Cardiology Guidelines Almost Never Mention LGBTQIA+ Patients, Analysis of 313 Documents Finds

Cardiovascular disease remains the leading cause of death worldwide, and the clinical guidelines that shape how physicians prevent and treat it are among the most influential documents in medicine. A new analysis suggests those documents are failing a significant share of the patients they are meant to serve. In a perspective published in the Journal of General Internal Medicine, researchers report that of 313 cardiology clinical guidelines issued by American, European, and international professional societies, only six, or 1.9 percent, contained any LGBTQIA+-related terms at all. The finding points to a striking disconnect between a growing body of evidence that sexual and gender minority patients face elevated cardiovascular risks and the near-total silence of the guidelines clinicians rely on at the bedside.

The research team, led by Cassandra Chu and Jiya Patel under the supervision of cardiologist Amgad N. Makaryus of the Donald and Barbara Zucker School of Medicine at Hofstra/Northwell and the Northwell Cardiovascular Institute, set out to measure just how visible the LGBTQIA+ community is in contemporary cardiovascular guidance. The stakes are not abstract. Roughly 7 percent of the United States population identified as LGBTQIA+ as of 2023, according to Pew Research Center data cited by the authors. Members of this community may carry a higher predisposition to cardiovascular disease driven by increased psychosocial stressors, higher rates of obesity and smoking, and, for some transgender and gender-diverse patients, the use of gender-affirming hormone therapy. Clinical studies have also linked certain LGBTQIA+ subgroups to higher body mass index and elevated HbA1c levels, both established predictors of cardiovascular events.

The methodology was deliberately systematic and broad. The authors searched GuidelineCentral, a platform providing free access to up-to-date international clinical guidelines, for cardiology guidelines published within the ten years preceding August 8, 2024. Their keyword list was built from credible LGBTQ+ health resources, including the UCSF LGBTQIA+ Glossary and the Human Rights Campaign Glossary of Terms, and spanned several semantic categories: sexual orientation terms such as lesbian, gay, bisexual, queer, pansexual, and asexual; gender identity terms including transgender, non-binary, gender fluid, and gender non-conforming; umbrella population labels such as LGBT, LGBTQ, LGBTQIA+, sexual minority, and gender minority; and clinically relevant phrases for gender-affirming healthcare, including gender-affirming care, hormone therapy, and gender reassignment surgery. Crucially, the team intentionally retained historical terminology such as homosexual and transsexual to avoid missing relevant content in older documents that may use outdated language.

The results were stark. Of the 313 guidelines analyzed, just six contained any of the searched terms. The 2023 ACC/AHA/ACCP/HRS Atrial Fibrillation Guideline offers a brief but meaningful statement that patients with atrial fibrillation, regardless of sex and gender diversity, should be equitably offered guideline-directed stroke risk reduction therapies. The 2023 AHA/ACC/ACCP/ASPC/NLA/PCNA Chronic Coronary Disease Guideline identifies sexual orientation as a social determinant of health that affects all stages of disease management and calls for future research into whether cardiovascular risk increases among hormone-treated transgender women with established coronary disease. The 2020 VA/DoD Obesity Guideline recommends further research into how individual differences, including transgender identity, might predict outcomes after bariatric procedures.

Perhaps the most substantive engagement came from an unexpected quarter. The 2024 KDIGO Clinical Practice Guideline for the Evaluation and Management of Chronic Kidney Disease, a kidney-focused document that nonetheless intersects with cardiovascular care, acknowledges that a small but increasing proportion of the world’s population identifies as transgender, gender-diverse, or nonbinary and describes an urgent need to build transgender cultural safety within all aspects of kidney disease management. It further recognizes the importance of evaluating sex differences in kidney function across hormonal stages of life and considering the effects of exogenous hormone use, explicitly including gender-affirming hormone therapy, on measures of kidney health. By contrast, two International Society for Heart and Lung Transplantation guidelines, one covering heart transplant recipients and one addressing the use of hepatitis C virus-infected organ donors, referenced men who have sex with men only in the narrow context of donor screening and HIV transmission risk, rather than in service of equitable or tailored care.

