion of the Quality of Life, San Raffaele Roma Open University, Via di Val Cannuta, 247, 00166 Rome, Italy
| |
Collapse
|
14
|
Andersson NW, Corn G, Dohlmann TL, Melbye M, Wohlfahrt J, Lund M. LDL-C Reduction With Lipid-Lowering Therapy for Primary Prevention of Major Vascular Events Among Older Individuals. J Am Coll Cardiol 2023; 82:1381-1391. [PMID: 37758432 DOI: 10.1016/j.jacc.2023.07.027] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/15/2023] [Accepted: 07/24/2023] [Indexed: 10/03/2023]
Abstract
BACKGROUND Reducing low-density lipoprotein (LDL) cholesterol with lipid-lowering therapy has consistently been shown to lower the risk of cardiovascular disease in primary prevention trials where the majority of individuals are aged <70 years. For older individuals, however, evidence is less clear. OBJECTIVES In this study, the authors sought to compare the clinical effectiveness of lowering LDL cholesterol by means of lipid-lowering therapy for primary prevention of cardiovascular disease among older and younger individuals in a Danish nationwide cohort. METHODS We included individuals aged ≥50 years who had initiated lipid-lowering therapy from January 1, 2008, to October 31, 2017, had no history of atherosclerotic cardiovascular disease, and had a baseline and a within-1-year LDL cholesterol measurement. We assessed the associated risk of major vascular events among older individuals (≥70 years) by HRs per 1 mmol/L reduction in LDL cholesterol compared with younger individuals (<70 years). RESULTS For both the 16,035 older and the 49,155 younger individuals, the median LDL cholesterol reduction was 1.7 mmol/L. Each 1 mmol/L reduction in LDL cholesterol in older individuals was significantly associated with a 23% lower risk of major vascular events (HR: 0.77; 95% CI: 0.71-0.83), which was equal to that of younger individuals (HR: 0.76; 95% CI: 0.71-0.80; P value for difference = 0.79). Similar results were observed across all secondary analyses. CONCLUSIONS Our study supports a relative clinical benefit of lowering LDL cholesterol for primary prevention of major vascular events in individuals aged ≥70 years similarly as in individuals aged <70 years.
Collapse
Affiliation(s)
| | - Giulia Corn
- Department of Epidemiology Research, Statens Serum Institut, Copenhagen, Denmark; Danish Cancer Institute, Copenhagen, Denmark
| | - Tine Lovsø Dohlmann
- Department of Epidemiology Research, Statens Serum Institut, Copenhagen, Denmark
| | - Mads Melbye
- Danish Cancer Institute, Copenhagen, Denmark; K.G. Jebsen Center for Genetic Epidemiology, Norwegian University of Science and Technology, Trondheim, Norway; Department of Genetics, Stanford University School of Medicine, Stanford, California, USA; Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Jan Wohlfahrt
- Department of Epidemiology Research, Statens Serum Institut, Copenhagen, Denmark; Danish Cancer Institute, Copenhagen, Denmark
| | - Marie Lund
- Department of Epidemiology Research, Statens Serum Institut, Copenhagen, Denmark; Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark; Department of Clinical Pharmacology, Copenhagen University Hospital-Bispebjerg and Frederiksberg, Copenhagen, Denmark
| |
Collapse
|
15
|
Khan SU. The Promise of Primary Prevention in Older Adults. J Am Coll Cardiol 2023; 82:1392-1394. [PMID: 37758433 DOI: 10.1016/j.jacc.2023.08.005] [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: 08/04/2023] [Accepted: 08/07/2023] [Indexed: 10/03/2023]
Affiliation(s)
- Safi U Khan
- Department of Cardiology, Houston Methodist DeBakey Heart and Vascular Center, Houston, Texas, USA.
| |
Collapse
|
16
|
Ogungbe O, Grant JK, Ayoola AS, Bansah E, Miller HN, Plante TB, Sheikhattari P, Commodore-Mensah Y, Turkson-Ocran RAN, Juraschek SP, Martin SS, Lin M, Himmelfarb CR, Michos ED. Strategies for Improving Enrollment of Diverse Populations with a Focus on Lipid-Lowering Clinical Trials. Curr Cardiol Rep 2023; 25:1189-1210. [PMID: 37787858 DOI: 10.1007/s11886-023-01942-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/13/2023] [Indexed: 10/04/2023]
Abstract
PURPOSE OF REVIEW We review under-representation of key demographic groups in cardiovascular clinical trials, focusing on lipid-lowering trials. We outline multilevel strategies to recruit and retain diverse populations in cardiovascular trials. RECENT FINDINGS Barriers to participation in trials occur at the study, participant, health system, sponsor, and policy level, requiring a multilevel approach to effectively increase participation of under-represented groups in research. Increasing the representation of marginalized and under-represented groups in leadership positions in clinical trials can ensure that their perspectives and experiences are considered. Trial design should prioritize patient- and community-indicated needs. Women and individuals from racially/ethnically diverse populations remain under-represented in lipid-lowering and other cardiovascular clinical trials relative to their disease burden in the population. This limits the generalizability of trial results to the broader population in clinical practice. Collaboration between community stakeholders, researchers, and community members can facilitate shared learning about trials and build trust.
Collapse
Affiliation(s)
- Oluwabunmi Ogungbe
- Johns Hopkins University School of Nursing, Baltimore, MD, USA
- Division of Cardiology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Jelani K Grant
- Division of Cardiology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
- Ciccarone Center for the Prevention of Cardiovascular Disease, Division of Cardiology, Department of Medicine, Johns Hopkins University School of Medicine, 600 N. Wolfe Street, Blalock 524-B, Baltimore, MD, 21287, USA
| | | | - Eyram Bansah
- Department of Epidemiology, Johns Hopkins University Bloomberg School of Public Health, Baltimore, MD, USA
| | - Hailey N Miller
- Johns Hopkins University School of Nursing, Baltimore, MD, USA
| | - Timothy B Plante
- Department of Medicine, Larner College of Medicine at the University of Vermont, Burlington, VT, USA
| | - Payam Sheikhattari
- School of Community Health & Policy, Morgan State University, Baltimore, MD, 21251, USA
- Prevention Sciences Research Center, Morgan State University, Baltimore, MD, 21251, USA
| | - Yvonne Commodore-Mensah
- Johns Hopkins University School of Nursing, Baltimore, MD, USA
- Department of Epidemiology, Johns Hopkins University Bloomberg School of Public Health, Baltimore, MD, USA
| | - Ruth-Alma N Turkson-Ocran
- Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
| | - Stephen P Juraschek
- Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
| | - Seth S Martin
- Division of Cardiology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
- Department of Epidemiology, Johns Hopkins University Bloomberg School of Public Health, Baltimore, MD, USA
- Ciccarone Center for the Prevention of Cardiovascular Disease, Division of Cardiology, Department of Medicine, Johns Hopkins University School of Medicine, 600 N. Wolfe Street, Blalock 524-B, Baltimore, MD, 21287, USA
| | | | - Cheryl R Himmelfarb
- Johns Hopkins University School of Nursing, Baltimore, MD, USA
- Division of General Internal Medicine, Johns Hopkins School of Medicine, Baltimore, MD, USA
- Department of Health, Behavior and Society, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Erin D Michos
- Division of Cardiology, Johns Hopkins University School of Medicine, Baltimore, MD, USA.
- Department of Epidemiology, Johns Hopkins University Bloomberg School of Public Health, Baltimore, MD, USA.
- Ciccarone Center for the Prevention of Cardiovascular Disease, Division of Cardiology, Department of Medicine, Johns Hopkins University School of Medicine, 600 N. Wolfe Street, Blalock 524-B, Baltimore, MD, 21287, USA.
| |
Collapse
|
17
|
Matyas C, Trojnar E, Zhao S, Arif M, Mukhopadhyay P, Kovacs A, Fabian A, Tokodi M, Bagyura Z, Merkely B, Kohidai L, Lajko E, Takacs A, He Y, Gao B, Paloczi J, Lohoff FW, Haskó G, Ding WX, Pacher P. PCSK9, A Promising Novel Target for Age-Related Cardiovascular Dysfunction. JACC Basic Transl Sci 2023; 8:1334-1353. [PMID: 38094682 PMCID: PMC10715889 DOI: 10.1016/j.jacbts.2023.06.005] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/01/2023] [Revised: 06/26/2023] [Accepted: 06/27/2023] [Indexed: 12/29/2023]
Abstract
Cardiovascular diseases (CVDs) are the leading cause of death among elderly people. Proprotein convertase subtilisin/kexin type 9 (PCSK9) is an important regulator of cholesterol metabolism. Herein, we investigated the role of PCSK9 in age-related CVD. Both in humans and rats, blood PCSK9 level correlated positively with increasing age and the development of cardiovascular dysfunction. Age-related fatty degeneration of liver tissue positively correlated with serum PCSK9 levels in the rat model, while development of age-related nonalcoholic fatty liver disease correlated with cardiovascular functional impairment. Network analysis identified PCSK9 as an important factor in age-associated lipid alterations and it correlated positively with intima-media thickness, a clinical parameter of CVD risk. PCSK9 inhibition with alirocumab effectively reduced the CVD progression in aging rats, suggesting that PCSK9 plays an important role in cardiovascular aging.
