Abstract Body (Do not enter title and authors here): Introduction: Transgender and gender diverse (TGD) adults have disproportionately greater burden of cardiovascular disease (CVD) risk. However, prevalent and incident heart failure (HF) and its risk factors have not been well-characterized in TGD populations.
Objective: To determine the prevalence and incidence of HF risk factors and phenotype by gender identity.
Methods: The study included commercial insurance claims data for 408,457 adults from 2006-2022. Gender identity was classified as cisgender male, cisgender female, transmasculine, transfeminine, or unclassified TGD identity. HF risk factors and phenotype (i.e., HFrEF, HFpEF, other HF) were abstracted using administrative billing codes. Multivariate logistic regression and Cox proportional hazard models examined associations between gender identity and prevalent and incident HF, respectively. Models were stratified by HF phenotype and adjusted for clinical comorbidities and presence of CVD.
Results: Of 57,471 TGD patients, 9,652 (16.8%) were transfeminine, 17,898 (31.1%) were transmasculine, and 29,921 (52.1%) had unclassified TGD identity. The mean age was 35±16 years, followed for 5.5±4.7 years. The prevalence of HF risk factors differed by gender identity (Table 1). Among TGD adults the overall prevalence of HFrEF, HFpEF, and other HF were 0.4% (n=204), 0.4% (n=222), and 1.8% (n=1,015), respectively. Prevalent HF differed by gender identity (p<0.001). In adjusted models compared to cisgender males, transmasculine persons had lower odds of HFrEF (OR 0.38 [95% CI 0.21-0.71], p<0.05), unclassified TGD persons had greater odds of HFpEF (OR 1.44 [95% CI 1.17-1.77], p<0.05) and lower odds of other HF (OR 0.77 [95% CI 0.69-0.85], p<0.05). Compared to cisgender males, transmasculine persons had less incident HFrEF, HFpEF, and other HF; transfeminine persons had less incident HFrEF; and unclassified TGD adults had greater incident HFpEF (Table 2).
Conclusions: Among a nationally representative administrative sample inclusive of TGD people, CVD risk factors, prevalent HF, and incident HF differ by gender identity. Gender identity and concomitant gender-affirming therapies represent underrecognized markers of HF risk and may act as HF risk modifiers in TGD adults.