Sex and Gender Bias as a Mechanistic Determinant of Cardiovascular Disease Outcomes

Gender disparities in delayed angina diagnosis: insights from 2001-2020 NHANES data

BACKGROUND

Women with coronary artery disease (CAD) are more likely than men to experience a delay in diagnosis, which is attributed to differences in clinical presentation. The objective of this study is to examine any persistent disparities in timely CAD diagnosis in the United States (U.S.) among women who present with clinically similar symptoms and demographic characteristics to their male counterparts.

METHODS

From the 2001 - 2020 National Health and Nutrition Examination Survey (NHANES) data, participants were categorized as having missed angina if they experienced angina and did not self-report a prior diagnosis of angina pectoris or CAD. We assessed the association between gender and missed angina using weighted multivariate logistic regression models representative of the U.S.

POPULATION

Mortality follow-up data were available for participants up to December 31, 2018.

RESULTS

Of 874 participants with missed angina, 551 (63%) were women and 323 (37.0%) were men. Baseline characteristics showed that women and men with missed angina were more likely than their diagnosed counterparts to be younger, of ethnic minorities, uninsured, and smokers. Women with missed angina were more likely to be in a relationship than diagnosed women, while the opposite pattern was observed in men. The odds ratio of missed angina in women compared to men was 2.61 (95% CI: 1.73, 3.94) after adjusting for age, race, education, body mass index, smoking, alcohol use, income, insurance, and comorbidities. Among participants who had a cardiac cause of death, the odds of missed angina in women compared to men was 3.02 (95% CI: 1.18, 7.75) in the adjusted model.

CONCLUSION

Women with similar CAD symptoms to their male counterparts still have higher odds of going undiagnosed. This relationship extends to individuals who ultimately die of cardiac causes. Potential solutions to this disparity include addressing overgeneralized perceptions of differences in the prevalence and presentation of CAD between genders and exploring targeted screening programs for women with risk factors. Further research accounting for healthcare access and proximity to care is needed to support our findings. Timely recognition of CAD in women is essential to decreasing preventable mortality.

Gender differences in self-reported participation in ultrasound-guided procedures: a retrospective analysis

BACKGROUND

Across multiple procedural specialties, female trainees tend to perform fewer procedures and receive less autonomy than their male counterparts. However, there is currently no data on procedure contribution levels for radiology trainees.

OBJECTIVE

To evaluate whether there was a difference in the degree of reported participation in ultrasound-guided procedures between male and female trainees at our institution.

METHODS

This retrospective study assessed for differences in the reported level of participation between male and female trainees in ultrasound (US) guided paracentesis and thoracentesis. We performed a radiology information system (RIS) search of US guided procedures performed on adult patients from 7/1/2018 to 2/29/2024. Trainee participation levels in the procedures were determined per available reports and classified into independently performed, assisted, or observed. We evaluated the differential reporting of procedure contributions for male and female trainees based on observed vs. expected frequencies, as well as the effect of the trainees' and supervising physicians' gender and experience level on these contributions.

RESULTS

A total of 189 trainees (52 female, 137 male) and 58 supervising physicians (18 female and 40 male) were included. The study evaluated 4156 reports, which showed no difference in the percentage of independently completed procedures (females 80.9% vs. 81.9%, X2 (1, N = 4156) = 0.494, p = 0.48) except when supervised by junior physicians less than 2 years out of training (females 81.0% vs. 86.5%, X2 (1, N = 1908) = 8.19, p = 0.0042). However, female trainees were more likely than male trainees to report observing procedures (females 9.2% vs. 5.2%, X2 (1, N = 4156) = 21.1, p < 0.00001) rather than actively participating in procedures despite a similar training level; this difference was not observed when supervising physicians were females.

CONCLUSION

Female radiology trainees report a similar percentage of independently performed procedures but a lower rate of active participation than male trainees.