The authors argue that this minimal acknowledgment constitutes a systemic oversight with real clinical consequences. There is a widening gap between emerging epidemiological data showing elevated smoking rates, higher BMI, and poorer glycemic control in LGBTQIA+ populations and the clinical protocols and prevention strategies that are supposed to act on such evidence. Gender-affirming hormone therapy illustrates the problem vividly: it is increasingly recognized as a potential modifier of cardiovascular risk, yet current cardiology guidelines rarely address its cardiovascular implications. The authors call for future guideline development to include dedicated sections evaluating the effects of estrogen- and testosterone-based therapies on cardiovascular outcomes and the downstream implications for management strategies, particularly for the transgender and gender-diverse populations most likely to receive these treatments.

A major barrier to progress, the researchers contend, is the absence of standardized terminology and data collection practices around sexual orientation and gender identity, often abbreviated SOGI. Inconsistent and outdated use of LGBTQIA+-related terms across studies impedes the synthesis of existing data and makes cross-population comparisons unreliable. Without a unified framework for identifying and categorizing subgroups within the community, designing inclusive research protocols or deriving conclusions that can meaningfully inform practice becomes exceedingly difficult. The limited inclusion of LGBTQIA+ individuals in clinical trials compounds the problem, reducing the generalizability of study findings and potentially masking subgroup-specific treatment responses or risk patterns. The authors argue that inclusive guidelines must therefore be preceded by intentional recruitment strategies and data disaggregation efforts that illuminate these populations’ unique health outcomes.

The proposed path forward is institutional as much as scientific. The authors call for interdisciplinary collaboration among clinicians, researchers, and LGBTQIA+ health advocates, supported by funding, ethical guidance, and community partnership. Integrating SOGI data collection into electronic health records, clinical trials, and large-scale epidemiologic studies is described as a crucial first step, but one that demands careful ethical handling. Because SOGI information is highly sensitive, patients may worry about privacy, discrimination, or unintended disclosure of their identity. The authors recommend voluntary disclosure, clear communication about the purpose and use of collected data, robust safeguards and secure storage to minimize the risk of unauthorized disclosure, and policies consistent with regional privacy requirements, noting that legal protections for sexual and gender minorities vary across jurisdictions. They further suggest that guideline-writing committees such as those of the ACC and AHA recruit diversity consultants with expertise in LGBTQIA+ health to strengthen the inclusivity and clinical relevance of future documents.

Notably, the authors acknowledge the limits of their own analysis. A keyword-based approach may underestimate implicit inclusivity or relevant content not captured by search terms, and the scarcity of studies specifically addressing LGBTQIA+ cardiovascular health reflects the broader research gap the paper seeks to close. They propose that future analyses employ artificial intelligence and natural language processing to broaden keyword coverage and identify semantically related language that standard searches overlook, and they call for comparative analyses of how multiple marginalized populations are represented across guidelines.

Ultimately, the paper’s conclusion reaches beyond the LGBTQIA+ community to a principle of guideline design: an effective clinical guideline should provide healthcare providers with accessible, inclusive, and actionable information regardless of their patients’ identities. The authors propose treating the inclusion of LGBTQIA+ data, terminology, and population-specific considerations as a standard quality metric during guideline development, analogous to how evidence levels are assessed in clinical recommendations, alongside attention to how race, socioeconomic status, and geography shape cardiovascular risk. History offers a precedent: women and racial and ethnic minority groups experienced similar underrepresentation in cardiovascular medicine, and the resulting delays in recognizing subgroup-specific disease presentations eventually prompted guideline revisions toward more equitable care. The authors argue that cardiology now faces the same inflection point, with an opportunity not only to improve outcomes for sexual and gender minority patients but to model inclusivity and justice in medicine more broadly.

Subject of Research: Representation of LGBTQIA+ patients in cardiovascular disease clinical practice guidelines

Article Title: Representation of the LGBTQIA+ Patient Community in Cardiovascular Disease Clinical Guidelines

Article References: Chu, C., Patel, J., Castillo, A., Zeltser, R., & Makaryus, A. N. (2026). Representation of the LGBTQIA+ Patient Community in Cardiovascular Disease Clinical Guidelines. Journal of General Internal Medicine. https://doi.org/10.1007/s11606-026-10857-x

Image Credits: AI Generated

DOI: 10.1007/s11606-026-10857-x

Keywords: LGBTQIA+ health, cardiovascular disease, clinical guidelines, health equity, gender-affirming therapy, sexual orientation and gender identity, cardiology, health disparities, Journal of General Internal Medicine, social determinants of health, clinical trials inclusion, guideline development