Treating cardiovascular disease in LGBTQ+ people - a systematic review of clinical practice guidelines

Background: Lesbian, gay, bisexual, transgender, and queer (LGBTQ+) people have unique risk factors for cardiovascular disease (CVD). There is evidence of a higher likelihood of tobacco use, inadequate exercise, diabetes, dyslipidemia, hypertension, and obesity among LGBTQ+ populations, which are assumed to be driven by increased psychosocial stressors across the lifespan. Moreover, specific
treatments, especially gender-affirming hormone therapy for transgender people, are thought to increase CVD risk. The present study aimed to analyze if and how the behavioral, psychosocial, and physiological factors contributing to an increased CVD risk in LGBTQ+ people are recognized in current clinical guidelines for the management of CVD. Methods: We systematically reviewed all CVD guidelines published by the American College of Cardiology (ACC) and the European Society of Cardiology (ESC) between 2010 and 2022. Each guideline was analyzed for the coverage of LGBTQ+-related cardiovascular issues using a systematic methodology. We searched the guidelines for LGBTQ+-related terminology (e.g., gay, lesbian, transgender) and the citation of publications on CVD risk in LGBTQ+ populations. We evaluated positive results to determine how the evidence on CVD risks of LGBTQ+ people was used (e.g., clinical scenarios, recommendations). Results: We analyzed 67 CVD guidelines. Only one guideline by the ESC mentioned LGBTQ+ populations (1.5%). This guideline on CVD prevention in clinical practice mentioned that “studies on the specificities of CVD disease in the transgender population are scarce.” Moreover, none of the guidelines cited existing clinical evidence on the increased CVD risk in LGBTQ+ patients. Conclusion: To develop evidence-based recommendations, high-quality observational research and clinical trials are needed. Implementing a tandardized collection of sexual orientation and gender identity data may help to achieve larger samples. Clinicians should continue following the current guidelines but also recognize specific risk factors contributing to increased CVD risk in LGBTQ+ patients.