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WHAT’S IN A NAME?
A CRITIQUE OF PROCRUSTEAN ACRONYMS

As the Editor of a medical journal, I read other journals from a distinct perspective. I’m always on the lookout for syntactic or stylistic stumbles, which I resolve to avoid here in JLGH.

But there is one practice that I find frequently distressing though it has nothing to do with an editor’s prerogatives: the creation of supposedly catchy and thus memorable acronyms for large collaborative (usually randomized) clinical trials. The use of acronyms like ACCORD, COURAGE, ALL-HAT, and ONTARGET is so ingrained in the medical literature that it seems almost petty to object. What could possibly be wrong with the practice?

Quite a bit, I venture to suggest. In my opinion, there are several things wrong with them, though I don’t object to their use per se. Rather, it’s because the Procrustean effort to fit a description of the trial into a “clever” acronym usually requires convoluted manipulations to create the sentence or phrase that underlies the acronym. (Procrustes, you may recall, was the bandit in Greek mythology who forcibly adjusted travelers to fit his bed by either stretching them or cutting off their legs.)

The problem is that these contorted titles from which the acronyms are extracted are usually not the same as the original titles for the studies’ published scientific reports. Those are accurate and unambiguous, but the titles that generate the acronyms are often not, and in the example I shall cite, can even misstate the actual design or purpose of the study.

Take, for example, the ONTARGET study. The report of that trial’s results was published recently in the New England Journal of Medicine with the title “Telmisartan, Ramipril, or Both in Patients at High Risk for Vascular Events.” [1] Clearly, this was a comparison of telmisartan, an angiotensin receptor blocker (ARB), ramipril, an ACE inhibitor, or the combination of the two drugs, in three distinct groups of patients.

But the somewhat cutesy acronym ONTARGET is derived from the artificially constructed title “Ongoing Telmisartan Alone and in Combination with Ramipril Global Endpoint Trial” (emphasis mine). This is starkly different from the title of the actual published trial. Take a close look at this acronym’s underlying descriptive phrase, because it indicates that ramipril was studied only with telmisartan, and noone received ramipril alone. But clearly, one group did receive ramipril as mono-therapy. Should a euphonious acronym trump scientific accuracy? I think not.

There are other problems as well. Consider the confusion that can result from clever acronyms that offer no hint of the disease or organ system they are studying. Other than specialists who are familiar with major randomized trials in their own specialty, everyone else is mystified by these acronyms. I was tempted to accompany this editorial with a table that placed a list of acronyms in one column, and the diseases they address in the other. There would be a prize for anyone who could match them all without resorting to a literature search!

The actual published title for the original report of the ALLHAT study is “Major outcomes in high-risk hypertensive patients randomized to angiotensin-converting enzyme inhibitor or calcium channel blocker vs diuretic.” [2] Clear enough, I should think, as it describes the study precisely. But in seeking an acronym, the investigators, rather than adapting a word that is actually in the dictionary, chose an acronym that is a neologism derived from “Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack Trial.” It fairly describes the study, but does require skipping the T&P; Procrustes would have been delighted. Still, wouldn’t it be even more useful if we categorized these influential trials by adding a word like PRESSURE to trials about management of hypertension (e.g. ALLHAT-PRESSURE)?

Similarly, the ACCORD trial was reported recently in the New England Journal of Medicine with the title “Effects of Intensive Glucose Lowering in Type 2 Diabetes.” [3] It looked at the effect of intense diabetes control (to achieve a glycated hemoglobin level of <6.0%) compared with standard therapy on a composite index of cardiovascular events. The acronym ACCORD is based on the phrase “The Action to Control Cardiovascular Risk in Diabetes.” Why not add the word SUGAR to trials about diabetes (as in ACCORD-SUGAR)?

Specialists in other disciplines would be able to remember and to differentiate studies with such categorized tags. Otherwise, the potential for confusion is almost boundless. My search of http://clinical/trials.gov revealed 11,458 active studies that are currently seeking new volunteers, and more than 28,000 overall.

In regard to the inaccuracy revealed by the acronym ONTARGET, it should be emphasized that the editors of the Journals that publish these reports have no control over this situation, since the acronyms and the titles are developed by the investigators when they submit their application for NIH funding. Shouldn’t the NIH, which funds almost all such collaborative studies, notice and refuse such distortions?

For the present, the acronyms we have are probably better than nothing because they do provide a handy way to refer to studies with long titles, but I suggest that we could make them more useful by adding a word that categorizes them. Finally, we should draw the line and refuse to accept acronyms like ONTARGET that baldly misstate the design or purpose of the trial.

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