Sex differences in the association between age-related decline in blood pressure and decline in cognition: A prospective cohort study

Background

Both high and declining blood pressure (BP) are associated with cognitive decline risk in older adults. In late-life, women have higher rates of hypertension, experience faster cognitive decline, and represent two-thirds of individuals with Alzheimer's disease dementia. However, sex differences in the association between BP decline and cognitive decline are unknown.

Methods

Data were analyzed from 4719 older adults without known baseline dementia (mean age = 76.7 [SD = 7.7] years; 74% women) enrolled in one of five US-based prospective community-based cohort studies, followed annually for up to 31 years (mean = 8.7 [SD = 5.7] years). A 19-test cognitive battery, yielding composite global and five domain-specific scores, and BP were assessed annually. Bivariate mixed-effects models simultaneously estimated change in BP and cognition, for the total group and by sex.

Findings

Systolic BP, diastolic BP, and cognition all declined over time (ps <0.01). Bivariate mixed-effect models revealed a sex difference in the correlation of decline in systolic BP and decline in global cognition (women: r = 0.26, 95%CI: 0.17 - 0.37; men: r = 0.01, 95%CI: -0.13 - 0.11), such that women exhibited a stronger correlation than men. Decline in systolic BP was related to decline in global and all five cognitive domains in women but none in men, with another sex difference identified in the working memory domain. An increase of diastolic BP was related to decline in working memory in men, and no other associations with diastolic BP were significant for either sex.

Interpretation

Systolic BP decline in late-life is related to decline in global and domain-specific cognition in women but not men, with sex differences in global cognition and the working memory domain. These findings suggest that in older women, declining systolic BP - a routinely-used clinical measure - may be an important marker of concurrent cognitive decline.

Migraine in men

BACKGROUND

Migraine is a common primary headache disorder, less frequently affecting men than women, and often regarded as predominantly a "women's disease." Despite this, migraine in men presents with unique characteristics in terms of symptoms, treatment responses, comorbidities, and pain perception. Historically, research has focused more on migraine in women, overlooking critical male-specific aspects.

RESULTS

This review delves into the epidemiology, clinical presentation, and particular challenges of diagnosing and managing migraine in men. It addresses sex-specific triggers, hormonal influences, and comorbid conditions affecting migraine prevalence and severity in men. Additionally, the review evaluates current therapeutic strategies, underscoring the necessity for individualized approaches. Men with migraine often exhibit atypical symptoms compared to the ICHD-3 criteria and are less likely to report common associated symptoms. They also tend to have fewer psychological comorbidities, respond more favorably to pharmacological treatments, yet are less likely to seek medical support. The reasons for these sex disparities are complex, involving biological, psychosocial, and cultural factors, such as brain structural differences, differences in functional responses to painful stimuli, hormonal effects, and behavioral influences like adherence to masculine norms and stigma.

CONCLUSION

Men are underrepresented in clinical migraine research. In contrast, preclinical studies often focus solely in male animals as a result of various misconceptions. This disparity necessitates greater focus on sex-specific aspects of migraine to enhance diagnosis, treatment, and research. Addressing stigma, increasing healthcare access, and ensuring balanced sex and gender representation in future studies is crucial for a comprehensive understanding and effective management of migraine for all patients.

Failure to Rescue Female Patients Undergoing High-Risk Surgery

Importance

Female patients have higher mortality rates after high-risk surgery than male patients. It is unknown whether this mortality gap is due to different rates of postoperative complications or if complications are addressed differently by sex, causing complications to lead to death-so-called failure to rescue.

Objective

To evaluate sex differences in failure to rescue across high-risk surgical procedures.

Design, Setting, and Participants

This retrospective cohort study was conducted using data from Medicare beneficiaries from October 2015 to February 2020 who underwent high-risk vascular or cardiac surgical procedures, including abdominal aortic aneurysm repair, coronary artery bypass grafting, aortic valve replacement, and mitral valve replacement or repair. Data analysis was performed from August 2023 to March 2024.

Exposures

The primary exposure was patient sex.

Main Outcomes and Measures

The primary outcomes were risk-adjusted rates of complications, 30-day mortality, and failure to rescue, which was defined as a death occurring after a serious complication. Categorical variables are presented as frequencies and proportions and compared using χ2 analysis. Continuous variables were tested for normality and compared using a t test.

