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

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 9,625 SGM participants, 1,460 (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.

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.

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.

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.

Perceptions on HIV-related Comorbidities and Usability of a Virtual Environment as CVD Prevention Education in Sexual Minority Men with HIV: Formative Phases of a Pilot RCT

BACKGROUND

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

OBJECTIVE

To explore perceptions about HIV-related comorbidities and assess the interest and usability of a virtual environment as CVD prevention education in Black and Latinx sexual minority men with HIV.

METHODS

This is a 3-phase pilot randomized control behavioral 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 25 individuals. In Phase 1, 15 participants completed interviews exploring HIV-related illnesses of concern that would be used to tailor the virtual environment. In Phase 2, usability and beta testing were conducted with 10 participants to assess interest, features, and content.

RESULTS

In Phase 1, we found CVD risk factors included high blood pressure, heart attack, stroke, and diabetes. Cancer (prostate, colon, and others) was a common concern and so were the development of 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 about health and HIV, 2) High risk for comorbid conditions, 3) Virtual environment features were promising, and 4) need for diverse avatar representations.

CONCLUSIONS

We identified several comorbid conditions of concern and findings carry significant implications for mitigating barriers to preventative health screenings given the shared risk factors between HIV and related comorbidities. Highly rated aspects of the virtual environment were anonymity, meeting others who identify as gay or bisexual with HIV, validating 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, 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.

CLINICALTRIAL

clinicaltrials.gov (NCT04061915).

INTERNATIONAL REGISTERED REPORT

RR2-10.2196/38348.

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.

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.

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.

Sexual and gender minority content in undergraduate medical education in the United States and Canada: current state and changes since 2011

PURPOSE

To characterize current lesbian, gay, bisexual, transgender, queer, and intersex (LGBTQI +) health-related undergraduate medical education (UME) curricular content and associated changes since a 2011 study and to determine the frequency and extent of institutional instruction in 17 LGBTQI + health-related topics, strategies for increasing LGBTQI + health-related content, and faculty development opportunities.

METHOD

Deans of medical education (or equivalent) at 214 allopathic or osteopathic medical schools in Canada and the United States were invited to complete a 36-question, Web-based questionnaire between June 2021 and September 2022. The main outcome measured was reported hours of LGBTQI + health-related curricular content.

RESULTS

Of 214 schools, 100 (46.7%) responded, of which 85 (85.0%) fully completed the questionnaire. Compared to 5 median hours dedicated to LGBTQI + health-related in a 2011 study, the 2022 median reported time was 11 h (interquartile range [IQR], 6-16 h, p < 0.0001). Two UME institutions (2.4%; 95% CI, 0.0%-5.8%) reported 0 h during the pre-clerkship phase; 21 institutions (24.7%; CI, 15.5%-33.9%) reported 0 h during the clerkship phase; and 1 institution (1.2%; CI, 0%-3.5%) reported 0 h across the curriculum. Median US allopathic clerkship hours were significantly different from US osteopathic clerkship hours (4 h [IQR, 1-6 h] versus 0 h [IQR, 0-0 h]; p = 0.01). Suggested strategies to increase content included more curricular material focusing on LGBTQI + health and health disparities at 55 schools (64.7%; CI, 54.6%-74.9%), more faculty willing and able to teach LGBTQI + -related content at 49 schools (57.7%; CI, 47.1%-68.2%), and more evidence-based research on LGBTQI + health and health disparities at 24 schools (28.2%; CI, 18.7%-37.8%).

CONCLUSION

Compared to a 2011 study, the median reported time dedicated to LGBTQI + health-related topics in 2022 increased across US and Canadian UME institutions, but the breadth, efficacy, or quality of instruction continued to vary substantially. Despite the increased hours, this still falls short of the number of hours based on recommended LGBTQI + health competencies from the Association of American Medical Colleges. While most deans of medical education reported their institutions' coverage of LGBTQI + health as 'fair,' 'good,' or 'very good,' there continues to be a call from UME leadership to increase curricular content. This requires dedicated training for faculty and students.

LGBTQ+ cardiovascular health equity: a brief review

Cardiovascular disease (CVD) is the leading cause of morbidity and mortality in the United States. Data shows that social drivers of health (SDOH), including economic stability, racial/cultural identity, and community, have a significant impact on cardiovascular morbidity and mortality. LGBTQ+ (lesbian, gay, bisexual, transgender, queer, and other gender and sexual minority) patients face a variety of unique health risk factors and bear a disproportionate burden of CVD compared to cis-gender, heterosexual peers. There is a paucity of research assessing the etiologies of CVD health disparities within the LGBTQ+ community. Herein, we seek to explore existing literature on LGBTQ+ health disparities with a focus on cardiovascular disease, examine trends impacting LGBTQ+ health equity, and identify strategies and interventions that aim to promote LGBTQ+ cardiovascular health equity on a regional and national level.

Emphasizing Sexual Orientation and Gender Identity Data Capture for Improved Cardiovascular Care of the LGBTQ+ Population

Importance

The rising self-identifying lesbian, gay, bisexual, transgender, and queer (LGBTQ+) population makes understanding the unique health care needs of sexual and gender minoritized patients an urgent one. The interaction between minority stress and cardiovascular disease has been well described among underrepresented minoritized populations. The underrepresentation of minoritized populations in clinical research is partly responsible for worse cardiovascular outcomes in these populations. The absence of sexual orientation and gender identity and expression (SOGIE) data makes it difficult to understand the cardiovascular health of LGBTQ+ adults, thereby widening health care disparities in this population. Advancing cardiovascular health equity for LGBTQ+ patients must begin with careful and accurate SOGIE data collection.

Observations

Current SOGIE data capture remains inadequate despite federal mandates. Challenges in data collection include political and regulatory discrimination, patient/practitioner hesitancy, lack of supportive guidance on SOGIE data collection, improper terminology, regulatory inertia, and inadequate and often incorrect integration of SOGIE data into electronic health records (EHRs). Additional challenges include grouping participants as "others" for statistical significance. The inclusion of SOGIE data has demonstrated an impact in other fields like cancer survivorship and surgery. The same needs to be done for cardiology.

Conclusions and Relevance

Potential solutions for improving much-needed SOGIE data collection include (1) implementing LGBTQ+ inclusive policies, (2) integrating SOGIE data into the EHR, (3) educating health care professionals on the relevance of SOGIE to patient-centered care, and (4) creating a diverse cardiovascular workforce. These steps can substantially enhance the ability to collect SOGIE data to address LGBTQ+ cardiovascular health care disparities.

Comparing Stroke Risk Factors Among Sexual Minority Groups in Texas

BACKGROUND

Knowledge gaps remain on stroke risk and disparities between sexual minority (SM) subgroups. In this study, stroke risk between SM subgroups, specifically gay/bisexual men and lesbian/bisexual women (G/BM and L/BW), was assessed.

