Assessing and Addressing Cardiovascular Health in LGBTQ Adults: A Scientific Statement From the American Heart Association

The intersection of the laboratory and transgender care

Transgender and gender diverse (TGD) individuals seeking gender affirming treatment are an increasing demographic in today's society; such treatments include hormonal and surgical interventions aimed at alleviating gender dysphoria and increasing quality of life. A number of diagnostic pathology tests are provided to medical professionals with sex specific reference intervals (RIs) for interpretation, due to sex specific physiological differences, organ size and hormone levels for example. These tests may be reported with RIs that are not appropriate, and interpretation for the medical professional can be challenging. From the laboratory perspective, there are limitations in Laboratory Information Management Systems (LIMS) and the ability of these databases to record both sex and gender identifiers, as well as the reporting of appropriate RIs. The use of RIs derived from the transgender population is complex, studies generally have a low sample size and include adults with long established hormonal treatments. The age of an individual undergoing gender affirming therapy has decreased, and the use of Gonadotrophin Releasing Hormone analogues adds complexity. In this review, we will discuss the current challenges and perspectives regarding the reporting of reference intervals in the TGD population, the derivation of personalized or transgender specific RIs and interpretation of specific diagnostic tests.

Examining the Associations of Family-Related Factors with Hypertension in Sexual Minority Women

Purpose: We examined the association between family-related factors (i.e., sexual identity disclosure to family and family social support) and hypertension (HTN) among sexual minority women (SMW; i.e., lesbian/gay, bisexual, or another sexual identity). Methods: We analyzed data from Waves 3 (2010-2012) and 4 (2017-2019) of the Chicago Health and Life Experiences of Women study. Using multiple logistic regression, we examined the cross-sectional and longitudinal associations of family-related factors with self-reported HTN (diagnosis of HTN at Wave 3 and newly diagnosed HTN at Wave 4) among SMW. We also explored whether race/ethnicity and sexual identity moderated these associations. Analyses were adjusted for relevant covariates (e.g., age, tobacco use). Results: Cross-sectional analyses included 651 SMW with a mean age of 40.2 (±13.8) years, 58% of whom identified as Black/African American or Hispanic. Family social support was inversely associated with the diagnosis of HTN (adjusted odds ratio: 0.85, 95% confidence interval: 0.75-0.97). Longitudinal analyses included 377 SMW (mean age of 38.8 [±13.0] years) with 51% identifying as Black/African American or Hispanic. Family social support was not associated with newly diagnosed HTN. Neither the cross-sectional nor longitudinal associations between sexual identity disclosure to family and HTN were significant. Neither race/ethnicity nor sexual identity were significant moderators. Conclusions: Family social support was associated with lower odds of HTN diagnosis among SMW. Families and clinicians should be educated about the protective role of family social support for sexual minority adults. Further research is needed to identify factors that contribute to HTN disparities observed among these populations.

An Education Intervention in Gastrointestinal Healthcare Workers Improves Knowledge of Sexual and Gender Minority Digestive Health

BACKGROUND

Sexual and gender minority (SGM) communities experience barriers in accessing healthcare. While literature exists in remedying SGM-related knowledge deficits in primary care, none exists for gastroenterology specialists.

AIMS

We detail a two-site experience with a focused education intervention for gastrointestinal healthcare workers on SGM digestive health.

METHODS

Gastroenterology and hepatology physicians, nurses, trainees, and staff at two academic medical centers participated. A 10-question pre-test and Likert scale questions on confidence in caring for sexual and gender minority patients were given. Participants then attended a lecture about SGM digestive health. After, they completed a post-test and 6-month follow-up assessment. Pre- and post-test averages of correct answers were compared to assess objective knowledge acquisition and identify gaps in knowledge.

RESULTS

Of 368 eligible participants, 143 (39.0%) completed the pre-test, 79 completed the post-test, and 93 completed 6-month follow-up. Pre-test average correct responses were 61%, while post-test correct responses increased to 70% (p < 0.001). At 6-month follow-up, average percent correct was 66% (p = 0.027 compared to pre-test). Confidence caring for SGM patients improved from 3.62 to 3.99. (1 = strongly disagree, 5 = strongly agree; p = .033). This persisted at 6 months (average 4.07, p = .007).

CONCLUSIONS

A lecture-based intervention results in significant and sustained improvement in confidence and knowledge surrounding digestive healthcare in SGM patients. This can be used as a starting point for curricular development at all medical education levels. Doing so may allow for more culturally inclusive care to be provided to SGM communities and foster cultural humility.

Risk of impairment in cognitive instrumental activities of daily living for sexual and gender minority adults with reported Parkinson's disease

Objective: To investigate the risk of impairment in cognitive instrumental activities of daily living (IADL) for people with Parkinson's (PwP) identifying as sexual and/or gender minorities (SGM). Method: Data were obtained from Fox Insight, an online, longitudinal study with self/informant-report questionnaires from PwP and people without Parkinson's. Groups consisted of PwP without cognitive IADL impairment at baseline, identifying as (1) SGM with female sex assigned at birth (SGM-F, n = 75); (2) cisgender, heterosexual with female sex assigned at birth (CH-F, n = 2046); (3) SGM with male sex assigned at birth (SGM-M, n = 84); (4) cisgender, heterosexual with male sex assigned at birth (CH-M, n = 2056). Impairment in cognitive IADL was based on Penn Parkinson's Daily Activities Questionnaire-15 (PDAQ-15). Group differences for PDAQ-15 and impairment likelihood during follow-up were assessed with unadjusted models and adjusting for variables that differed between the groups. Results: SGM-F were the youngest at Parkinson's diagnosis; SGM-M had the lowest PDAQ-15 at baseline (p ≤ .014 for all). Scores declined more for males than females in unadjusted and adjusted models (p < .001 for both). In unadjusted models, SGM-M had a higher impairment risk than PwP identifying as cisgender and heterosexual (p ≤ .018). In adjusted models, females had a lower impairment risk than males (p < .001). Age, education, and discrimination level were significant moderators (p < .001 for all). Conclusions: SGM-M can be at a higher risk for impairment in cognitive IADL, associated with social determinants. Female sex assigned at birth may be associated with a lower level of impairment risk, although this advantage can disappear with social determinants.

Cerebrovascular Health Among Sex- and Gender-Diverse People: A Narrative Review

Purpose of Review

Sex and gender diversity includes people who are intersex, transgender, and nonbinary. Americans are identifying as sex and gender diverse (SGD) in increasing numbers. Although data are limited on the diagnosis and management of stroke in SGD communities, the current literature suggests that there may be unique health needs among these marginalized populations.

Recent Findings

Health disparities and community-specific stressors may influence the frequency of stroke and traditional cerebrovascular disease risk factors among SGD people. In addition, transgender and gender-diverse people have higher rates of atypical stroke risk factors, such as sexually transmitted infections and an increased mental health burden. The adverse effects of some gender-affirming therapies can increase the rates of stroke, particularly in transfeminine people who use long-term estrogen as part of their medical gender transition. Decisions to discontinue hormonal therapy after stroke should be weighed against the psychological risks of doing so. In addition, some commonly prescribed medications for stroke prevention could interact with gender-affirming hormone therapies. Neurologists should collaborate with primary care providers and endocrinologists to screen for and manage cerebrovascular disease risk factors for the primary and secondary prevention of stroke. Limited evidence suggests intersex people may be at higher risk of cerebrovascular disease, particularly those with congenital adrenal hyperplasia (CAH). People diagnosed with CAH have unique risk factors of stroke including treatment with stress-dose corticosteroids or polycythemia due to hyperandrogenism.

Summary

Creating affirming environments and increasing knowledge of health care for SGD communities may lead to improved equitable treatment of SGD patients with stroke by increasing community trust in health providers and incorporating use of best practices in clinical care and research settings. Limited data exist on stroke clinical presentations and how stroke is experienced and treated among SGD people, particularly among those with multiple marginalized identities, those presenting with acute stroke, and those requiring secondary stroke prevention.

Preparedness of Practicing Nurses in the Care of Sexual and Gender Diverse People in the United States: A Scoping Review

BACKGROUND

Sexual and gender diverse (SGD) people in the United States (US) experience health inequities due to societal stigma and marginalisation. The nursing workforce must provide evidence-based affirming, inclusive and culturally responsive care for SGD people to meet individual and community health needs and eliminate disparities.

AIMS

The purpose of this scoping review was to synthesise what is known about (1) nurses' knowledge, skills and attitudes related to caring for SGD people in the US and (2) the existence, development and evaluation of SGD-related educational offerings available to practicing nurses in the US to develop the knowledge and skills needed to promote the health and wellbeing of SGD individuals, families and communities.

METHODS

This review followed the scoping review methodology and PRISMA for Scoping Reviews (PRISMA-ScR).

DATA SOURCES

In conjunction with a health librarian, an electronic literature search was conducted using PubMed, LGBT Health, CINAHL, ERIC and Health Source-Nursing.

