CAP TODAY Pathology/Laboratory Medicine/Laboratory Management
The impact of the sex hormones on the physiological mechanism that accounts for the sex-based difference in hs-cTn concentrations is an area for further study. “I would love to see heart imaging…before and after taking gender-affirming hormones,” Dr. Greene says. “Understanding the anatomical changes that happen would help us better understand the physiological measurements we’re seeing.”
Dr. Greene and her colleagues report that transgender women have a distribution of NT-proBNP concentrations similar to that of cisgender women, and that transgender men trend similarly to cisgender men. “These differences,” they write, “do not lead to distinct sex-specific NT-proBNP diagnostic thresholds owing to the significant concentration elevations in overt heart failure and cardiovascular disease but likely signify the importance of sex hormone concentrations in cardiac metabolism.” The data as a whole indicate, Dr. Greene says, that “the sex differences that we see in the cardiac biomarkers have a sex hormone component.”
“It all trends together. Troponin concentrations increasing in trans men and NT-proBNP decreasing is exactly what we see in cisgender men, relative to cisgender women. It completes the package with these common biomarkers that we study.”
The observed differences in hs-cTn and NT-proBNP concentrations between cisgender women and transgender men, and cisgender men and transgender women, suggest the possibility of adverse cardiac remodeling from gender-affirming therapy, Dr. Greene and coauthors write, “but the clinical implications of the small differences remain unclear and deserve further study.” The study’s findings do not suggest that those who could benefit from gender-affirming hormone therapy need to consider potential adverse cardiac consequences, Dr. Greene says. “Nothing that changes in the heart based on gender-affirming hormone therapy could make me say there are adverse cardiac effects from using hormones, because the benefits of hormones are so important. Gender-affirming hormones save lives.”
Though some publications have illustrated that transgender people may have a slightly higher risk for some cardiovascular diseases, Dr. Greene and coauthors write, “the etiology is unclear and hard to differentiate from social determinants of health affecting the transgender population.” Similarly, they write, teasing out the clinical implications of sex-specific hs-cTn upper reference limits for ruling in acute myocardial infarction is complicated by biological and social factors that contribute to the poorer outcomes observed in women.
The socialization that leads to differences in clinical care “before that sample ever hits the lab” is important to understand, Dr. Greene says.
“By definition you cannot correct for the socialized bias that happens between individuals. You cannot correct for the way women and men handle symptoms differently because of the way they’ve been socialized about how much their pain matters,” she says. “I’m not saying we shouldn’t do the work—I’m saying we should do the work, and we should talk about how much these things matter first and foremost, in our discussion, in our results, and in our introductions, not as a single line as a limitation at the end of a discussion.”
Charna Albert is CAP TODAY associate contributing editor.