Determinants of Cardiovascular Disease Risk Among LGBTQ+ Populations: A Systematic Review of Empirical Evidence

ABSTRACT

Background

Understanding the multifactorial drivers of cardiovascular disease (CVD) risk in LGBTQ+ populations is critical to advancing equitable cardiovascular care.

Objective

To evaluate and synthesize empirical evidence on factors influencing CVD risk among sexual minority populations.

Methods

A systematic review was conducted following PRISMA guidelines. Five databases (PubMed, Scopus, MEDLINE, ScienceDirect and ProQuest) were searched for studies published between 2019 and 2024 that examined CVD risk factors among LGBTQ+ adults. Eligible studies were appraised using the Joanna Briggs Institute critical appraisal tool, and findings were synthesized using a convergent integrated approach.

Results

Twenty studies met the inclusion criteria, most of which were cross‐sectional and conducted in high‐income countries. Identified CVD risk factors were classified into six domains: behavioural (e.g., nicotine use, health behaviours, substance use), blood biomarker (e.g., lipid or total cholesterol, HbA1c, C‐reactive protein), physical (e.g., BMI, blood pressure, age), comorbidities (e.g., metabolic syndrome, COPD, HIV), psychological (e.g., positive and negative factors) and social (e.g., discrimination, loneliness, marital status). Bisexual, lesbian and gay individuals were most frequently represented. Across studies, minority stress and adverse social determinants were consistently associated with elevated CVD risk.

Conclusion

Sexual minority populations face disproportionate cardiovascular risk shaped by behavioural, biological and psychosocial stressors. These findings highlight the need for inclusive, culturally competent nursing practice and identity‐informed screening strategies.

Implications for Nursing Practice and Policy

Nurses should integrate sexual orientation and gender identity into cardiovascular risk assessments, adopt trauma‐informed and resilience‐promoting approaches, and advocate for policies that reduce structural barriers to equitable care.

Patient or Public Contribution

No patients or members of the public were directly involved in the design, conduct or reporting of this systematic review.

1. Background

Cardiovascular disease (CVD), encompassing conditions such as coronary artery disease, stroke, heart failure and hypertension, remains a leading cause of morbidity and mortality worldwide (Chong et al. 2024; Militaru et al. 2021). Its development and progression are influenced by a combination of clinical risk factors (e.g., hypertension, dyslipidaemia, diabetes) (Militaru et al. 2021), lifestyle factors (e.g., smoking, physical inactivity) (Stephens et al. 2024) and social and psychosocial determinants (Troy et al. 2025).

In 2021, approximately 612 million people globally were affected by CVD, with an age‐adjusted prevalence rate of 7178 per 100,000 individuals (Martin et al. 2025). Notably, LGBTQ+ (lesbian, gay, bisexual, transgender, queer and other gender and sexual minority) adults exhibit a higher prevalence of multiple cardiovascular disease risk factors compared with cisgender heterosexual populations (Caceres, Jackman, et al. 2020). These include, but are not limited to, higher rates of diabetes (Duncan et al. 2025), hypertension (Nessen et al. 2025), elevated body mass index (BMI) (Bonomo et al. 2024), tobacco use and alcohol consumption (Zalabak and Gantioque 2025), dyslipidaemia and substance use (Bonomo et al. 2024). Understanding and addressing these disparities are essential in mitigating the impact of CVD on this vulnerable population.

LGBTQ+ individuals face unique social, economic and environmental stressors that significantly affect their cardiovascular health (Caceres, Brody, et al. 2017; Caceres, Jackman, et al. 2020), a relationship that can be understood within the framework of minority stress theory, which posits that chronic exposure to stigma, discrimination and social marginalization contributes to adverse health outcomes (Brubaker et al. 2024; Meyer and Frost 2013). Research suggests that discrimination, stigma and limited access to culturally competent healthcare contribute to higher rates of hypertension (Bonomo et al. 2024), obesity (Panza et al. 2020) and other CVD risk factors in this population (Caceres, Streed, et al. 2020; Streed et al. 2021). Additionally, structural barriers such as employment discrimination and unstable housing exacerbate health disparities by restricting access to healthcare services and health‐promoting resources (Pinnamaneni et al. 2022; Safer et al. 2016). Addressing these issues requires a comprehensive understanding of the factors influencing CVD risk in this population.