RESULTS

Thirty-two studies were included in this review, including quantitative and qualitative studies that sought to understand the knowledge, attitudes and clinical experiences of nurses related to the care of SGD people; studies that tested educational interventions and studies that identified educational barriers and facilitators. Major gaps in education, practice and research, as well as methodological limitations of existing studies, were noted.

CONCLUSION

Nurses would benefit from expanded access to effective standardised foundational SGD-related health continuing education to help prepare them to care for diverse patient populations. Equity, inclusivity and dignity are key values of the nursing profession. It is imperative that nurses have the knowledge and skills to apply these values consistently in day-to-day professional practice across populations and settings.

IMPACT

There is an urgent need to develop standardised, easily accessible evidence-based educational content to address nurses' knowledge of and attitudes towards caring for SGD people.

REPORTING METHOD

This study adhered to the PRISMA-ScR reporting guidelines.

PATIENT OR PUBLIC CONTRIBUTION

There was no patient or public contribution to this study.

Treatment of Cardiovascular Manifestations in Transgender Individuals

The transgender population has been steadily increasing, with more individuals seeking gender-affirming care to align their physical characteristics with their gender identity. Despite advances in healthcare, transgender individuals face significant barriers to accessing culturally competent care, resulting in heightened cardiovascular risks and disparities. Cardiovascular disease prevalence among transgender individuals is influenced by a combination of physiological, psychological, and social factors, including the impacts of gender-affirming hormone therapy, surgical interventions, and minority stress. This review examines the cardiovascular risks associated with estrogen therapy in transfeminine individuals and testosterone therapy in transmasculine individuals, highlighting their effects on lipid profiles, thromboembolic risks, and metabolic parameters. Furthermore, it explores the implications of gender-affirming surgeries and the role of psychosocial stress in cardiovascular outcomes. Current evidence underscores the need for tailored risk assessment, proactive management strategies, and lifestyle interventions to optimize cardiovascular health in this population. Significant research gaps remain regarding the long-term cardiovascular effects of gender-affirming care. Large-scale, prospective studies and the development of transgender-specific cardiovascular care guidelines are crucial to address these gaps. This review advocates for a multidisciplinary, patient-centered approach to mitigate cardiovascular risks and improve outcomes for transgender individuals.

Sleep health among sexual and gender minority people in the United States: A scoping review

Sleep has been found to be essential to physical and mental health. Sexual and gender minority (SGM; e.g., lesbian, gay, bisexual, transgender, nonbinary) individuals experience significant health disparities, and emerging research indicates that this includes disparities in sleep health. However, the current literature on sleep health in this population has not previously been rigorously reviewed. This scoping review provides a comprehensive overview and synthesis of the current literature on SGM sleep health in the United States. Following established scoping review methodology, we systematically searched PubMed, CINAHL, PsycINFO, LGBTQ + Source, and Scopus; 76 studies met inclusion criteria. Included studies indicated significant sleep disparities exist for SGM people, particularly sexual minority women and gender minority people. Social determinants of health, including bullying and discrimination, were associated with worse sleep health. Included studies were heterogeneous and had methodological weaknesses, leaving opportunities for future research. Overall, findings point to the need for more rigorous research to advance understanding of sleep health across SGM subgroups and inform interventions to improve sleep health among SGM people, given the known negative impact of poor sleep on overall health.

Allostatic Load and Cardiovascular Disease: A Systematic Review

INTRODUCTION

Cardiovascular disease is a leading cause of morbidity and mortality. In the past 3 decades, allostatic load-a physiological representation of cumulative life stress-has been associated with increased risk of cardiovascular disease incidence and mortality. Additionally, differences in allostatic load may partially explain persistent disparities in cardiovascular disease outcomes. However, there is notable variation in cardiovascular disease types and subsequent impairments suggesting this association may not be similar across cardiovascular disease types and demographic characteristics.

METHODS

This study is a systematic review conducted in 2024 of current knowledge on the relationship between allostatic load and cardiovascular disease. A literature search using the electronic databases PubMed, SCOPUS, and Web of Science and the keywords allostatic load and cardiovascular disease was conducted. A total of 233 articles were identified in initial review and 22 studies were identified for inclusion in this review.

RESULTS

This review found that allostatic load was associated with a composite score of cardiovascular disease incidence but there was less clarity on the relationship with cardiovascular disease mortality and other cardiovascular disease outcomes. Additionally, there was some variation between cardiovascular disease types and the relationship with allostatic load as well as intersectional race and gender differences.

CONCLUSIONS

This review revealed notable gaps in the current knowledge of the relationship between cardiovascular disease and allostatic load. Future research is necessary to evaluate how this relationship differs across demographic characteristics, cardiovascular disease types, cardiovascular disease outcomes such as impairment, and disease processes. Future research should also identify standardized measures of allostatic load and determine how the social determinants impact allostatic load across the lifespan.

Increased Rate of Unique Mitochondrial DNA Deletion Breakpoints in Young Adults With Early-Life Stress

Background

Mounting evidence suggests that mitochondria respond to psychosocial stress. Recent studies suggest mitochondrial DNA (mtDNA) deletions may be increased in some psychiatric disorders, but no studies have examined early-life stress (ELS) and mtDNA deletions. In this study, we assessed mtDNA deletions in peripheral blood mononuclear cells of medically healthy young adults with and without ELS.

Methods

Participants (n = 181; 69% female), ages 18 to 40 years, were recruited from the community. Participants with ELS (n = 108) had moderate to severe childhood maltreatment; 83 also had parental loss, and 59 had psychiatric disorders. Participants in the control group (n = 73) had no maltreatment, parental loss, or psychiatric disorders. Standardized interviews and self-report measures assessed demographic variables, stress, and mental health. mtDNA from peripheral blood mononuclear cells was amplified via long-range polymerase chain reaction; mtDNA deletions were quantified via Seq-Well, next-generation sequencing, and the Splice-Break pipeline. Linear regression models were used to assess relationships of mtDNA deletion metrics with ELS, adult stressors, psychiatric disorders, and demographics.

Results

Participants with ELS had significantly greater rates of unique mtDNA deletion breakpoints per 10,000 coverage than participants without ELS (p < .001), correcting for age, sex, and sequencing depth. Cumulative mtDNA deletion read percentage was not significantly different between groups. Psychiatric disorders and adult stressors were associated with greater unique mtDNA deletion breakpoints (ps < .05) but did not account for associations of ELS with mtDNA deletions.

Conclusions

The increased number of unique mtDNA deletion breakpoints in participants with ELS suggests that mitochondrial genomes undergo observable alterations in the context of early stress. Future studies will examine mtDNA deletions with metabolic health measures.

Enhancing student understanding of cardiovascular disease burden in marginalized communities in the physiology classroom

Physiology education is at the core of biomedical science and medicine. Physiology unites multiple disciplines to explain the mechanisms whereby a risk factor is associated with disease. Race, ethnicity, sexual orientation, and gender identity are associated with risk of cardiovascular disease (CVD). Minority stress theory attempts to explain the association of identity variables in sex and gender minority (SGM) and Black, Indigenous, and people of color (BIPOC) populations with CVD. However, instruction on how to effectively incorporate the ways that social determinants of health are linked to disease outcomes in marginalized populations, such as the SGM and BIPOC communities, is needed. We investigated the efficacy of teaching minority stress theory concepts in a single lecture in an upper-level cardiovascular pathophysiology course (N = 44 students). To test students' understanding of minority-related disease, we used both subjective and objective measures to evaluate student understanding before and after the lecture. Student self-assessment of understanding of health disparity physiological mechanisms and lifestyle and pharmacological interventions to reduce health disparities in SGM communities increased post intervention. We observed similar results of self-assessment of understanding of health disparity physiological mechanisms and appropriate lifestyle and pharmacological interventions to reduce health disparities regarding the BIPOC community. Our findings suggest that integrating social determinants of health into pathophysiology courses may result in a more inclusive-minded scientific and medical workforce.NEW & NOTEWORTHY Physiology education has historically lacked the inclusion of the social determinants of health and discussion of medically marginalized communities. Here, we show that discussion of cardiovascular disease and psychosocial stress in marginalized communities improves student understanding of the distribution of and causes of cardiovascular disease in marginalized groups. We conclude that more physiology instructors should include discussions on chronic diseases within multiple communities and programs should incorporate social determinants of health into their curricula.

Intervention mapping for systematic development of a community-engaged CVD prevention intervention in ethnic and racial sexual minority men with HIV

Introduction

Cardiovascular disease (CVD) is a leading cause of mortality in the United States, disproportionately affecting marginalized populations such as Black and Latinx sexual minority men with HIV. These individuals face heightened CVD risk due to chronic inflammation related to HIV, side effects from treatment, and intersecting social disadvantages, including stigma and discrimination. Behavioral interventions specifically targeting these populations have been limited, with insufficient uptake in marginalized communities.

Methods

This study used Intervention Mapping (IM) to develop a culturally tailored CVD prevention intervention for Black and Latinx sexual minority men with HIV. IM is a systematic, theory- and evidence-based framework for health promotion program planning. We focused on the first three of six steps in the IM process: (1) assessing community needs through literature review, framework development, and community-engaged research; (2) identifying program outcomes to develop a logic model of change; and (3) selecting theory-based methods and practical strategies for program design.