Collapse
Affiliation(s)
- Csaba Matyas
- Laboratory of Cardiovascular Physiology and Tissue Injury, National Institute on Alcohol Abuse and Alcoholism, National Institutes of Health, Bethesda, Maryland, USA
- Department of Medical Imaging, Medical School, University of Pécs, Pécs, Hungary
| | - Eszter Trojnar
- Laboratory of Cardiovascular Physiology and Tissue Injury, National Institute on Alcohol Abuse and Alcoholism, National Institutes of Health, Bethesda, Maryland, USA
| | - Suxian Zhao
- Laboratory of Cardiovascular Physiology and Tissue Injury, National Institute on Alcohol Abuse and Alcoholism, National Institutes of Health, Bethesda, Maryland, USA
| | - Muhammad Arif
- Laboratory of Cardiovascular Physiology and Tissue Injury, National Institute on Alcohol Abuse and Alcoholism, National Institutes of Health, Bethesda, Maryland, USA
| | - Partha Mukhopadhyay
- Laboratory of Cardiovascular Physiology and Tissue Injury, National Institute on Alcohol Abuse and Alcoholism, National Institutes of Health, Bethesda, Maryland, USA
| | - Attila Kovacs
- Heart and Vascular Center, Semmelweis University, Budapest, Hungary
| | - Alexandra Fabian
- Heart and Vascular Center, Semmelweis University, Budapest, Hungary
| | - Marton Tokodi
- Heart and Vascular Center, Semmelweis University, Budapest, Hungary
| | - Zsolt Bagyura
- Heart and Vascular Center, Semmelweis University, Budapest, Hungary
| | - Bela Merkely
- Heart and Vascular Center, Semmelweis University, Budapest, Hungary
| | - Laszlo Kohidai
- Department of Genetics, Cell and Immunobiology, Semmelweis University, Budapest, Hungary
| | - Eszter Lajko
- Department of Genetics, Cell and Immunobiology, Semmelweis University, Budapest, Hungary
| | - Angela Takacs
- Department of Genetics, Cell and Immunobiology, Semmelweis University, Budapest, Hungary
| | - Yong He
- Laboratory of Liver Diseases, National Institute on Alcohol Abuse and Alcoholism, National Institutes of Health, Bethesda, Maryland, USA
| | - Bin Gao
- Laboratory of Liver Diseases, National Institute on Alcohol Abuse and Alcoholism, National Institutes of Health, Bethesda, Maryland, USA
| | - Janos Paloczi
- Laboratory of Cardiovascular Physiology and Tissue Injury, National Institute on Alcohol Abuse and Alcoholism, National Institutes of Health, Bethesda, Maryland, USA
| | - Falk W. Lohoff
- Section on Clinical Genomics and Experimental Therapeutics, National Institute on Alcohol Abuse and Alcoholism, National Institutes of Health, Bethesda, Maryland, USA
| | - György Haskó
- Department of Anesthesiology, Columbia University, New York, New York, USA
| | - Wen-Xing Ding
- Department of Pharmacology, Toxicology and Therapeutics, University of Kansas Medical Center, Kansas City, Kansas, USA
- Department of Internal Medicine, University of Kansas Medical Center, Kansas City, Kansas, USA
| | - Pal Pacher
- Laboratory of Cardiovascular Physiology and Tissue Injury, National Institute on Alcohol Abuse and Alcoholism, National Institutes of Health, Bethesda, Maryland, USA
| |
Collapse
|
18
|
Azizi Z, Adedinsewo D, Rodriguez F, Lewey J, Merchant RM, Brewer LC. Leveraging Digital Health to Improve the Cardiovascular Health of Women. CURRENT CARDIOVASCULAR RISK REPORTS 2023; 17:205-214. [PMID: 37868625 PMCID: PMC10587029 DOI: 10.1007/s12170-023-00728-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/29/2023] [Indexed: 10/24/2023]
Abstract
Purpose of Review In this review, we present a comprehensive discussion on the population-level implications of digital health interventions (DHIs) to improve cardiovascular health (CVH) through sex- and gender-specific prevention strategies among women. Recent Findings Over the past 30 years, there have been significant advancements in the diagnosis and treatment of cardiovascular diseases, a leading cause of morbidity and mortality among men and women worldwide. However, women are often underdiagnosed, undertreated, and underrepresented in cardiovascular clinical trials, which all contribute to disparities within this population. One approach to address this is through DHIs, particularly among racial and ethnic minoritized groups. Implementation of telemedicine has shown promise in increasing adherence to healthcare visits, improving BP monitoring, weight control, physical activity, and the adoption of healthy behaviors. Furthermore, the use of mobile health applications facilitated by smart devices, wearables, and other eHealth (defined as electronically delivered health services) modalities has also promoted CVH among women in general, as well as during pregnancy and the postpartum period. Overall, utilizing a digital health approach for healthcare delivery, decentralized clinical trials, and incorporation into daily lifestyle activities has the potential to improve CVH among women by mitigating geographical, structural, and financial barriers to care. Summary Leveraging digital technologies and strategies introduces novel methods to address sex- and gender-specific health and healthcare disparities and improve the quality of care provided to women. However, it is imperative to be mindful of the digital divide in specific populations, which may hinder accessibility to these novel technologies and inadvertently widen preexisting inequities.
Collapse
Affiliation(s)
- Zahra Azizi
- Center for Digital Health, Stanford University, Stanford, CA USA
- Department of Cardiovascular Medicine and the Cardiovascular Institute, Stanford University, Stanford, CA USA
| | | | - Fatima Rodriguez
- Department of Cardiovascular Medicine and the Cardiovascular Institute, Stanford University, Stanford, CA USA
| | - Jennifer Lewey
- Department of Medicine, Division of Cardiology, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA USA
| | - Raina M. Merchant
- Center for Digital Health, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA USA
| | - LaPrincess C. Brewer
- Department of Cardiovascular Medicine, Mayo Clinic College of Medicine, Rochester, MN USA
- Center for Health Equity and Community Engagement Research, Mayo Clinic, Rochester, MN USA
| |
Collapse
|
19
|
Aslam FN, Manochakian R, Lou Y, Colon‐Otero G, Sher T. Trends in participant race and sex reporting in lung cancer phase III clinical trials. Cancer Rep (Hoboken) 2023; 6 Suppl 1:e1856. [PMID: 37421166 PMCID: PMC10440837 DOI: 10.1002/cnr2.1856] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2023] [Revised: 06/09/2023] [Accepted: 06/12/2023] [Indexed: 07/09/2023] Open
Abstract
BACKGROUND Clinical trials are an essential part of advancing care for cancer patients. Historically, however, racial minorities and females have been underrepresented in these trials. Efforts like the National Institute of Health Revitalization Act attempted to mitigate these disparities, but despite these efforts, they continue to exist. These disparities can subsequently lead to minorities and females receiving suboptimal care. AIMS The purpose of our study was to understand the changing trends in reporting of participant race and sex as a demographic variable in phase III lung cancer clinical trials published over the last 35 years given these consequences of poor representation. METHODS AND RESULTS A total of 426 articles reporting the results of phase III lung cancer clinical trials published from 1984 to 2019 were identified in PubMed. From these articles, data on participant sex and race were collected from the demographic tables to construct the database for this study. This database was subsequently used to determine the rate of reporting of demographic factors like race and sex and the participation trends over the time of minority and female participation in lung cancer phase III clinical trials. The SciPy Stats package for Python was used to calculate descriptive statistics, 95% confidence intervals, two sample t-test, one-way analysis of variance test, and Pearson's correlation coefficients. The Matplotlib package for Python was used for figure generation. Only 137 (32.2%) of the 426 studies analyzed reported the race of participants. Among those studies, we found that the mean participation rate of White participants was significantly higher (82.65%; p < .001). We found a decrease in African American participants and an increase in Asian participants over time. When looking at sex, we found that although the rate of male participation (69.02%) was significantly higher than that of female participation (30.98%), female participation has improved with time at a rate of 0.65% per year. CONCLUSION We found that the reporting and participation of minority races continue to lag that of other demographic factors like sex in phase III clinical trials in lung cancer. Based on our analysis, we note a decline in participation of African Americans in lung cancer phase III clinical trials despite the rising incidence of lung cancer.
Collapse
Affiliation(s)
- Faaiq N. Aslam
- Mayo Clinic Alix School of MedicineJacksonvilleFloridaUSA
| | | | - Yanyan Lou
- Mayo Clinic FloridaJacksonvilleFloridaUSA
| | | | | |
Collapse
|
20
|
Khoja A, Andraweera PH, Lassi ZS, Ali A, Zheng M, Pathirana MM, Aldridge E, Wittwer MR, Chaudhuri DD, Tavella R, Arstall MA. Risk Factors for Premature Coronary Heart Disease in Women Compared to Men: Systematic Review and Meta-Analysis. J Womens Health (Larchmt) 2023; 32:908-920. [PMID: 37184900 DOI: 10.1089/jwh.2022.0517] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/16/2023] Open
Abstract
Background: We aimed to systematically examine literature on the prevalence of known modifiable and nonmodifiable risk factors for premature coronary heart disease (PCHD) in women compared with men. Materials and Methods: PubMed, CINAHL, Embase, and Web of Science databases were searched. Review protocol is registered in PROSPERO (CRD42020173216). Quality was assessed using the National Heart, Lung, and Blood Institute tool. Review Manager 5.3 was used for meta-analysis. Effect sizes were expressed as odds ratio (OR) and mean differences/standardized mean differences (SMD) with 95% confidence intervals (CIs) for categorical and continuous variables. Results: In this PCHD cohort (age <65 years), the mean age of presentation in women was 3 years older than men. Women had higher total cholesterol (SMD 0.11; 95% CI 0.00 to 0.23) and higher high-density lipoprotein cholesterol (SMD 0.49; 95% CI 0.29 to 0.69). Women were more likely to have hypertension (OR 1.51, 95% CI 1.42 to 1.60), diabetes mellitus (OR 1.78, 95% CI 1.55 to 2.04), obesity (OR 1.33, 95% CI 1.24 to 1.42), metabolic syndrome (OR 3.73, 95% CI 1.60 to 8.69), stroke (OR 1.63, 95% CI 1.51 to 1.77), peripheral vascular disorder (OR 1.67, 95% CI 1.43 to 1.96), and depression (OR 2.29, 95% CI 1.96 to 2.67). Women were less likely to be smokers (OR 0.60, 95% CI 0.55 to 0.66), have reported alcohol intake (OR 0.36, 95% CI 0.33 to 0.40), and reported use of illicit drug (OR 0.32, 95% CI 0.16 to 0.62). Conclusions: Risk factor profile in PCHD has a clear sex difference that supports early, aggressive, holistic, but sex-specific, approach to prevention.