Despite increasing recognition of cardiovascular health disparities among LGBTQ+ individuals, there remains a critical need for a systematic evaluation of the factors contributing to these disparities (Caceres, Streed, et al. 2020; Kharlamov et al. 2024). Previous studies have explored predictors of cardiovascular risk in LGBTQ+ individuals. For instance, Sherman et al. (2022) found that LGBTQ+ populations have a higher risk of developing CVD, are more likely to develop it at an earlier age, and are more likely to use tobacco products compared to heterosexual individuals. Minority stress resulting from discrimination and stigma may contribute to increased CVD risk by elevating stress hormone levels, promoting systemic inflammation and encouraging unhealthy coping behaviours such as smoking (Sherman et al. 2022). Similarly, Alzahrani et al. (2019) reported that transgender individuals experience higher rates of smoking, inadequate physical activity and minority stress‐related health disparities, leading to an increased incidence of myocardial infarction compared to their cisgender counterparts (Alzahrani et al. 2019).

A previous systematic review has examined cardiovascular disease risk among sexual minority populations (Caceres, Brody, et al. 2017); however, these reviews were largely based on studies published before 2016 and primarily focused on selected behavioural and psychosocial risk factors using predominantly self‐reported measures. For example, earlier syntheses highlighted elevated cardiovascular risk related to tobacco use, alcohol consumption, mental health and body mass index among sexual minority adults, while reporting limited differences in diagnosed cardiovascular conditions. These reviews did not comprehensively examine a broader range of biological, social and structural determinants, nor did they reflect more recent advances in population‐based data, improved measurement of sexual orientation and gender identity, or emerging evidence from the COVID‐19 era. Consequently, an updated and comprehensive systematic review is warranted to synthesize contemporary evidence on cardiovascular disease risk across sexual and gender minority populations.

By synthesizing existing evidence, this systematic review aimed to investigate the potential risk factors for CVD among LGBTQ+ individuals. Understanding these factors is crucial for developing evidence‐based interventions and policies aimed at reducing cardiovascular health disparities and ensuring equitable healthcare outcomes for individuals of all sexual orientations and gender identities. Addressing this gap is key to advancing cardiovascular health equity and fostering inclusive healthcare practices tailored to the unique needs of the LGBTQ+ population.

2. Objective

This systematic review aimed to evaluate and synthesize empirical evidence on factors influencing cardiovascular disease (CVD) risk among LGBTQ+ populations.

3. Methods

3.1. Identify Relevant Studies

For this systematic review, we adhered to the guidelines set by the Preferred Reporting Items for Systematic Reviews and Meta‐Analyses (PRISMA) to outline the processes involved in literature identification, screening, inclusion and exclusion. No protocol was prospectively registered for this systematic review. A comprehensive search was conducted across five electronic databases—Scopus, PubMed, Medline, ScienceDirect and ProQuest—aimed at identifying studies published from 2019 to 2024 that focused on factors influencing cardiovascular disease risk in the LGBTQ+ population. The 2019–2024 period was selected to capture contemporary empirical evidence reflecting recent methodological advances and improved inclusion of LGBTQ+ populations in cardiovascular research, as well as studies conducted during the COVID‐19 pandemic, a period that may have influenced cardiovascular risk through changes in healthcare access, psychosocial stressors and health behaviours.

To ensure comprehensive coverage, we employed Boolean operators and a broad range of search terms, including: (“LGBTQ” OR “LGBT*” OR “LGB” OR “gay” OR “lesbian” OR “bisexual” OR “transgender” OR “homosexual” OR “sexual minority”) AND (“cardiovascular disease” OR “cardiovascular health” OR “cardiovascular risk” OR “cardiovascular event” OR “CVD”) (Table S1). In addition to the database searches, we manually reviewed the reference lists of the selected studies to identify any further relevant articles. All references were organized and managed using EndNote for subsequent review and analysis.

