Transgender individuals may be more likely to suffer from a heart attack than their cisgender counterparts, according to Medical Xpress.

A new study led by researchers at George Washington University found that, in some cases, the risk of cardiac arrest could be four times higher for trans people.

Researchers looked at data spanning three years – 2014 to 2017 – from a national health survey conducted by the Centers for Disease Control and Prevention. Among many questions, respondents were asked if they had ever had a heart attack and if they identified as transgender.

After adjusting for risk factors like age, high blood pressure, and lack of exercise, trans men were found to experience heart attacks four times as much as cisgender women and twice as much as cisgender men. Transgender women had twice the rate of heart attacks as cisgender women, but there was no significant difference between the rates of trans women and cis men.

“This has not been a topic that has been discussed a lot in the past,” said Dr. Tran Nguyen, one of the principal authors of the study and an internal medicine resident at George Washington University School of Medicine and Health Sciences in Washington, D.C.. “But previous studies have shown that the transgender population has been more prone to more cardiovascular risk factors, such as poverty, smoking … and depression. What surprised us was that the rate of heart attacks would be that much higher.”

The study is preliminary, said Dr. Paul Chan, a cardiologist and professor at the University of Missouri-Kansas City School of Medicine, due to its limited scope.

“It begins the conversation and that’s the important thing,” Chan said, “But it’s an observational study, and that is very limited.”

The survey didn’t ask when the heart attack occurred– before or after transitioning – whether the respondent had undergone gender reassignment surgery, or if they had been taking hormone therapy, which has been linked to an increased risk of heart disease.

“We need large cohort studies to follow up,” Chan said. “And we need to think about how we design gender questions, not just perpetuate the issue as binary because we only give two options. That will give us a lot more data about risks and benefits.”

“We need more research about causation,” Nguyen said. “But I hope this will bring awareness to both health care providers and the transgender population.”

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