Acronymesis

Acronyms are a product of the 20th century and have become an everyday part of the English language. Well-known examples are LASER (Light Amplification by Stimulated Emission of Radiation), RADAR (RAdio Detecting And Ranging), AWOL (Absent WithOut Leave), and SCUBA (Self-Contained Underwater Breathing Apparatus).

Anyone who reads current scientific journals also knows that acronyms are flooding the medical literature, especially the literature on clinical research trials in cardiology. Acronyms of major cardiologic trials have increased exponentially during the past decade—from around 250 in 1992 ¹ to nearly 4,200^* in 2002. ² The coined words “acronymania” ³ and “acronymophilia” ^3–5 underscore this rapid growth but fail to emphasize the downside. In fact, improper use of acronyms has become a nemesis. Hence, our term “acronymesis.”

We are not saying that all acronyms are “evil.” On the contrary. Acronyms can simplify and facilitate communication, enhance recall, and save time, space, and effort for everyone involved. This is particularly true for the many clinical research trials with long, unwieldy names that are cumbersome to recite and difficult to remember. Could anyone deny that BIG-MAC is a lot more “palatable” than Beaumont Interventional Group—Mevacor, ACE inhibitor, Colchicine restenosis trial? But what if BIG-MAC were not defined?

Failure to define acronyms is all too frequent and reflects inconsiderate writing, careless editing, and irresponsible publishing. ² As an example, the following sentence appeared in the abstract supplement of a major cardiology journal: “The study population comprised 2,950 patients (3,549 lesions) prospectively enroled [sic] into 4 restenosis trials (MERCATOR, MARCATOR, CARPORT, PARK).” ⁶ Nowhere were these acronyms defined, leaving readers to wonder whether they were looking at a used-car advertisement. Moreover, 70 other abstracts in that same issue contained undefined acronyms. And in one recent review article alone, we counted over 90 undefined acronyms, including some that appeared more than once! ⁷

What is obvious to members of one specialty may be obscure to members of another specialty and to those still in training. To complicate the matter, multiple trials—often unrelated—may share the same acronym. HEART, for example, currently represents no fewer than 16 different studies in which the acronym stands for different words in different combinations (Table I). In situations like this, defining the acronym when first mentioned is clearly essential.

TABLE I. Sixteen Different Clinical Trials with the Acronym HEART

Worse, when the first phase of a study evolves into the second phase, the acronym may remain the same, but the words represented by the acronym change. In CONSENSUS, which represents COoperative North Scandinavian ENalapril SUrvival Study, the first N stands for North, but in CONSENSUS II, it stands for New. Similarly, in VALID (Velocity Assessment for Lesions of IntermeDiate severity), the letters I and D stand for IntermeDiate, but in VALID II, they stand for InDeterminate. And in PLAC, which refers to Pravastatin Limitation of Atherosclerosis in the Coronary arteries, the C stands for Coronary, but in PLAC-2, the C stands for Carotid and the L for Lipids. ^2,8

An acronym may also assume an entirely different meaning when it becomes part of another acronym. For example, STOP refers to Shunt Thrombotic Occlusion prevention by Picotamide. But STOP-IT refers to Sites Testing Osteoporosis Prevention - Intervention Treatment. ²

Rarely questioned is the potentially coercive nature of certain acronyms. ⁹ CURE, HELP, HOPE, MIRACLE, and SAVE may entice research subjects by subliminally or outwardly promising something that the trial might not ultimately deliver. As a consequence, both the subjects and the investigators may become favorably biased. And because the results of clinical trials are preeminent in determining therapeutic priorities, ¹⁰ practitioners might prescribe medications on the simple basis of the acronym's connotation.

Trials with a positive-sounding acronym but with negative results include ATLAS, LIMIT AMI, IMPROVED, and PROMISE. The PROMISE trial, in fact, was not promising at all and had to be terminated prematurely. ¹¹ Therefore, institutional review boards, sponsors of trials, and the researchers conducting the trials should discourage or prohibit the use of coercive acronyms. ¹²

Certain acronyms may taint MEDLINE searches. ^13,14 Trial names such as PACT, SMART, and START are hard to find in databases, because the words themselves are so common. Consequently, unless you know what the acronym stands for, you're likely to retrieve a ton of irrelevant information. Even worse are the trials with names known as “stop” words—words so common that MEDLINE considers them to be useless and not searchable. Examples are ITS, THIS, THAT, and WHAT. If the author does not define the acronym in the title, abstract, or text of the article, a text word search will be impossible.