3.2. Study Selection

Initially, two reviewers independently screened the titles and abstracts to identify studies meeting the eligibility criteria. Full texts of potentially relevant studies were then independently assessed for inclusion. Any disagreements were resolved through discussion and consensus, with consultation of a third reviewer when necessary. Inclusion and exclusion criteria were applied to ensure that only studies relevant to the review objectives were included (Table 1).

TABLE 1.

Inclusion and Exclusion Criteria.

Inclusion Criteria

Exclusion Criteria

Studies focused on the LGBTQ+ population aged 18 years or older (including studies examining the full LGBTQ+ spectrum or specific subgroups, such as LGB‐only or transgender/gender‐diverse populations). Studies examining factors affecting cardiovascular disease risk in the LGBTQ+ population. Studies published in the English language. Studies published between 2019 and 2024. Studies were eligible regardless of whether a heterosexual or cisgender comparator group was included.

All types of reviews, unpublished master's theses and doctoral dissertations, conference proceedings, abstracts, pilot studies, protocols, letters to the editor, brief reports, or statement papers. Studies not involving human participants or those involving animal models. Studies that do not specifically focus on the LGBTQ+ population. Studies that do not address cardiovascular disease risk.

3.3. Quality Assessment

The purpose of the quality assessment is to assess the methodological strength of each study and evaluate how effectively potential biases in its design, execution and analysis have been addressed. In this review, two researchers independently evaluated the quality of the included studies using the Joanna Briggs Institute (JBI) critical appraisal tools, which are tailored for use in systematic reviews (JBI 2024). The JBI tools are structured according to study design and include domains such as clarity of inclusion criteria, appropriateness of the study population and setting, validity and reliability of measurements, identification and control of confounding factors and suitability of statistical analysis. Discrepancies between reviewers were resolved through discussion or consultation with a third reviewer.

3.4. Data Extraction

The standardized chart for data extraction (Table S2) developed for this review included the following data for each study: References, Published year, Country, Settings, Target population, Study design, Sample size (n), Age of participants (mean), Gender orientation included, Quality assessment, Purpose of Study, Cardiovascular disease risk measure, Main Outcome and Implications/Suggestions.

3.5. Data Synthesis

For this review, we employed the convergent integrated analysis framework recommended by the Joanna Briggs Institute (JBI) for systematic reviews to synthesize data from the selected studies. This process involved identifying key themes from the primary findings of the studies by recognizing both similarities and differences. Additionally, sub‐themes were derived to highlight more detailed aspects of the findings, akin to the methods used in qualitative thematic analysis (Moola et al. 2017).

4. Results

A total of 1448 articles were retrieved from five electronic databases: Scopus (n = 459), PubMed (n = 295), MEDLINE (n = 207), ScienceDirect (n = 171) and ProQuest (n = 316), with no additional sources contributing to the search. After eliminating duplicate records (n = 50), the remaining 1398 articles underwent an initial screening process. Titles and abstracts were assessed against the inclusion and exclusion criteria (Table 1), resulting in the removal of 1362 articles that did not meet the eligibility requirements. This left 36 articles for a detailed full‐text review. Following the full‐text assessment, 16 studies were excluded for the following reasons: 11 studies did not align with the research aim, 3 studies only had an abstract available, 1 study was a review rather than an empirical investigation, and 1 study included participants younger than 18 years old. Ultimately, 20 studies met the inclusion criteria and were incorporated into the final systematic review (Figure 1) (Page et al. 2021).

FIGURE 1.

PRISMA flowchart diagram. Adapted from: Page MJ, McKenzie JE, Bossuyt PM, Boutron I, Hoffmann TC, Mulrow CD, et al. The PRISMA 2020 statement: An updated guideline for reporting systematic reviews. bmj. 2021;372.