Collapse
Affiliation(s)
- Adeel Khoja
- Adelaide Medical School, Faculty of Health and Medical Sciences, The University of Adelaide, Adelaide, South Australia, Australia
- The Robinson Research Institute, The University of Adelaide, Adelaide, South Australia, Australia
- Cardiology Unit, Northern Adelaide Local Health Network, Adelaide, South Australia, Australia
| | - Prabha H Andraweera
- Adelaide Medical School, Faculty of Health and Medical Sciences, The University of Adelaide, Adelaide, South Australia, Australia
- The Robinson Research Institute, The University of Adelaide, Adelaide, South Australia, Australia
- Cardiology Unit, Northern Adelaide Local Health Network, Adelaide, South Australia, Australia
| | - Zohra S Lassi
- Adelaide Medical School, Faculty of Health and Medical Sciences, The University of Adelaide, Adelaide, South Australia, Australia
- The Robinson Research Institute, The University of Adelaide, Adelaide, South Australia, Australia
| | - Anna Ali
- Adelaide Medical School, Faculty of Health and Medical Sciences, The University of Adelaide, Adelaide, South Australia, Australia
- The Robinson Research Institute, The University of Adelaide, Adelaide, South Australia, Australia
| | - Mingyue Zheng
- Adelaide Medical School, Faculty of Health and Medical Sciences, The University of Adelaide, Adelaide, South Australia, Australia
- School of Health and Rehabilitation, Chengdu University of Traditional Chinese Medicine, Chengdu, China
| | - Maleesa M Pathirana
- Adelaide Medical School, Faculty of Health and Medical Sciences, The University of Adelaide, Adelaide, South Australia, Australia
- The Robinson Research Institute, The University of Adelaide, Adelaide, South Australia, Australia
- Cardiology Unit, Northern Adelaide Local Health Network, Adelaide, South Australia, Australia
| | - Emily Aldridge
- Adelaide Medical School, Faculty of Health and Medical Sciences, The University of Adelaide, Adelaide, South Australia, Australia
- The Robinson Research Institute, The University of Adelaide, Adelaide, South Australia, Australia
- Cardiology Unit, Northern Adelaide Local Health Network, Adelaide, South Australia, Australia
| | - Melanie R Wittwer
- Adelaide Medical School, Faculty of Health and Medical Sciences, The University of Adelaide, Adelaide, South Australia, Australia
- Cardiology Unit, Northern Adelaide Local Health Network, Adelaide, South Australia, Australia
| | - Debajyoti D Chaudhuri
- Adelaide Medical School, Faculty of Health and Medical Sciences, The University of Adelaide, Adelaide, South Australia, Australia
- Cardiology Unit, Northern Adelaide Local Health Network, Adelaide, South Australia, Australia
| | - Rosanna Tavella
- Adelaide Medical School, Faculty of Health and Medical Sciences, The University of Adelaide, Adelaide, South Australia, Australia
- Department of Cardiology, Basil Hetzel Institute for Translational Health Research, The Queen Elizabeth Hospital, Woodville South, South Australia, Australia
| | - Margaret A Arstall
- Cardiology Unit, Northern Adelaide Local Health Network, Adelaide, South Australia, Australia
- Medical Specialties, Faculty of Health Sciences, The University of Adelaide, Adelaide, South Australia, Australia
| |
Collapse
|
21
|
Baretella O, Alwan H, Feller M, Aubert CE, Del Giovane C, Papazoglou D, Christiaens A, Meinders AJ, Byrne S, Kearney PM, O'Mahony D, Knol W, Boland B, Gencer B, Aujesky D, Rodondi N. Overtreatment and associated risk factors among multimorbid older patients with diabetes. J Am Geriatr Soc 2023; 71:2893-2901. [PMID: 37286338 DOI: 10.1111/jgs.18465] [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: 10/09/2022] [Revised: 04/21/2023] [Accepted: 05/16/2023] [Indexed: 06/09/2023]
Abstract
BACKGROUND In multimorbid older patients with type 2 diabetes mellitus (T2DM), the intensity of glucose-lowering medication (GLM) should be focused on attaining a suitable level of glycated hemoglobin (HbA1c ) while avoiding side effects. We aimed at identifying patients with overtreatment of T2DM as well as associated risk factors. METHODS In a secondary analysis of a multicenter study of multimorbid older patients, we evaluated HbA1c levels among patients with T2DM. Patients were aged ≥70 years, with multimorbidity (≥3 chronic diagnoses) and polypharmacy (≥5 chronic medications), enrolled in four university medical centers across Europe (Belgium, Ireland, Netherlands, and Switzerland). We defined overtreatment as HbA1c < 7.5% with ≥1 GLM other than metformin, as suggested by Choosing Wisely and used prevalence ratios (PRs) to evaluate risk factors of overtreatment in age- and sex-adjusted analyses. RESULTS Among the 564 patients with T2DM (median age 78 years, 39% women), mean ± standard deviation HbA1c was 7.2 ± 1.2%. Metformin (prevalence 51%) was the most frequently prescribed GLM and 199 (35%) patients were overtreated. The presence of severe renal impairment (PR 1.36, 1.21-1.53) and outpatient physician (other than general practitioner [GP], i.e. specialist) or emergency department visits (PR 1.22, 1.03-1.46 for 1-2 visits, and PR 1.35, 1.19-1.54 for ≥3 visits versus no visits) were associated with overtreatment. These factors remained associated with overtreatment in multivariable analyses. CONCLUSIONS In this multicountry study of multimorbid older patients with T2DM, more than one third were overtreated, highlighting the high prevalence of this problem. Careful balancing of benefits and risks in the choice of GLM may improve patient care, especially in the context of comorbidities such as severe renal impairment, and frequent non-GP healthcare contacts.
Collapse
Affiliation(s)
- Oliver Baretella
- Institute of Primary Health Care (BIHAM), University of Bern, Bern, Switzerland
- Department of General Internal Medicine, Inselspital, Bern University Hospital, Bern, Switzerland
| | - Heba Alwan
- Institute of Primary Health Care (BIHAM), University of Bern, Bern, Switzerland
- Graduate School for Health Sciences, University of Bern, Bern, Switzerland
| | - Martin Feller
- Institute of Primary Health Care (BIHAM), University of Bern, Bern, Switzerland
- Department of General Internal Medicine, Inselspital, Bern University Hospital, Bern, Switzerland
| | - Carole E Aubert
- Institute of Primary Health Care (BIHAM), University of Bern, Bern, Switzerland
- Department of General Internal Medicine, Inselspital, Bern University Hospital, Bern, Switzerland
| | - Cinzia Del Giovane
- Institute of Primary Health Care (BIHAM), University of Bern, Bern, Switzerland
| | - Dimitrios Papazoglou
- Institute of Primary Health Care (BIHAM), University of Bern, Bern, Switzerland
- Department of General Internal Medicine, Inselspital, Bern University Hospital, Bern, Switzerland
| | - Antoine Christiaens
- Institut Pierre Louis d'Epidémiologie et de Santé Publique, Sorbonne Université, INSERM, Paris, France
- Clinical Pharmacy research group, Louvain Drug Research Institute (LDRI), Université catholique de Louvain, Brussels, Belgium
| | - Arend-Jan Meinders
- Department of Internal Medicine, St Antonius Hospital, Nieuwegein, the Netherlands
| | - Stephen Byrne
- School of Pharmacy, University College Cork - National University of Ireland, Cork, Republic of Ireland
| | - Patricia M Kearney
- School of Public Health, University College Cork, Cork, Republic of Ireland
- Department of Medicine Cork, University College Cork - National University of Ireland, Cork, Republic of Ireland
| | - Denis O'Mahony
- Department of Medicine Cork, University College Cork - National University of Ireland, Cork, Republic of Ireland
- Department of Geriatric Medicine Cork, Cork University Hospital Group, Cork, Republic of Ireland
| | - Wilma Knol
- Department of Geriatrics and Expertise Centre Pharmacotherapy in Old Persons (EPHOR), University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands
| | - Benoît Boland
- Clinical Pharmacy research group, Louvain Drug Research Institute (LDRI), Université catholique de Louvain, Brussels, Belgium
- Department of Geriatric Medicine, Cliniques universitaires Saint-Luc, Université catholique de Louvain, Brussels, Belgium
| | - Baris Gencer
- Institute of Primary Health Care (BIHAM), University of Bern, Bern, Switzerland
- Service de cardiologie, Hôpitaux Universitaires de Genève (HUG), Geneva, Switzerland
| | - Drahomir Aujesky
- Department of General Internal Medicine, Inselspital, Bern University Hospital, Bern, Switzerland
| | - Nicolas Rodondi
- Institute of Primary Health Care (BIHAM), University of Bern, Bern, Switzerland
- Department of General Internal Medicine, Inselspital, Bern University Hospital, Bern, Switzerland
| |
Collapse
|
22
|
Assadpour E, Van Spall HGC. Pregnant and lactating women should be included in clinical trials for cardiovascular disease. Nat Med 2023; 29:1897-1899. [PMID: 37365348 DOI: 10.1038/s41591-023-02416-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/28/2023]
Affiliation(s)
- Elnaz Assadpour
- Schulich School of Medicine and Dentistry, Western University, London, Ontario, Canada
| | - 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, St. Joseph's Healthcare Hamilton, Hamilton, Ontario, Canada.
| |
Collapse
|
23
|
Thynne TR, Gabb GM. Limitations of randomised controlled trials as evidence of drug safety. Aust Prescr 2023; 46:22-23. [PMID: 38053569 PMCID: PMC10664096 DOI: 10.18773/austprescr.2023.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/07/2023] Open
Affiliation(s)
- Tilenka Rj Thynne
- Division of Medicine, Cardiac and Critical Care, Flinders Medical Centre, Bedford Park, South Australia
- College of Medicine and Public Health, Flinders University, Bedford Park, South Australia
| | - Genevieve M Gabb
- Division of Medicine, Cardiac and Critical Care, Flinders Medical Centre, Bedford Park, South Australia
- College of Medicine and Public Health, Flinders University, Bedford Park, South Australia
- Acute and Urgent Care, Royal Adelaide Hospital
- Discipline of Medicine, School of Medicine, Faculty of Health Science, University of Adelaide
| |
Collapse
|
24
|
Sandek A, Hasenfuß G. [Gender-specific differences in cardiology]. INNERE MEDIZIN (HEIDELBERG, GERMANY) 2023; 64:727-735. [PMID: 36456657 DOI: 10.1007/s00108-022-01437-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 10/26/2022] [Indexed: 12/05/2022]
Abstract
BACKGROUND Evidence in cardiovascular patient care is currently skewed to the disadvantage of women. This article provides a summary of the current state of knowledge on gender differences with a special focus on the epidemiology, pathophysiology, risk factors and treatment of the most frequent cardiovascular diseases. MATERIAL AND METHODS Evaluation and discussion of background research and expert recommendations. RESULTS The necessity for a gender-specific analysis of results is a relatively recent development in clinical trials. There is increasing evidence for pathogenic mechanisms specific for women as well as pharmacodynamic and pharmacokinetic differences between women and men. Women are currently less likely to receive treatment for cardiac diseases according to medical guidelines than men. CONCLUSION For improvement of the treatment options and effective disease prevention, it is pivotal to investigate pathogenetic mechanisms specific to women.
Collapse
Affiliation(s)
- Anja Sandek
- Herzzentrum Göttingen, Klinik für Kardiologie und Pneumologie, Universitätsmedizin Göttingen, Georg-August-Universität, Robert-Koch-Str. 40, 37075, Göttingen, Deutschland.
- Deutsches Zentrum für Herz-Kreislauf-Forschung, Standort Göttingen, Göttingen, Deutschland.
| | - Gerd Hasenfuß
- Herzzentrum Göttingen, Klinik für Kardiologie und Pneumologie, Universitätsmedizin Göttingen, Georg-August-Universität, Robert-Koch-Str. 40, 37075, Göttingen, Deutschland.
- Deutsches Zentrum für Herz-Kreislauf-Forschung, Standort Göttingen, Göttingen, Deutschland.
| |
Collapse
|
25
|
Garrison SR, Youngson E, Perry DA, Campbell FN, Kolber MR, Korownyk C, Allan GM, Green L, Bakal J. Bedtime versus morning use of antihypertensives in frail continuing care residents (BedMed-Frail): protocol for a prospective, randomised, open-label, blinded end-point pragmatic trial. BMJ Open 2023; 13:e074777. [PMID: 37527898 PMCID: PMC10394547 DOI: 10.1136/bmjopen-2023-074777] [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] [Indexed: 08/03/2023] Open
Abstract
INTRODUCTION BedMed-Frail explores risks and benefits of switching antihypertensives from morning to bedtime in a frail population at greater risk of hypotensive adverse effects. METHODS AND ANALYSIS Design: Prospective parallel randomised, open-label, blinded end-point trial.Participants: Hypertensive continuing care residents, in either long-term care or supportive living, who are free from glaucoma, and using ≥1 once daily antihypertensive.Setting: 16 volunteer continuing care facilities in Alberta, Canada, with eligible residents identified using electronic health claims data.Intervention: All non-opted out eligible residents are randomised centrally by the provincial health data steward to bedtime versus usual care (typically morning) administration of once daily antihypertensives. Timing changes are made (maximum one change per week) by usual care facility pharmacists.Follow-up: Via linked governmental healthcare databases tracking hospital, continuing care and community medical services.Primary outcome: Composite of all-cause death, or hospitalisation for myocardial infarction/acute-coronary syndrome, stroke, or congestive heart failure.Secondary outcomes: Each primary outcome element on its own, all-cause unplanned hospitalisation or emergency department visit, non-vertebral fracture and, as assessed roughly 135 days postrandomisation, fall in the last 30 days, deteriorated cognition, urinary incontinence, decubitus skin ulceration, inappropriate or disruptive behaviour a minimum of 4 days per week, and receipt of antipsychotic medication or physical restraints in the last 7 days.Process outcome: Proportion of blood pressure medication doses taken at bedtime (broken down monthly).Primary outcome analysis: Cox-Proportional Hazards Survival Analysis.Sample size: The trial will continue until a projected 368 primary outcome events have occurred.Current status: Enrolment is ongoing with 642 randomisations to date (75% female, mean age 88 years). ETHICS AND DISSEMINATION BedMed-Frail has ethical approval from the University of Alberta Health Ethics Review Board (Pro00086129) and will publish results in a peer-reviewed journal. TRIAL REGISTRATION NUMBER NCT04054648.