Results

The needs assessment revealed significant barriers to cardiovascular health, including medical distrust, stigma, and lack of access to culturally appropriate healthcare. The logic model of change highlighted behavioral and environmental determinants influencing cardiovascular health, leading to specific performance objectives and change objectives. Strategies included leveraging eHealth technologies, such as avatar-led interactive videos, to provide private, culturally relevant health education and reduce barriers like medical distrust. Community-based participatory methods were integral to ensure the intervention was culturally resonant and acceptable.

Discussion

This study demonstrated the use of IM to systematically develop a culturally tailored CVD prevention intervention for Black and Latinx sexual minority men with HIV. The findings highlight the importance of community-engaged and culturally appropriate approaches in developing interventions for historically marginalized populations. These strategies aimed to address health disparities and empower them to engage in cardiovascular health-promoting behaviors, ultimately improving cardiovascular health outcomes. Leveraging technology to foster engagement and providing culturally relevant support were crucial elements of the intervention. The insights gained may inform future cardiovascular health promotion efforts targeting similar populations.

2025 Heart Disease and Stroke Statistics: A Report of US and Global Data From the American Heart Association

BACKGROUND

The American Heart Association (AHA), in conjunction with the National Institutes of Health, annually reports the most up-to-date statistics related to heart disease, stroke, and cardiovascular risk factors, including core health behaviors (smoking, physical activity, nutrition, sleep, and obesity) and health factors (cholesterol, blood pressure, glucose control, and metabolic syndrome) that contribute to cardiovascular health. The AHA Heart Disease and Stroke Statistical Update presents the latest data on a range of major clinical heart and circulatory disease conditions (including stroke, brain health, complications of pregnancy, kidney disease, congenital heart disease, rhythm disorders, sudden cardiac arrest, subclinical atherosclerosis, coronary heart disease, cardiomyopathy, heart failure, valvular disease, venous thromboembolism, and peripheral artery disease) and the associated outcomes (including quality of care, procedures, and economic costs).

METHODS

The AHA, through its Epidemiology and Prevention Statistics Committee, continuously monitors and evaluates sources of data on heart disease and stroke in the United States and globally to provide the most current information available in the annual Statistical Update with review of published literature through the year before writing. The 2025 AHA Statistical Update is the product of a full year's worth of effort in 2024 by dedicated volunteer clinicians and scientists, committed government professionals, and AHA staff members. This year's edition includes a continued focus on health equity across several key domains and enhanced global data that reflect improved methods and incorporation of ≈3000 new data sources since last year's Statistical Update.

RESULTS

Each of the chapters in the Statistical Update focuses on a different topic related to heart disease and stroke statistics.

CONCLUSIONS

The Statistical Update represents a critical resource for the lay public, policymakers, media professionals, clinicians, health care administrators, researchers, health advocates, and others seeking the best available data on these factors and conditions.

Social Determinants of Health, Cardiovascular Health, and Mortality in Sexual Minority Individuals in the United States

BACKGROUND

Despite recent efforts to address health disparities regarding social determinants of health (SDOH), the intersection between SDOH and cardiovascular health (CVH) outcomes in sexual minority (SM) individuals remain largely underexplored.

OBJECTIVES

This study sought to investigate associations between SDOH profile and CVH and mortality outcomes among SM individuals in the United States.

METHODS

All participants aged ≥18 years surveyed in the 2013 to 2017 National Health Interview Survey were included, except those with missing data on SM status, any CVH or SDOH domain, or any other covariate. SM status was self-reported and categorized as lesbian/gay, bisexual, or uncertain. Participants' SDOH profile was quantified using a 6-domain (economic stability, neighborhood/physical environment/social cohesion, community and social context, food, education, and health care system), 38-item score, with higher scores indicating greater social deprivation. CVH was adapted from the American Heart Association's Life's Essential 8 framework. Because detailed dietary data were unavailable, a 7-item (hypertension, diabetes mellitus, hypercholesterolemia, smoking, physical inactivity, inadequate sleep, and obesity) CVH score was used, with higher scores indicating worse CVH. Additionally, cardiovascular mortality was ascertained through the National Death Index using death certificate information.

RESULTS

The study sample consisted of 57,182 participants, representing a population of 82,826,690 persons. A worse composite SDOH score was associated with a worse CVH score in both heterosexual (adjusted rate ratio: 1.14; 95% CI: 1.13-1.15; P < 0.001) and SM individuals (adjusted rate ratio: 1.16; 95% CI: 1.12-1.20; P < 0.001), with associations appearing to be potentially stronger in the latter (Pinteraction = 0.042). Subgroup analysis demonstrated consistent associations among gay/lesbian individuals and bisexual individuals, but not in those with other or uncertain sexual orientations. Further exploratory analysis showed that a worse composite SDOH score was significantly associated with higher risk of cardiovascular mortality in both heterosexual (adjusted HR: 1.17; 95% CI: 1.06-1.28; P = 0.002) and SM individuals (adjusted HR: 2.25; 95% CI: 1.24-4.08; P = 0.008), with associations being significantly stronger in the latter (P interaction = 0.006).

CONCLUSIONS

An unfavorable SDOH profile was associated with worse CVH scores and higher cardiovascular mortality risk among SM individuals in the United States compared to their heterosexual counterparts.

Influence of Experiences of Discrimination and Anticipated Discrimination on Cardiovascular Health Outcomes

PURPOSE OF REVIEW

This review summarizes recent evidence linking experiences of discrimination and anticipated discrimination with cardiovascular health outcomes.

RECENT FINDINGS

Experiences of discrimination were consistently associated with increased risk of nicotine exposure, poor sleep health, obesity, diabetes, hypertension, and subclinical cardiovascular disease. Evidence is mixed for cardiovascular disease diagnoses and cardiovascular mortality. Although research is limited, anticipated discrimination is an independent risk factor for poor sleep health and subclinical cardiovascular disease. Key methodological limitations included the limited use of gold-standard objective measures of health behaviors and well-validated self-report measures, inadequate consideration of intersectionality, and lack of robust examinations of psychological, behavioral, and physiological mechanisms linking discrimination with cardiovascular health outcomes. There is substantial evidence linking experiences of discrimination with cardiovascular outcomes. Yet, before translating these findings into clinical practice, more rigorous studies are needed to address methodological limitations and uncover mechanisms by which discrimination influences cardiovascular health. There is a need for studies to inform the development of evidence-based interventions focused on reducing the influence of discrimination-related stressors on cardiovascular health outcomes. Findings have important implications for future work to advance cardiovascular health equity.

Mortality among sexual and gender minority populations: A systematic review

Sexual and gender minority (SGM) populations experience elevated rates of negative health outcomes (e.g., suicidality) and social determinants (e.g., poverty), which have been associated with general population mortality risk. Despite evidence of disparities in threats to well-being, it remains unclear whether SGM individuals have greater risk of mortality. This systematic review synthesized evidence on mortality among studies that included information about SGM. Three independent coders examined 6,255 abstracts, full-text reviewed 107 articles, and determined that 38 met inclusion criteria: 1) contained a sexual orientation or gender identity (SOGI) measure; 2) focused on a mortality outcome; 3) provided SGM vs non-SGM (i.e., exclusively heterosexual and cisgender) or general population comparisons of mortality outcomes; 4) were peer-reviewed; and 5) were available in English. A search of included articles' references yielded 5 additional studies (total n = 43). The authors used the NIH's Quality Assessment Tool for Observational Cohort and Cross-Sectional Studies to assess included studies. Mortality outcomes included all-cause (n = 27), suicide/intentional self harm (n = 23), homicide (n = 7), and causes related to drug use (n = 3). Compared to non-SGM people, 14 studies (32.6%) supported higher mortality for SGM, 28 studies (65.1%) provided partial support of higher mortality for SGM (e.g., greater mortality from one cause but not another), one study (2.3%) found no evidence of higher mortality for SGM. There was considerable heterogeneity in operational definitions of SGM populations across studies. Although mixed, findings suggest elevated mortality for SGM versus non-SGM populations. Integrating SOGI measures into mortality surveillance would enhance understanding of disparities by standardizing data collection, thereby reducing heterogeneity and increasing capacity to aggregate results (e.g., meta-analyses).

Getting to the Heart of the Matter: Exploring the Intersection of Cardiovascular Disease, Sex and Race and How Exercise, and Gut Microbiota Influence these Relationships

Cardiovascular disease (CVD) is the leading cause of death worldwide, with physical inactivity being a known contributor to the global rates of CVD incidence. CVD incidence, however, is not uniform with recognized sex differences as well and racial and ethnic differences. Furthermore, gut microbiota have been associated with CVD, sex, and race/ethnicity. Researchers have begun to examine the interplay of these complicated yet interrelated topics. This review will present evidence that CVD (risk and development), and gut microbiota are distinct between the sexes and racial/ethnic groups, which appear to be influenced by acculturation, discrimination, stress, and lifestyle factors like exercise. Furthermore, this review will address the beneficial impacts of exercise on the cardiovascular system and will provide recommendations for future research in the field.