Results

A total of 863 305 Medicare beneficiaries were included in this study cohort, of whom 304 176 (35.2%) were female. Mean (SD) age was slightly higher in female patients (74.8 [9.3] years) than male patients (73.4 [8.5] years), and female patients had more comorbidities than male patients (≥2 Elixhauser comorbidities, female: 262 809 [86.4%] vs male: 465 231 [83.2%]). Female patients were more likely to receive care at large hospitals and hospitals with a higher surgical case volume. Overall, female and male patients had similar rates of complications (female: 14.98% vs male: 14.37%; adjusted relative risk [aRR], 1.04; 95% CI, 1.03-1.05; P < .001). However, female patients had higher rates of 30-day mortality (female: 4.22% vs male: 3.34%; aRR, 1.26; 95% CI, 1.23-1.29; P < .001) and higher rates of failure to rescue (female: 10.71% vs male: 8.58%; aRR, 1.25; 95% CI, 1.22-1.28; P < .001). A similar pattern was observed when stratified by each procedure.

Conclusions and Relevance

In this cohort study among Medicare beneficiaries undergoing high-risk surgery, male and female patients experienced similar rates of serious complications, but female patients with complications were more likely to die. In other words, clinicians fail to rescue female patients with complications after high-risk surgery more often than male patients. Improving the recognition and management of female patients' complications postoperatively may narrow the sex disparity after high-risk surgery.

Intersectionality and Social Drivers of Health in Cardiovascular Care

Social drivers of health (SDOH) are a significant contributor to persistent cardiovascular health disparities in the United States and globally. SDOH include psychosocial, environmental, socioeconomic, cultural, and governmental factors that impact health behaviors and outcomes. Multiple social drivers have been associated with trends in cardiovascular disease risk and health outcomes. These social drivers intersect in complex ways, and applying the concept of intersectionality is critical when considering ways to best address SDOH in cardiovascular care. Applying intersectionality, which considers the unique combination of social drivers associated with a community, allows for tailored interventions to address cardiovascular health disparities.

"I just kept asking and asking and there was nothing": re-thinking community resources & supports for young adult stroke survivors

PURPOSE

Stroke is often regarded as a disease of the elderly. However, 10-15% of strokes occur in people aged 18 to 50, and rates continue to rise. Young stroke survivors face unique challenges due to their occupational, family and personal commitments, which current stroke rehabilitation services may not fully address. Our qualitative study aimed to identify gaps in patient care and resources for young stroke survivors. We used these findings to develop recommendations to inform clinical care, healthcare system design, and health policy.

METHODS

Using Interpretive Description, we conducted semi-structured interviews with 19 stroke survivors aged 18-55 living in British Columbia, Canada, to explore their experiences during stroke recovery and assess current gaps in support and resources. We applied broad-based coding and thematic analysis to the transcripts.

RESULTS

Key themes included: (1) the need for longitudinal medical follow-up and information provision, (2) the need for psychological/psychiatric care, (3) the need to adapt community supports and resources to young survivors, and (4) the need to centralize and integrate community stroke services and resources.

CONCLUSION

Young stroke survivors experience unique challenges and lack appropriate services and resources. Many of our findings may be representative of remediable gaps that persist nationally and internationally.

Gender Disparities in Statin Prescriptions in People With HIV With Low/Moderate to High Cardiovascular Risk

The REPRIEVE trial suggests that primary cardiovascular disease (CVD) prevention could be considered among people with HIV at low CVD risk. We found cisgender women with low/moderate and high CVD risk are less likely to receive statins than cisgender men. Efforts are needed to guarantee equal access to statin-based CVD prevention.

