An analysis of almost 400 research papers on heart failure found a lack of female authors, which could negatively impact female representation in clinical trials.

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Lack of female representation in heart failure publications may impact the number of female participants in clinical trials.

Like many fields of science and medicine, women face significant barriers to progression in cardiology.

An article in Circulation noted that women are more likely than men to gain employment as faculty at highly ranked schools. However, on average, female cardiologists have fewer publications, are less likely to have a registered clinical trial, and are awarded slightly fewer grants from the National Institutes of Health (NIH).

These barriers mean that among the top 40 cardiology programs in the United States, not a single woman is head of a cardiology division or department.

To understand how this impacts the literature on heart failure, a team from The University of Pennsylvania School of Medicine, PA, looked at female representation in the authorship of guidelines and clinical trials on heart failure.

Their findings appear in the journal Circulation: Heart Failure.

In one of the first studies to explore gender disparities in heart failure guidelines and clinical trials, the Penn Medicine team analyzed the authorship of 173 class I recommendations (the strongest clinical guidelines for heart failure in the U.S.), 100 European guidelines, and 118 clinical trials.

The studies and guidelines dated from 2001–2016 and the researchers determined the sex of the authors using a multinational database and name-matching algorithm.

The researchers focused on the first and last authors of the articles, as these positions indicate the most significant contributions to the conception and production of an academic paper.

The scientists found that the median proportion of female authors in U.S. guidelines was just 20%. For European guidelines, it was even less, at 14%.

They found that less than 20% of first authors on manuscripts used to support heart failure guidelines in the U.S. were women, and only 16% of clinical trials had a woman as a first or senior author.

This seems to be significant for representation in the clinical trial itself and could affect patient outcomes. The authors note that clinical trials with a female author tend to have a higher proportion of female participants.

The average female participation in a clinical trial with a female first or last author was 39%, compared to 26% for trials without female authorship.

“Diversity in authorship can have a snowball effect across the field — not only in improving gender equity in cardiovascular medicine but also perhaps in reducing the underrepresentation of women in clinical trials,” explains Dr. Nosheen Reza, the study’s lead author, and an advanced heart failure and transplant cardiologist.

The authors suggest that women may be more likely to enroll in a clinical trial that they know is being led by a female investigator. It could also be that female trial leads are more likely to refer female patients to clinical trials. “This is certainly an area in which future research is needed,” says Dr. Reza.

These findings show that the proportion of women authors of heart failure trials have not significantly improved over the past 15 years. The authors call for efforts to increase female representation in heart failure research and guidelines.

They further encourage editorial boards to prioritize the inclusion of women as editors, peer reviewers, and referees, which could help promote the development of female investigators in heart failure and, thus, the enrollment of more women in clinical trials.

They say systemic change is needed to boost diversity and inclusion in the academic system, a message which extends far beyond the field of cardiology.

“Institutions must come together to make a committed effort to improve diversity, inclusion, and equity on promotions committees, editorial boards, steering committees, and other leadership bodies in the [heart failure] research enterprise.”

– Dr. Nosheen Reza

She continues, “Women will not overcome these hurdles if these metrics and efforts don’t change. By advocating for broad-scale efforts in these domains, such as including more women in leadership positions and increasing the mentorship of women across career stages in medicine, we’ll be able to develop future generations of experienced and accomplished women investigators and mentors in [heart failure], and advance science together without leaving anyone behind.”