METHOD

Data were collected in June 2022 using a bilingual (English and Spanish) cross-sectional paper-and-pen survey distributed among 183 SM individuals attending the 2022 Houston Pride Parade and Festival, as well as across Texas via phone call or online format. Relevant sociodemographic and stroke risk factors were compared between G/BM and L/BW using chi-square (or Fisher's exact, when appropriate) and two-sample t-tests. Sexual orientation was used to predict stroke risk using multiple binomial logistic regression, adjusting for other sociodemographic determinants.

RESULTS

While comparing the stroke risk factors between G/BW and L/BW, statistically significant differences were found in hypertension (p = 0.047), age (p < 0.001), smoking status (p = 0.043), cholesterol level (p < 0.001), and HIV (p = 0.038). G/BM were 2.79 times more likely to have a higher stroke risk compared to L/BW (aOR = 2.79; CI, 1.11-6.05, p = 0.032), after adjusting for other sociodemographic factors.

CONCLUSION

This pilot study, conducted in Texas, adds to the existing scientific literature on stroke risk among the SM population and revealed that G/BM might have a higher stroke risk compared to L/BW. These findings can inform future research and intervention designs tailored to G/BM and L/BW communities and improve their overall health.

The Canadian Women's Heart Health Alliance ATLAS on the Epidemiology, Diagnosis, and Management of Cardiovascular Disease in Women - Chapter 7: Sex, Gender, and the Social Determinants of Health

Women vs men have major differences in terms of risk-factor profiles, social and environmental factors, clinical presentation, diagnosis, and treatment of cardiovascular disease. Women are more likely than men to experience health issues that are complex and multifactorial, often relating to disparities in access to care, risk-factor prevalence, sex-based biological differences, gender-related factors, and sociocultural factors. Furthermore, awareness of the intersectional nature and relationship of sociocultural determinants of health, including sex and gender factors, that influence access to care and health outcomes for women with cardiovascular disease remains elusive. This review summarizes literature that reports on under-recognized sex- and gender-related risk factors that intersect with psychosocial, economic, and cultural factors in the diagnosis, treatment, and outcomes of women's cardiovascular health.

Health Equity and Policy Considerations for Pediatric and Adult Congenital Heart Disease Care among Minoritized Populations in the United States

Achieving health equity in populations with congenital heart disease (CHD) requires recognizing existing disparities throughout the lifespan that negatively and disproportionately impact specific groups of individuals. These disparities occur at individual, institutional, or system levels and often result in increased morbidity and mortality for marginalized or racially minoritized populations (population subgroups (e.g., ethnic, racial, social, religious) with differential power compared to those deemed to hold the majority power in the population). Creating actionable strategies and solutions to address these health disparities in patients with CHD requires critically examining multilevel factors and health policies that continue to drive health inequities, including varying social determinants of health (SDOH), systemic inequities, and structural racism. In this comprehensive review article, we focus on health equity solutions and health policy considerations for minoritized and marginalized populations with CHD throughout their lifespan in the United States. We review unique challenges that these populations may face and strategies for mitigating disparities in lifelong CHD care. We assess ways to deliver culturally competent CHD care and to help lower-health-literacy populations navigate CHD care. Finally, we review system-level health policies that impact reimbursement and research funding, as well as institutional policies that impact leadership diversity and representation in the workforce.

Heteronormative biases and distinctive experiences with prostate cancer among men who have sex with men: a qualitative focus group study

BACKGROUND

Men who have sex with men (MSM) face many challenges and biases in healthcare. Within urology there is a need to better understand how prostate cancer impacts MSM given the unique ways in which side effects that accompany treatment may affect this population. The goal of this study is to explore the experience of MSM with prostate cancer to advance the existing literature in this area and inform implementation and delivery of clinical practice and policy guidelines.

METHODS

Four focus groups were conducted with a semi-structured interview guide. Using a phenomenological qualitative approach consistent with grounded theory [1] and naturalistic inquiry principles we sought to better understand the direct experiences of MSM with prostate cancer. Audio transcriptions were thematically analyzed to identify themes that impact MSM throughout their prostate cancer journey. An iterative, team-wide classification process was used to identify, organize, and group common codes into higher-order categories and themes.

RESULTS

Patient's choice of provider and their interactions with the healthcare system were strongly impacted by their sexual identities. Participants commented on navigating the heteronormative healthcare environment and the impact of assumptions they encountered. MSM experienced the sexual side effects of prostate cancer treatment in unique ways. Issues with erectile dysfunction and ejaculatory dysfunction had significant impacts on patient's sexual experience, with some describing being forced to explore new modes of sexual expression. Anejaculation was a theme that was distressing for many participants. The emotional impact of a prostate cancer diagnosis was significant in the men interviewed. Common themes included loss of identity and fear for future relationships.

CONCLUSIONS

MSM have unique concerns after prostate cancer treatment that differ from men who don't identify as MSM. It is critical that providers familiarize themselves with the concerns of this patient population regarding prostate cancer treatment. An important step toward reducing heteronormative bias in prostate cancer care is to better understand the goals, identity, and sexual practices of MSM and to provide informed anticipatory guidance.

Improving Stroke Risk Factor Management Focusing on Health Disparities and Knowledge Gaps

Stroke is a leading cause of death and disability in the United States and worldwide, necessitating comprehensive efforts to optimize stroke risk factor management. Health disparities in stroke incidence, prevalence, and risk factor management persist among various race/ethnic, geographic, and socioeconomic populations and negatively impact stroke outcomes. This review highlights existing literature and guidelines for stroke risk factor management, emphasizing health disparities among certain populations. Moreover, stroke risk factors for special groups, including the young, the very elderly, and pregnant/peripartum women are outlined. Strategies for stroke risk factor improvement at every level of the health care system are discussed, from the individual patient to providers, health care systems, and policymakers. Improving stroke risk factor management in the context of the social determinants of health, and with the goal of eliminating inequities and disparities in stroke prevention strategies, are critical steps to reducing the burden of stroke and equitably improving public health.

Long-term stability of respiratory sinus arrhythmia among adults with and without a history of depression

Respiratory sinus arrhythmia (RSA) is an index of parasympathetic nervous system activity reflecting respiratory influences on heart rate. This influence is typically measured as high frequency heart rate variability (HF-HRV) or root mean square of successive differences (RMSSD) of adjacent inter-beat intervals. Examining the long-term stability of its measurement is important as levels of resting RSA have been conceptualized as a marker of individual differences; in particular, of an individual's autonomic regulation and affect-related processes, including emotion regulation. At present, it is not known if resting RSA levels reflect stable differences over a long-term period (i.e., >1 year). Even less is known about how RSA stability differs as a function of depression history and whether it relates to depression risk trajectories. In the present study, we examined the 1.5-year test-retest reliability of resting RSA using the intraclass correlation coefficient (ICC) in 82 adults: n = 41 with a history of depression (ever-depressed); n = 41 controls with no depression history (never-depressed). HF-HRV was fairly stable in both groups (ever-depressed ICC = 0.55, never-depressed ICC = 0.54). RMSSD was also fairly stable in ever-depressed adults (ICC = 0.57) and never-depressed controls (ICC = 0.40). ICC values for both indices did not differ between groups per overlapping 95% confidence intervals. Therefore, RSA stability as assessed by both frequency (HF-HRV) and time domain (RMSSD) measures was not attenuated by a depression history. Implications and the need for future research are discussed.