Collapse
Affiliation(s)
- Scott R Garrison
- Family Medicine, University of Alberta Faculty of Medicine & Dentistry, Edmonton, Alberta, Canada
- Pragmatic Trials Collaborative, University of Alberta Faculty of Medicine & Dentistry, Edmonton, Alberta, Canada
| | - Erik Youngson
- Provincial Research Data Services, Alberta Health Services, Edmonton, Alberta, Canada
| | - Danielle A Perry
- Pragmatic Trials Collaborative, University of Alberta Faculty of Medicine & Dentistry, Edmonton, Alberta, Canada
- Programs and Practice Support, College of Family Physicians of Canada, Mississauga, Alberta, Canada
| | - Farah N Campbell
- Pragmatic Trials Collaborative, University of Alberta Faculty of Medicine & Dentistry, Edmonton, Alberta, Canada
| | - Michael R Kolber
- Family Medicine, University of Alberta Faculty of Medicine & Dentistry, Edmonton, Alberta, Canada
- Pragmatic Trials Collaborative, University of Alberta Faculty of Medicine & Dentistry, Edmonton, Alberta, Canada
| | - Christina Korownyk
- Family Medicine, University of Alberta Faculty of Medicine & Dentistry, Edmonton, Alberta, Canada
- Pragmatic Trials Collaborative, University of Alberta Faculty of Medicine & Dentistry, Edmonton, Alberta, Canada
| | - Gary Michael Allan
- Pragmatic Trials Collaborative, University of Alberta Faculty of Medicine & Dentistry, Edmonton, Alberta, Canada
- Programs and Practice Support, College of Family Physicians of Canada, Mississauga, Alberta, Canada
| | - Lee Green
- Family Medicine, University of Alberta Faculty of Medicine & Dentistry, Edmonton, Alberta, Canada
- Pragmatic Trials Collaborative, University of Alberta Faculty of Medicine & Dentistry, Edmonton, Alberta, Canada
| | - Jeffrey Bakal
- Provincial Research Data Services, Alberta Health Services, Edmonton, Alberta, Canada
| |
Collapse
|
26
|
Kazzi B, Shankar B, Elder-Odame P, Tokgözoğlu LS, Sierra-Galan LM, Michos ED. A Woman's Heart: Improving Uptake and Awareness of Cardiovascular Screening for Middle-Aged Populations. Int J Womens Health 2023; 15:1171-1183. [PMID: 37520181 PMCID: PMC10377626 DOI: 10.2147/ijwh.s328441] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2023] [Accepted: 07/11/2023] [Indexed: 08/01/2023] Open
Abstract
Mid-life, the years leading up to and following the menopause transition, in women is accompanied by a change in cardiometabolic risk factors, including increases in body weight, changes in body composition, a more insulin-resistant state, and a shift towards a more atherogenic dyslipidemia pattern. Cardiovascular disease (CVD) risk assessment should be performed continually throughout the lifespan, as risk is not stagnant and can change throughout the life course. However, mid-life is a particularly important time for a woman to be evaluated for CVD risk so that appropriate preventive strategies can be implemented. Along with assessing traditional risk factors, ascertainment of a reproductive history is an integral part of a comprehensive CVD risk assessment to recognize unique female-specific or female-predominant factors that modify a woman's risk. When there is uncertainty about CVD risk and the net benefit of preventive pharmacotherapy interventions (such as statins), measuring a coronary artery calcium score can help further refine risk and guide shared decision-making. Additionally, there should be heightened sensitivity around identifying signs and symptoms of ischemic heart disease in women, as these may present differently than in men. Ischemia from coronary microvascular disease and/or vasospasm may be present even without obstructive coronary artery disease and is associated with a heightened risk for major cardiovascular events and reduced quality of life. Therefore, correctly identifying CVD in women and implementing preventive and treatment therapies is paramount. Unfortunately, women are underrepresented in cardiovascular clinical trials, and more data are needed about how to best incorporate novel and emerging risk factors into CVD risk assessment. This review outlines an approach to CVD screening and risk assessment in women using several methods, focusing on the middle-aged population.
Collapse
Affiliation(s)
- Brigitte Kazzi
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Bairavi Shankar
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Petal Elder-Odame
- Department of Medicine, Division of Cardiology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Lale S Tokgözoğlu
- Department of Cardiology, Hacettepe University Faculty of Medicine, Ankara, Turkey
| | - Lilia M Sierra-Galan
- Cardiology Department of the Cardiovascular Division, American British Cowdray Medical Center, Mexico City, Mexico
| | - Erin D Michos
- Department of Medicine, Division of Cardiology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| |
Collapse
|
27
|
Perera ND, Bellomo TR, Schmidt WM, Litt HK, Shyu M, Stavins MA, Wang MM, Bell A, Saleki M, Wolf KI, Ionescu R, Tao JJ, Ji S, O’Keefe RM, Pun M, Takasugi JM, Steinberg JR, Go RS, Turner BE, Mahipal A. Analysis of Female Participant Representation in Registered Oncology Clinical Trials in the United States from 2008 to 2020. Oncologist 2023; 28:510-519. [PMID: 36848266 PMCID: PMC10243778 DOI: 10.1093/oncolo/oyad009] [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: 06/20/2022] [Accepted: 12/20/2022] [Indexed: 03/01/2023] Open
Abstract
BACKGROUND Female underrepresentation in oncology clinical trials can result in outcome disparities. We evaluated female participant representation in US oncology trials by intervention type, cancer site, and funding. MATERIALS AND METHODS Data were extracted from the publicly available Aggregate Analysis of ClinicalTrials.gov database. Initially, 270,172 studies were identified. Following the exclusion of trials using Medical Subject Heading terms, manual review, those with incomplete status, non-US location, sex-specific organ cancers, or lacking participant sex data, 1650 trials consisting of 240,776 participants remained. The primary outcome was participation to prevalence ratio (PPR): percent females among trial participants divided by percent females in the disease population per US Surveillance, Epidemiology, and End Results Program data. PPRs of 0.8-1.2 reflect proportional female representation. RESULTS Females represented 46.9% of participants (95% CI, 45.4-48.4); mean PPR for all trials was 0.912. Females were underrepresented in surgical (PPR 0.74) and other invasive (PPR 0.69) oncology trials. Among cancer sites, females were underrepresented in bladder (odds ratio [OR] 0.48, 95% CI 0.26-0.91, P = .02), head/neck (OR 0.44, 95% CI 0.29-0.68, P < .01), stomach (OR 0.40, 95% CI 0.23-0.70, P < .01), and esophageal (OR 0.40 95% CI 0.22-0.74, P < .01) trials. Hematologic (OR 1.78, 95% CI 1.09-1.82, P < .01) and pancreatic (OR 2.18, 95% CI 1.46-3.26, P < .01) trials had higher odds of proportional female representation. Industry-funded trials had greater odds of proportional female representation (OR 1.41, 95% CI 1.09-1.82, P = .01) than US government and academic-funded trials. CONCLUSIONS Stakeholders should look to hematologic, pancreatic, and industry-funded cancer trials as exemplars of female participant representation and consider female representation when interpreting trial results.
Collapse
Affiliation(s)
| | - Tiffany R Bellomo
- Department of Vascular Surgery, Massachusetts General Hospital Harvard Medical Center, Boston, MA, USA
| | | | - Henry K Litt
- Department of Medicine, University of California San Francisco, San Francisco, CA, USA
| | - Margaret Shyu
- Department of Medicine, Mount Sinai, New York, NY, USA
| | | | - Max M Wang
- Feinberg School of Medicine, Northwestern, Chicago, IL, USA
| | - Alexander Bell
- School of Medicine, University of California San Francisco, San Francisco, CA, USA
| | - Massoud Saleki
- Department of Medicine, University of Vermont, Burlington, VT, USA
| | - Katherine I Wolf
- Department of Medicine, University of Michigan Medical Center, Ann Arbor, MI, USA
| | | | - Jacqueline J Tao
- Department of Medicine, New York-Presbyterian Weill Cornell, New York, NY, USA
| | - Sunjong Ji
- Department of Medicine, University of Michigan Medical Center, Ann Arbor, MI, USA
| | - Ryan M O’Keefe
- Department of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Matthew Pun
- Department of Medicine, University of Michigan Medical Center, Ann Arbor, MI, USA
| | | | - Jecca R Steinberg
- Department of Obstetrics & Gynecology, Northwestern, Chicago, IL, USA
| | - Ronald S Go
- Department of Oncology, Mayo Clinic, Rochester, MN, USA
| | - Brandon E Turner
- Department of Radiation Oncology, Dana Farber Cancer Institute Harvard Medical Center, Boston, MA, USA
| | - Amit Mahipal
- Department of Oncology, Mayo Clinic, Rochester, MN, USA
- Department of Oncology, University Hospitals, Case Western University, Cleveland, OH, USA
| |
Collapse
|
28
|
Broadwin C, Azizi Z, Rodriguez F. Clinical Trial Technologies for Improving Equity and Inclusion in Cardiovascular Clinical Research. Cardiol Ther 2023; 12:215-225. [PMID: 37043079 PMCID: PMC10090744 DOI: 10.1007/s40119-023-00311-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2023] [Accepted: 03/20/2023] [Indexed: 04/13/2023] Open
Abstract
Approximately one-third of clinical trials fail to meet their recruitment goals, which can cause costly delays to sponsors and compromise the scientific integrity and generalizability of a trial. Inadequate recruitment and retention of patient groups who have the disease under investigation may produce insufficient medical knowledge about the therapeutic effects of drugs or products for the population at large. It is essential to address these issues to ensure that certain groups are not unduly subjected to disproportionate risks or denied the benefits of research. This commentary will present opportunities for clinical trialists to use emerging technologies and decentralized approaches to improve clinical trial recruitment, mitigate disparities, and improve individual and population-level outcomes within cardiovascular medicine.