Barriers to Access to Cardiac Surgery: Canadian Situation and Global Context

Cardiovascular disease is the leading cause of morbidity and mortality worldwide. Cardiovascular care spans primary, secondary, and tertiary prevention and care, whereby tertiary care is particularly prone to disparities in care. Challenges in access to care especially affect low- and middle-income countries (LMICs), however, multiple barriers also exist and persist across high-income countries. Canada is lauded for its universal health coverage but is faced with health care system challenges and substantial geographic barriers. Canada possesses 203 active cardiac surgeons, or 5.02 per million population, ranging from 3.70 per million in Newfoundland and Labrador to 7.48 in Nova Scotia. As such, Canada possesses fewer cardiac surgeons per million population than the average among high-income countries (7.15 per million), albeit more than the global average (1.64 per million) and far higher than the low-income country average (0.04 per million). In Canada, adult cardiac surgeons are active across 32 cardiac centres, representing 0.79 cardiac centres per million population, which is just above the global average (0.73 per million). In addition to centre and workforce variations, barriers to care exist in the form of waiting times, sociodemographic characteristics, insufficient virtual care infrastructure and electronic health record interoperability, and health care governance fragmentation. Meanwhile, Canada has highly favourable surgical outcomes, well established postacute cardiac care infrastructure, considerable spending on health, robust health administrative data, and effective health technology assessment agencies, which provides a foundation for continued improvements in care. In this narrative review, we describe successes and challenges surrounding access to cardiac surgery in Canada and globally.

Socioeconomic Disparities in Women's Cardiovascular Health in the United States and Canada

Cardiovascular disease has been the leading cause of death in the United States and Canada for decades. Although it affects millions of people across a multitude of backgrounds, notable disparities in cardiovascular health are observed among women and become more apparent when accounting for race and socioeconomic status. Although intrinsic sex-specific physiologic differences predispose women to poorer outcomes, social determinants of health (SDOH) and biases at both the individual provider and the larger health care system levels play an equal, if not greater, role. This review examines socioeconomic disparities in women compared with men regarding cardiovascular risk factors, treatments, and outcomes. Although various at-risk subpopulations exist, we highlight the impact of SDOH in specific populations, including patients with disabilities, transgender persons, and South Asian and Indigenous populations. These groups are underrepresented in studies and experience poorer health outcomes owing to structural barriers to care. These findings emphasise the significance of understanding the interplay of different socioeconomic factors and how their stacking can negatively affect women's cardiovascular health. To address these disparities, we propose a multipronged approach to augment culturally sensitive and patient-centred care. This includes increased cardiovascular workforce diversity, inclusion of underrepresented populations into analyses of cardiovascular metrics, and greater utilisation of technology and telemedicine to improve access to health care. Achieving this goal will necessitate active participation from patients, health care administrators, physicians, and policy makers, and is imperative in closing the cardiovascular health gap for women over the coming decades.

Sex in cardiovascular disease: Why this biological variable should be considered in in vitro models

Cardiovascular disease (CVD), the world's leading cause of death, exhibits notable epidemiological, clinical, and pathophysiological differences between sexes. Many such differences can be linked back to cardiovascular sexual dimorphism, yet sex-specific in vitro models are still not the norm. A lack of sex reporting and apparent male bias raises the question of whether in vitro CVD models faithfully recapitulate the biology of intended treatment recipients. To ensure equitable treatment for the overlooked female patient population, sex as a biological variable (SABV) inclusion must become commonplace in CVD preclinical research. Here, we discuss the role of sex in CVD and underlying cardiovascular (patho)physiology. We review shortcomings in current SABV practices, describe the relevance of sex, and highlight emerging strategies for SABV inclusion in three major in vitro model types: primary cell, stem cell, and three-dimensional models. Last, we identify key barriers to inclusive design and suggest techniques for overcoming them.

Health information-seeking behavior in patients with coronary artery disease: Activating methods

INTRODUCTION

Coronary artery disease (CAD) has a high mortality rate worldwide, and continuous health behavior practice and careful management are required owing to risks such as rapid changes in symptoms and emergency hospitalization. The utilization of health-related information is an important factor for long-term disease management in patients with CAD. For this purpose, an understanding of health information-seeking behavior is needed first.

