Representation of the elderly, women, and minorities in heart failure clinical trials.

BACKGROUND Appropriate representation of specific groups of patients in randomized controlled trials (RCTs) and generalizability of evidence obtained have been questioned. We sought to compare the characteristics of patients in heart failure (HF) RCTs with those of patients with HF in the community, and to document these trends over time. METHODS MEDLINE was searched from 1985 through December 1999 for all HF RCTs. Additional trials were obtained through bibliographies of the reviewed articles, previous meta-analyses, and overviews of the HF trials. Original reports of RCTs of interventions for chronic HF were selected if they were published in the English language and included 50 or more participants. Publication year, sources of support, location of principal investigator, sample size, type of intervention, inclusion and exclusion criteria, characteristics of participants, and the use of invasive diagnostic tests were extracted. RESULTS Participants in the 59 HF RCTs we reviewed were markedly different from the patients with HF in the community. Patients in RCTs were younger, more often male, more likely to have subnormal systolic ejection fraction, and were most commonly white. We did not find a significant improvement in the representation of the trials, with respect to these characteristics, among those published recently compared with those from the late 1980s and early 1990s. CONCLUSIONS Clinical trials are focusing on a relatively small segment of the HF population. The consequences of underrepresenting minorities, women, and elderly are unknown but may be particularly important for HF. Future clinical trials should adequately include populations that carry the burden of the disease.

[1]  H. Krumholz,et al.  Long-term outcome of myocardial infarction in women and men: a population perspective. , 2000, American journal of epidemiology.

[2]  E. Peterson,et al.  The effect of race on coronary bypass operative mortality. , 2000, Journal of the American College of Cardiology.

[3]  L. Kozak,et al.  National hospital discharge survey: annual summary, 1998. , 2000, Vital and health statistics. Series 13, Data from the National Health Survey.

[4]  S. Fremes,et al.  The influence of gender on the outcome of coronary artery bypass surgery. , 2000, The Annals of thoracic surgery.

[5]  David J Harris,et al.  Enrollment of women in cardiovascular clinical trials funded by the National Heart, Lung, and Blood Institute. , 2000, The New England journal of medicine.

[6]  A. Cohen-Solal,et al.  A national survey of heart failure in French hospitals. The Myocardiopathy and Heart Failure Working Group of the French Society of Cardiology, the National College of General Hospital Cardiologists and the French Geriatrics Society. , 2000, European heart journal.

[7]  Simon Stewart,et al.  Epidemiology, aetiology, and prognosis of heart failure , 2000, Heart.

[8]  S. Neubauer,et al.  Age- and gender-specific differences in left and right ventricular cardiac function and mass determined by cine magnetic resonance imaging , 2000, European Radiology.

[9]  C. Coltman,et al.  Underrepresentation of patients 65 years of age or older in cancer-treatment trials. , 1999, The New England journal of medicine.

[10]  E. Vesell,et al.  Are the Elderly Underrepresented in Clinical Drug Trials? , 1999, Journal of clinical pharmacology.

[11]  S. Dunlap,et al.  Association of body mass, gender and race with heart failure primarily due to hypertension. , 1999, Journal of the American College of Cardiology.

[12]  W. Aronow,et al.  Comparison of incidences of congestive heart failure in older African-Americans, Hispanics, and whites. , 1999, The American journal of cardiology.

[13]  Jeffrey M. Hausdorff,et al.  Congestive heart failure with preserved systolic function: is it a woman's disease? , 1999, Women's health issues : official publication of the Jacobs Institute of Women's Health.

[14]  D. Levy,et al.  Congestive heart failure in subjects with normal versus reduced left ventricular ejection fraction: prevalence and mortality in a population-based cohort. , 1999, Journal of the American College of Cardiology.

[15]  G. Koch,et al.  Gender differences in survival in advanced heart failure. Insights from the FIRST study. , 1999, Circulation.

[16]  C Bain,et al.  Threats to Applicability of Randomised Trials: Exclusions and Selective Participation , 1999, Journal of health services research & policy.

[17]  S G Thompson,et al.  Incidence and aetiology of heart failure; a population-based study. , 1999, European heart journal.

[18]  A Hofman,et al.  Prevalence of heart failure and left ventricular dysfunction in the general population; The Rotterdam Study. , 1999, European heart journal.

[19]  Hall Wd Representation of blacks, women, and the very elderly (aged > or = 80) in 28 major randomized clinical trials. , 1999 .

[20]  K. Bailey,et al.  Congestive heart failure in the community: a study of all incident cases in Olmsted County, Minnesota, in 1991. , 1998, Circulation.

[21]  H. Schunkert,et al.  Gender specific differences in left ventricular adaptation to obesity and hypertension , 1998, Journal of Human Hypertension.