Healthcare discrimination and treatment adherence among sexual and gender minority individuals living with chronic illness: the mediating effects of anticipated discrimination and depressive symptoms

Background: Sexual and gender minority (SGM) individuals are at increased risk for an array of chronic illness due to minority stress. Up to 70% of SGM individuals report healthcare discrimination, which may cause additional challenges for SGM people living with chronic illness including avoiding necessary healthcare. The extant literature highlights how healthcare discrimination is associated with depressive symptoms and treatment nonadherence. However, there is limited evidence on the underlying mechanisms between healthcare discrimination and treatment adherence among SGM people living with chronic illness.Methods: Among a sample of SGM individuals living with chronic illness (n = 149) recruited from social media, the current study examined the mediating roles of anticipated discrimination and depressive symptoms on the relation between healthcare discrimination and treatment adherence in a serial mediation model.Results: We found that healthcare discrimination was associated with greater anticipated discrimination, increased depressive symptoms, and, in turn, poorer treatment adherence. Conclusion: These findings highlight the association between minority stress and both depressive symptoms and treatment adherence among SGM individuals living with chronic illness. Addressing institutional discrimination and the consequences of minority stress may improve treatment adherence among SGM individuals living with chronic illness.

Experiences of Lesbian, Gay, Bisexual, Transgender, and Queer Cardiology Physicians and Fellows in Training

Background

The number of practicing lesbian, gay, bisexual, transgender, and queer (LGBTQ+) cardiologists is unknown despite diversity initiatives focused on understanding workforce demographics.

Objectives

The aim of this study was to evaluate the prevalence, sources of mistreatment, and measures of wellness among the LGBTQ+ cardiology community.

Methods

An online survey was sent to the American College of Cardiology Fellow in Training and Early Career Professional Listservs and shared on social media sites. The survey included the Short-Negative Acts Questionnaire and LGBTQ+ -specific harassment questions. Chi-square analysis and Fisher exact tests were performed to compare responses between LGBTQ+ and non-LGBTQ+ respondents.

Results

A total of 188 respondents completed the survey (56% Fellow in Training). One-third (33%) identified as LGBTQ+. Gender identity data included: transgender (3%), nonbinary (2%), gender queer (1%), and agender (1%). LGBTQ+ physicians were less likely to agree with the statements 'LGBTQ+ patients were treated fairly' (40% vs 66%, P < 0.001), and 'leadership dealt with people demonstrating poor behavior fairly' (34% vs 51%, P = 0.029) compared to heterosexual peers. LGBTQ+ physicians were more likely to report gender policing and heterosexist harassment compared to heterosexual peers (P = 0.002). The majority of physicians (91%) were satisfied with their decision to become a cardiologist.

Conclusions

This current analysis of LGBTQ+ cardiologists in the workplace identifies opportunities to address mistreatment impacting the LGBTQ+ community. Despite experiencing mistreatment, LGBTQ+ cardiologists report high job satisfaction. Further work is necessary to create a safe space and diverse cohort of physicians required to meet the needs of LGBTQ+ patients at risk for cardiovascular disease.

A transgender medicine curriculum for Internal Medicine residents at a single academic institution

BACKGROUND

Transgender or gender diverse patients present with health care needs as it relates to gender-affirming care, psychosocial support, and medication access. Considering this, medical education strategies should be implemented to train the next generation of Internal Medicine physicians in this area.

METHODS

We adopted Kern's six step approach to curriculum design to create and implement an educational curriculum for teaching Internal Medicine residents about transgender patients at a single academic institution in Canada (Kern et al, Curriculum Development for Medical Education, 2009). Semi-structured individual interviews of Internal Medicine faculty and residents were conducted to understand the needs for delivering content related to transgender health during residency training. The results informed the development and implementation of an academic half day session and objective structured clinical examination (OSCE). Prior to the academic half day, participants were sent three journal articles highlighting key concepts related to the medical care of transgender patients (CMAJ 193:E562-5, 2021; BMC Public Health 15:525, 2015; Bourns A, Guidelines for gender-affirming primary care with trans and non-binary patients, 2019). A pre- and post-intervention numeric assessment form evaluated residents' comfort in providing gender-affirming care across five domains: general care, communication, hormone therapy, side effects, and prevention strategies. Faculty raters, equipped with training in transgender health, evaluated performance in an OSCE on key transgender health issues. Both the clinical case and OSCE scenario were developed via an iterative review process by study investigators.

RESULTS

Residents reported an increase in subjective comfort of providing gender-affirming care (p = 0.042) following delivery of the academic half day content. The OSCE demonstrated that most residents achieved "acceptable" or "exemplary" ratings across multiple domains.

CONCLUSIONS

We implemented a Transgender Medicine curriculum for Internal Medicine residents in the Canadian context. The curriculum improved resident comfort in providing gender-affirming care including basic knowledge on gender-affirming hormone therapy, and health promotion activities (e.g., screening for and management of chronic disease, discussion of sexual health, community supports, peer engagement). Further assessment is needed to determine whether these skills are retained in clinical practice.

Artificial intelligence evaluation of electrocardiographic characteristics and interval changes in transgender patients on gender-affirming hormone therapy

Aims

Gender-affirming hormone therapy (GAHT) is used by some transgender individuals (TG), who comprise 1.4% of US population. However, the effects of GAHT on electrocardiogram (ECG) remain unknown. The objective is to assess the effects of GAHT on ECG changes in TG.

Methods and results

Twelve-lead ECGs of TG on GAHT at the Mayo Clinic were inspected using a validated artificial intelligence (AI) algorithm. The algorithm assigns a patient's ECG male pattern probability on a scale of 0 (female) to 1 (male). In the primary analysis, done separately for transgender women (TGW) and transgender men (TGM), 12-lead ECGs were used to estimate the male pattern probability before and after GAHT. In a subanalysis, only patients with both pre- and post-GAHT EGCs were included. Further, the autopopulated PR, QRS, and QTc intervals were compared before and after GAHT. Among TGW (n = 86), the probability (mean ± SD) of an ECG male pattern was 0.84 ± 0.25 in the pre-GAHT group, and it was lowered to 0.59 ± 0.36 in the post-GAHT group (n = 173, P < 7.8 × 10-10). Conversely, among TGM, male pattern probability was 0.16 ± 0.28 (n = 47) in the pre-GAHT group, and it was higher at 0.41 ± 0.38 in the post-GAHT group (n = 53, P < 2.4×10-4). The trend persisted in the subanalysis. Furthermore, both the PR (P = 5.68 × 10-4) and QTc intervals (P = 6.65×10-6) prolonged among TGW. Among TGM, the QTc interval shortened (P = 4.8 × 10-2).

Conclusion

Among TG, GAHT is associated with ECG changes trending towards gender congruence, as determined by the AI algorithm and ECG intervals. Prospective studies are warranted to understand GAHT effects on cardiac structure and function.

Cardiac Rehabilitation Outcomes in a Transgender Woman With Coronary Artery Disease

The presented case report examines the effects of cardiac rehabilitation (CR) on a 69-year-old transgender woman with coronary artery disease (CAD). The patient engaged in 19 CR sessions without experiencing any adverse effects. Pre- to post-CR assessments revealed a worsening of body composition, characterized by an approximate 3% increase in fat mass and a 4% reduction in lean mass. In contrast, peak oxygen uptake and exercise time increased by 6% and 9%, respectively. This case report highlights the need for additional targeted strategies to improve both body composition and cardiorespiratory fitness in transgender woman undergoing CR for coronary artery disease management.

Development of a multidimensional measure of health care access among LGBTQ midlife and older adults in the United States

Purpose

Lesbian, gay, bisexual, transgender, and queer (LGBTQ) midlife and older adults are a health disparity population whose health and health care needs are distinguished by the intersection of gender, sexuality, and age. Research and measurement considering multidimensional factors influencing health care access among this population, however, remain limited. Theoretically cohesive indicators of health care access were combined to develop a comprehensive and reliable, yet parsimonious scale that assesses the unique health care access needs and experiences of LGBTQ midlife and older adults.

Methods

Data from the U.S.-based Aging with Pride: National Health, Aging, and Sexuality/Gender Study (NHAS) were used, including 2322 LGBTQ participants from the 2015 wave of data collection. Twenty-four items were initially included in an assessment of scale reliability. The underlying factor structure of health care access was tested. Differences in mean health care access scores were examined across sexual identity, current gender, gender identity, and age cohort.

Results

Nineteen items remained in the final scale (α=0.90). Data supported health care access as multidimensional among NHAS participants. Heterogeneity in health care access scores was identified across participants. Bisexual, straight, and sexually diverse participants, women and gender diverse participants, and transgender participants faced more difficulties accessing care. Participants aged 66-80 and 81+ reported significantly higher health care access scores.

Conclusion

Final indicators represented the complex health care experiences of LGBTQ midlife and older adults. This scale can be utilized in future health equity research. Using NHAS longitudinal data, future research could assess changes in access over the life-course and as a predictor of health outcomes.