Health Disparities Among Sexual and Gender Minorities With Adverse Childhood Experiences: Insights From the 2021 Behavioral Risk Factor Surveillance System Data

Objectives. To identify the prevalence of adverse childhood experiences (ACEs) among sexual or gender minorities (SGMs) and examine the impact of ACEs on their health. Methods. We analyzed 2021 Behavioral Risk Factor Surveillance System (BRFSS) data. Respondents from Arkansas, Iowa, Mississippi, Nevada, and Wisconsin completed modules on 10 individual ACEs, sexual orientation and gender identity, and health. Results. Among the 38 483 eligible respondents, 2329 (6.1%) identified as an SGM. SGMs reported higher ACE prevalence than did their non-SGM counterparts. ACEs partially attenuated relationships between SGMs and a higher risk for depression, cardiovascular disease, chronic kidney disease, electronic nicotine delivery system use, and cannabis use. Conclusions. Evaluating and better understanding the ACE and health outcome relationship among SGMs should be prioritized. Targeted interventions are needed to mitigate the impact of ACE-associated sequelae in this population. (Am J Public Health. 2023;113(12):1343-1351. https://doi.org/10.2105/AJPH.2023.307420).

HIV Infection and 90-Day Stroke Outcomes in Uganda: A Prospective Observational Cohort Study

Background and Objectives

Little is known about the impact of HIV infection on the clinical presentation and outcomes after stroke in the modern antiretroviral therapy (ART) era. We aimed to compare stroke characteristics and outcomes between persons with HIV (PWH) and without HIV (PWOH) presenting with stroke in Uganda.

Methods

We conducted a matched cohort study at Mulago National Referral Hospital and Mbarara Regional Referral Hospital between January 2018 and November 2020. We enrolled consecutive PWH presenting with CT-confirmed acute or subacute stroke (symptom onset ≤14 days) and matched them by sex and stroke type to 2 consecutive available PWOH admitted to the same hospital. We obtained baseline clinical data and followed participants for 90 days from the day of clinical presentation. We compared stroke severity (defined by the NIH stroke scale [NIHSS]) and 90-day all-cause mortality and morbidity (using the modified Rankin Scale [mRS]) by HIV serostatus with and without adjustment for confounders.

Results

We enrolled 105 PWH and 157 PWOH with stroke. PWH were younger (mean [SD] age 49 [14] vs 59 [16] years, p < 0.001), and nearly 80% (82/105) were on ART for a median of 5 years and a median CD4 count of 214 cells/uL (interquartile range 140, 337). Compared with PWOH, PWH presented with a 3-point lower median NIHSS (16 vs 19, p = 0.011), a 20% lower proportion of all-cause mortality at 90 days (p = 0.001), and had less disability at 90 days (median mRS 4 vs 5, p = 0.004). Age and NIHSS-adjusted odds ratio of 90-day all-cause mortality in PWH compared with PWOH was 0.45 (95% CI 0.22-0.96, p = 0.037).

Discussion

In the modern ART era, PWH with acute stroke in Uganda present with modest stroke and are significantly less likely to die within 90 days than PWOH. This potentially reflects the protective effects of ART, enhanced health care access, and their younger age at stroke presentation.

Sexual Health and Well-Being in Adults With Congenital Heart Disease: A International Society of Adult Congenital Heart Disease Statement

As health care outcomes improve the priority for those living with adult congenital heart disease have changed to a more holistic focus on quality of life and well-being. Although health care has embraced this, there are still areas where there is a deficit in advice, allyship, and advocacy. One of these deficits is in the area of sexual health and well-being. A healthy sexual life has a myriad of physical and psychosocial benefits. However, individuals with adult congenital heart disease may have significant barriers to achieving well-being in this aspect of their lives. These barriers and their potential solutions are outlined in this paper.

Minority Stress and Health Disparities in Lesbian, Gay, Bisexual, Transgender, and Queer or Questioning Adults

In recent decades, much attention has been placed on reducing health disparities that have plagued the lesbian, gay, bisexual, transgender, and queer or questioning community. Significant health disparities continue to exist compared with the heterosexual population. Sexual minorities tend to experience higher rates of acute and chronic conditions than the general population. Sexual minorities are more likely to delay seeking medical care and are less likely to lack a consistent source for health care. A provider's failure to recognize and a person's lack of disclosure prevent vital discussions about human immunodeficiency virus risk, hormone therapy, cancer risk, hepatitis, and sexual health.

A case report of myocardial infarction in a young transgender man with testosterone therapy: raising awareness on healthcare issues in the transgender community and a call for further research

Background

People who are transgender may utilize masculinizing or feminizing gender-affirming hormonal therapy. Testosterone and oestrogen receptors are expressed throughout the cardiovascular system, yet the effects of these therapies on cardiovascular risk and outcomes are largely unknown. We report the case of a young transgender man with no discernible cardiovascular risk factors presenting with an acute coronary syndrome.

Case summary

A 31-year-old transgender man utilizing intramuscular testosterone masculinizing gender-affirming hormonal therapy presented with central chest pain radiating to the left arm. He had no past medical history of hypertension, dyslipidaemia, diabetes, or smoking. Electrocardiography demonstrated infero-septal ST depression, and high-sensitivity troponin-I was elevated and increased to 19 686 ng/L. He was diagnosed with a non-ST-segment elevation myocardial infarction. Inpatient coronary angiography confirmed a critical focal lesion in the mid right coronary artery, which was managed with two drug-eluting stents. Medical management (i.e. aspirin, ticagrelor, atorvastatin, ramipril, and bisoprolol) and surveillance of residual plaque disease evident in the long tubular left main stem, proximal left anterior descending, and proximal circumflex vessels was undertaken. The masculinizing gender-affirming hormonal therapy was continued.

Discussion

Despite a greater awareness of the potential risk of increased cardiovascular disease in transgender people, the fundamental lack of data regarding cardiovascular outcomes in transgender people may be contributing to healthcare inequalities in this population. We must implement better training, awareness, and research into transgender cardiovascular health to facilitate equitable and evidence-based outcomes.

Investigating the Associations of Sexual Minority Stressors and Incident Hypertension in a Community Sample of Sexual Minority Adults

BACKGROUND

Sexual minority adults are at higher risk of hypertension than their heterosexual counterparts. Sexual minority stressors (i.e., unique stressors attributed to sexual minority identity) are associated with a variety of poor mental and physical health outcomes. Previous research has not tested associations between sexual minority stressors and incident hypertension among sexual minority adults.

PURPOSE

To examine the associations between sexual minority stressors and incident hypertension among sexual minority adults assigned female sex at birth.

