The need for increased pragmatism in cardiovascular clinical trials

Muhammad Shariq Usman, Harriette G.C. Van Spall, Stephen J. Greene, Ambarish Pandey, Darren K. McGuire, Ziad A. Ali, Robert J. Mentz, Gregg C. Fonarow, John A. Spertus, Stefan D. Anker, Javed Butler, Stefan K. James, Muhammad Shahzeb Khan

Research output: Contribution to journalReview articlepeer-review

11 Scopus citations


The majority of cardiovascular randomized controlled trials (RCTs) test interventions in selected patient populations under explicitly protocol-defined settings. Although these ‘explanatory’ trial designs optimize conditions to test the efficacy and safety of an intervention, they limit the generalizability of trial findings in broader clinical settings. The concept of ‘pragmatism’ in RCTs addresses this concern by providing counterbalance to the more idealized situation underpinning explanatory RCTs and optimizing effectiveness over efficacy. The central tenets of pragmatism in RCTs are to test interventions in routine clinical settings, with patients who are representative of broad clinical practice, and to reduce the burden on investigators and participants by minimizing the number of trial visits and the intensity of trial-based testing. Pragmatic evaluation of interventions is particularly important in cardiovascular diseases, where the risk of death among patients has remained fairly stable over the past few decades despite the development of new therapeutic interventions. Pragmatic RCTs can help to reveal the ‘real-world’ effectiveness of therapeutic interventions and elucidate barriers to their implementation. In this Review, we discuss the attributes of pragmatism in RCT design, conduct and interpretation as well as the general need for increased pragmatism in cardiovascular RCTs. We also summarize current challenges and potential solutions to the implementation of pragmatism in RCTs and highlight selected ongoing and completed cardiovascular RCTs with pragmatic trial designs.

Original languageEnglish (US)
Pages (from-to)737-750
Number of pages14
JournalNature Reviews Cardiology
Issue number11
StatePublished - Nov 2022

ASJC Scopus subject areas

  • Cardiology and Cardiovascular Medicine


Dive into the research topics of 'The need for increased pragmatism in cardiovascular clinical trials'. Together they form a unique fingerprint.

Cite this