2024 Guideline for the Primary Prevention of Stroke: A Guideline From the American Heart Association/American Stroke Association

AIM

The "2024 Guideline for the Primary Prevention of Stroke" replaces the 2014 "Guidelines for the Primary Prevention of Stroke." This updated guideline is intended to be a resource for clinicians to use to guide various prevention strategies for individuals with no history of stroke.

METHODS

A comprehensive search for literature published since the 2014 guideline; derived from research involving human participants published in English; and indexed in MEDLINE, PubMed, Cochrane Library, and other selected and relevant databases was conducted between May and November 2023. Other documents on related subject matter previously published by the American Heart Association were also reviewed.

STRUCTURE

Ischemic and hemorrhagic strokes lead to significant disability but, most important, are preventable. The 2024 primary prevention of stroke guideline provides recommendations based on current evidence for strategies to prevent stroke throughout the life span. These recommendations align with the American Heart Association's Life's Essential 8 for optimizing cardiovascular and brain health, in addition to preventing incident stroke. We also have added sex-specific recommendations for screening and prevention of stroke, which are new compared with the 2014 guideline. Many recommendations for similar risk factor prevention were updated, new topics were reviewed, and recommendations were created when supported by sufficient-quality published data.

Dietary intakes differ between LGBTQ + and non-LGBTQ + college students

Objective: To compare dietary intakes between LGBTQ + and non-LGBTQ + college students. Participants: Participants were LGBTQ+ (n = 92) and non-LGBTQ+ (n = 491) college students. Methods: The 26-item Dietary Screener Questionnaire assessed intakes of added sugars, fiber, whole grains, fruits and vegetables, dairy, and calcium. Percentage of participants meeting Dietary Guidelines for Americans were also computed. Multivariate ANCOVA assessed differences in dietary intake. Chi-square analyses assessed differences in proportions of LGBTQ + and non-LGBTQ + students meeting recommendations. Results: LGBTQ + students reported lower intakes of fiber, whole grains, fruit, and fruits and vegetables both including and excluding French fries (all p < 0.05). Fewer LGBTQ + students met recommendations for fruit (5.7%) compared to their non-LGBTQ + counterparts (14.2%; p = .03). Conclusions: LGBTQ + students report poorer indices of diet quality compared to non-LGBTQ + students. Health promotion programming efforts to improve these outcomes may need to be tailored differently for students who identify as LGBTQ+.

Interaction between nutrition-related parameters and sexual orientation on depression

OBJECTIVES

Sexual minorities may be more vulnerable to mental disorders. Previous studies have found associations between diet and depression, but no studies have focused on the interaction between nutrition-related parameters and sexual orientation regarding depression. This study aims to explore the interaction between nutrition-related parameters and sexual orientation regarding depression.

STUDY DESIGN

Cross-sectional analysis using NHANES 2007-2016 data.

METHODS

This study utilized data from NHANES 2007-2016, with 11,065 participants involved. Nutrition-related parameters were evaluated using the healthy eating index-2015 (HEI-2015) and the dietary inflammation index (DII), while depression was obtained through Patient Health Questionnaire (PHQ-9). Logistic regression and stratified analysis of subgroups were used in this study.

RESULTS

Compared to those who consumed healthy and anti-inflammatory diets, the ORs for depression in groups consuming unhealthy and pro-inflammatory diets were 1.366 (95%CI:1.073,1.738) and 1.652 (95%CI:1.345,2.028), respectively. Sexual minorities have a higher risk of depression than heterosexuals. There is an interaction effect (P = 0.037) between HEI-2015 and sexual orientation on depression, while it was not found in DII. Subgroup analysis indicated that the interaction between sexual orientation and HEI-2015 persisted in males (P = 0.024), but not in females.

CONCLUSION

Both diet and sexual orientation had impacts on depression. There was an interaction between HEI-2015 and sexual orientation on depression, and this association was different by gender. Sexual minorities who are Gay/lesbian, Bisexual, and Something else are at higher risk for depression, and adopting healthy eating patterns and anti-inflammatory diets that are consistent with the recommendations of the USDA may appropriately reduce the risk of depression.

Laboratory Informatics Approaches to Improving Care for Gender- Diverse Patients

Improving care for gender-diverse (GD) patients necessitates developing informatics tools and approaches to support optimal laboratory testing. This requires increased functionality and standardization of laboratory information system/electronic health record and data collection processes. Data tailored to accommodate immediate clinical care and clinical decision support (CDS) also have an impact on interoperability and downstream data needs for patients. Informatics tools can shape the clinical care experience for GD patients by careful design of laboratory-patient interactions.

Association of Current and Long-Term Estradiol Use with Carotid Intima Media Thickness Among Transgender Women: A Cross-Sectional Study

Purpose

Epidemiologic studies suggest that the transgender population has a higher burden of cardiovascular (CV) disease. We aimed to assess CV risk and investigate the relationship between estradiol (E2) or ethinylestradiol (EE) use and carotid intima media thickness (cIMT) in transgender women.

Methods

This is a cross-sectional analysis nested into a transgender-specific cohort in Rio de Janeiro, Brazil, from August 2015 to February 2018. Increased cIMT was defined as a measurement above the 75th percentile. We tested the association of E2, EE, or both with cIMT. We calculated odds ratios (ORs) using adjusted logistic regression models to assess the association of current use (use in the last 30 days) and long-term use (using for at least 365 consecutive days) of the hormone categories with cIMT.

Results

We included 298 transgender women with a median age of 31 years (interquartile range [IQR]=25-38), 54.2% had human immunodeficiency virus (HIV) infection. Among transgender women currently on hormone therapy (44.9%), most were on estradiol (27.2%), a combination of E2/EE (12.7%), or EE alone (5.1%). Median cIMT was 0.57 mm (IQR=0.52-0.64). In the final adjusted models, current (OR=0.37; 95% confidence interval [95% CI]=0.14 to 0.93) and long-term (OR=0.20; 95% CI=0.04 to 0.7) E2 use was negatively associated with increased cIMT.

Conclusions

Both current- and long-term E2 use had a negative association with increased cIMT in a young population of transgender women. Follow-up studies are needed to confirm its safety and support hormone recommendations for transgender women.

Improving dissemination products and practices for community-based organisations serving LGBTQ+ communities in the USA: a thematic analysis

Background

In the USA, lesbian, gay, bisexual, transgender and queer (LGBTQ+) people report higher rates of tobacco use than non-LGBTQ+ people due to diverse factors, from anti-LGBTQ stigma to targeted marketing by the tobacco industry. There is an opportunity to support behavioural changes by delivering evidence-based health communication campaigns through community-based organisations (CBOs), but an insufficient evidence base and organisational resource restrictions limit this potential. Our previous research with CBO staff and leaders serving LGBTQ+ communities identified gaps in evidence-based campaigns, such as insufficient centering of LGBTQ+ communities in campaign development and execution. This qualitative study explores opportunities to improve the products and services supporting the dissemination of evidence-based health communication campaigns for LGBTQ+ audiences.

Methods

We conducted key informant interviews between January and June 2021 with individuals who direct or run health promotion programmes in CBOs serving LGBTQ+ populations in the USA (n=26 individuals from 22 organisations). Using critical and constructivist perspectives, we leveraged the analysis team and advisory committee's diverse research, lived and practice expertise related to LGBTQ+ health. We employed a team-based, reflexive thematic analysis approach.

Results

We identified two key opportunities. Theme 1-show us your work: participants requested (a) details about the evidence-based campaigns, including underlying values and extent of community engagement, and (b) information about campaign mechanisms and impact. Theme 2-support us in our work: participants suggested that evidence-based campaigns should (a) be designed for flexibility and adaptation, (b) offer tools and guidance for adaptation and (c) share granular data and relevant resources. Participants nominated dissemination products and processes to address gaps, including supports to integrate campaigns into multi-level action, data collection tools for adaptation and engagement with campaign developers.

Conclusions

The findings highlight the potential for CBOs to be integral partners in the development and dissemination of evidence-based health communication campaigns that address tobacco-related inequities among LGBTQ+ communities.

Prevalent Atherosclerotic Cardiovascular Disease Among Veterans by Sexual Orientation

BACKGROUND

Seven million lesbian, gay, and bisexual (LGB) adults will be aged >50 years by 2030; assessing and addressing their risk for cardiovascular disease is critical.

METHODS AND RESULTS

We analyzed a nationwide cohort using the Veterans Health Administration data. Sexual orientation (SO) was classified via a validated natural language processing algorithm. Prevalent atherosclerotic cardiovascular disease (ASCVD) (history of acute myocardial infarction, ischemic stroke, or revascularization) was identified via International Classification of Diseases, Ninth and Tenth Revision (ICD-9 and ICD-10) codes. The index date was the date of the first primary care appointment on or after October 1, 2009. We ascertained covariates and prevalent ASCVD in the year following the index date; the baseline date was 1 year after the index date. We calculated sample statistics by sex and SO and used logistic regression analyses to assess associations between SO and prevalent ASCVD. Of 1 102 193 veterans with natural language processing-defined SO data, 170 861 were classified as LGB. Prevalent ASCVD was present among 25 031 (4105 LGB). Adjusting for age, sex, race, and Hispanic ethnicity, LGB veterans had 1.24 [1.19-1.28] greater odds of prevalent ASCVD versus non-LGB identified veterans. This association remained significant upon additional adjustment for the ASCVD risk factors substance use, anxiety, and depression (odds ratio [OR],1.17 [95% CI, 1.13-1.21]). Among a subset with self-reported SO, findings were consistent (OR, 1.53 [95% CI, 1.20-1.95]).

