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Peer-reviewedCC BY-NC-ND 4.0JACC: Advances

Heart Failure Phenotypes and Trajectory by Gender Identity in a National Veteran Cohort

  • Ian K. Everitt, MD, MPH1
  • Meredith S. Duncan, PhD2
  • Kory R. Heier, MS2
  • Lauren B. Beach, PhD, JD3
  • Guneet K. Jasuja, PhD
  • Hill L. Wolfe, PhD, MPA4
  • Landon D. Hughes, PhD5
  • Joseph L. Goulet, PhD, MS6
  • Monica Mukherjee, MD, MPH1
  • Carl G. Streed, Jr, MD, MPH7
7 affiliations
  1. 1Division of Cardiology, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
  2. 2Department of Biostatistics, University of Kentucky, Lexington, Kentucky, USA
  3. 3Department of Medical Social Sciences, Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA
  4. 4Department of Biostatistics, Yale School of Public Health, New Haven, Connecticut, USA
  5. 5Department of Population Medicine, Harvard Medical School, Boston, Massachusetts, USA; Harvard Pilgrim Health Care Institute, Boston, Massachusetts, USA
  6. 6Department of Emergency Medicine, Yale School of Medicine, New Haven, Connecticut, USA
  7. 7Department of Medicine, Section of General Internal Medicine, Boston University Chobanian and Avedisian School of Medicine, Boston, Massachusetts, USA; GenderCare Center, Boston Medical Center, Boston, Massachusetts, USA
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Abstract

Background: Differences in heart failure (HF) phenotypes and trajectories among transgender and gender diverse (TGD) populations may provide insight into mechanisms of HF risk. Objectives: The objective of the study was to evaluate associations between gender identity, incident HF, and trajectories between HF phenotypes. Methods: We conducted a retrospective cohort study of 1,103,923 veterans in the Veterans Health Administration (October 1, 2010–September 30, 2019; median follow-up 9.4 years). TGD status (n = 42,157; 3.8%) was identified using natural language processing. Gender identity was categorized as cisgender men, cisgender women, transmasculine, transfeminine, or unclassified TGD. Incident HF was defined using administrative codes and classified by ejection fraction (EF) as HF with reduced EF (<40%), HF with preserved EF (HFpEF) (>50%), HFpEF with EF decline, and HF with improved EF. Multivariable Cox regression estimated associations. Results: The mean age of TGD veterans was 46 years. 107,766 incident HF events occurred, including 3,078 among TGD veterans. Incident HF rates ranged from 6.22 to 8.89 per 1,000 person-years across TGD identities vs 3.87 in cisgender women and 13.05 in cisgender men. TGD status was associated with higher HF risk than cisgender women (HR: 1.53; 95% CI: 1.46 to 1.60), but lower than cisgender men (HR: 0.90; 95% CI: 0.86-0.93). HF with reduced EF rates were intermediate between cisgender men and women; associations with HFpEF were inconsistent after adjustment. Rates of HFpEF with EF decline and HF with improved EF varied (130.0-163.3 and 161.3-262.6 per 1,000 person-years, respectively). Conclusions: Gender identity is associated with differences in HF incidence and trajectory among veterans. HF epidemiology may be incompletely characterized without inclusion of TGD populations.

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Cite

BibTeXRIS
BibTeX
@article{iankeveritt2026heart,
  title = {{Heart Failure Phenotypes and Trajectory by Gender Identity in a National Veteran Cohort}},
  author = {Ian K. Everitt, MD, MPH and Meredith S. Duncan, PhD and Kory R. Heier, MS and Lauren B. Beach, PhD, JD and Guneet K. Jasuja, PhD and Hill L. Wolfe, PhD, MPA and Landon D. Hughes, PhD and Joseph L. Goulet, PhD, MS and Monica Mukherjee, MD, MPH and Carl G. Streed, Jr, MD, MPH},
  journal = {JACC: Advances},
  year = {2026},
  month = sep,
  doi = {10.1016/j.jacadv.2026.103198},
  url = {https://doi.org/10.1016/j.jacadv.2026.103198},
  note = {CC BY-NC-ND 4.0},
}
RIS
TY  - JOUR
TI  - Heart Failure Phenotypes and Trajectory by Gender Identity in a National Veteran Cohort
AU  - Ian K. Everitt, MD, MPH
AU  - Meredith S. Duncan, PhD
AU  - Kory R. Heier, MS
AU  - Lauren B. Beach, PhD, JD
AU  - Guneet K. Jasuja, PhD
AU  - Hill L. Wolfe, PhD, MPA
AU  - Landon D. Hughes, PhD
AU  - Joseph L. Goulet, PhD, MS
AU  - Monica Mukherjee, MD, MPH
AU  - Carl G. Streed, Jr, MD, MPH
PY  - 2026
DA  - 2026/09/09
JO  - JACC: Advances
DO  - 10.1016/j.jacadv.2026.103198
UR  - https://doi.org/10.1016/j.jacadv.2026.103198
AB  - Background: Differences in heart failure (HF) phenotypes and trajectories among transgender and gender diverse (TGD) populations may provide insight into mechanisms of HF risk. Objectives: The objective of the study was to evaluate associations between gender identity, incident HF, and trajectories between HF phenotypes. Methods: We conducted a retrospective cohort study of 1,103,923 veterans in the Veterans Health Administration (October 1, 2010–September 30, 2019; median follow-up 9.4 years). TGD status (n = 42,157; 3.8%) was identified using natural language processing. Gender identity was categorized as cisgender men, cisgender women, transmasculine, transfeminine, or unclassified TGD. Incident HF was defined using administrative codes and classified by ejection fraction (EF) as HF with reduced EF (<40%), HF with preserved EF (HFpEF) (>50%), HFpEF with EF decline, and HF with improved EF. Multivariable Cox regression estimated associations. Results: The mean age of TGD veterans was 46 years. 107,766 incident HF events occurred, including 3,078 among TGD veterans. Incident HF rates ranged from 6.22 to 8.89 per 1,000 person-years across TGD identities vs 3.87 in cisgender women and 13.05 in cisgender men. TGD status was associated with higher HF risk than cisgender women (HR: 1.53; 95% CI: 1.46 to 1.60), but lower than cisgender men (HR: 0.90; 95% CI: 0.86-0.93). HF with reduced EF rates were intermediate between cisgender men and women; associations with HFpEF were inconsistent after adjustment. Rates of HFpEF with EF decline and HF with improved EF varied (130.0-163.3 and 161.3-262.6 per 1,000 person-years, respectively). Conclusions: Gender identity is associated with differences in HF incidence and trajectory among veterans. HF epidemiology may be incompletely characterized without inclusion of TGD populations.
SN  - 2772-963X
ER  -