Collapse
Affiliation(s)
- Cassandra Broadwin
- Center for Digital Health, Stanford University School of Medicine, Stanford, CA, USA
| | - Zahra Azizi
- Center for Digital Health, Stanford University School of Medicine, Stanford, CA, USA
| | - Fatima Rodriguez
- Department of Medicine, Center for Academic Medicine, Division of Cardiovascular Medicine and Cardiovascular Institute, Stanford University School of Medicine, 453 Quarry Road, Mail Code 5687, Palo Alto, CA, 94304, USA.
| |
Collapse
|
29
|
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: 10] [Impact Index Per Article: 10.0] [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.
Collapse
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
| |
Collapse
|
30
|
Fogacci F, Borghi C, Cicero AFG. The short-circuit evidence on lipid-lowering drugs use in pregnancy. Atherosclerosis 2023; 368:12-13. [PMID: 36754660 DOI: 10.1016/j.atherosclerosis.2023.01.023] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/19/2023] [Revised: 01/24/2023] [Accepted: 01/26/2023] [Indexed: 01/31/2023]
Affiliation(s)
- Federica Fogacci
- Hypertension and Cardiovascular risk factors Research Center, Medical and Surgical Sciences Department, Alma Mater Studiorum University of Bologna, Bologna, Italy.
| | - Claudio Borghi
- Hypertension and Cardiovascular risk factors Research Center, Medical and Surgical Sciences Department, Alma Mater Studiorum University of Bologna, Bologna, Italy; IRCCS AOU S. Orsola-Malpighi, Bologna, Italy
| | - Arrigo F G Cicero
- Hypertension and Cardiovascular risk factors Research Center, Medical and Surgical Sciences Department, Alma Mater Studiorum University of Bologna, Bologna, Italy; IRCCS AOU S. Orsola-Malpighi, Bologna, Italy
| |
Collapse
|
31
|
Barus R, Bergeron S, Chen Y, Gautier S. Sex differences: From preclinical pharmacology to clinical pharmacology. Therapie 2023; 78:189-194. [PMID: 36302696 DOI: 10.1016/j.therap.2022.10.005] [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: 06/28/2022] [Accepted: 08/29/2022] [Indexed: 11/05/2022]
Abstract
Sex is a crucial variable to take into account in medical research. In this review, we attempted to present its importance at all stages of research and even during drug's post-marketing surveillance. Most preclinical research studies do not take sex into account while many diseases are known to present sexual dimorphism. However, a shift in thinking occurred since the January 2016 implementation of the US Institutes of Health recommendations to take sex into account in research. Nevertheless, in preclinical studies, the lack of sex-based statistical analyses persists. Moreover, in humans, women are often under-represented in some clinical trials, despite well-identified sexual dimorphism. In addition, some pathologies are subject to social representations of diseases considered "male" or "female" which can also lead to a delay in diagnosis and management for both sexes. Finally, many drug classes may be subject to sex differences in efficacy and safety. For example, women present more adverse events than men, mainly because of different pharmacokinetic parameters. Accounting sex as a variable from the preclinical phase is essential to improve the transposition of observed results and move towards personalized medicine.
Collapse
Affiliation(s)
- Romain Barus
- Inserm, Pharmacology Department, CHU de Lille, U1172 - LilNCog - Lille Neuroscience & Cognition, Université de Lille, 59000 Lille, France
| | - Sandrine Bergeron
- Inserm, Pharmacology Department, CHU de Lille, U1172 - LilNCog - Lille Neuroscience & Cognition, Université de Lille, 59000 Lille, France
| | - Yaohua Chen
- Inserm, Pharmacology Department, CHU de Lille, U1172 - LilNCog - Lille Neuroscience & Cognition, Université de Lille, 59000 Lille, France
| | - Sophie Gautier
- Inserm, Pharmacology Department, CHU de Lille, U1172 - LilNCog - Lille Neuroscience & Cognition, Université de Lille, 59000 Lille, France.
| |
Collapse
|
32
|
Galvis Y, Pineda K, Zapata J, Aristizabal J, Estrada A, Fernandez ML, Barona-Acevedo J. Consumption of Eggs Alone or Enriched with Annatto ( Bixa orellana L.) Does Not Increase Cardiovascular Risk in Healthy Adults-A Randomized Clinical Trial, the Eggant Study. Nutrients 2023; 15:nu15020369. [PMID: 36678239 PMCID: PMC9865189 DOI: 10.3390/nu15020369] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2022] [Revised: 01/06/2023] [Accepted: 01/09/2023] [Indexed: 01/13/2023] Open
Abstract
Most atherosclerotic cardiovascular diseases can be prevented by modifying lifestyles, including unhealthy diets. Eggs contain important carotenoids that may impact cardiovascular risk. The lipid nature of eggs can improve the bioavailability of other carotenoids, such as Annatto (Bixa orellana L.), with reported antioxidant properties. Although numerous studies have shown that there is no association between egg consumption and cardiovascular risk, there is still controversy. In addition, there is limited information about Annatto's effects on human health. This study evaluated the association between egg consumption and its enrichment with Annatto in lipid biomarkers of cardiovascular disease. In a parallel clinical trial, one hundred and five (n = 105) men and women were randomized by age, sex, and body mass index (BMI), and distributed into three groups. Subjects consumed daily, for 8 weeks, either two eggs, two eggs with Annatto, or two egg whites. Plasma lipids were measured by enzymatic colorimetric methods, plasma apolipoproteins and lipoprotein subfractions and size by nuclear magnetic resonance. There were no differences between groups in age, sex, and BMI. No significant changes were found over time or between groups in plasma triglycerides, LDL cholesterol, HDL cholesterol, apolipoprotein (apo) A1, apo B, or lipoprotein subfraction concentrations. In healthy adults, the intake of two eggs a day, or two eggs with Annatto for eight weeks, did not generate adverse changes in cardiovascular risk markers.
Collapse
Affiliation(s)
- Yeisson Galvis
- Research Group of Toxinology, Food and Therapeutic Alternatives, Universidad de Antioquia UdeA, Medellín 050010, Colombia
- School of Microbiology, Universidad de Antioquia UdeA, Medellín 050010, Colombia
| | - Keilly Pineda
- Research Group of Toxinology, Food and Therapeutic Alternatives, Universidad de Antioquia UdeA, Medellín 050010, Colombia
| | - Juliana Zapata
- Research Group of Toxinology, Food and Therapeutic Alternatives, Universidad de Antioquia UdeA, Medellín 050010, Colombia
| | - Juan Aristizabal
- School of Nutrition and Dietetics, Universidad de Antioquia UdeA, Medellín 050010, Colombia
- Physiology and Biochemistry Research Group-PHYSIS, Universidad de Antioquia UdeA, Medellín 050010, Colombia
| | - Alejandro Estrada
- School of Nutrition and Dietetics, Universidad de Antioquia UdeA, Medellín 050010, Colombia
| | - María Luz Fernandez
- School of Nutritional Sciences and Wellness, University of Arizona, Tucson, AZ 85721, USA
| | - Jacqueline Barona-Acevedo
- Research Group of Toxinology, Food and Therapeutic Alternatives, Universidad de Antioquia UdeA, Medellín 050010, Colombia
- School of Microbiology, Universidad de Antioquia UdeA, Medellín 050010, Colombia
- Correspondence:
| |
Collapse
|
33
|
Demographic recruitment bias of adults in United States randomized clinical trials by disease categories between 2008 to 2019: a systematic review and meta-analysis. Sci Rep 2023; 13:42. [PMID: 36593228 PMCID: PMC9807581 DOI: 10.1038/s41598-022-23664-1] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2022] [Accepted: 11/03/2022] [Indexed: 01/03/2023] Open
Abstract
To promote health equity within the United States (US), randomized clinical trials should strive for unbiased representation. Thus, there is impetus to identify demographic disparities overall and by disease category in US clinical trial recruitment, by trial phase, level of masking, and multi-center status, relative to national demographics. A systematic review and meta-analysis were conducted using MEDLINE, Embase, CENTRAL, and ClinicalTrials.gov, between 01/01/2008 to 12/30/2019. Clinical trials (N = 5,388) were identified based on the following inclusion criteria: study type, location, phase, and participant age. Each clinical trial was independently screened by two researchers. Data was pooled using a random-effects model. Median proportions for gender, race, and ethnicity of each trial were compared to the 2010 US Census proportions, matched by age. A second analysis was performed comparing gender, race, and ethnicity proportions by trial phase, multi-institutional status, quality, masking, and study start year. 2977 trials met inclusion criteria (participants, n = 607,181) for data extraction. 36% of trials reported ethnicity and 53% reported race. Three trials (0.10%) included transgender participants (n = 5). Compared with 2010 US Census data, females (48.3%, 95% CI 47.2-49.3, p < 0.0001), Hispanics (11.6%, 95% CI 10.8-12.4, p < 0.0001), American Indians and Alaskan Natives (AIAN, 0.19%, 95% CI 0.15-0.23, p < 0.0001), Asians (1.27%, 95% CI 1.13-1.42, p < 0.0001), Whites (77.6%, 95% CI 76.4-78.8, p < 0.0001), and multiracial participants (0.25%, 95% CI 0.21-0.31, p < 0.0001) were under-represented, while Native Hawaiians and Pacific Islanders (0.76%, 95% CI 0.71-0.82, p < 0.0001) and Blacks (17.0%, 95% CI 15.9-18.1, p < 0.0001) were over-represented. Inequitable representation was mirrored in analysis by phase, institutional status, quality assessment, and level of masking. Between 2008 to 2019 representation improved for only females and Hispanics. Analysis stratified by 44 disease categories (i.e., psychiatric, obstetric, neurological, etc.) exhibited significant yet varied disparities, with Asians, AIAN, and multiracial individuals the most under-represented. These results demonstrate disparities in US randomized clinical trial recruitment between 2008 to 2019, with the reporting of demographic data and representation of most minorities not having improved over time.
Collapse
|
34
|
Daitch V, Turjeman A, Poran I, Tau N, Ayalon-Dangur I, Nashashibi J, Yahav D, Paul M, Leibovici L. Underrepresentation of women in randomized controlled trials: a systematic review and meta-analysis. Trials 2022; 23:1038. [PMID: 36539814 PMCID: PMC9768985 DOI: 10.1186/s13063-022-07004-2] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2022] [Accepted: 12/12/2022] [Indexed: 12/24/2022] Open
Abstract
BACKGROUND Although regulatory changes towards correcting the underrepresentation of women in randomized controlled trials (RCTs) occurred (National Institutes of Health 1994), concerns exist about whether an improvement is taking place. In this systematic review and meta-analysis, we aimed to assess the inclusion rates of women in recent RCTs and to explore the potential barriers for the enrollment of women. METHODS RCTs published in 2017 examining any type of intervention in adults were searched in PubMed and Cochrane Library. The following predefined medical fields were included: cardiovascular diseases, neoplasms, endocrine system diseases, respiratory tract diseases, bacterial and fungal infections, viral diseases, digestive system diseases, and immune system diseases. Studies were screened independently by two reviewers, and an equal number of studies was randomly selected per calendric month. The primary outcome was the enrollment rate of women, calculated as the number of randomized women patients divided by the total number of randomized patients. Rates were weighted by their inverse variance; statistical significance was tested using general linear models (GLM). RESULTS Out of 398 RCTs assessed for eligibility, 300 RCTs were included. The enrollment rate of women in all the examined fields was lower than 50%, except for immune system diseases [median enrollment rate of 68% (IQR 46 to 81)]. The overall median enrollment rate of women was 41% (IQR 27 to 54). The median enrollment rate of women decreased with older age of the trials' participants [mean age of trials' participants ≤ 45 years: 47% (IQR 30-64), 46-55 years: 46% (IQR 33-58), 56-62 years: 38% (IQR 27-50), ≥ 63 years: 33% (IQR 20-46), p < 0.001]. Methodological quality characteristics showed no significant association with the enrollment rates of women. Out of the 300 included RCTs, eleven did not report on the number of included women. There was no significant difference between these studies and the studies included in the analysis. CONCLUSIONS Women are being inadequately represented, in the selected medical fields analyzed in our study, in recent RCTs. Older age is a potential barrier for the enrollment of women in clinical trials. Low inclusion rates of elderly women might create a lack of crucial knowledge in the adverse effects and the benefit/risk profile of any given treatment. Factors that might hinder the participation of women should be sought and addressed in the design of the study.