CONCLUSIONS

This is one of the first studies to examine cardiovascular risk factors and disease of the veteran population stratified by natural language processing-defined SO. Future research must explore psychological, behavioral, and physiological mechanisms that result in poorer cardiovascular health among LGB veterans.

Reporting Sex and Gender Differences in Cardiovascular Research

Incorporating sexual orientation, gender identity, and expression (SOGIE) data into cardiovascular research design is necessary to reduce cardiovascular healthcare disparities among sexual and gender minority (SGM) people. To achieve this, researchers should not only understand appropriate terminology, but also implement inclusive survey tools that respect privacy and cultural nuances, as the benefit of obtaining SOGIE information is critical to tailoring cardiovascular interventions and ensuring equitable healthcare outcomes. In order to address potential concerns related to disclosing SOGIE information, we must prioritize sensitivity training for healthcare professionals to foster an inclusive environment for data collection, ethical considerations, and confidentiality safeguards. This review aims to develop and inform critical thinking about sex and gender and to identify strategic mechanisms to include SOGIE data in cardiovascular research, thus improving cardiovascular health outcomes for SGM individuals. By embracing a more comprehensive and inclusive approach to data collection, cardiovascular research can contribute significantly to advancing personalized and inclusive healthcare practices and medical education, and ultimately promote better health outcomes for all SGM individuals.

Intersectionality and Social Drivers of Health in Cardiovascular Care

Social drivers of health (SDOH) are a significant contributor to persistent cardiovascular health disparities in the United States and globally. SDOH include psychosocial, environmental, socioeconomic, cultural, and governmental factors that impact health behaviors and outcomes. Multiple social drivers have been associated with trends in cardiovascular disease risk and health outcomes. These social drivers intersect in complex ways, and applying the concept of intersectionality is critical when considering ways to best address SDOH in cardiovascular care. Applying intersectionality, which considers the unique combination of social drivers associated with a community, allows for tailored interventions to address cardiovascular health disparities.

Patient-reported and Clinical Outcomes following Gender-affirming Chest Surgery: A Comparison of Binary and Nonbinary Transmasculine Individuals

Background

Nonbinary individuals assigned female at birth are increasingly presenting for gender-affirming chest surgery (GCS). However, little is known about psychosocial outcomes in this group. We compare patient-reported and clinical outcomes after GCS between nonbinary and binary transmasculine individuals who underwent GCS.

Methods

We performed an institutional retrospective chart review. Demographic information, medical comorbidities, history of gender-affirming medical care, operative details, and complications were collected and compared between nonbinary and binary patients. Two validated patient-reported outcomes measures, the Gender Congruence and Life Satisfaction (GCLS) scale and the chest dysphoria measure were administered postoperatively.

Results

A total of 281 patients were included, of which 40.6% (114) identified as nonbinary and 59.4% (167) identified as binary transgender men. Fewer nonbinary patients used testosterone (P < 0.001). Nonbinary patients underwent a wider variety of masculinizing chest operations than binary patients, with fewer nonbinary patients electing for free nipple-areolar complex grafts (P < 0.001) and more nonbinary patients undergoing breast reduction (P = 0.001). A total of 137 (48.7%) patients responded to postoperative surveys. Nonbinary and binary respondents had comparable scores on the overall GCLS (P = 0.86), GCLS chest subscale (P = 0.38), and chest dysphoria measure (P = 0.40). The absence of nipple-areolar complex grafts was associated with higher GCLS chest scores (P = 0.004).

Conclusions

Nonbinary individuals have similarly positive outcomes following GCS compared with binary individuals. Surgeons should be aware of greater medical and surgical heterogeneity in this population and seek to understand individual patients' goals and priorities.

Benzodiazepine Utilization in Ischemic Stroke Survivors: Analyzing Initial Excess Supply and Longitudinal Trends

BACKGROUND

Benzodiazepines are commonly prescribed for post-acute ischemic stroke for anxiety, insomnia, and agitation. While guidelines discourage use in those aged ≥65 years, little is known about prescription patterns at the national level.

METHODS

We analyzed a 20% sample of US Medicare claims from April 1, 2013, to September 30, 2021. We selected beneficiaries aged ≥65 years discharged alive following an acute ischemic stroke who had traditional Medicare coverage and 6 months' prior enrollment in Parts A (hospital insurance), B (Medical insurance), and D (drug coverage). We excluded those with prior benzodiazepine prescriptions, self-discharges, or discharge to skilled nursing facilities. We examined demographics, comorbidities, first prescription days' supply, cumulative incidences of benzodiazepine first prescription fills within 90 days after discharge, and geographic and yearly trends.

RESULTS

We included 126 050 beneficiaries with a mean age of 78 years (SD, 8); 54% were female and 82% were White. Within 90 days, 6127 (4.9%) initiated a benzodiazepine. Among new prescriptions, lorazepam (40%) and alprazolam (33%) were the most prescribed. Most (76%) of first fills had a day's supply over 7 days and 55% between 15 and 30 days. Female initiation rates were higher (5.5% [95% CI, 5.3-5.7]) than male initiation rates (3.8% [95% CI, 3.6%-3.9%]). Rates were highest in the southeast (5.1% [95% CI, 4.8%-5.3%]) and lowest in the midwest (4.0% [95% CI, 3.8%-4.3%]), with a modest nationwide initiation decline from 2013 to 2021 (cumulative incidence difference, 1.6%).

CONCLUSIONS

Despite a gradual decline in benzodiazepine initiation from 2013 to 2021, we noted excessive supplies in prescriptions post-acute ischemic stroke discharge, underscoring the need for improved policies.

Sexual identity differences in the association between psychological distress and cardiometabolic health among women: 2013-2018 National Health Interview Survey

Poor psychological health has been consistently documented for sexually minoritized women. However, little is known about the association between poor psychological health and physical health. This study examined associations between psychological distress and cardiometabolic health, including cardiovascular disease risk conditions (hypertension, high cholesterol, and diabetes) and diagnoses (stroke, coronary heart disease, myocardial infarction, and angina), by sexual identity among women. Data are from the 2013-2018 National Health Interview Survey and included 102,279 women, who were straight (n = 97,909), lesbian/gay (n = 1,424), bisexual (n = 1,235), something else (n = 360), did not know (n = 712), and refused to disclose (n = 639). Multivariable multinomial logistic regression models were fit to estimate associations between psychological distress (measured with Kessler-6) and cardiometabolic health (self-reported diagnosis) and to examine sexual-identity differences in these associations. Covariates included sociodemographic characteristics. Overall, severe psychological distress was associated with significantly higher odds of having a cardiometabolic health condition (OR = 2.66). These associations generally did not statistically significantly differ based on sexual identity. However, potential substantive differences in the magnitude of the association existed among lesbian/gay (OR = 4.00) compared to straight women (OR = 2.73). Moreover, women who identified as gay/lesbian, bisexual, "something else," or "I don't know" all reported significantly higher prevalence of severe psychological distress than straight women. Given the overall positive association between psychological distress and cardiometabolic health as well as the higher prevalence of severe psychological distress among sexual minority women, more work is needed to longitudinally examine the effects of psychological distress on health among sexually minoritized women. (PsycInfo Database Record (c) 2024 APA, all rights reserved).

Brain Health Outcomes in Sexual and Gender Minority Groups: Results From the All of Us Research Program

BACKGROUND AND OBJECTIVES

Sexual and gender minority (SGM) groups have been historically underrepresented in neurologic research, and their brain health disparities are unknown. We aim to evaluate whether SGM persons are at higher risk of adverse brain health outcomes compared with cisgender straight (non-SGM) individuals.

METHODS

We conducted a cross-sectional study in the All of Us Research Program, a US population-based study, including all participants with information on gender identity and sexual orientation. We used baseline questionnaires to identify sexual minority (lesbian, gay, bisexual, diverse sexual orientation; nonstraight sexual orientation) and gender minority (gender diverse and transgender; gender identity different from sex assigned at birth) participants. The primary outcome was a composite of stroke, dementia, and late-life depression, assessed using electronic health record data and self-report. Secondarily, we evaluated each disease separately. Furthermore, we evaluated all subgroups of gender and sexual minorities stratified by sex assigned at birth. We used multivariable logistic regression (adjusted for age, sex assigned at birth, race/ethnicity, cardiovascular risk factors, other relevant comorbidities, and neighborhood deprivation index) to assess the relationship between SGM groups and the outcomes.