METHODS

This study analyzed data from the 2021 Korea Medical Panel Survey, and logistic regression analysis was conducted to confirm the factors influencing the health information-seeking behavior of patients with CAD.

RESULTS

The health information-seeking behavior of patients with CAD differed according to demographic characteristics, and differences in preferred information use were confirmed. Finally, it was identified that insufficient levels of health literacy were a major reason for CAD patients not engaging in health information-seeking behaviors (OR, 0.17; 95% CI, 0.09-0.33; p < 0.001).

CONCLUSION

This study suggests that to improve health information-seeking behaviors, the application of education and intervention programs to increase the level of health literacy is necessary.

Primary care clinicians' perspectives on interacting with patients with gynaecological conditions: a systematic review

BACKGROUND

Studies have found that women with gynaecological conditions and symptoms do not feel listened to by primary care clinicians (PCCs). Less understood is whether PCCs perceive that there are challenges around listening to and interacting with this patient group.

AIM

To understand PCCs' perspectives on the challenges of listening to and interacting with women patients with gynaecological conditions and symptoms.

DESIGN & SETTING

Systematic review of English-language studies.

METHOD

We searched ASSIA (Applied Social Sciences Index and Abstracts), CINAHL (Cumulative Index to Nursing and Allied Health Literature), Embase, HMIC (Healthcare Management Information Consortium), and MEDLINE from inception to July 2023. We also conducted forward and backward citation searches of included studies. Identified records were screened independently by two reviewers. Data extraction was undertaken by one reviewer and checked by a second. Quality appraisal used the Wallace checklist. 'Best-fit' framework synthesis was used to synthesise findings around themes that explored the challenges of patient-clinician interaction.

RESULTS

We identified 25 relevant articles. Perceived challenges associated with listening to and interacting with patients with gynaecological conditions and symptoms were identified at four 'levels': individual clinician level factors; structural and organisational factors; community and external factors; and factors related to gynaecological conditions. Interpretive analysis identified specific challenges relating to sociocultural factors affecting the consultation experience; the need for further education, training, or guidance for clinicians; factors affecting referral decisions; and factors related to service structure and organisation.

CONCLUSION

PCCs acknowledge that empathy, respect, and attentive listening are important when interacting with women patients with gynaecological conditions and symptoms. However, these ideals are impeded by several factors.

Sex-Based Analysis of Workflow and Outcomes in Acute Ischemic Stroke Patients Treated With Alteplase Versus Tenecteplase

BACKGROUND

Understanding sex differences in stroke care is important in reducing potential disparities. Our objective was to explore sex differences in workflow efficiency, treatment efficacy, and safety in the AcT trial (Alteplase Compared to Tenecteplase).

METHODS

AcT was a multicenter, registry-linked randomized noninferiority trial comparing tenecteplase (0.25 mg/kg) with alteplase (0.9 mg/kg) in acute ischemic stroke within 4.5 hours of onset. In this post hoc analysis, baseline characteristics, workflow times, successful reperfusion (extended Thrombolysis in Cerebral Infarction score ≥2b), symptomatic intracerebral hemorrhage, 90-day functional independence (modified Rankin Scale score, 0-1), and 90-day mortality were compared by sex. Mixed-effects regression analysis was used adjusting for age, stroke severity, and occlusion site for outcomes.

RESULTS

Of 1577 patients treated with intravenous thrombolysis (2019-2022), 755 (47.9%) were women. Women were older (median, 77 [68-86] years in women versus 70 [59-79] years in men) and had a higher proportion of severe strokes (National Institutes of Health Stroke Scale score >15; 32.4% versus 24.9%) and large vessel occlusions (28.7% versus 21.5%) compared with men. All workflow times were comparable between sexes. Women were less likely to achieve functional independence (31.7% versus 39.8%; unadjusted relative risk, 0.80 [95% CI, 0.70-0.91]) and had higher mortality (17.7% versus 13.3%; unadjusted relative risk, 1.33 [95% CI, 1.06-1.69]). Adjusted analysis showed no difference in outcomes between sexes.