METHODS

Using data from a longitudinal study, we examined associations between three sexual minority stressors and self-reported hypertension. We ran multiple logistic regression models to estimate the associations between sexual minority stressors and hypertension. We conducted exploratory analyses to determine whether these associations differed by race/ethnicity and sexual identity (e.g., lesbian/gay vs. bisexual).

RESULTS

The sample included 380 adults, mean age 38.4 (± 12.81) years. Approximately 54.5% were people of color and 93.9% were female-identified. Mean follow-up was 7.0 (± 0.6) years; during which 12.4% were diagnosed with hypertension. We found that a 1-standard deviation increase in internalized homophobia was associated with higher odds of developing hypertension (AOR 1.48, 95% Cl: 1.06-2.07). Stigma consciousness (AOR 0.85, 95% CI: 0.56-1.26) and experiences of discrimination (AOR 1.07, 95% CI: 0.72-1.52) were not associated with hypertension. The associations of sexual minority stressors with hypertension did not differ by race/ethnicity or sexual identity.

CONCLUSIONS

This is the first study to examine the associations between sexual minority stressors and incident hypertension in sexual minority adults. Implications for future studies are highlighted.

Nutrition and Health in the Lesbian, Gay, Bisexual, Transgender, Queer/Questioning Community: A Narrative Review

Sexual and gender minorities have a higher risk for health and nutrition-related disparities across the life course compared to the heterosexual or cisgender population. Experiences of stigmatization and discrimination are associated with diminished mental health quality and psychological distress, which are risk factors for developing various eating disorders. Other nutrition disparities include increased risk for food insecurity, body dissatisfaction, and weight complications, such as those experienced by the transgender population in association with gender-affirming hormone therapies. Despite the need for tailored nutrition recommendations that address the unique needs of the lesbian, gay, bisexual, transgender, queer/questioning (LGBTQ+) community, there are currently no such guidelines in North America. The purpose of this review is to summarize major LGBTQ+ nutrition disparities and highlight the need for tailored recommendations. We examine the evidence on mental health and social disparities in this group, including vulnerabilities to disordered eating, food insecurity, and healthcare provider discrimination. Importantly, we identify a scarcity of literature on dietary concerns and nutrition care guidelines for LGBTQ+ groups, including studies that address intersectionality and differences among specific gender and sexual orientations. These gaps underline the urgency of prioritizing nutrition for LGBTQ+ health needs and for developing tailored public health nutrition recommendations for this underserved population. Our review suggests that future LGBTQ+ health and nutrition research agendas should include personalized and precision nutrition, social determinants of health, diet quality, body image, and healthcare provider cultural competency and responsiveness. Moreover, the current evidence on LGBTQ+ nutrition and health will be strengthened when research studies (including clinical trials) with robust methodologies amplify inclusion and representation of this community to elucidate health and nutrition disparities in sexual and gender minorities.

Cardiovascular disease in transgender individuals

The population of people identifying as transgender has grown rapidly in recent years, resulting in a substantive increase in individuals obtaining gender-affirming medical care to align their secondary sex characteristics with their gender identity. This has established benefits for patients including improvements in gender dysphoria and psychosocial functioning, while reducing adverse mental health outcomes. Despite these potential advantages, recent evidence has suggested that gender-affirming hormone therapy (GAHT) may increase the risk of cardiovascular disease. However, owing to a paucity of research, the mechanisms underpinning these increased risks are poorly understood. Moreover, previous research has been limited by heterogenous methodologies, being underpowered, and lacking appropriate control populations. Consequently, the need for evidence regarding cardiovascular health in LGBTQ + individuals has been recognised as a critical area for future research to facilitate better healthcare and guidance. Recent research investigating the effect of transmasculine (testosterone) GAHT on cardiovascular disease risk points to testosterone effecting the nitric oxide pathway, triggering inflammation, and promoting endothelial dysfunction. Equivalent studies focussing on transfeminine (oestrogen) GAHT are required, representing a crucial area of future research. Furthermore, when examining the effects of GAHT on the vasculature, it cannot be ignored that there are multiple factors that may increase the burden of cardiovascular disease in the transgender population. Such stressors include major psychological stress; increased adverse health behaviours, such as smoking; discrimination; and lowered socioeconomic status; all of which undoubtedly impact upon cardiovascular disease risk and offers the opportunity for intervention.

Lifetime and Acute Stress Predict Functional Outcomes Following Stroke: Findings From the Longitudinal STRONG Study

BACKGROUND

Stroke is a sudden-onset, uncontrollable event; stroke-related stress may impede rehabilitation and recovery. Lifetime stress may sensitize patients to experiencing greater stroke-related stress and indirectly affect outcomes. We examine lifetime stress as predictor of poststroke acute stress and examine lifetime and acute stress as predictors of 3- and 12-month functional status. We also compare acute stress and baseline National Institutes of Health Stroke Scale as predictors of poststroke functional status.

METHODS

Between 2016 and 2020 the STRONG Study (Stroke, Stress, Rehabilitation, and Genetics) enrolled adults with new radiologically confirmed stroke 2 to 10 days poststroke onset at 28 acute care US hospitals. Participants were interviewed 3 times: acute admission (acute stress; Acute Stress Disorder Interview), 3 months (Fugl-Meyer Upper Extremity motor impairment [Fugl-Meyer Upper Arm Assessment; N=431], modified Rankin Scale [3 months; N=542], Stroke Impact Scale-Activities of Daily Living [3 months; N=511], Lifetime Stress Exposure Inventory), and 12 months (modified Rankin Scale, N=533; Stroke Impact Scale 3.0 Activities of Daily Living; N=485; Telephone Montreal Cognitive Assessment; N=484) poststroke. Structural equation models examined whether acute stress predicted 3- and 12-month functional outcomes, and mediated an association between lifetime stress and outcomes controlling for demographics and initial National Institutes of Health Stroke Scale. Standardized betas are reported.

RESULTS

Sample (N=763) was 19 to 95 years old (mean=63; SD=14.9); 448 (58.7%) were male. Acute stress scores ranged from 0 to 14 (mean, 3.52 [95% CI, 3.31-3.73]). Controlling for age, gender, baseline National Institutes of Health Stroke Scale, and race and ethnicity, higher lifetime stress predicted higher acute stress (β=0.18, P<0.001), which predicted lower 3-month Fugl-Meyer Upper Arm Assessment scores (β=-0.19, P<0.001), lower Stroke Impact Scale 3.0 Activities of Daily Living scores at 3 months (β=-0.21, P<0.001) and 12 months (β=-0.21, P<0.001), higher modified Rankin Scale scores at 3 months (β=0.23, P<0.001) and 12 months (β=0.22, P<0.001), and lower 12-month Telephone Montreal Cognitive Assessment scores (β=-0.20, P<0.001). Acute stress predicted 12-month tMoCA (χ2[1]=5.29, P=0.022) more strongly, 3-month and 12-month modified Rankin Scale and SIS scores as strongly (all Ps>0.18), but Fugl-Meyer scores (χ2[1]=7.01, P=0.008) less strongly than baseline National Institutes of Health Stroke Scale.

