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Everywhere researchers looked in a series of studies, women were still substantially underrepresented in cardiology.

In particular, despite recent progress, women still haven't reached parity in the makeup of clinical trials, training programs, and journal editorial boards, according to research published together in the Feb. 18 issue of Circulation.

Participation in Cardiovascular Clinical Trials

In 740 completed cardiovascular trials from 2010-2017, women made up only 38.2% of the more than 860,000 participants, one study showed.

Female:male ratios among participants varied according to certain trial characteristics, reported Lijing Yan, PhD, of China's Duke Kunshan University, and colleagues:

• Age: 1.02 in the ≤55-year age group and 0.40 among 61-65 year olds
• Type of intervention: 0.44 for procedural trials and 0.78 for lifestyle intervention trials
• Disease type: 0.34 for acute coronary syndrome (ACS) and 3.20 for pulmonary hypertension
• Geographic region: 0.45 for Western Pacific and 0.55 for the Americas
• Sponsor type: 0.14 for government-funded and 0.73 for multiple sponsors
• Trial size: 0.56 for studies with 47 people or fewer and 0.49 for studies with 399 or more

"Among cardiovascular trials in the current decade, men still predominate overall, but the varies with disease and trial characteristics, and has improved in stroke and heart failure trials," the authors said, noting better participation among women in the 2013-2017 period.

Women were overrepresented in pulmonary hypertension trials relative to their prevalence in the disease population, but relatively well-represented in hypertension ones, according to Yan's group. On the other hand, lower female participation was observed in arrhythmia, coronary heart disease, ACS, and heart failure trials.

"Increasing the number of women who choose to enroll in clinical trials requires novel approaches to the recruitment and enrollment process," they said.

The ongoing aims to study how women view participation in cardiovascular research trials, the authors noted. "This research identified that potential barriers to female trial participation included the minimal understanding of trial process and logistics, limited clinical trial information from physicians, and misperceptions around the risks and benefits of participation."

The present study was based solely on studies registered on ClinicalTrials.gov and therefore was not as comprehensive as one might want, the investigators acknowledged. They added that they had found only three trials each from Southeastern Asia and the Eastern Mediterranean, a potential flag for bias.

Yan's group also noted that 28 of the trials had been funded by the U.S. Department of Veteran Affairs, which may explain the lower female participation.

Representation among Cardiology Trainees

Another study found that the gender disparity in cardiology training programs is almost as bad as that observed in the surgical subspecialties.

Most Accreditation Council for Graduate Medical Education (ACGME) training programs continued to have more men placed than women in 2017-2018:

• All adult cardiology trainees: 21.4% women
• Interventional cardiology: 10.2%
• Electrophysiology: 11.6%
• Advanced heart failure/transplantation: 31.2%
• Adult congenital heart disease: 46.7%
• Pediatric cardiology: 51.9%

Women's presence has been increasing, as they made up just 15.9% of cardiology trainees in 2007-2008 (P<0.01). Even so, this is "little change over the past decade," according to researchers led by Muhammad Shahzeb Khan, MD, of John H. Stroger, Jr. Hospital of Cook County in Chicago.

"In summary, this found that cardiology ranked second for the greatest underrepresentation of women, preceded only by orthopedic surgery. This prevalent disparity within cardiology, particularly for the procedural cardiovascular subspecialties, mirrors that of surgical specialties in many ways," the group said.

For this study, Khan and colleagues had accessed data from the Association of American Medical Colleges.

"Because the two most commonly identified factors guiding trainees' subspecialty selection are supportive role models and positive encouragement, efforts for change will effectively be initiated around these two factors," the authors noted.

They suggested focused mentoring and volunteer programs to ignite interest and reduce misconceptions about cardiology among medical students; providing students with travel grants to attend cardiology conferences; and sponsoring visiting rotations to increase exposure of early trainees to the cardiology field and to female role models.

Given that the data were based on U.S. training programs, Khan's team noted that the findings may not be generalizable to worldwide trends.

"Data were limited to materials published by the Association of American Medical Colleges and ACGME, so further exploration by variables such as age, year of residency, and U.S. region could not be carried out," the investigators added.

Missing Voices in Cardiology Journals

Finally, cardiology journals were also found to be lacking in female leadership, another paper showed.

"There were no women editors-in-chief for U.S. general cardiology journals between 1998 and 2018 and only one woman editor-in-chief for a general European cardiology journal," reported Sowmya Balasubramanian, MD, MSc, of the University of Michigan, Ann Arbor, and colleagues.

"The is consistent with the low representation of women in the cardiovascular medicine specialty. There was, however, a higher percentage of women professors on U.S. editorial boards [13.4% vs 9%, P=0.01]," the authors found.

U.S. journal mastheads boosted the number of women over time in a subset of publications, particularly in subspecialty journals founded after 2000.

U.S. and European subspecialty journals generally had similar proportions of female deputy editors and editorial board members (from 10% to 20%). Invasive subspecialty publications in the U.S., however, had significantly more women in these roles as compared to noninvasive journals (20.5% vs 13.4%, P=0.04), according to the investigators.

"Diversity in editorial boards not only can improve the societal relevance and quality of the journal but also can provide women role models for future generations. A more sex-balanced and diverse editorial team adds value by decreasing publication bias against women, providing a favorable impression of the journal, and increasing the likelihood of competitive submissions," Balasubramanian's group argued.

The good news was that two new journals from the American College of Cardiology -- JACC: CardioOncology and JACC: Case Reports -- had named female editors-in-chief for 2019, they said.