Use of sex-specific troponin levels does not impact MI outcomes for transgender patients
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Key takeaways:
- Use of sex-specific thresholds aligned with gender identity was not associated with significant reclassification for MI.
- Troponin thresholds that align with a patient’s gender identity may help reduce distress.
Implementing sex-specific troponin thresholds for diagnosing acute MI did not significantly affect outcomes for transgender patients, researchers reported.
“Diagnosing acute MI requires the detection of cardiac troponin above the 99th percentile upper reference limit,” Ming-Sum Lee, MD, PhD, FACC, FAHA, FASE, program director of cardiology fellowship at Kaiser Permanente Los Angeles Medical Center, and colleagues wrote in JAMA Network Open. “The sex-specific 99th percentile cutoff for cisgender males is approximately twice that for cisgender females and is recommended to improve identification of acute MI in cisgender females.”
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In 2021, the Kaiser Permanente Southern California health system implemented a high-sensitivity cardiac troponin I assay with sex-specific diagnostic thresholds, replacing a conventional troponin assay with a single threshold. However, for transgender adults prescribed hormone therapy, there may be effects on cardiac biomarkers, and there is currently no established cardiac troponin diagnostic threshold for transgender people, the researchers noted.
“This study aimed to determine the role of implementing sex-specific troponin thresholds in the diagnosis and management of suspected ACS in transgender patients,” the researchers wrote.
In a population-based cohort study, Lee and colleagues analyzed data from 1,108 patients who presented with suspected ACS from 2007 to 2022, including 661 transgender women and 447 transgender men (median age, 33 years; 47.3% white; 32.5% Hispanic). Researchers identified transgender patients through review of an internal registry, hormonal treatment history, sex assigned at birth and medical records; patients never treated with hormonal therapy were excluded.
The researchers assessed troponin levels on presentation, adjudicated the cause of troponin elevation and followed patients for up to 30 days for outcomes.
Within the cohort, 23.6% of patients were evaluated after implementation of the high-sensitivity cardiac troponin I assay; all other patients were evaluated using a conventional troponin assay with a single threshold.
With the conventional troponin assay, 2.8% had abnormal troponin levels. With the high-sensitivity cardiac troponin I assay, researchers detected abnormal levels for 4.2% of patients if the threshold used was for their sex assigned at birth and for 3.8% of patients if the threshold aligned with their affirmed gender identity.
The overall concordance for classifying patients into having normal vs. abnormal troponin levels was high (98.9%). Three patients (1.1%), who would be reclassified if their sex assigned at birth were used for the threshold, had type 2 MI or myocardial injury. There were no patients with type 1 MI who would have been reclassified.
Researchers did not observe any differences in clinical outcomes at 30 days before and after implementation of sex-specific troponin diagnostic thresholds.
The researchers noted that patients presenting with STEMI and type 1 non-STEMI had troponin levels that were much higher than the diagnostic thresholds and were appropriately identified regardless of the threshold used.
“The findings suggest that troponin thresholds in accordance with the patient’s affirmed gender identity may be used in transgender individuals,” the researchers wrote. “Doing so may reduce confusion and distress for both patients and clinicians and help patients receive truly gender-affirming care.”
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