RESULTS

Of 413,457 US adults enrolled between May 31, 2017, and June 30, 2022, we included 393,041 participants with available information on sexual orientation and gender identity (mean age 51 [SD 17] years), of whom 39,632 (10%) belonged to SGM groups. Of them, 38,528 (97%) belonged to a sexual minority and 4,431 (11%) to a gender minority. Compared with non-SGM, SGM persons had 15% higher odds of the brain health composite outcome (odds ratio [OR] 1.15, 95% CI 1.08-1.22). In secondary analyses, these results persisted across sexual and gender minorities separately (all 95% CIs > 1). Assessing individual diseases, all SGM groups had higher odds of dementia (SGM vs non-SGM: OR 1.14, 95% CI 1.00-1.29) and late-life depression (SGM vs non-SGM: OR 1.27, 95% CI 1.17-1.38) and transgender women had higher odds of stroke (OR 1.68, 95% CI 1.04-2.70).

DISCUSSION

In a large US population study, SGM persons had higher odds of adverse brain health outcomes. Further research should explore structural causes of inequity to advance inclusive and diverse neurologic care.

Comparison of machine learning models for the prediction of hypertension in transgender patients undergoing gynecologic surgery

BACKGROUND

Transgender patients face a higher burden of cardiovascular morbidity due to structural and biological stressors, particularly in low-resource settings. No studies exist comparing machine learning model development strategies for this unique patient cohort and limited literature exists comparing data/outcomes between transgender and cisgender populations.

METHODS

We compare machine learning models trained solely on transgender patients against models developed on a size-matched and ratio-matched cohort of cisgender patients and a 300-fold larger, ratio-matched cohort of cisgender patients undergoing obstetric/gynecologic procedures in the National Surgical Quality Improvement Program from January 1, 2005 through December 31, 2019. All models were developed to predict the outcome of hypertension. Statistical significance between models was calculated using 5-by-2 fold cross validation hypothesis testing.

RESULTS

Among 626,102 patients having an obstetric/gynecologic surgery, there are 1959 transgender patients of which 85,405 (13.7%) have hypertension requiring medication. Saliently, the logistic regression machine learning models trained selectively on the transgender cohort have an AUC of 0.865 (95% CI: 0.83-0.90), with an accuracy of 85% (95% CI: 0.80-0.87) compared to (p < 0.05) the logistic regression model trained on the 300-fold larger combined cohort which has an AUC of 0.861 (95% CI: 0.82-0.90), with an accuracy of 83% (95% CI: 0.80-0.87).

CONCLUSION

Machine learning models can be trained on smaller, selectively transgender populations and may perform similarly or better to predict cardiovascular outcomes in transgender patients, than models developed on predominantly cisgender patients; this can be useful in lower-resource settings with smaller-volume transgender patients.

Considerations for the care of transgender patients in orthopaedics and sports medicine: a narrative review

Orthopaedic and sports medicine clinicians can improve outcomes for transgender patients by understanding the physiological effects of gender-affirming hormone therapy (GAHT). This narrative review investigated the role of GAHT on bone mineral density, fracture risk, thromboembolic risk, cardiovascular health and ligament/tendon injury in this population. A search from the PubMed database using relevant terms was performed. Studies were included if they were levels 1-3 evidence. Due to the paucity of studies on ligament and tendon injury risk in transgender patients, levels 1-3 evidence on the effects of sex hormones in cisgender patients as well as basic science studies were included for these two topics. This review found that transgender patients on GAHT have an elevated fracture risk, but GAHT has beneficial effects on bone mineral density in transgender women. Transgender women on GAHT also have an increased risk of venous thromboembolism, stroke and myocardial infarction compared with cisgender women. Despite these elevated risks, studies have found it is safe to continue GAHT perioperatively for both transgender women and men undergoing low-risk operations. Orthopaedic and sports medicine clinicians should understand these unique health considerations for equitable patient care.

Transgender and Nonbinary Individuals' Perceptions Regarding Gender-Affirming Hormone Therapy and Cardiovascular Health: A Qualitative Study

BACKGROUND

Transgender and nonbinary individuals face substantial cardiovascular health uncertainties. The use of gender-affirming hormone therapy can be used to achieve one's gender-affirming goals. As self-rated health is an important predictor of health outcomes, an understanding of how this association is perceived by transgender and nonbinary individuals using gender-affirming hormone therapy is required. The objective of this research was to explore transgender and nonbinary individuals' perceptions of cardiovascular health in the context of using gender-affirming hormone therapy.

METHODS

In this qualitative study, English-speaking transgender and nonbinary adults using gender-affirming hormone therapy for 3 months or more were recruited from across Canada using purposive and snowball sampling methods. Semistructured interviews were conducted through videoconference to explore transgender and nonbinary individuals' perceptions of the association between gender-affirming hormone therapy and cardiovascular health between May and August 2023. Data were transcribed verbatim, and transcripts were analyzed independently by 3 reviewers using thematic analysis.

RESULTS

Twenty-one participants were interviewed (8 transgender women, 9 transgender men, and 3 nonbinary individuals; median [range] age, 27 [20-69] years; 80% White participants). Three main themes were identified: cardiovascular health was not a primary concern in the decision-making process with regard to gender-affirming hormone therapy, the improved well-being associated with gender-affirming hormone therapy was felt to contribute to improved cardiovascular health, and health care provider knowledge and attitude facilitate the transition process.

CONCLUSIONS

Gender-affirming hormone therapy in transgender and nonbinary individuals is perceived to improve cardiovascular health. Given the positive associations between care aligned with patient priorities, self-rated health, and health outcomes, these findings should be considered as part of shared decision-making and person-centered care.

Perceptions of a Cardiovascular Risk Reduction Intervention for Sexual Minority Adults

Sexual minority (SM) adults have a higher prevalence of risk factors for cardiovascular disease (CVD), largely attributable to increased exposure to minority stressors. There are no evidence-based CVD risk reduction interventions tailored to the needs of SM adults. We conducted a qualitative descriptive study to explore SM adults' perceptions and preferences for a culturally tailored, minority stress-informed intervention for CVD risk reduction. SM adults without CVD were interviewed and presented with a 10-week proposed intervention that combined elements of existing interventions for minority stress and CVD risk reduction. Participants were asked about preferences regarding intervention delivery methods, setting, and duration. Interviews were deductively coded into cognitive, behavioral, and socio-environmental themes informed by the Social Cognitive Theory. Themes were also inductively coded based on participant responses. The sample included 22 SM adults with a mean age of 52 (±7.16) years; approximately 55% were female-identified and 59% were non-Latinx White. Cognitive themes included recognition of stress associated with minoritized identities and self-efficacy for behavior change. Behavioral themes included stress management skills and maintaining a healthy lifestyle (e.g., exercise). Socio-environmental themes included barriers (e.g., time commitment) and facilitators (e.g., financial incentives) for participating in the proposed intervention. All participants were interested in an intervention that would improve their cardiovascular health. A majority indicated they preferred a 12-week, virtual, synchronous, group intervention. All participants endorsed the proposed intervention with particular emphasis on stress-reduction components. This study provides important knowledge that should be considered in designing tailored interventions for CVD risk reduction among SM adults.

Parenthood and the physical and mental health of sexual and gender minority parents: A cross-sectional, observational analysis from The PRIDE Study

PURPOSE

To compare the physical and mental health of sexual and gender minority (SGM) parents to SGM non-parents.

METHODS

A cross-sectional analysis using 2018-2020 data from The PRIDE Study, a national longitudinal cohort of SGM adults. We used Poisson regression adjusted for age, gender, relationship status, race/ethnicity, household income, and education to assess the association between parental status and each outcome.

RESULTS

Among 9625 SGM participants, 1460 (15 %) were parents. Older participants were more likely to be parents: 2% of participants aged 18-30, 18% aged 30-39, and 38% aged 40+ were parents. In adjusted analyses, parenthood was associated with greater depression, anxiety, and post-traumatic stress symptoms as well as ever cigarette smoking. Among individuals assigned female sex at birth, parents were twice as likely to have been diagnosed with pelvic inflammatory disease compared to non-parents. There was no association between parenthood status and alcohol use, substance use, diabetes, HIV, hypertension, or autism.

CONCLUSIONS

In this national cohort of SGM adults, parenthood was associated with differences in physical and mental health measures. Understanding how parenthood influences the health and well-being of the estimated 3 million SGM parents in the US will help our health systems support diverse families.

Perceptions of HIV-Related Comorbidities and Usability of a Virtual Environment for Cardiovascular Disease Prevention Education in Sexual Minority Men With HIV: Formative Phases of a Pilot Randomized Controlled Trial

BACKGROUND

Sexual minority men with HIV are at an increased risk of cardiovascular disease (CVD) and have been underrepresented in behavioral research and clinical trials.

OBJECTIVE

This study aims to explore perceptions of HIV-related comorbidities and assess the interest in and usability of a virtual environment for CVD prevention education in Black and Latinx sexual minority men with HIV.

METHODS

This is a 3-phase pilot behavioral randomized controlled trial. We report on formative phases 1 and 2 that informed virtual environment content and features using qualitative interviews, usability testing, and beta testing with a total of 25 individuals. In phase 1, a total of 15 participants completed interviews exploring HIV-related illnesses of concern that would be used to tailor the virtual environment. In phase 2, usability testing and beta testing were conducted with 10 participants to assess interest, features, and content.