CONCLUSIONS

Lifetime stress/trauma is associated with more poststroke acute stress, which is associated with greater motor and cognitive impairment and disability 3 and 12 months poststroke. Poststroke interventions for acute stress may help mitigate stroke-related disability.

Strategies for Improving Enrollment of Diverse Populations with a Focus on Lipid-Lowering Clinical Trials

PURPOSE OF REVIEW

We review under-representation of key demographic groups in cardiovascular clinical trials, focusing on lipid-lowering trials. We outline multilevel strategies to recruit and retain diverse populations in cardiovascular trials.

RECENT FINDINGS

Barriers to participation in trials occur at the study, participant, health system, sponsor, and policy level, requiring a multilevel approach to effectively increase participation of under-represented groups in research. Increasing the representation of marginalized and under-represented groups in leadership positions in clinical trials can ensure that their perspectives and experiences are considered. Trial design should prioritize patient- and community-indicated needs. Women and individuals from racially/ethnically diverse populations remain under-represented in lipid-lowering and other cardiovascular clinical trials relative to their disease burden in the population. This limits the generalizability of trial results to the broader population in clinical practice. Collaboration between community stakeholders, researchers, and community members can facilitate shared learning about trials and build trust.

Associations Between Childhood Victimization, Adult Victimization, and Physical Health Among Sexually Diverse Adults at Different Stages of Life

Purpose: Research examining health disparities in sexually diverse populations is quite variable. The purpose of the present article was to shed light on the conflicting findings pertaining to minority stress and health by examining the potential impact of age, childhood victimization, and different measurements of health. Methods: The present research used data from the Generations Study, a questionnaire study of sexually diverse adults (ages 18-60) surveyed between 2016 and 2019. We modeled direct and indirect links among (1) childhood exposure to physical or sexual abuse, (2) adult exposure to victimization or harassment, and (3) adult physical health status, assessed both subjectively and objectively. Participants were 1398 sexually diverse adults (e.g., lesbian, gay, bisexual); the present work only utilizes wave one of the data collected in 2016. Results: We found that both childhood abuse and adult harassment/victimization predicted sexually diverse adults' health status, but these associations only manifested as diagnosable disease outcomes among adults over 50. Associations between childhood abuse and adult health were partly attributable to the fact that abuse-exposed children were disproportionately exposed to harassment and victimization as adults. Conclusion: Our research makes a novel contribution to our understanding of the health effects of stigma by pinpointing the multiple, cascading pathways through which adversity relates to health.

Mindfulness-Based Mobile Health to Address Unhealthy Eating Among Middle-Aged Sexual Minority Women With Early Life Adversity: Mixed Methods Feasibility Trial

BACKGROUND

Sexual minority women (lesbian, gay, bisexual, pansexual, queer, and other nonheterosexual women) remain considerably underrepresented in health research despite being at a higher risk for diabetes and obesity as well as stigma and psychological distress than their heterosexual peers. In addition, early life adversity (ELA) is prevalent among sexual minority women, which further increases risks for obesity, psychological distress, and poor cardiovascular health. App-based mindfulness interventions are potentially promising for this group in mitigating the adverse health effects of ELA, reducing food craving and unhealthy eating, addressing the risks associated with obesity.

OBJECTIVE

This mixed methods feasibility trial aimed to test a mindfulness-based mobile health approach for middle-aged sexual minority women (aged 30-55 years) with ELA and overweight or obesity (BMI ≥25 kg/m2) to improve health outcomes.

METHODS

The single-arm trial was advertised on social media and various lesbian, gay, bisexual, transgender, and queer web-based groups. At baseline, after the intervention (2 months), and at the 4-month follow-up, participants completed assessments of primary outcomes (food craving, emotional eating, and weight via a mailed scale) and secondary outcomes (depression, anxiety, mindfulness, and emotion dysregulation). A standardized weight measure was mailed to participants for weight reporting. Feasibility and acceptability were assessed after the intervention via surveys and semistructured exit interviews.

RESULTS

We screened 442 individuals, among which 30 eligible sexual minority women (mean age 40.20, SD 7.15 years) from various US regions were enrolled in the study. At baseline, 86% (26/30) and 80% (24/30) of participants had elevated depressive and anxiety symptoms, respectively. Among the 30 enrolled participants, 20 (66%) completed all intervention modules, 25 (83%) were retained at the 2-month follow-up, and 20 (66%) were retained at the 4-month follow-up. None reported adverse effects. From baseline to the 4-month follow-up, large effects were found in food craving (Cohen d=1.64) and reward-based eating (Cohen d=1.56), whereas small effects were found with weight (Cohen d=0.20; 4.21 kg on average). Significant improvements were also found in the secondary outcomes (depression, Cohen d=0.98; anxiety, Cohen d=0.50; mindfulness, Cohen d=0.49; and emotion dysregulation, Cohen d=0.44; all P<.05). Participants with higher levels of parental verbal and emotional abuse were particularly responsive to the intervention. Participants reported that the program aligned with their goals and expectations, was easy to use, and facilitated changes in eating behavior and mental health. Barriers to engagement included the need for diverse teachers, individualized support, and body positive language.

CONCLUSIONS

This early phase feasibility trial provides proof-of-concept support for a mindfulness mobile health approach to improve obesity-related outcomes among sexual minority women and warrants a larger randomized controlled trial in the future. The findings also suggest the need to address trauma and psychological health when addressing weight-related outcomes among sexual minority women.

Proposed mechanisms of hypertension and risk of adverse cardiovascular outcomes in LGBT communities

Hypertension (HTN), a highly prevalent public issue affecting one in two adults in the United States, has recently been shown to differentially burden individuals belonging to marginalized communities, such as the lesbian, gay, bisexual, and transgender (LGBT) communities. The minority stress theory posits that a unique combination of marginalization-related psychosocial stressors and coping behaviors may underlie the increased burden of diseases like HTN in LGBT populations. Uncontrolled or poorly managed HTN often leads to the development of adverse cardiovascular outcomes, such as heart failure (HF). Despite our understanding of minority stress theory and demonstrated associations between LGBT identities and HTN, the mechanisms whereby psychosocial stress drives HTN in LGBT populations remain unclear. This mini-review discusses the physiological systems governing blood pressure and the epidemiology of HTN across different subgroups of LGBT people. In addition, we propose mechanisms demonstrated in the general population whereby psychological stress has been implicated in elevating blood pressure that may be occurring in LGBT populations. Finally, we discuss the limitations of current studies and methodological frameworks to make suggestions for study designs to better delineate the mechanisms of psychosocial stress-related HTN in LGBT communities.

Caring for Sexual and Gender Minority Adults with Cardiovascular Disease

This article summarizes existing evidence on cardiovascular disease (CVD) risk and CVD diagnoses among sexual and gender minority adults and provides recommendations for providing nursing care to sexual and gender minority adults with CVD. More research is needed to develop evidence-based strategies to care for sexual and gender minority adults with CVD.