4.1. Description of Included Studies

The characteristics of the included studies are summarized in Table 2. The majority were published in 2019 (n = 6, 30.0%) and 2022 (n = 5, 25.0%), followed by 2020 (n = 4, 20.0%). Most studies originated from the United States (n = 18, 90.0%), with one study each from Australia and Poland (n = 1, 5.0% each). Regarding study design, cross‐sectional studies were the most common (n = 11, 55.0%), followed by retrospective cohort studies (n = 5, 25.0%) and prospective cohort studies (n = 4, 20.0%).

TABLE 2.

Characteristics of Included Studies.

Characteristics	Number of Studies b	Percentage (%)
Publication Year
2019	6	30.0
2020	4	20.0
2021	1	5.0
2022	5	25.0
2023	2	10.0
2024	2	10.0
Country
USA	18	90.0
Australia	1	5.0
Poland	1	5.0
Study Design
Cross‐sectional Study	11	55.0
Prospective Cohort Study	4	20.0
Retrospective Cohort Study	5	25.0
Sample Size
> 100,000	4	20.0
10,000–100,000	5	25.0
< 10,000	11	55.0
Population Type
Database‐based	16	80.0
Survey‐based	4	20.0
Sexual Orientation/Gender Identity
Bisexual	9	22.0
Lesbian	8	19.5
Gay	7	17.1
Heterosexual	2	4.9
Transgender	2	4.9
Others a	13	31.7
Cardiovascular disease risk measure
Behavioural factor	10	22.2
Blood biomarker	4	8.9
Physical factor	12	26.7
Comorbidity	7	15.6
Psychological factor	8	17.8
Social factor	4	8.9

^a The category “Others” includes identity terms reported in individual studies that could not be consistently disaggregated into mutually exclusive categories due to heterogeneous or aggregated reporting. Although some studies reported identities such as “transgender men” and “transgender women,” these were included in the “Others” category when they were embedded within broader or overlapping groupings (e.g., sexual and gender minorities) or when disaggregation was not possible. Additional terms included “not sure,” “mostly lesbian,” “queer,” “cisgender,” “gender‐nonconforming,” “cisgender gay men,” and aggregated categories such as “sexual minority women,” “sexual minority men” and “sexual and gender minorities.”

^b Some characteristics (e.g., sexual orientation and gender identity) were reported using overlapping categories; therefore, a single study could contribute to more than one category, and totals may exceed the number of included studies.

Sample sizes varied across studies: 11 studies (55.0%) included fewer than 10,000 participants, 5 studies (25.0%) included between 10,000 and 100,000 participants, and 4 studies (20.0%) included over 100,000 participants. In terms of data source, most studies utilized database‐derived samples (n = 16, 80.0%), while the remainder used survey‐based samples (n = 4, 20.0%).

A wide range of sexual orientations and gender identities were reported. Bisexual individuals were the most commonly represented group (22.0%), followed by lesbian (19.5%) and gay (17.1%) individuals. Heterosexual and transgender identities were each reported in 4.9% of the identity mentions, while 31.7% were categorized as “Others,” which includes diverse identities such as “not sure,” “queer,” “cisgender,” “nonconform,” and various broader groupings. Regarding cardiovascular disease risk measures, physical factors were the most frequently examined (26.7%), followed by behavioural factors (22.2%), psychological factors (17.8%), comorbidities (15.6%), blood biomarkers (8.9%) and social factors (8.9%).

4.2. Assessment of Methodological Quality

The methodological rigour of the included studies was assessed using the Joanna Briggs Institute (JBI) critical appraisal checklist. Overall, the studies demonstrated strong adherence to methodological quality standards, with an updated average assessment score of 77.77%. All 20 studies (100%) scored above 60%, 6 studies (30.0%) scored above 80% and 7 studies (35.0%) achieved a perfect score of 100%. For a comprehensive breakdown of the quality assessment results, refer to Table S2.

4.3. Description of the Factors Influencing Cardiovascular Disease Risk

A synthesis of findings on factors influencing cardiovascular disease (CVD) risk in the LGBTQ+ population is presented in Table 3. The analysis identified six key themes: (1) behavioural factors, (2) blood biomarkers, (3) physical factors, (4) comorbidities, (5) psychological factors and (6) social factors. Additionally, several subthemes and supplementary factors were identified within these broader themes. A detailed summary of each theme is provided in the following section.