[22]  L. Goldman,et al.  Gender differences in 1-year survival and quality of life among patients admitted with congestive heart failure. , 1998, Medical care.

[23]  W. Aronow,et al.  Normal left ventricular ejection fraction in older persons with congestive heart failure. , 1998, Chest.

[24]  M. Legato Cardiovascular disease in women: gender-specific aspects of hypertension and the consequences of treatment. , 1998, Journal of women's health.

[25]  C. Lavie,et al.  Usefulness of peak oxygen consumption in predicting outcome of heart failure in women versus men. , 1997, The American journal of cardiology.

[26]  M. Nettleman,et al.  Predictors of survival and the role of gender in postoperative myocardial infarction. , 1997, The American journal of medicine.

[27]  M. Rich,et al.  CONGESTIVE HEART FAILURE IN OLDER ADULTS * : Epidemiology, Pathophysiology, and Etiology of Congestive Heart Failure in Older Adults , 1997, Journal of the American Geriatrics Society.

[28]  A. Jacobs,et al.  Congestive heart failure in patients with coronary artery disease: the gender paradox. , 1997, American heart journal.

[29]  E. Schron,et al.  Clinical Trial Participant Satisfaction: Survey of SHEP Enrollees , 1997, Journal of the American Geriatrics Society.

[30]  David P Miller,et al.  Long-Term Follow-Up of Gender-Specific Outcomes After Thrombolytic Therapy for Acute Myocardial Infarction from the GUSTO-I Trial , 1997 .

[31]  J. Heikkilä,et al.  Congestive heart failure in old age: prevalence, mechanisms and 4‐year prognosis in the Helsinki Ageing Study , 1997, Journal of internal medicine.

[32]  A. Carter,et al.  Gender-specific associations of the fibrinogen B beta 448 polymorphism, fibrinogen levels, and acute cerebrovascular disease. , 1997, Arteriosclerosis, thrombosis, and vascular biology.

[33]  J. Torner,et al.  Why are African Americans under-represented in medical research studies? Impediments to participation. , 1997, Ethnicity & health.

[34]  J. Herlitz,et al.  Female sex is associated with increased mortality and morbidity early, but not late, after coronary artery bypass grafting. , 1996, European heart journal.

[35]  C. Held,et al.  Age and gender differences in left ventricular function among patients with stable angina and a matched control group. A report from the Angina Prognosis Study in Stockholm. , 1996, Cardiology.

[36]  L. Køber,et al.  Influence of gender on short- and long-term mortality after acute myocardial infarction. TRACE study group. , 1996, The American journal of cardiology.

[37]  C. Naylor,et al.  Characteristics and mortality outcomes of thrombolysis trial participants and nonparticipants: a population-based comparison. , 1996, Journal of the American College of Cardiology.

[38]  R. Schmieder,et al.  Gender-specific cardiovascular adaptation due to circadian blood pressure variations in essential hypertension. , 1995, American journal of hypertension.

[39]  N. Geller,et al.  Inclusion of women and minorities in clinical trials and the NIH Revitalization Act of 1993--the perspective of NIH clinical trialists. , 1995, Controlled clinical trials.

[40]  P. Kligfield,et al.  Gender-specific criteria and performance of the exercise electrocardiogram. , 1995, Circulation.

[41]  D. Tresch,et al.  Heart Failure with Normal Systolic Function: A Common Disorder in Older People , 1995, Journal of the American Geriatrics Society.

[42]  J. Deckers,et al.  Characteristics and prognosis of non-participants of a multi-centre trial of long-term anticoagulant treatment after myocardial infarction. , 1995, International journal of cardiology.

[43]  E. Trimble,et al.  Representation of older patients in cancer treatment trials , 1994 .

[44]  K. Bailey,et al.  Long-term survival after pacemaker implantation for heart block in patients > or = 65 years. , 1994, The American journal of cardiology.

[45]  C. Simpfendorfer,et al.  Risk stratification for long-term outcome after elective coronary angioplasty: a multivariate analysis of 5,000 patients. , 1994, Journal of the American College of Cardiology.

[46]  D. Levy,et al.  The epidemiology of heart failure: the Framingham Study. , 1993, Journal of the American College of Cardiology.

[47]  J. Avorn,et al.  The exclusion of the elderly and women from clinical trials in acute myocardial infarction. , 1992, JAMA.

[48]  S. Karjalainen,et al.  Do treatment protocols improve end results? A study of survival of patients with multiple myeloma in Finland. , 1989, BMJ.

[49]  C. K. Svensson,et al.  Representation of American blacks in clinical trials of new drugs. , 1989, JAMA.

[50]  S. Davis,et al.  Participants in prospective, randomized clinical trials for resected non‐small cell lung cancer have improved survival compared with nonparticipants in such trials , 1985, Cancer.