Dr Rasha Al-Lamee

" Welcome. I'm Rasha Al-Lamee from Imperial College London, and we're brought here today by Radcliffe Cardiology and Women as One. And I'm here with good friends and colleagues. Valeria Paradies from Rotterdam and Róisín Colleran from Dublin. So, Róisín, Valeria, thank you very much for joining us. How's ESC been for you, Valeria?

Dr Valeria Paradies

Wow, amazing. I can say it's my hometown, so it's fantastic to be here in Amsterdam. It's a great venue, amazingly big location, and a lot of things going on, like interest for science patients, perspective. There's so many things going on. It's really been fantastic, hasn't it, Róisín? How's your time been?

Dr Róisín Colleran

It's been a great conference. It's great to be back in Amsterdam, having missed it, of course, during the COVID pandemic, there's been a lot of science, there's been so many late-breaking trials. It just seems to get better and better every year. ESC upped the bar. I think by yesterday at lunchtime, I had counted nine New England Journal of Medicine publications. So, really, it's been an exciting year for science at the ESC.

Dr Rasha Al-Lamee

Yeah, it really has. And here on this final day, our topic at hand is cardiovascular disease in women. So, Róisín, have you seen anything at the conference that's been particularly around that subject?

Dr Róisín Colleran

Yeah, so the Atherosclerosis Society, the European Atherosclerosis Society, did release a document a couple of days ago which was basically a call to action to target cardiovascular disease risk factor modification in women to prevent atherosclerotic cardiovascular disease. The document for me was a real eye-opener. I mean, it tells us that middle-aged women are the fastest increasing rise in atherosclerotic cardiovascular disease deaths, that women, I suppose we know, tend to be recognised later, both in terms of symptoms and in terms of risk factors, and they tend to be under-treated. So it calls, for example, on us to target women earlier, to check for risk factors and to treat them according to guideline-based therapies, which often isn't done in women until much later. It tells us to look at sex-specific risk factors, such as pregnancy-related disorders or PCOS, all of which increase our cardiovascular risk, which men, of course, don't have to deal with. And, for example, suggested that it might be worth checking LP(a) in women twice in life, as opposed to what guidelines recommend once that over 50 women's LPA and also during pregnancy can increase. So a few of those were real eye-openers for me, and I think it's really important to take that stuff on board and hopefully it will be taken up by the cardiovascular community.

Dr Rasha Al-Lamee

Yeah, so that's all very interesting data. And what do you think, Valeria? Is that the kind of thing you're applying in your clinical practice? Because I have to say myself, I think I need to get better at thinking about my female patients and how I treat them differently.

Dr Valeria Paradies

Absolutely. And I think we don't have so much data about that. So that's probably the most important thing. We have to underline that there are little data that women are underrepresented in clinical trials. That's a matter of fact. As we look at the participation to prevalence ratio in clinical trials, we see that cardiovascular clinical trial actually account for 1.6 in this ratio, which is really low. We need to do better. And, yeah, if we think about the barriers, well, I can, of course, enlist a lot of them socioeconomic cultural, but simply thinking of the fact that most women are caregivers, they have competing priorities or yeah, sometimes there's also inadequate cultural exposure to knowledge and to awareness of cardiovascular condition. So we have barriers. How can we overcome this barrier in order to get data and use this data, apply this data into our daily practice? Well, you can answer that. What do you do in your clinical practice, in your randomized control trial?

Dr Rasha Al-Lamee

It is incredibly difficult, actually. And as a clinical trialist, I'm constantly trying to think about how we increase representation from both women, but also from many underrepresented minorities. And one of the major issues is you do your best, you try and make things as easy as possible. We bring the research to them, we try and try and get down to some of those barriers. So, for example, providing transport, trying to cover the various costs of things, of the extra visits to hospital, etc. But one of the major things we found with women is that I think that they can be much more risk averse sometimes than their male counterparts. And of course, if you are a caregiver and you do have a household to worry about, you're far less likely to take on risk, knowing that there's a lot of people that you're responsible for. And so there is something to be done now, I think, in terms of educating our female patients and the wider female community on the need for them to participate in trials so that we get that data through. And Róisín, I mean, we know there was a very important Lancet Commission for Cardiovascular disease in women. What did you think of some of the statements they had there? Because I know that they are keen to try and address some of these issues. Yeah, so that was a very important document.