TABLE 3.

Factors Influencing Cardiovascular Disease Risk.

References	Factors Influencing Cardiovascular Disease Risks in Sexual Minority Populations
	1. Behavioural factor			2. Blood biomarker			3. Physical factors			4. Comorbidity			5. Psychological factor					6. Social factor
	Nicotine use	Health Behaviours	Substance use	Lipid or Total cholesterol	HbA1C or Fasting glucose	CRP	BMI or Overweight or Obesity	BP	Older age or age	Metabolic syndrome	COPD	HIV infection	Positive		Negative			Discrimination experiences	Loneliness	Marital status
													Resilience	Mastery	Trauma	Mental distress	Perceived stress
Caceres et al. (2023)	X	X		X			X
Caceres et al. (2022)				X	X		X	X
Caceres, Streed, et al. (2020)		X					X			X
Caceres, Veldhuis, et al. (2019)							X			X					X
Caceres, Makarem, et al. (2019)	X	X	X				X			X						X
Caceres, Markovic, et al. (2019)	X				X		X
Caceres, Veldhuis, et al. (2019)	X						X			X						X
Jacklyn D Foley et al. (2022)													X					X
Malhotra et al. (2022)									X	X	X					X
Mereish and Goldstein (2020)														X
Morgan et al. (2019)							X									X	X
Mijas et al. (2021)							X
Puhr et al. (2019)												X
Rosendale et al. (2024)	X						X	X
Rosenson et al. (2020)												X
Emily J Ross et al. (2024)			X																X
Sherman et al. 2022	X								X
Ashley J Simenson et al. (2020)	X					X	X									X
Solazzo et al. (2020)		X																		X
Solberg et al. (2023)															X
Total, n (%)	7 (35%)	4 (20%)	2 (10%)	2 (10%)	2 (10%)	1 (5%)	11 (55%)	2 (10%)	2 (10%)	5 (25%)	1 (5%)	2 (10%)	1 (5%)	1 (5%)	2 (10%)	5 (25%)	1 (5%)	1 (5%)	1 (5%)	1 (5%)

Abbreviations: BP, Blood Pressure; COPD, Chronic Obstructive Pulmonary Disease; CRP, C‐reactive protein.

4.3.1. Behavioural Factors

Behavioural factors were organized into distinct subthemes (nicotine use, health behaviours such as diet and physical activity, and substance use) to reflect differences in how these behaviours were measured, analysed and conceptualized as cardiovascular risk factors across the included studies.

4.3.1.1. Nicotine Use

Findings from seven included studies (Caceres, Jackman, et al. 2020; Caceres, Markovic, et al. 2019; Caceres et al. 2023; Caceres, Veldhuis, et al. 2019; Rosendale et al. 2024; Sherman et al. 2022; Ashley J Simenson et al. 2020) consistently indicate that nicotine use and tobacco use among LGBTQ+ populations are significantly associated with increased CVD risk. In a U.S.‐based study, Caceres, Jackman, et al. (2020) found that gay individuals had higher rates of current tobacco use compared to heterosexual individuals (Caceres, Jackman, et al. 2020). Among sexual minority women (SMW), lesbian participants reported greater tobacco use, as did bisexual women, when compared to heterosexual women. Racial disparities compounded these trends. One study (Caceres, Veldhuis, et al. 2019) found higher tobacco use rates among Black SMW, while another (Rosendale et al. 2024) reported that both Black and White SMW had less favourable nicotine use scores compared to their heterosexual peers. In broader terms, sexual minorities showed increased tobacco product use overall, contributing to elevated CVD risk (Sherman et al. 2022). Furthermore, longitudinal evidence suggests that disparities in smoking rates between lesbian and heterosexual women persist over time (Ashley J Simenson et al. 2020).