RESULTS

In phase 1, we found that CVD risk factors included high blood pressure, myocardial infarction, stroke, and diabetes. Cancer (prostate, colon, and others) was a common concern, as were mental health conditions. In phase 2, all participants completed the 12-item usability checklist with favorable feedback within 30 to 60 minutes. Beta-testing interviews suggested (1) mixed perceptions of health and HIV, (2) high risk for comorbid conditions, (3) virtual environment features were promising, and (4) the need for diverse avatar representations.

CONCLUSIONS

We identified several comorbid conditions of concern, and findings carry significant implications for mitigating barriers to preventive health screenings, given the shared risk factors between HIV and related comorbidities. Highly rated aspects of the virtual environment were anonymity; meeting others with HIV who identify as gay or bisexual; validating lesbian, gay, bisexual, transgender, queer, and others (LGBTQ+) images and content; and accessibility to CVD prevention education. Critical end-user feedback from beta testing suggested more options for avatar customization in skin, hair, and body representation. Our next phase will test the virtual environment as a new approach to advancing cardiovascular health equity in ethnic and racial sexual minority men with HIV.

TRIAL REGISTRATION

ClinicalTrials.gov NCT04061915; https://clinicaltrials.gov/study/NCT05242952.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

RR2-10.2196/38348.

Chronic Illness Perceptions and Cardiovascular Disease Risk Behaviors in Black and Latinx Sexual Minority Men with HIV: A Cross-Sectional Analysis

Ethnic and racial sexual minority men with HIV have a disproportionately higher risk of HIV-related cardiovascular disease (CVD). There is a lack of tailored and culturally salient behavioral interventions to address HIV-related chronic illness in ethnic and racial sexual minority men, and literature on their understanding and awareness of modifiable behavioral risks is limited. The purpose of this study was to assess illness perceptions about HIV and HTN, and describe physical activity, tobacco, and e-cigarette use in Black and Latinx sexual minority men living with HIV. We used the validated Illness Perception Questionnaire-Revised (IPQ-R) to assess perceptions about two interrelated chronic diseases, HIV and CVD. To assess CVD behavioral risk, we assessed physical activity using the International Physical Activity Questionnaire. Tobacco and e-cigarette use were assessed using items from the Behavioral Risk Factor Surveillance System. Sleep difficulties were the most prevalent symptom attributed to HIV, and were statistically associated with fatigue, upset stomach, and loss of strength. Anxiety was reported to be caused by HIV (57%) and HTN (39%). Half of the participants engaged in vigorous activity for 128 min (SD = 135) daily, and 63% engaged in moderate activity for 94 min (SD = 88) daily. Over a third reported current tobacco use and 20% reported current e-cigarette use. This study provides formative data to better understand how Black and Latinx sexual minority men with HIV perceive intersecting chronic illnesses and their engagement in modifiable CVD risk behaviors. Sleep, mental health disparities, and financial hardships were commonly reported. More research is needed to address intersecting chronic illnesses and mental health conditions that are influenced by social positioning over the life course, and impact CVD risk factors. This study was not registered.

Socioeconomic status as a potential mediator of arterial aging in marginalized ethnic and racial groups: current understandings and future directions

Cardiovascular diseases (CVDs) are the leading cause of death in the United States. However, disparities in CVD-related morbidity and mortality exist as marginalized racial and ethnic groups are generally at higher risk for CVDs (Black Americans, Indigenous People, South and Southeast Asians, Native Hawaiians, and Pacific Islanders) and/or development of traditional CVD risk factors (groups above plus Hispanics/Latinos) relative to non-Hispanic Whites (NHW). In this comprehensive review, we outline emerging evidence suggesting these groups experience accelerated arterial dysfunction, including vascular endothelial dysfunction and large elastic artery stiffening, a nontraditional CVD risk factor that may predict risk of CVDs in these groups with advancing age. Adverse exposures to social determinants of health (SDOH), specifically lower socioeconomic status (SES), are exacerbated in most of these groups (except South Asians-higher SES) and may be a potential mediator of accelerated arterial aging. SES negatively influences the ability of marginalized racial and ethnic groups to meet aerobic exercise guidelines, the first-line strategy to improve arterial function, due to increased barriers, such as time and financial constraints, lack of motivation, facility access, and health education, to performing conventional aerobic exercise. Thus, identifying alternative interventions to conventional aerobic exercise that 1) overcome these common barriers and 2) target the biological mechanisms of aging to improve arterial function may be an effective, alternative method to aerobic exercise to ameliorate accelerated arterial aging and reduce CVD risk. Importantly, dedicated efforts are needed to assess these strategies in randomized-controlled clinical trials in these marginalized racial and ethnic groups.

MicroRNA in cardiometabolic health and disease: The perspectives of sex, gender and personalised medicine

BACKGROUND

Personalized medicine represents a novel and integrative approach that focuses on an individual's genetics and epigenetics, precision medicine, lifestyle and exposures as key players of health status and disease phenotypes.

METHODS

In this narrative review, we aim to carefully discuss the current knowledge on gender disparities in cardiometabolic diseases, and we consider the sex- specific expression of miRNAs and their role as promising tool in precision medicine.

RESULTS

Personalised medicine overcomes the restricted care of patient based on a binomial sex approach, by enriching itself with a holistic and dynamic gender integration. Recognized as a major worldwide health emergency, cardiometabolic disorders continue to rise, impacting on health systems and requiring more effective and targeted strategies. Several sex and gender drivers might affect the onset and progression of cardiometabolic disorders in males and females at multiple levels. In this respect, distinct contribution of genetic and epigenetic mechanisms, molecular and physiological pathways, sex hormones, visceral fat and subcutaneous fat and lifestyle lead to differences in disease burden and outcomes in males and females.

CONCLUSIONS

Sex and gender play a pivotal role in precision medicine because the influence the physiology of each individual and the way they interact with environment from intrauterine life.

Exercise to Prevent Accelerated Vascular Aging in People Living With HIV

Given advances in antiretroviral therapy, the mortality rate for HIV infection has dropped considerably over recent decades. However, people living with HIV (PLWH) experience longer life spans coupled with persistent immune activation despite viral suppression and potential toxicity from long-term antiretroviral therapy use. Consequently, PLWH face a cardiovascular disease (CVD) risk more than twice that of the general population, making it the leading cause of death among this group. Here, we briefly review the epidemiology of CVD in PLWH highlighting disparities at the intersections of sex and gender, age, race/ethnicity, and the contributions of social determinants of health and psychosocial stress to increased CVD risk among individuals with marginalized identities. We then overview the pathophysiology of HIV and discuss the primary factors implicated as contributors to CVD risk among PLWH on antiretroviral therapy. Subsequently, we highlight the functional evidence of premature vascular dysfunction as an early pathophysiological determinant of CVD risk among PLWH, discuss several mechanisms underlying premature vascular dysfunction in PLWH, and synthesize current research on the pathophysiological mechanisms underlying accelerated vascular aging in PLWH, focusing on immune activation, chronic inflammation, and oxidative stress. We consider understudied aspects such as HIV-related changes to the gut microbiome and psychosocial stress, which may serve as mechanisms through which exercise can abrogate accelerated vascular aging. Emphasizing the significance of exercise, we review various modalities and their impacts on vascular health, proposing a holistic approach to managing CVD risks in PLWH. The discussion extends to critical future study areas related to vascular aging, CVD, and the efficacy of exercise interventions, with a call for more inclusive research that considers the diversity of the PLWH population.

Sex-based tuberculosis mortality in Newfoundland, 1900-1949: Implications for populations in transition

OBJECTIVE

During the second epidemiological transition, tuberculosis (TB) is one disease that declined substantially enough to reduce all-cause mortality. Sex-based differences in TB mortality may reveal an important dimension of population health transitions between the urbanizing and rural regions of Newfoundland.

MATERIALS AND METHODS

For the island of Newfoundland, yearly age-standardized sex-based TB mortality rates were calculated using individual death records from 1900 to 1949 (n = 30 393). Multiple linear regression models predict the relative rates (RR) of sex-based mortality and the absolute difference between males and females while controlling for time and region (the urbanizing Avalon Peninsula or rural Newfoundland). Multiple linear regression models also predict the median age at death from TB while controlling for time, region, and sex to assess if TB was shifting to an older adult disease compared to those typically afflicted in ages 20-44.

RESULTS

Female TB mortality was relatively and absolutely higher than males; additionally, RR and absolute differences between male and female mortality were significantly lower in rural Newfoundland than the Avalon Peninsula. Median age at death for males was significantly higher than females, and differences in median age at death increased over time.

DISCUSSION

The historically high prevalence of TB throughout Newfoundland, including domestic, social, and public health responsibilities of women, likely contributed to increased exposure and transmission, leading to higher observed mortality. Sex-based TB outcomes should be considered in the discussion of the progression of the epidemiological transition as dynamic inequalities that do not necessarily fit contemporary generalizations of sex-based TB epidemiology.