Collapse
Affiliation(s)
- Vered Daitch
- grid.413156.40000 0004 0575 344XDepartment of Medicine E, Rabin Medical Center, Beilinson Hospital, 39 Jabotinski Road, 49100 Petah Tikva, Israel ,grid.12136.370000 0004 1937 0546Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Adi Turjeman
- grid.413156.40000 0004 0575 344XDepartment of Medicine E, Rabin Medical Center, Beilinson Hospital, 39 Jabotinski Road, 49100 Petah Tikva, Israel ,grid.12136.370000 0004 1937 0546Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Itamar Poran
- grid.413156.40000 0004 0575 344XDepartment of Medicine E, Rabin Medical Center, Beilinson Hospital, 39 Jabotinski Road, 49100 Petah Tikva, Israel ,grid.12136.370000 0004 1937 0546Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Noam Tau
- grid.12136.370000 0004 1937 0546Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel ,grid.413795.d0000 0001 2107 2845Department of Diagnostic Imaging, Sheba Medical Center, Ramat Gan, Israel
| | - Irit Ayalon-Dangur
- grid.413156.40000 0004 0575 344XDepartment of Medicine E, Rabin Medical Center, Beilinson Hospital, 39 Jabotinski Road, 49100 Petah Tikva, Israel
| | - Jeries Nashashibi
- grid.413731.30000 0000 9950 8111Department of Internal Medicine D, Rambam Health Care Campus, Haifa, Israel
| | - Dafna Yahav
- grid.12136.370000 0004 1937 0546Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel ,grid.413156.40000 0004 0575 344XInfectious Diseases Unit, Rabin Medical Center, Beilinson Hospital, Petah Tikva, Israel
| | - Mical Paul
- grid.413731.30000 0000 9950 8111Infectious Diseases Institute, Rambam Health Care Campus, Haifa, Israel ,grid.6451.60000000121102151The Ruth and Bruce Rappaport Faculty of Medicine, Technion-Israel Institute of Technology, Haifa, Israel
| | - Leonard Leibovici
- grid.413156.40000 0004 0575 344XDepartment of Medicine E, Rabin Medical Center, Beilinson Hospital, 39 Jabotinski Road, 49100 Petah Tikva, Israel ,grid.12136.370000 0004 1937 0546Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| |
Collapse
|
35
|
Barus R, Bergeron S, Chen Y, Gautier S. Les différences entre les sexes : de la pharmacologie préclinique à la pharmacologie clinique. Therapie 2022. [DOI: 10.1016/j.therap.2022.10.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/25/2023]
|
36
|
Pinho-Gomes AC, Gong J, Harris K, Woodward M, Carcel C. Dementia clinical trials over the past decade: are women fairly represented? BMJ Neurol Open 2022; 4:e000261. [PMID: 36110923 PMCID: PMC9445798 DOI: 10.1136/bmjno-2021-000261] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2021] [Accepted: 08/07/2022] [Indexed: 11/06/2022] Open
Abstract
Background Lack of progress in finding disease-modifying treatments for dementia may be due to heterogeneity in treatment effects among subgroups, such as by sex. Therefore, we investigated the characteristics of dementia trials completed in the last decade, with a focus on women's representation and sex-disaggregated outcomes. Methods Clinical trials on dementia completed since 2010 were identified from ClinicalTrials.gov. Randomised, phase III/IV trials with ≥100 participants were selected to quantify women's representation among participants, by computing the participation to prevalence ratio (PPR) and investigate whether sex-disaggregated analyses had been performed. Results A total of 1351 trials were identified between January 2010 and August 2021 (429 520 participants), of which 118 were eligible for analysis of women's representation and sex-stratified analysis. Only 113 reported the sex of participants and were included in the analysis of women's representation. Of the 110 469 participants in these 113 trials, 58% were women, lower than their estimated representation in the global dementia population of 64%. The mean PPR was 0.90 (95% CI 0.86 to 0.94). Women's participation tended to be higher when the first or last authors of the trial report were women. Eight out of the 118 trials reported sex-disaggregated outcomes, and three of those found significant sex differences in efficacy outcomes. None of the trials reported screening failures or adverse events stratified by sex. Conclusions Overall, women and men were equally represented in dementia trials carried out over the past decade, but women's representation was lower than in the underlying dementia population. Sex-disaggregated efficacy and safety outcomes were rarely reported.
Collapse
Affiliation(s)
- Ana-Catarina Pinho-Gomes
- The George Institute for Global Health, Imperial College London, London, UK,Institute for Health Informatics, University College London, London, UK
| | - Jessica Gong
- The George Institute for Global Health, University of New South Wales, Camperdown, New South Wales, Australia
| | - Katie Harris
- The George Institute for Global Health, University of New South Wales, Camperdown, New South Wales, Australia
| | - Mark Woodward
- The George Institute for Global Health, Imperial College London, London, UK,The George Institute for Global Health, University of New South Wales, Camperdown, New South Wales, Australia
| | - Cheryl Carcel
- The George Institute for Global Health, University of New South Wales, Camperdown, New South Wales, Australia
| |
Collapse
|
37
|
Gaine SP, Quispe R, Patel J, Michos ED. New Strategies for Lowering Low Density Lipoprotein Cholesterol for Cardiovascular Disease Prevention. CURRENT CARDIOVASCULAR RISK REPORTS 2022; 16:69-78. [PMID: 36213094 PMCID: PMC9543364 DOI: 10.1007/s12170-022-00694-y] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/18/2022] [Indexed: 11/03/2022]
Abstract
Purpose of review The primary and secondary prevention of atherosclerotic cardiovascular disease (ASCVD) relies on optimizing cardiovascular health and appropriate pharmacotherapy, a mainstay of which is low-density lipoprotein-cholesterol (LDL-C) lowering. Typically, statin therapy remains the first line approach. Advances in technology and understanding of lipid metabolism have facilitated the development of several novel therapeutic targets and medications within the last decade. This review focuses on medications recently approved by the U.S. Food and Drug Administration (FDA) for the reduction of LDL-C and ASCVD risk, as well as new therapies in the pipeline. Recent findings Novel lipid therapies aim to lower risk of ASCVD by targeting reduction of atherogenic compounds, such as LDL, lipoprotein(a) (Lp(a)), and triglyceride-rich lipoproteins. Evolocumab and alirocumab, monoclonal antibody proprotein convertase subtilisin-kexin type 9 (PCSK9) inhibitors which lower LDL-C by approximately 60%, have emerged as important therapies for use in patients with ASCVD as well as familial hypercholesterolemia (FH). Bempedoic acid, an ATP citrate lyase inhibitor, is an oral medication recently approved that can lower LDL-C by approximately 18% alone and 38% when combined with ezetimibe. Inclisiran, a small-interfering RNA (siRNA) molecule which inhibits the translation of PCSK9, is the most recently FDA-approved LDL-C lowering medication, and can reduce LDL-C by approximately 50% with twice yearly subcutaneous dosing. The cardiovascular outcome trials for bempedoic acid and inclisiran are still on-going. Evinacumab, a monoclonal antibody which targets angiopoietin-like protein 3 (ANGPTL3), has been approved for use in patients with homozygous FH. SiRNAs and anti-sense oligonucleotides (ASO) facilitating selective inhibition of the production of targeted proteins including Lp(a) and ANGLPTL3 are active areas of clinical investigation. Summary Recently several novel LDL-C lowering medications have been approved. New therapeutic targets have been identified and present additional means of lowering LDL-C and other atherogenic compounds for patients who remain at high ASCVD risk.
Collapse
Affiliation(s)
- Sean Paul Gaine
- Ciccarone Center for the Prevention of Cardiovascular Disease, Division of Cardiology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Renato Quispe
- Ciccarone Center for the Prevention of Cardiovascular Disease, Division of Cardiology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Jaideep Patel
- Ciccarone Center for the Prevention of Cardiovascular Disease, Division of Cardiology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Erin D. Michos
- Ciccarone Center for the Prevention of Cardiovascular Disease, Division of Cardiology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| |
Collapse
|
38
|
Enogela EM, Buchanan T, Carter CS, Elk R, Gazaway SB, Goodin BR, Jackson EA, Jones R, Kennedy RE, Perez-Costas E, Zubkoff L, Zumbro EL, Markland AD, Buford TW. Preserving independence among under-resourced older adults in the Southeastern United States: existing barriers and potential strategies for research. Int J Equity Health 2022; 21:119. [PMID: 36030252 PMCID: PMC9419141 DOI: 10.1186/s12939-022-01721-5] [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] [Received: 05/24/2022] [Accepted: 08/15/2022] [Indexed: 11/10/2022] Open
Abstract
Disability prevention and preservation of independence is crucial for successful aging of older adults. To date, relatively little is known regarding disparities in independent aging in a disadvantaged older adult population despite widely recognized health disparities reported in other populations and disciplines. In the U.S., the Southeastern region also known as “the Deep South”, is an economically and culturally unique region ravaged by pervasive health disparities – thus it is critical to evaluate barriers to independent aging in this region along with strategies to overcome these barriers. The objective of this narrative review is to highlight unique barriers to independent aging in the Deep South and to acknowledge gaps and potential strategies and opportunities to fill these gaps. We have synthesized findings of literature retrieved from searches of computerized databases and authoritative texts. Ultimately, this review aims to facilitate discussion and future research that will help to address the unique challenges to the preservation of independence among older adults in the Deep South region.
