Key result
Women were underrepresented in the evidence base of the 2019 ESC chronic coronary syndromes guidelines, though having a woman as last author was associated with higher female inclusion.
Why the study?
Sex and gender inequalities persist in ischemic heart disease, and literature cited in recent cardiovascular guideline recommendations may contain unaddressed sex and gender biases.
Does the primary scientific literature informing the 2019 ESC chronic coronary syndromes guidelines contain sex and gender biases?
Systematic Review (n=1,614,569)
Does the primary scientific literature informing the 2019 ESC chronic coronary syndromes guidelines contain sex and gender biases?
The primary literature informing the 2019 ESC chronic coronary syndromes guidelines insufficiently addresses sex and gender differences and significantly underrepresents women, limiting applicability across diverse patient needs.
Answers are grounded in this paper and cite their sources.
Underrepresentation of women in CCS guideline evidence limits applicability to female patients; challenges evidence robustness and extends support for female last authorship boosting inclusion.
Background: Sex and gender inequalities in ischemic heart diseases persist. Although ischemic heart disease is less common in women, they experience worse clinical outcomes and are less likely to receive guideline-recommended treatments. The primary scientific literature from which clinical guideline recommendations are derived may not have considered potential sex- and gender biases. This study aims to determine whether the literature cited in recent cardiovascular guidelines' clinical recommendations contain sex and gender biases. Methods: We analysed publications cited in the 2019 European Society of Cardiology (ESC) guideline recommendations on chronic coronary syndromes, using a checklist to guide data extraction and evaluate the individual studies for sex- and gender-related aspects, such as inclusion/exclusion criteria, outcome measures, and demographic data reporting. To assess representation over time, the proportion of women participants in each study was computed and analysed using a beta regression model. We also examined the associations between women's representation, journal impact factor and author gender. Findings: Among the 20 ESC recommendations on chronic coronary syndromes, four contained sex-related statements; we did not identify any gender-specific suggestions. The referenced literature upon which these recommendations were based consisted of 108 articles published between 1991 and 2019, encompassing more than 1.6 million study participants (26.8%; 432,284 women). Only three studies incorporated sex-sensitive designs; none were gender-specific. The term "gender" did not occur in 84% (n = 91/108) of the publications; when used, it was exclusively to denote biological sex. The proportion of women (assumed by investigators) among study participants fluctuated over time. Having a woman as first (odds ratio (OR) = 1.68, 95% CI: 1.19-2.39) or last author (OR = 2.28, 95% CI: 1.31-3.97), was significantly associated with having more women participants in the study. Interpretation: The data underlying ESC guideline recommendations largely lack reporting of possible sex- and gender-specific aspects, and women are distinctly underrepresented. To what extent these recommendations apply to members of specific population groups who are not well-represented in the underlying evidence base remains unknown. Funding: This study is part of the Gender and Health Inequalities (GENDHI) project, ERC-2019-SyG. This project has received funding from the European Research Council (ERC).
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Bastian et al. (2024) conducted a systematic review in Chronic coronary syndromes (guideline literature base) (n=1,614,569). Woman as last author vs. Man as last author was evaluated on Having more women participants in the study (OR 2.28, 95% CI 1.31-3.97). Women were underrepresented in the evidence base of the 2019 ESC chronic coronary syndromes guidelines, though having a woman as last author was associated with higher female inclusion.
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