CONCLUSIONS

Differences in prognostic factors of age, stroke severity, and occlusion site largely accounted for higher functional dependence and mortality in women. No sex disparities were apparent in workflow quality indicators. Given the integration of the AcT trial into clinical practice, these results provide reassurance that no major sex biases are apparent in acute stroke management throughout participating Canadian centers.

REGISTRATION

URL: https://www.clinicaltrials.gov; Unique identifier: NCT03889249.

Appraising features and outlook of women and men discharged after an acute coronary syndrome: evidence from the 23,700-patient PRAISE International Registry

BACKGROUND

Acute coronary syndromes (ACS) are a common cause of morbidity and mortality. Several studies have focused on ACS at admission, but limited evidence is available on sex-based comparison of patients discharged after ACS. We appraised the outlook of women and men discharged after ACS.

METHODS

Details on women enrolled in the PRAISE registry, an international cohort study spanning 23,700 patients included between 2003 and 2019, were systematically collected. We focused on patient and procedural features, medications at discharge, and 1-year outcomes. The primary endpoint was the composite of death, myocardial infarction, or major bleeding after discharge.

RESULTS

A total of 17,804 (76.5%) men and 5466 (23.5%) women were included. Several baseline differences were found, including risk factors and prior revascularization (all P<0.05). Men underwent more frequently radial access, and at discharge they received more commonly dual antiplatelet therapy and guideline-directed medical therapy (P<0.001). At 1-year follow-up, risks of death, reinfarction, major bleeding, and non-fatal major bleeding, jointly or individually, were all significantly higher in women (all P≤0.01). All such differences however did not hold true at multivariable analysis, with the exception of major bleeding, which appeared surprisingly less common in females at fully adjusted analysis (P=0.017).

CONCLUSIONS

Women, albeit only apparently, had worse outcomes 1 year after discharge for ACS, but adjusted analysis suggested instead that they faced a lower risk of major bleeding after discharge. These findings support the call for more aggressive management of women after ACS.

No Sex-Based Differences Exist in Clinical Outcomes of Extended Aortic Arch Repair for Acute Type A Aortic Dissection

BACKGROUND

Reports regarding the association between sex and clinical outcomes after surgical repair of acute type A aortic dissection (ATAAD) are not exhaustive and in part even conflicting.

METHODS

A total of 786 eligible adult patients with ATAAD undergoing extended arch repair from January 2015 to December 2021 were included. They were divided into a female group (n = 161) and a male group (n = 625). In-hospital outcomes (surgical mortality and major postoperative morbidity) and midterm outcomes (survival and aortic reintervention) between the 2 groups were compared before and after propensity score matching (1:1).

RESULTS

Compared with male patients, female patients were more likely to be older (median [interquartile range]: 57 [46-67] vs 50 [42-59] years; P < 0.001) and to have a lower body mass index, but were less likely to be current smokers. Operative death occurred in 66 patients (6.8% female vs 8.8% male), without significant differences between groups before and after matching (P = 0.422 and P > 0.999, respectively). Major postoperative morbidity was observed in 313 patients (39.8%), including 57 (35.4%) female and 256 (41.0%) male patients (P = 0.199). Sex-based grouping was not significantly associated with operative mortality or major postoperative morbidity. The 5-year cumulative survival and incidence of aortic reintervention among female patients were 90.6% and 6.0%, respectively, which were not statistically different from those observed in male patients before and after matching.

CONCLUSIONS

No sex-based differences were found in terms of in-hospital and midterm outcomes of extended arch repair for ATAAD.

Cardiometabolic sex differences in adults born small for gestational age

Aim

This study aimed to assess the cardiometabolic sex similarities and differences in adults born small for gestational age.

Methods

This study was an ambispective cohort study from a birth registry in Barcelona, Spain, including 523 adult participants (20-40 years-old) subdivided as born small for gestational age (SGA, if birth weight <10th centile) or adequate fetal growth for gestational age (AGA). Cardiometabolic health was assessed by echocardiography, electrocardiogram, blood pressure measurement, vascular ultrasound, anthropometric measurements, and serum glycemia and lipid profile. Stratified analyses by sex were performed by estimation of adjusted absolute difference (AAD) using inverse probability weighting.