Dr Róisín Colleran

Thank you, Rasha, that really is trying to, I suppose, the call to action again to try and encourage people to increase the participation and the enrollment of women in randomized trials, because as we've seen again at this conference, women account for 25, 30% of patients enrolled, particularly in trials of interventional cardiology. And really, we don't really know the answers or whether all of these treatments are applicable to women. So I suppose that document is very important in trying to reduce the burden of cardiovascular mortality in women by 2030 by increasing enrollment in trials and generating more data.

Dr Rasha Al-Lamee

Yeah, it's really difficult. I mean, there's a part of you that thinks, should we have some minimum thresholds, we have to reach certain levels of women within our trials for a trial to be published or perhaps for it to be considered adequately powered to answer the questions. But the difficulty it's already hard to recruit patients, it's already hard to fund these trials. And if we start setting new targets, as important as they might be, they might hinder the whole process of research. So it's a very difficult balance that and do you see what about educating your female patients? Do you think your female patients, Valeria, have a real understanding that they have a higher risk of cardiovascular disease? Or where do they put that in the kind of the ranking of the diseases that may be important to them?

Dr Valeria Paradies

Well, first of all, probably they are not aware how important is how big is the burden needed of cardiovascular disease and the risk of mortality? They are not aware of it. We do know that the presentation of symptoms are different in women as compared to men, and that's probably why they underestimate themselves. And, for example, the GPS, they simply do not refer the patient with cardiac disease to a cardiologist. So that's the first barrier, first of all. Yeah, I think it 's absolutely raising awareness, educating campaigns. That's the way to go. And probably from a trialist perspective, how can we improve more like a larger enrollment of these minorities in general, women and minorities? Well, I think a direct relationship within the research team and the patients, for example, using simple tools that can address some barriers. Sometimes it's just a matter of communication, language barrier why don't we use simple tools to address these gaps.

Dr Rasha Al-Lamee

And Róisín for your patients, or maybe even wider, your friends, your family, etc. Do you think there's enough understanding of cardiovascular disease? We talk a lot about breast cancer and the other major killers, but do you think if you think about your mother, your grandmother, the rest of them around them.

Dr Róisín Colleran

I think it's still perceived largely as a man's disease, which, of course, we know isn't the case. It's the number one killer in women as well. And I think there does need to be more education around that, both in the lay media and I suppose through doctors in primary care as well as in hospitals. Yeah, I think checking of cardiovascular risk factors at a young age, checking your blood pressure every year, checking your lipids from a young age, I think is really important because I think it really is neglected. And we know it's the cumulative, for example, exposure to cholesterol that does the damage over time and causes atherosclerosis. So it's really something that needs to be highlighted.

Dr Rasha Al-Lamee

Yeah. And maybe we can kind of come towards the close now. But Valeria, what do you see as the future? Where do you think this kind of is going to go? Are we going to get better at including these women in trials? Are we going to get better with our education and the kind of public education measures for women?

Dr Valeria Paradies

Well, thanks, Rasha. That's a really important, crucial question. I think only the fact that we're here talking about it and people watching us, I think that's raising, first of all, awareness among us as physicians. And I think there are a lot of initiatives from the societies and from the journals as well, also to improve, to stimulate enrollment of these patients. So getting more data will bring ultimately us to better treat our patients.

Dr Rasha Al-Lamee

Thank you very much for that. Thank you very much for joining me today. Thank you very much for watching. And I hope you've enjoyed this very enjoyable conversation for us this morning.