Collapse
Affiliation(s)
- Ene M Enogela
- Department of Medicine - Division of Gerontology, Geriatrics, and Palliative Care, University of Alabama at Birmingham, 1313 13thSt. South, Birmingham, AL, 35205, USA
| | - Taylor Buchanan
- Department of Medicine - Division of Gerontology, Geriatrics, and Palliative Care, University of Alabama at Birmingham, 1313 13thSt. South, Birmingham, AL, 35205, USA
| | - Christy S Carter
- Department of Medicine - Division of Gerontology, Geriatrics, and Palliative Care, University of Alabama at Birmingham, 1313 13thSt. South, Birmingham, AL, 35205, USA
| | - Ronit Elk
- Department of Medicine - Division of Gerontology, Geriatrics, and Palliative Care, University of Alabama at Birmingham, 1313 13thSt. South, Birmingham, AL, 35205, USA
| | - Shena B Gazaway
- Department of Family, Community, and Health Systems, School of Nursing, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Burel R Goodin
- Department of Psychology, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Elizabeth A Jackson
- Department of Medicine - Division of Cardiology, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Raymond Jones
- Department of Medicine - Division of Gerontology, Geriatrics, and Palliative Care, University of Alabama at Birmingham, 1313 13thSt. South, Birmingham, AL, 35205, USA
| | - Richard E Kennedy
- Department of Medicine - Division of Gerontology, Geriatrics, and Palliative Care, University of Alabama at Birmingham, 1313 13thSt. South, Birmingham, AL, 35205, USA
| | - Emma Perez-Costas
- Department of Medicine - Division of Gerontology, Geriatrics, and Palliative Care, University of Alabama at Birmingham, 1313 13thSt. South, Birmingham, AL, 35205, USA
| | - Lisa Zubkoff
- Department of Medicine - Division of Preventive Medicine, University of Alabama at Birmingham, Birmingham, AL, USA.,Birmingham/Atlanta Geriatric Research, Education, and Clinical Center, Birmingham VA Medical Center, Birmingham, AL, USA
| | - Emily L Zumbro
- Department of Medicine - Division of Gerontology, Geriatrics, and Palliative Care, University of Alabama at Birmingham, 1313 13thSt. South, Birmingham, AL, 35205, USA
| | - Alayne D Markland
- Department of Medicine - Division of Gerontology, Geriatrics, and Palliative Care, University of Alabama at Birmingham, 1313 13thSt. South, Birmingham, AL, 35205, USA.,Birmingham/Atlanta Geriatric Research, Education, and Clinical Center, Birmingham VA Medical Center, Birmingham, AL, USA
| | - Thomas W Buford
- Department of Medicine - Division of Gerontology, Geriatrics, and Palliative Care, University of Alabama at Birmingham, 1313 13thSt. South, Birmingham, AL, 35205, USA. .,Birmingham/Atlanta Geriatric Research, Education, and Clinical Center, Birmingham VA Medical Center, Birmingham, AL, USA.
| |
Collapse
|
39
|
Gordis TM, Cagle JL, Nguyen SA, Newman JG. Human Papillomavirus-Associated Oropharyngeal Squamous Cell Carcinoma: A Systematic Review and Meta-Analysis of Clinical Trial Demographics. Cancers (Basel) 2022; 14:cancers14164061. [PMID: 36011055 PMCID: PMC9406828 DOI: 10.3390/cancers14164061] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2022] [Revised: 08/02/2022] [Accepted: 08/08/2022] [Indexed: 11/18/2022] Open
Abstract
Simple Summary HPV-associated oropharyngeal squamous cell carcinoma (OPSCC) is unique amongst oropharyngeal cancers in its high responsiveness to treatment and its lower mortality rate. As a result, numerous clinical trials have been conducted to identify treatment modalities and protocols. In order for these trials to have meaningful impact on HPV-associated OPSCC patients, proper demographic representation by trial participants is essential. The aim of our systematic review and meta-analysis was to assess the demographics of trial participants for HPV-associated OPSCC clinical trials and compare them with those reported by national databases. We determined that clinical-trial participants were predominately non-smoking white men, with tonsils as the primary tumor site. These findings reflect the demographics reported by the National Cancer Database. Our results imply that HPV-associated OPSCC clinical trials appropriately represent the target population and offer immense benefit. Abstract The objective of our paper was to answer the following question: how do patients with HPV-related oropharyngeal squamous cell carcinoma OPSCC (Population) enrolled in clinical trials (Intervention), compared with national database reports of HPV-associated OPSCC patients (Comparison), present demographically (Outcome)? We conducted a systematic review and meta-analysis of studies pertaining to clinical trials of HPV-associated OPSCC and participant demographics in the United States. PubMed, Scopus, CINAHL, and the Cochrane Library were searched from inception to 2 February 2022. Studies of overlapping participant cohorts and/or studies conducted outside of the United States were excluded. Primary outcomes were patient age, sex, and race. Secondary outcomes were smoking history, alcohol history, history of prior cancer, and tumor origin site. Meta-analysis of single means (mean, N for each study, and standard deviation) for age, pack years, and smoking years was performed. Pooled prevalence rates of gender, race, alcohol history, tobacco history, and tumor origin site were expressed as a percentage, with 95% confidence intervals. Meta-analysis found patients to be predominately non-smoking white males, with tumors originating from the tonsil. Our findings reflected the demographics reported by the National Cancer Database (NCDB) for HPV-associated OPSCC. This indicates that HPV-associated OPSCC patients are appropriately represented in clinical trial demographics.
Collapse
|
40
|
Grant JK, Dangl M, Koester M, Tegegn M, Knijiik L, Singh H, Orringer CE. Under-reporting and Under-representation of Non-Hispanic Black Subjects in Lipid-Lowering Atherosclerotic Cardiovascular Disease Outcomes Trials: A Systematic Review. J Clin Lipidol 2022; 16:608-616. [DOI: 10.1016/j.jacl.2022.08.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2022] [Revised: 08/10/2022] [Accepted: 08/18/2022] [Indexed: 10/14/2022]
|
41
|
Sabouret P, Angoulvant D, Cannon CP, Banach M. Low levels of low-density lipoprotein cholesterol, intracerebral haemorrhage, and other safety issues: is there still a matter of debate? EUROPEAN HEART JOURNAL OPEN 2022; 2:oeac038. [PMID: 36117951 PMCID: PMC9472780 DOI: 10.1093/ehjopen/oeac038] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 04/11/2022] [Revised: 05/07/2022] [Accepted: 05/23/2022] [Indexed: 11/17/2022]
Abstract
Although some observational studies suggest a potential association of low levels of low-density lipoprotein cholesterol (LDL-C) with intracerebral haemorrhage (ICH), these analyses have issues of confounding where other factors (e.g. older age, frailty) that likely explain the findings, and the number of events was very low. More recent results from randomized clinical trials have not found an increased risk in ICH, most notably trials using PCSK9 inhibitors that achieve very low levels of LDL-C, but also in the long-term follow-up of the IMPROVE-IT trial. Also, other statin-associated safety issues, including new onset diabetes and the cancer risk should not be the reason of statin discontinuation, especially for the former, the benefits highly outweigh the risk (even 5×), and for the latter, there is no confirmed link suggesting any increased risk, in opposite, data exist suggesting benefits of statin therapy in cancer prevention. Furthermore, use of intensive lipid-lowering strategies with statins and non-statin drugs leads to decrease of ischaemic major adverse cardiac events, without safety concern, in a large population of patients with atherosclerotic cardiovascular disease (ASCVD). These data should promote the concept ‘the earlier, the lower, the longer, the better’ for the lipid management of patients with ASCVD. While few uncertainties remain in several populations that have been underrepresented in clinical trials (African American and Asian patients, low weight individuals), the most recent data with intensive LDL-C lowering with PCSK9 inhibitors are reassuring that the benefit outweighs any possible risk.
Collapse
Affiliation(s)
| | - Denis Angoulvant
- Cardiology Department - Loire Valley Cardiovascular Collaboration and EA4245, CHRU de Tours and Tours University, Tours, France
| | - Christopher P Cannon
- Cardiovascular Division, Harvard Medical School, Brigham and Women’s Hospital, Boston, MA, USA
| | - Maciej Banach
- Department of Preventive Cardiology and Lipidology, Medical University of Lodz (MUL), Lodz, Poland
| |
Collapse
|
42
|
Chilbert MR, VanDuyn D, Salah S, Clark CM, Ma Q. Combination Therapy of Ezetimibe and Rosuvastatin for Dyslipidemia: Current Insights. Drug Des Devel Ther 2022; 16:2177-2186. [PMID: 35832642 PMCID: PMC9273150 DOI: 10.2147/dddt.s332352] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2022] [Accepted: 06/30/2022] [Indexed: 11/23/2022] Open
Abstract
Cardiovascular disease is one of the leading causes of death around the world with various efforts being made to reduce risk in patients through preventive measures. One major method for prevention has been managing cholesterol, particularly low-density lipoprotein to decrease atherosclerotic plaque burden, potentially decreasing future cardiac complications. Statins have been the gold standard therapy for hypercholesterolemia treatment due to their ease of dosing, limited drug interactions, and favorable safety profile. Unfortunately, statin therapy alone is not always effective enough to adequately control a patient’s elevated lipid levels and combination therapy may be warranted. Ezetimibe is commonly added to regimens to help augment cholesterol lowering by inhibiting the absorption of cholesterol. The recent approval of a combination tablet of high-intensity rosuvastatin and ezetimibe has introduced a potentially more beneficial option for cholesterol management in addition to the only available combination of moderate intensity simvastatin and ezetimibe. We aimed to identify potential beneficial effects of ezetimibe by comparing its use in combination with high-intensity rosuvastatin compared to a statin therapy alone or in combination with moderate intensity simvastatin through a literature review. The current evidence indicated that combination therapy outperformed statin monotherapy in reduction of low-density lipoprotein cholesterol and patients were more likely to achieve their target low-density lipoprotein cholesterol goal level. This suggests rosuvastatin/ezetimibe combination holds a potential place in therapy for patients requiring a more aggressive reduction in cholesterol to help prevent atherosclerotic disease.
Collapse
Affiliation(s)
- Maya R Chilbert
- Department of Pharmacy Practice, School of Pharmacy and Pharmaceutical Sciences, University at Buffalo, Buffalo, NY, USA
- Department of Pharmacy, Buffalo General Medical Center, Buffalo, NY, USA
- Correspondence: Maya R Chilbert, Department of Pharmacy Practice, University at Buffalo School of Pharmacy and Pharmaceutical Sciences, 202 Pharmacy Building, Buffalo, NY, USA, Tel +1 716 829-5172, Fax +1 716-829-6093, Email
| | - Dylan VanDuyn
- Department of Pharmacy, Buffalo Veterans Affairs Medical Center, Buffalo, NY, USA
| | - Sara Salah
- Department of Pharmacy Practice, School of Pharmacy and Pharmaceutical Sciences, University at Buffalo, Buffalo, NY, USA
| | - Collin M Clark
- Department of Pharmacy Practice, School of Pharmacy and Pharmaceutical Sciences, University at Buffalo, Buffalo, NY, USA
- Department of Pharmacy, Buffalo General Medical Center, Buffalo, NY, USA
| | - Qing Ma
- Department of Pharmacy Practice, School of Pharmacy and Pharmaceutical Sciences, University at Buffalo, Buffalo, NY, USA
| |
Collapse
|
43
|
Liu E, Bigeh A, Ledingham L, Mehta L. Prevention of Coronary Artery Disease in Women. Curr Cardiol Rep 2022; 24:1041-1048. [PMID: 35699818 DOI: 10.1007/s11886-022-01721-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/13/2022] [Indexed: 01/10/2023]
Abstract
PURPOSE OF REVIEW Cardiovascular disease remains the leading cause of morbidity and mortality in women. Women were historically underrepresented in landmark trials for which cardiovascular guidelines are based on and are prone to gender-specific risk factors that predispose to coronary heart disease. RECENT FINDINGS More attention has been made on gender and pregnancy-associated risk factors such as autoimmune disorders and preeclampsia. The most recent guidelines have reflected the need to consider risk-enhancing factors that are unaccounted for in traditional risk assessment tools. As the population ages and the burden of cardiovascular disease in women increases, it is crucial to continue focusing on preventative of cardiovascular disease in women.