2023 AHA/ACC/ACCP/ASPC/NLA/PCNA Guideline for the Management of Patients With Chronic Coronary Disease: A Report of the American Heart Association/American College of Cardiology Joint Committee on Clinical Practice Guidelines

AIM

The "2023 AHA/ACC/ACCP/ASPC/NLA/PCNA Guideline for the Management of Patients With Chronic Coronary Disease" provides an update to and consolidates new evidence since the "2012 ACCF/AHA/ACP/AATS/PCNA/SCAI/STS Guideline for the Diagnosis and Management of Patients With Stable Ischemic Heart Disease" and the corresponding "2014 ACC/AHA/AATS/PCNA/SCAI/STS Focused Update of the Guideline for the Diagnosis and Management of Patients With Stable Ischemic Heart Disease."

METHODS

A comprehensive literature search was conducted from September 2021 to May 2022. Clinical studies, systematic reviews and meta-analyses, and other evidence conducted on human participants were identified that were published in English from MEDLINE (through PubMed), EMBASE, the Cochrane Library, Agency for Healthcare Research and Quality, and other selected databases relevant to this guideline.

STRUCTURE

This guideline provides an evidenced-based and patient-centered approach to management of patients with chronic coronary disease, considering social determinants of health and incorporating the principles of shared decision-making and team-based care. Relevant topics include general approaches to treatment decisions, guideline-directed management and therapy to reduce symptoms and future cardiovascular events, decision-making pertaining to revascularization in patients with chronic coronary disease, recommendations for management in special populations, patient follow-up and monitoring, evidence gaps, and areas in need of future research. Where applicable, and based on availability of cost-effectiveness data, cost-value recommendations are also provided for clinicians. Many recommendations from previously published guidelines have been updated with new evidence, and new recommendations have been created when supported by published data.

2023 AHA/ACC/ACCP/ASPC/NLA/PCNA Guideline for the Management of Patients With Chronic Coronary Disease: A Report of the American Heart Association/American College of Cardiology Joint Committee on Clinical Practice Guidelines

AIM

The "2023 AHA/ACC/ACCP/ASPC/NLA/PCNA Guideline for the Management of Patients With Chronic Coronary Disease" provides an update to and consolidates new evidence since the "2012 ACCF/AHA/ACP/AATS/PCNA/SCAI/STS Guideline for the Diagnosis and Management of Patients With Stable Ischemic Heart Disease" and the corresponding "2014 ACC/AHA/AATS/PCNA/SCAI/STS Focused Update of the Guideline for the Diagnosis and Management of Patients With Stable Ischemic Heart Disease."

METHODS

A comprehensive literature search was conducted from September 2021 to May 2022. Clinical studies, systematic reviews and meta-analyses, and other evidence conducted on human participants were identified that were published in English from MEDLINE (through PubMed), EMBASE, the Cochrane Library, Agency for Healthcare Research and Quality, and other selected databases relevant to this guideline.

STRUCTURE

This guideline provides an evidenced-based and patient-centered approach to management of patients with chronic coronary disease, considering social determinants of health and incorporating the principles of shared decision-making and team-based care. Relevant topics include general approaches to treatment decisions, guideline-directed management and therapy to reduce symptoms and future cardiovascular events, decision-making pertaining to revascularization in patients with chronic coronary disease, recommendations for management in special populations, patient follow-up and monitoring, evidence gaps, and areas in need of future research. Where applicable, and based on availability of cost-effectiveness data, cost-value recommendations are also provided for clinicians. Many recommendations from previously published guidelines have been updated with new evidence, and new recommendations have been created when supported by published data.

Self-Perception of Aging and Hypertension in a Cohort of Sexual Minority

Objectives To determine whether self-perception of aging is an important marker of health and hypertension among older sexual minority men. Methods We evaluated associations between self-perception of aging (chronologic-subjective age discrepancy and aging satisfaction) and hypertension among 1,180 sexual minority men (51.6% with HIV/48.4% without HIV) from the Multicenter AIDS Cohort Study using a manifest Markov chain model adjusted for HIV status, age, race/ethnicity, education, smoking status, inhaled nitrite use, diabetes, dyslipidemia, kidney and liver disease. Results The overall prevalence of hypertension increased from 73.1% to 82.6% over three years of follow-up. Older age discrepancy (aOR (adjusted odds ratio): 1.13 95% CI: 0.35-3.69) and low aging satisfaction (aOR: 0.88; 95% CI: 0.31-2.52) were not associated with an increased prevalence of hypertension, regardless of HIV status. Discussion More than 80% of sexual minority men had a diagnosis of hypertension but self-perception of aging was not predictive of incident hypertension.

A Woman's Heart: Improving Uptake and Awareness of Cardiovascular Screening for Middle-Aged Populations

Mid-life, the years leading up to and following the menopause transition, in women is accompanied by a change in cardiometabolic risk factors, including increases in body weight, changes in body composition, a more insulin-resistant state, and a shift towards a more atherogenic dyslipidemia pattern. Cardiovascular disease (CVD) risk assessment should be performed continually throughout the lifespan, as risk is not stagnant and can change throughout the life course. However, mid-life is a particularly important time for a woman to be evaluated for CVD risk so that appropriate preventive strategies can be implemented. Along with assessing traditional risk factors, ascertainment of a reproductive history is an integral part of a comprehensive CVD risk assessment to recognize unique female-specific or female-predominant factors that modify a woman's risk. When there is uncertainty about CVD risk and the net benefit of preventive pharmacotherapy interventions (such as statins), measuring a coronary artery calcium score can help further refine risk and guide shared decision-making. Additionally, there should be heightened sensitivity around identifying signs and symptoms of ischemic heart disease in women, as these may present differently than in men. Ischemia from coronary microvascular disease and/or vasospasm may be present even without obstructive coronary artery disease and is associated with a heightened risk for major cardiovascular events and reduced quality of life. Therefore, correctly identifying CVD in women and implementing preventive and treatment therapies is paramount. Unfortunately, women are underrepresented in cardiovascular clinical trials, and more data are needed about how to best incorporate novel and emerging risk factors into CVD risk assessment. This review outlines an approach to CVD screening and risk assessment in women using several methods, focusing on the middle-aged population.

Prevalence of 12 Common Health Conditions in Sexual and Gender Minority Participants in the All of Us Research Program

Importance

Limited data describe the health status of sexual or gender minority (SGM) people due to inaccurate and inconsistent ascertainment of gender identity, sex assigned at birth, and sexual orientation.

Objective

To evaluate whether the prevalence of 12 health conditions is higher among SGM adults in the All of Us Research Program data compared with cisgender heterosexual (non-SGM) people.

Design, Setting, and Participants

This cross-sectional study used data from a multidisciplinary research consortium, the All of Us Research Program, that links participant-reported survey information to electronic health records (EHR) and physical measurements. In total, 372 082 US adults recruited and enrolled at an All of Us health care provider organization or by directly visiting the enrollment website from May 31, 2017, to January 1, 2022, and were assessed for study eligibility.

Exposures

Self-identified gender identity and sexual orientation group.