Results

Compared with AGA, the stratified analyses by sex showed a more pronounced reduction in ejection fraction [AAD: female -1.73 (95% CI -3.2 to -0.28) vs. male -1.33 (-3.19 to 0.52)] and increment in heart rate [female 3.04 (0.29-5.8) vs. male 2.25 (-0.82 to 5.31)] in SGA females compared with SGA males. In contrast, a more pronounced reduction in PR interval [female -1.36 (-6.15 to 3.42) vs. male -6.61 (-11.67 to -1.54)] and an increase in systolic blood pressure [female 0.06 (-2.7 to 2.81) vs. male 2.71 (-0.48 to 5.9)] and central-to-peripheral fat ratio [female 0.05 (-0.03 to 0.12) vs. male 0.40 (0.17-0.62)] were mainly observed in SGA male compared with SGA female.

Conclusions

Sex differences were observed in the effect of SGA on cardiometabolic endpoints with female being more prone to cardiac dysfunction and male to electrocardiographic, vascular, and metabolic changes. Future research including sex-stratification data is warranted.

Gender Bias in Clinical Trial Enrollment: Female Authorship Matters

BACKGROUND

Despite initiatives to promote equal enrollment of human subjects in clinical trials, females continue to be underrepresented. The goal of this work is to determine if female enrollment in human clinical trials published in 3 high-impact journals from 2015 to 2019 is correlated with gender of first and/or senior authors.

METHODS

Clinical trials published in the Journal of the American Medical Association (JAMA), The Lancet, and the New England Journal of Medicine (NEJM) from January 1, 2015, to December 31, 2019, were reviewed. Trials were excluded for ongoing enrollment, sex-specific disease research, or author name without gender assignment. One-sample χ2 pairwise comparisons and two-tailed proportion tests on the proportion of females between gender author pairings were done overall and for each subset analysis.

RESULTS

In total, 1,427 articles enrolled a total of 2,104,509 females and 2,616,981 males (44.6% vs. 55.4%, P ≤ 0.0001) in clinical trials. Overall, more females were enrolled if both first and senior authors were female (51.7% vs. 48.3%, P ≤ 0.0001). Proportion of females enrolled decreased with the following first and senior author pairings: female-male (48.9%), male-female (48.6%), and male-male (40.5%, P ≤ 0.0001 compared to female-female authorship). Greater female enrollment in clinical trials with female-female compared to male-male authorship persisted in subset analyses by funding source, phase, randomization for study participants, drug and/or device trial, and geographic location. Female enrollment was higher in 3 surgical specialties: neurosurgery (all authors: 52%, P ≤ 0.01), ophthalmology (all authors: 53.6%, P ≤ 0.0001), and surgery (all authors: 54.4%, P ≤ 0.0001). The majority of surgical specialties did not publish trials with female-female authorship but when stratifying by author gender pairing, surgical oncology had the highest female enrollment with female-female authorship (98.4%, P ≤ 0.0001).

CONCLUSIONS

Female authorship of clinical trial publications, specifically having both first and senior authors as female, was correlated with higher female enrollment in clinical trials when compared to male authorship and endured with multiple subset analyses.

Toward Community-Based Natural Language Processing (CBNLP): Cocreating With Communities

Rapid development and adoption of natural language processing (NLP) techniques has led to a multitude of exciting and innovative societal and health care applications. These advancements have also generated concerns around perpetuation of historical injustices and that these tools lack cultural considerations. While traditional health care NLP techniques typically include clinical subject matter experts to extract health information or aid in interpretation, few NLP tools involve community stakeholders with lived experiences. In this perspective paper, we draw upon the field of community-based participatory research, which gathers input from community members for development of public health interventions, to identify and examine ways to equitably involve communities in developing health care NLP tools. To realize the potential of community-based NLP (CBNLP), research and development teams must thoughtfully consider mechanisms and resources needed to effectively collaborate with community members for maximal societal and ethical impact of NLP-based tools.