Collapse
Affiliation(s)
- Ellen Liu
- Division of Cardiovascular Medicine, The Ohio State University Wexner Medical Center, Columbus, OH, 43210, USA
| | - Allison Bigeh
- Division of Cardiovascular Medicine, The Ohio State University Wexner Medical Center, Columbus, OH, 43210, USA
| | - Lauren Ledingham
- Department of Internal Medicine, The Ohio State University Wexner Medical Center, Columbus, OH, 43210, USA
| | - Laxmi Mehta
- Division of Cardiovascular Medicine, The Ohio State University Wexner Medical Center, Columbus, OH, 43210, USA.
| |
Collapse
|
44
|
Secular and Regional Trends among Pulmonary Arterial Hypertension Clinical Trial Participants. Ann Am Thorac Soc 2022; 19:952-961. [PMID: 34936541 PMCID: PMC9169130 DOI: 10.1513/annalsats.202110-1139oc] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022] Open
Abstract
Rationale: The population of patients with pulmonary arterial hypertension (PAH) has evolved over time from predominantly young White women to an older, more racially diverse and obese population. Whether these changes are reflected in clinical trials is not known. Objectives: To determine secular and regional trends among PAH trial participants. Methods: We performed a pooled cohort analysis using harmonized data from phase III clinical trials of PAH therapies submitted to the U.S. Food and Drug Administration. We used mixed-effects linear and logistic regression to assess regional differences in participant age, sex, body habitus, and hemodynamics over time. Results: A total of 6,599 participants were enrolled in 18 trials between 1998 and 2013; 78% were female. The mean age of participants in North America, Europe, and Latin America at the time of study start increased by 2.09 (95% confidence interval [CI], 0.67-3.51), 1.62 (95% CI, 0.24-3.00), and 4.75 (95% CI, 2.29-7.21) years per 5 years, respectively (P = 0.01). Body mass index at the time of study start increased by 0.72 kg/m2 per 5 years (95% CI, 0.44-0.99; P < 0.001) across all regions. Eighty-five percent of participants in early studies were non-Hispanic White, but this decreased over time to 70%. Ninety-seven percent of Asians and 74% of Hispanics in the sample were recruited from Asia and Latin America. Conclusions: Patients enrolled in more recent PAH therapy trials are older and more obese, mirroring the changing epidemiology of observational cohorts. However, these trends varied by geographic region. PAH cohorts remain predominantly female, presenting challenges for generalizability to male patients. Although the proportion of non-White participants increased over time, this was primarily through recruitment in Asia and Latin America.
Collapse
|
45
|
Witting C, Devareddy A, Rodriguez F. Review of Lipid-Lowering Therapy in Women from Reproductive to Postmenopausal Years. Rev Cardiovasc Med 2022; 23:183. [PMID: 38031574 PMCID: PMC10686310 DOI: 10.31083/j.rcm2305183] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2023] Open
Abstract
Although cardiovascular disease is the leading cause of death in women, cardiovascular risk factors remain underrecognized and undertreated. Hyperlipidemia is one of the leading modifiable risk factors for CVD. Statins are the mainstay of lipid lowering therapy (LLT), with additional agents such as ezetimibe and proprotein convertase subtilisin/kexin type 9 (PCSK9) inhibitors as additive or alternative therapies. Clinical trials have demonstrated that these LLTs are equally efficacious in lipid lowering and cardiovascular risk reduction in women as they are in men. Although the data on statin teratogenicity is evolving, in times of pregnancy or attempted pregnancy, most lipid-lowering agents are generally avoided due to lack of high-quality safety data. This leads to limited treatment options in pregnant women with hyperlipidemia or cardiovascular disease. During the perimenopausal period, the mainstay of lipid management remains consistent with guidelines across all ages. Hormone replacement therapy for cardiovascular risk reduction is not recommended. Future research is warranted to target sex-based disparities in LLT initiation and persistence across the life course.
Collapse
Affiliation(s)
| | | | - Fatima Rodriguez
- Stanford University School of Medicine, Stanford, CA 94305
- Division of Cardiovascular Medicine, Stanford Healthcare, Stanford, CA 94305
| |
Collapse
|
46
|
Carland C, Hansra B, Parsons C, Lyubarova R, Khandelwal A. Adequate enrollment of women in cardiovascular drug trials and the need for sex-specific assessment and reporting. AMERICAN HEART JOURNAL PLUS : CARDIOLOGY RESEARCH AND PRACTICE 2022; 17:100155. [PMID: 38559887 PMCID: PMC10978324 DOI: 10.1016/j.ahjo.2022.100155] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 11/24/2021] [Revised: 06/09/2022] [Accepted: 06/14/2022] [Indexed: 04/04/2024]
Abstract
Cardiovascular disease (CVD) is the leading cause of death for women in the United States and globally. There is an abundance of evidence-based trials evaluating the efficacy of drug therapies to reduce morbidity and mortality in CVD. Additionally, there are well-established influences of sex, through a variety of mechanisms, on pharmacologic treatments in CVD. Despite this, the majority of drug trials are not powered to evaluate sex-specific outcomes, and much of the data that exists is gathered post hoc and through meta-analysis. The FDA established a committee in 1993 to increase the enrollment of women in clinical trials to improve this situation. Several authors, reviewing committees, and professional societies have highlighted the importance of sex-specific analysis and reporting. Despite these statements, there has not been a major improvement in representation or reporting. There are ongoing efforts to assess trial design, female representation on steering committees, and clinical trial processes to improve the representation of women. This review will describe the pharmacologic basis for the need for sex-specific assessment of cardiovascular drug therapies. It will also review the sex-specific reporting of landmark drug trials in hypertension, coronary artery disease (CAD), hyperlipidemia, and heart failure (HF). In reporting enrollment of women, several therapeutic areas like antihypertensives and newer anticoagulation trials fare better than therapeutics for HF and acute coronary syndromes. Further, drug trials and cardiometabolic or lifestyle intervention trials had a higher percentage of female participants than the device or procedural trials.
Collapse
Affiliation(s)
- Corinne Carland
- Department of Medicine, University of Pennsylvania, United States of America
| | - Barinder Hansra
- Division of Cardiology and Department of Critical Care Medicine, UPMC, United States of America
| | - Cody Parsons
- Cardiovascular Health, Stanford Health Care, United States of America
| | - Radmila Lyubarova
- Division of Cardiology, Albany Medical College, United States of America
| | - Abha Khandelwal
- Division of Cardiology, Stanford School of Medicine, United States of America
| |
Collapse
|
47
|
Gottfried S. Women: Diet, Cardiometabolic Health, and Functional Medicine. Phys Med Rehabil Clin N Am 2022; 33:621-645. [DOI: 10.1016/j.pmr.2022.04.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
|
48
|
Iribarren A, Diniz MA, Merz CNB, Shufelt C, Wei J. Are we any WISER yet? Progress and contemporary need for smart trials to include women in coronary artery disease trials. Contemp Clin Trials 2022; 117:106762. [PMID: 35460916 DOI: 10.1016/j.cct.2022.106762] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2021] [Revised: 04/07/2022] [Accepted: 04/11/2022] [Indexed: 01/09/2023]
Abstract
Despite calls to ensure proportionate representation of both sexes in biomedical research, women continue to be underrepresented in cardiovascular disease (CVD) clinical trials. A comprehensive analysis of seven large suspected ischemic heart disease/coronary artery disease (HD/CAD) clinical trials (PROMISE, ISCHEMIA, CIAO-ISCHEMIA, ORBITA, FAME, FAME 2 and COURAGE trial) provides understanding of contributions to barriers to enrollment of women and leads to strategies to address these barriers. Specifically, in the seven trials, enrollment of women did not exceed 27%, while numerous barriers are evident. Proposed strategies to improve women´s inclusion in clinical trials, include adding reproductive stage/estrogen status, attention to study design inclusion/exclusion criteria using female thresholds, consideration of diagnostic and intervention study design to be inclusive, increasing women and minorities in leadership positions, including sex as a biological variable (SABV) in study design and statistical analysis, and addressing social and race/ethnicity barriers. Dedicated action to actualizing these steps are needed at this time to developing diagnostic and therapeutic strategies resulting in better care and improved outcomes for CVD in women.
Collapse
Affiliation(s)
- Ana Iribarren
- Barbra Streisand Women's Heart Center, Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Márcio Augusto Diniz
- Barbra Streisand Women's Heart Center, Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - C Noel Bairey Merz
- Barbra Streisand Women's Heart Center, Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Chrisandra Shufelt
- Barbra Streisand Women's Heart Center, Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Janet Wei
- Barbra Streisand Women's Heart Center, Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, California, USA.
| |
Collapse
|
49
|
Bumanlag IM, Jaoude JA, Rooney MK, Taniguchi CM, Ludmir EB. Exclusion of Older Adults from Cancer Clinical Trials: Review of the Literature and Future Recommendations. Semin Radiat Oncol 2022; 32:125-134. [PMID: 35307114 PMCID: PMC8944215 DOI: 10.1016/j.semradonc.2021.11.003] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
In this review, we present the context of older adult (OA) cancer patients within the broader cancer population, including cancer burdens and trial representation. We first describe the proportion of older adults in clinical trials, with studies showing strong evidence that the proportion of OA in cancer trials is much less than the proportion of OA in the overall cancer population. We highlight the lack of generalizability that can lead to challenges in treatment decisions for OA as well as concerns regarding health inequity. We then discuss barriers to OA enrollment related to trial structure and design, physician perspective, and patient and/or caregiver perspective. We expand on this further by outlining these barriers throughout the process of trial design, patient enrollment/trial implementation, and data analysis in post-market settings. We summarize guidelines from national societies, regulatory agencies, and other institutional bodies, then present a compilation of on-the-ground actionable recommendations to address the challenges of clinical trial design, focusing on geriatric assessments and OA-specific trials. We conclude by providing an outline for future directions, noting specifically the potential impact that radiotherapy and radiation oncology may have on clinical trials related to OA patients.
Collapse
Affiliation(s)
- Isabela M Bumanlag
- The University of Texas, Anderson Cancer Center, Houston, TX.; The University of Texas Health Science Center, McGovern Medical School, Houston, TX
| | | | | | | | - Ethan B Ludmir
- The University of Texas, Anderson Cancer Center, Houston, TX..
| |
Collapse
|
50
|
Christensen DM, Strange JE, Phelps M, Schjerning AM, Sehested TS, Gerds T, Gislason G. Age- and sex-specific trends in the incidence of myocardial infarction in Denmark, 2005 to 2021. Atherosclerosis 2022; 346:63-67. [DOI: 10.1016/j.atherosclerosis.2022.03.003] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/14/2022] [Accepted: 03/01/2022] [Indexed: 01/24/2023]
|