Disturbing, too, is the practice of building acronyms not from the first or first 2 letters of the words referred to, but from the third, fourth, or even last letters. ^2,15 Witness RENAISSANCE (Randomized Etanercept North AmerIcan Strategy to Study An-tago-Nism of CytokinEs), RENEWAL (Randomized EtaNErcept Worldwide evALuation), and ACCESS (A Comparison of perCutaneous Entry SiteS for coronary angioplasty).

But it gets even worse. We have acronyms made of acronyms. ⁴ AIMS, for example, refers to APSAC International Mortality Study; APSAC, in turn, means Anisoylated Plasminogen Streptokinase Activator Complex. And TAPS refers to TPA APSAC Patency Study; TPA, in turn, means Tissue Plasminogen Activator.

We also have acronyms that contain an extra consonant or vowel that does not appear in the title of the trial but is inserted to make the acronym sound better, ⁸ e.g., E in BASE (Berlin Aging Study) and U in PUTS (Perindopril Therapeutic Safety study). Likewise, words are often excluded from acronyms to make pronunciation easier. Examples are GUSTO for Global Utilization (of) Streptokinase (and) TPA (for) Occluded (arteries), and EPIC for Evaluation (of IIb/IIIa) Platelet (receptor antagonist 7E3 in preventing) Ischemic Complications.

Some acronyms are easily confused with each other because they sound alike. ⁸ Yet they may represent completely different trials, e.g., TOMHS (Treatment Of Mild Hypertension Study) and TOHMS (Trials Of Hypertensive Medications Study).

And when all letters of an unexplained acronym are not capitalized in the title, especially when the acronym itself is a common word, the uninitiated reader will not necessarily know which is the acronym and which is the common word, e.g., ACUTE vs Acute, COURAGE vs Courage, EPIC vs Epic, EPILOG vs Epilog, LIFE vs Life, and MIRACLE vs Miracle. ²

Finally, inventing acronyms for cardiologic research trials has become a game of “one-upmanship.” The goal seems to be finding an acronym that is cuter or wittier than the previous one. Categorizing them has become popular as well. ¹⁶ Thus, we have anatomic terms such as ARMS, BRAINS, CAVA, EARS, FACET, HEART, INTIMA, IRIS, PROSTATE, and RADIUS, or food items such as APRICOT, BIG-MAC, MOCHA, SALAD, SALT, and TOAST (or just zestful eating, e.g., GUSTO). There are geographical locations—MIAMI, NEVADA, PARIS, SIAM, and TIBET; matters of LIFE or DEATH; feminine names—ELSA, ERICA, EVA, GRACE, MONICA, NORA, PAMELA, PHYLLIS, and RITA; masculine names—ADAM, ARCHER, BERT, CAESAR, CHIP, DAVE, DAVID, DONALD, ERNST, HAROLD, ISAAC, MARVIN, and OSCAR; and on and on and on. In fact, we have reached the point where investigators are selecting a colorful acronym, and then dreaming up a suitable study to match it. ¹⁵

In conclusion, acronymesis has become a Macho-driven Major Malady of Modern Medical Miscommunication (MMMMMM). Meaningful Management of this MMMMMM Mandates Maximum effort to Minimize acronymic Misuse (MMMMMM). Oops! We just used the same “acronym” for 2 different messages. Does that ring a bell?

We can overcome acronymesis if we choose our acronyms with circumspection, derive them from the first or first 2 letters of each word in the phrase being condensed, define them at first mention, capitalize all of their letters consistently, and refrain from including common MEDLINE search words. ^2,17

Given their proven usefulness, acronyms undoubtedly are here to stay. But because of their aforementioned drawbacks, we have 2 suggestions:

• Editors need to Concentrate On Nixing This Rarely Obvious Lingo (CONTROL), and

• Authors need to remember that good Communicators Resist Acronymic Proliferation (CRAP).