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Heart Failure Publications, Trial Research Continue to Lack Women Authors


Increasing their numbers could help to improve both trial enrollment diversity and improve patient outcomes, according to research published in Circulation: Heart Failure.

Heart failure (HF) research led by women continues to lag behind that of men, so that less than 20% of first authors and less than 15% of senior authors are women, according to findings published recently in Circulation: Heart Failure. This is despite close to 25% of physicians and researchers in the space being women.

“The research is the first of its kind to explore gender disparities in authorship of [heart failure] guideline citations and clinical trials,” the study authors noted, adding that their data show consistent low numbers of women authors across guidelines and heart failure trials.

In their research, they also found that the more female participants enrolled in trials, the more likely they were to have women listed as first or senior author: 39% vs 26% (P = .01). After accounting for confounders, this was “the only significant predictor of female participant enrollment.”

For their study period of 2001 through 2016, the investigators identified authors referenced in class 1 recommendations for the following guidelines: the 2013 American College of Cardiology Foundation/American Heart Association, 2017 American College of Cardiology/American Heart Association/Heart Failure Society of America, and 2016 European Society of Cardiology. A search of PubMed/MEDLINE yielded heart failure clinical trials (2001-2004, 2005-2008, 2009-2012, 2013-2016).

This was for both the United States (n = 173) and Europe (n = 100), as well as authors listed for trials with more than 400 participants (n = 118). Gender was determined through a multinational database and name-matching algorithm, as well as a search of social media accounts and institutional websites. Linear regression and nonparametric testing evaluated authorship patterns.

Analysis revealed the following about women authors per publication and for trials:

  • They represented a median (interquartile range [IQR]) of 20% (8%-33%) of authors in United States guidelines.
  • European guidelines had just a median 14% (IQR, 2%-20%) of women authors.
  • In the United States, women represented 18% and 16% of first and last (aka, senior) authors, respectively, compared with 13% and 12% in Europe.
  • Heart failure trials overall had a median 11% (IQR, 4%-20%) of women authors.
  • Their proportions increased in both the United States (β = 0.005) and Europe (β = 0.003) from 1986 to 2016 (P < .001).
  • Total women authors represented in heart failure trials dropped, from a median 12.5% (IQR, 0%-20%) in 2001-2004 to 8.9% (IQR, 0%-20%) in 2013-2016 (P > .60).
  • There was a consistent 16% of women listed as first or last authors (P = .60).
  • At 24%, a women was more likely to be a first or senior author for North American trials.
  • Industry-sponsored trials were less likely to have women authors vs government-sponsored trials and those funded by nonprofits or universities:
    • Industry: median 7% (IQR, 0%-15%)
    • Government: median 20% (IQR, 14%-33%)
    • Nonprofits/universities: median 10% (IQR, 10%-33%; P < .001).
  • Chronic-therapy trials were more likely to have a first/senior woman author vs acute-therapy trials: 17% vs 7%.

Limitations to this research include that gender could not be assigned to 1.3% of author guideline citations and 2% of trial authors, possible misclassification of gender through the algorithm, and the inability to quantify women entering the heart failure field over time.

“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. Women will not overcome these hurdles if these metrics and efforts don't change,” Nosheen Reza, MD, the study's lead author and an advanced heart failure and transplant cardiologist in the Perelman School of Medicine at the University of Pennsylvania, said in a statement.


Reza N, Tahhan AS, Mahmud N, et al. Representation of women authors in international heart failure guidelines and contemporary clinical trials. Circ Heart Fail. Published online August 6, 2020. doi:10.1161/CIRCHEARTFAILURE.119.006605

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