Main Outcomes and Measures

Twelve health conditions were evaluated: 11 using EHR data and 1, body mass index (BMI; calculated as weight in kilograms divided by height in meters squared), using participants' physical measurements. Logistic regression (adjusting for age, income, and employment, enrollment year, and US Census division) was used to obtain adjusted odds ratios (AORs) for the associations between each SGM group and health condition compared with a non-SGM reference group.

Results

The analytic sample included 346 868 participants (median [IQR] age, 55 [39-68] years; 30 763 [8.9%] self-identified as SGM). Among participants with available BMI (80.2%) and EHR data (69.4%), SGM groups had higher odds of anxiety, depression, HIV diagnosis, and tobacco use disorder but lower odds of cardiovascular disease, kidney disease, diabetes, and hypertension. Estimated associations for asthma (AOR, 0.39 [95% CI, 0.24-0.63] for gender diverse people assigned male at birth; AOR, 0.51 [95% CI, 0.38-0.69] for transgender women), a BMI of 25 or higher (AOR, 1.65 [95% CI, 1.38-1.96] for transgender men), cancer (AOR, 1.15 [95% CI, 1.07-1.23] for cisgender sexual minority men; AOR, 0.88 [95% CI, 0.81-0.95] for cisgender sexual minority women), and substance use disorder (AOR, 0.35 [95% CI, 0.24-0.52] for gender diverse people assigned female at birth; AOR, 0.65 [95% CI, 0.49-0.87] for transgender men) varied substantially across SGM groups compared with non-SGM groups.

Conclusions and Relevance

In this cross-sectional analysis of data from the All of Us Research Program, SGM participants experienced health inequities that varied by group and condition. The All of Us Research Program can be a valuable resource for conducting health research focused on SGM people.

Implications of Social Disadvantage Score in Cardiovascular Outcomes and Risk Assessment: Findings From the Multi-Ethnic Study of Atherosclerosis

BACKGROUND

Social determinants of health contribute to disparate cardiovascular outcomes, yet they have not been operationalized into the current paradigm of cardiovascular risk assessment.

METHODS

Data from the Multi-Ethnic Study of Atherosclerosis, which includes participants from 6 US field centers, were used to create an index of baseline Social Disadvantage Score (SDS) to explore its association with incident atherosclerotic cardiovascular disease (ASCVD) and all-cause mortality and impact on ASCVD risk prediction. SDS, which ranges from 0 to 4, was calculated by tallying the following social factors: (1) household income less than the federal poverty level; (2) educational attainment less than a high school diploma; (3) single-living status; and (4) experience of lifetime discrimination. Cox models were used to examine the association between SDS and each outcome with adjustment for traditional cardiovascular risk factors. Changes in the discrimination and reclassification of ASCVD risk by incorporating SDS into the pooled cohort equations were examined.

RESULTS

A total of 6434 participants (mean age, 61.9±10.2 years; female 52.8%; non-white 60.9%) had available SDS 1733 (26.9%) with SDS 0; 2614 (40.6%) with SDS 1; 1515 (23.5%) with SDS 2; and 572 (8.9%) with SDS ≥3. In total, 775 incident ASCVD events and 1573 deaths were observed over a median follow-up of 17.0 years. Increasing SDS was significantly associated with incident ASCVD and all-cause mortality after adjusting for traditional risk factors (ASCVD: per unit increase in SDS hazard ratio, 1.15 [95% CI, 1.07-1.24]; mortality: per unit increase in SDS hazard ratio, 1.13 [95% CI, 1.08-1.19]). Adding SDS to pooled cohort equations components in a Cox model for 10-year ASCVD risk prediction did not significantly improve discrimination (P=0.208) or reclassification (P=0.112).

CONCLUSIONS

Although SDS is independently associated with incident ASCVD and all-cause mortality, it does not improve 10-year ASCVD risk prediction beyond pooled cohort equations.

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.

Inequity in care delivery in cardio-oncology: dissecting disparities in underrepresented populations

It is well known that patients with cancer have a significantly higher cardiovascular mortality risk than the general population. Cardio-oncology has emerged to focus on these issues including risk reduction, detection, monitoring, and treatment of cardiovascular disease or complications in patients with cancer. The rapid advances in early detection and drug development in oncology, along with socioeconomic differences, racial inequities, lack of support, and barriers to accessing quality medical care, have created disparities in various marginalized populations. In this review, we will discuss the factors contributing to disparities in cardio-oncologic care in distinct populations, including Hispanic/Latinx, Black, Asian and Pacific Islander, indigenous populations, sex and gender minorities, and immigrants. Some factors that contribute to differences in outcomes in cardio-oncology include the prevalence of cancer screening rates, genetic cardiac/oncologic risk factors, cultural stressors, tobacco exposure rates, and physical inactivity. We will also discuss the barriers to cardio-oncologic care in these communities from the racial and socioeconomic context. Appropriate and timely cardiovascular and cancer care in minority groups is a critical component in addressing these disparities, and there need to be urgent efforts to address this widening gap.

Validation of an administrative algorithm for transgender and gender diverse persons against self-report data in electronic health records

OBJECTIVE

To adapt and validate an algorithm to ascertain transgender and gender diverse (TGD) patients within electronic health record (EHR) data.

METHODS

Using a previously unvalidated algorithm of identifying TGD persons within administrative claims data in a multistep, hierarchical process, we validated this algorithm in an EHR data set with self-reported gender identity.

RESULTS

Within an EHR data set of 52 746 adults with self-reported gender identity (gold standard) a previously unvalidated algorithm to identify TGD persons via TGD-related diagnosis and procedure codes, and gender-affirming hormone therapy prescription data had a sensitivity of 87.3% (95% confidence interval [CI] 86.4-88.2), specificity of 98.7% (95% CI 98.6-98.8), positive predictive value (PPV) of 88.7% (95% CI 87.9-89.4), and negative predictive value (NPV) of 98.5% (95% CI 98.4-98.6). The area under the curve (AUC) was 0.930 (95% CI 0.925-0.935). Steps to further categorize patients as presumably TGD men versus women based on prescription data performed well: sensitivity of 97.6%, specificity of 92.7%, PPV of 93.2%, and NPV of 97.4%. The AUC was 0.95 (95% CI 0.94-0.96).

CONCLUSIONS

In the absence of self-reported gender identity data, an algorithm to identify TGD patients in administrative data using TGD-related diagnosis and procedure codes, and gender-affirming hormone prescriptions performs well.

"We're always an afterthought"- Designing tobacco control campaigns for dissemination with and to LGBTQ +-serving community organizations: a thematic analysis

PURPOSE

Evidence-based health communication campaigns can support tobacco control and address tobacco-related inequities among lesbian, gay, bisexual, transgender, and queer (LGBTQ +) populations. Community organizations focused on LGBTQ + health (e.g., nonprofits, community centers, and community health centers) can be prime channels for delivering evidence-based health communication campaigns. However, it is unclear how to balance the goals of a) designing campaigns to support broad adoption/uptake and b) adaptation addressing the needs of diverse communities and contexts. As part of an effort to support "designing for dissemination," we explored the key challenges and opportunities staff and leaders of LGBTQ + -serving community organizations encounter when adopting or adapting evidence-based health communication campaigns.