[Gender-specific differences in cardiology]

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.

Sex differences and predictors of completion of a 6-month exercise-based cardiac rehabilitation program in 1,536 people following stroke

OBJECTIVE

To retrospectively examine sex-differences and predictors of completion in consecutively-referred patients to a 6-month exercise-based cardiac rehabilitation program (CRP) from 2006 to 2017.

MATERIALS/METHODS

People with hemiplegic gait participated in stroke-adapted-CRP; otherwise, traditional-CRP. Reasons for non-completion were ascertained by interview. Regression-analyses were conducted to determine non-completion in all patients and women and men separately.

RESULTS

There were 1536 patients (30.3% women), mean age 64.5 ± 12.5 with 23% initiating the stroke-adapted-CRP. Overall, 75.1% completed the CRP (87.3% stroke-adapted-CRP vs 71.5% traditional-CRP; p < .001). There was no difference in completion between women and men (74.5% vs 75.4%; p=0.7), or in attendance to pre-scheduled sessions (p=0.6) or reasons for non-completion (p > .05, all). The only sex difference in completion by age (decade) occurred in those <41 years (59% women vs 85% men; p=.02). Baseline predictors of non-completion among all patients included not being enrolled in the stroke-adapted-CRP, lower V̇O_2peak, smoking, diabetes (prescribed insulin) and depression but not sex (p=.5) or age (p=.15). Unique predictors in women vs men were younger age, lower V̇O_2peak, smoking, diabetes (prescribed insulin), depression, and cancer diagnoses. Unique to men was having >1 stroke and diabetes (any anti-diabetes medication). The strongest predictor of non-completion among all models was not being enrolled in stroke-adapted-CRP.

CONCLUSIONS

While there were no sex-differences in adherence to the CRP, women and men have mostly unique predictors of non-completion. Younger women are at greatest risk for non-completion. Practitioners should provide sex-specific, tailored strategies for enhancing completion with a focus on younger women and offering a stroke-adapted-CRP with close attention to those with diabetes.

Temporal Trends of the Prevalence of Angina With No Obstructive Coronary Artery Disease (ANOCA)

BACKGROUND

Angina with no obstructive coronary artery disease (ANOCA) is a common entity. There is still under-recognition of this condition, but it is unclear if the referral patterns for chest pain diagnosis have changed. We aimed to determine if the prevalence of patients diagnosed with ANOCA by means of coronary angiography has changed over time.

METHODS

A population-based cohort of patients who had their first coronary angiogram for a chest pain syndrome in Alberta from 1995 to 2020 was extracted retrospectively from the Alberta Provincial Project for Outcome Assessment in Coronary Heart Disease (APPROACH) database. A temporal trend analysis was performed to compare patients with ANOCA vs obstructive coronary artery disease (CAD), and the predictors of ANOCA were investigated.

RESULTS

In our analysis, 121,066 patients were included (26% ANOCA, 31% female, overall mean age 62 years). The percentages of ANOCA vs obstructive CAD ranged from 24.2% to 26.7% in all patients (P < 0.001), from 19.4% to 21.4% in patients with acute coronary syndromes (P = 0.002), and from 30.6% to 37.5% in patients with stable angina (P < 0.001). Independent predictors of ANOCA were female sex (odds ratio [OR] 3.34, 95% confidence interval [CI] 3.05-3.66), younger age (OR 0.96, 95% CI 0.95-0.96), history of atrial fibrillation (OR 2.18, 95% CI 1.73-2.73), and stable angina (vs myocardial infarction: OR 0.25, 95% CI 0.23-0.28; vs unstable angina: OR 0.79, 95% CI 0.70-0.89). Traditional cardiovascular risk factors were associated with obstructive CAD.

CONCLUSIONS

There remained a high prevalence of ANOCA detected during invasive coronary angiography, which remained stable over time. This study demonstrates an opportunity to exclude obstructive CAD with less invasive testing, particularly in women.