METHODS

A team of researchers and advisory committee members conducted this study, many of whom have lived, research, and/or practice experience with LGBTQ + health. We interviewed 22 staff members and leaders of community organizations serving LGBTQ + populations in the US in early 2021. We used a team-based, reflexive thematic analysis approach.

RESULTS

The findings highlight the challenges of attempting to use health communication campaigns misaligned with the assets and needs of organizations and community members. The three major themes identified were as follows: (1) available evidence-based health communication campaigns typically do not sufficiently center LGBTQ + communities, (2) negotiation regarding campaign utilization places additional burden on practitioners who have to act as "gatekeepers," and (3) processes of using health communication campaigns often conflict with organizational efforts to engage community members in adoption and adaptation activities.

CONCLUSIONS

We offer a set of considerations to support collaborative design and dissemination of health communication campaigns to organizations serving LGBTQ + communities: (1) develop campaigns with and for LGBTQ + populations, (2) attend to the broader structural forces impacting campaign recipients, (3) support in-house testing and adaptations, and (4) increase access to granular data for community organizations.

A systematic review of U.S. nursing faculty's knowledge, awareness, inclusion, and perceived importance of sexual and gender minority-related content in nursing curricula

BACKGROUND

In the US, sexual and gender minority (SGM) individuals continue to experience health inequities, and nursing curricula content and nursing faculty with SGM health expertise in the US remain limited. Addressing health disparities begins with the preparation of future nurses-US nursing faculty must be supported to meet these growing needs.

PURPOSE

To describe, appraise, and synthesize research from 2000-2020 on US nursing faculty knowledge, awareness, inclusion, and perceived importance of SGM health content.

METHODS

Following PRISMA 2020 guidelines, we registered a systematic review and appraisal protocol in PROSPERO, and then executed the protocol and synthesized the literature.

DISCUSSION

We found an empirical evidence base surrounding US nursing faculty and SGM health much more limited than expected. Only four cross-sectional, descriptive empirical articles fit the a priori inclusion criteria. The studies were of moderate quality at best and often relied on unvalidated or older measures. In general, the studies focused on examining characteristics of nursing programs, faculty comfort with content, faculty perceptions of content importance, and hours dedicated to content.

CONCLUSION

Since the close of the review, new commentaries and editorials expanding the call for change in the US were published-the time for commentary has passed. It remains unclear whether US nursing faculty are adequately prepared to educate future nurses about SGM health issues-and an unprepared healthcare workforce is yet another barrier to SGM health equity. The evidence base supporting US nursing faculty development desperately needs more studies using rigorous methodologies.

Gender medicine: effects of sex and gender on cardiovascular disease manifestation and outcomes

Despite a growing body of evidence, the distinct contributions of biological sex and the sociocultural dimension of gender to the manifestations and outcomes of ischaemic heart disease and heart failure remain unknown. The intertwining of sex-based differences in genetic and hormonal mechanisms with the complex dimension of gender and its different components and determinants that result in different disease phenotypes in women and men needs to be elucidated. The relative contribution of purely biological factors, such as genes and hormones, to cardiovascular phenotypes and outcomes is not yet fully understood. Increasing awareness of the effects of gender has led to efforts to measure gender in retrospective and prospective clinical studies and the development of gender scores. However, the synergistic or opposing effects of sex and gender on cardiovascular traits and on ischaemic heart disease and heart failure mechanisms have not yet been systematically described. Furthermore, specific considerations of sex-related and gender-related factors in gender dysphoria or in heart-brain interactions and their association with cardiovascular disease are still lacking. In this Review, we summarize contemporary evidence on the distinct effects of sex and gender as well as of their interactions on cardiovascular disease and how they favourably or unfavourably influence the pathogenesis, clinical manifestations and treatment responses in patients with ischaemic heart disease or heart failure.

Differences in Ideal Cardiovascular Health Between Sexual Minority and Heterosexual Adults

Importance

Research on the cardiovascular health (CVH) of sexual minority adults has primarily examined differences in the prevalence of individual CVH metrics rather than comprehensive measures, which has limited development of behavioral interventions.

Objective

To investigate sexual identity differences in CVH, measured using the American Heart Association's revised measure of ideal CVH, among adults in the US.

Design, Setting, and Participants

This cross-sectional study analyzed population-based data from the National Health and Nutrition Examination Survey (NHANES; 2007-2016) in June 2022. Participants included noninstitutional adults aged 18 to 59 years. We excluded individuals who were pregnant at the time of their interview and those with a history of atherosclerotic cardiovascular disease or heart failure.

Exposures

Self-identified sexual identity categorized as heterosexual, gay/lesbian, bisexual, or something else.

Main Outcomes and Measures

The main outcome was ideal CVH (assessed using questionnaire, dietary, and physical examination data). Participants received a score from 0 to 100 for each CVH metric, with higher scores indicating a more favorable CVH profile. An unweighted average was calculated to determine cumulative CVH (range, 0-100), which was recoded as low, moderate, or high. Sex-stratified regression models were performed to examine sexual identity differences in CVH metrics, disease awareness, and medication use.

Results

The sample included 12 180 participants (mean [SD] age, 39.6 [11.7] years; 6147 male individuals [50.5%]). Lesbian (B = -17.21; 95% CI, -31.98 to -2.44) and bisexual (B = -13.76; 95% CI, -20.54 to -6.99) female individuals had less favorable nicotine scores than heterosexual female individuals. Bisexual female individuals had less favorable body mass index scores (B = -7.47; 95% CI, -12.89 to -1.97) and lower cumulative ideal CVH scores (B = -2.59; 95% CI, -4.84 to -0.33) than heterosexual female individuals. Compared with heterosexual male individuals, gay male individuals had less favorable nicotine scores (B = -11.43; 95% CI, -21.87 to -0.99) but more favorable diet (B = 9.65; 95% CI, 2.38-16.92), body mass index (B = 9.75; 95% CI, 1.25-18.25), and glycemic status scores (B = 5.28; 95% CI, 0.59-9.97). Bisexual male individuals were twice as likely as heterosexual male individuals to report a diagnosis of hypertension (adjusted odds ratio [aOR], 1.98; 95% CI, 1.10-3.56) and use of antihypertensive medication (aOR, 2.20; 95% CI, 1.12-4.32). No differences in CVH were found between participants who reported their sexual identity as something else and heterosexual participants.

Conclusion and Relevance

Results of this cross-sectional study suggest that bisexual female individuals had worse cumulative CVH scores than heterosexual female individuals, whereas gay male individuals generally had better CVH than heterosexual male individuals. There is a need for tailored interventions to improve the CVH of sexual minority adults, particularly bisexual female individuals. Future longitudinal research is needed to examine factors that might contribute to CVH disparities among bisexual female individuals.