4.3.1.2. Health Behaviours

Health behaviours, including diet and physical activity, show notable variations in CVD risk across sexual and gender minority groups (Caceres, Streed, et al. 2020; Caceres, Jackman, et al. 2020; Caceres et al. 2023; Solazzo et al. 2020). Caceres et al. (2023) examined differences in cardiovascular health (CVH) scores by sexual identity and found that gay men had more favourable diet scores compared to heterosexual men (Caceres et al. 2023). However, exercise patterns varied significantly by both sexual orientation and gender identity. Caceres, Jackman, et al. (2020) reported that transgender women and gender nonconforming individuals were less likely to have exercised in the past 30 days compared to cisgender men (Caceres, Streed, et al. 2020). In contrast, sexual minority women, including lesbian and bisexual individuals, reported higher rates of exercise than heterosexual women (Caceres, Jackman, et al. 2020). Solazzo et al. (2020) further found that disparities in health behaviours, particularly in physical activity, contributed to poorer cardiovascular outcomes among LGBTQ+ populations (Solazzo et al. 2020). These findings underscore the complex interaction between sexual and gender identity, lifestyle behaviours and cardiovascular health, reinforcing the need for tailored health promotion strategies in these populations.

4.3.1.3. Substance Use

Two included studies (Caceres, Jackman, et al. 2020; Emily J Ross et al. 2024) reported a significant association between substance use and CVD risk among LGBTQ+ populations. Caceres, Jackman, et al. (2020) found that sexual minority women reported higher rates of heavy drinking compared to heterosexual women (Caceres, Jackman, et al. 2020). Specifically, lesbian women had greater odds of heavy alcohol use, as did bisexual women. Ross et al. (2024) explored associations among loneliness, stimulant use and cardiovascular risk in sexual minority men with and without HIV during the COVID‐19 era (Emily J Ross et al. 2024). Among those who used methamphetamine, greater loneliness was significantly associated with lower LDL and total cholesterol levels. Although counterintuitive, these findings suggest complex interactions between psychosocial stressors, substance use and cardiometabolic profiles in this population.

4.3.2. Blood Biomarkers

4.3.2.1. Lipid or Total Cholesterol

Two studies (Caceres et al. 2022; Caceres et al. 2023) reported that cholesterol levels among LGBTQ+ populations differ significantly from those of their heterosexual counterparts, contributing to CVD risk. Caceres et al. (2023) analysed sexual identity differences in CVD risk scores among U.S. adults and found that bisexual men with non‐high‐density lipoprotein (non‐HDL) cholesterol ≥ 130 mg/dL had significantly higher CVD risk compared to heterosexual men (Caceres et al. 2023). Similarly, Caceres et al. (2022) examined racial and ethnic differences in physiological CVD risk factors across sexual orientations. Bisexual women had significantly higher total cholesterol levels than heterosexual women (p < 0.001), while bisexual men had lower levels than heterosexual men (p = 0.04). Lesbian women also had significantly lower total cholesterol levels compared to heterosexual women. Racial disparities were also evident: White lesbian women and Black bisexual women had lower total cholesterol than White heterosexual women (Caceres et al. 2022).

4.3.2.2. HbA1C Or Fasting Glucose

Fasting glucose and glycated haemoglobin (HbA1c) levels were identified as cardiovascular risk factors in two included studies focusing on LGBTQ+ populations (Caceres et al. 2022; Caceres, Markovic, et al. 2019). Caceres et al. (2022) examined racial and ethnic differences in physiological CVD risk factors among sexual minority and heterosexual adults. The study found that individuals identifying as “not sure” had significantly higher HbA1c levels than their heterosexual counterparts—both women (p = 0.02) and men (p < 0.01) (Caceres et al. 2022). In contrast, gay men had significantly lower HbA1c levels (p < 0.001). Racial and ethnic disparities were also evident. Higher HbA1c levels were observed among Black bisexual women (p < 0.001), Latina “not sure” women (p < 0.01), Black sexual minority men (p < 0.05 to p < 0.01) and Latino “not sure” men (p < 0.01) when compared to White heterosexual individuals. Additionally, Caceres, Markovic, et al. (2019) reported that sexual minority women were less likely than heterosexual women to meet ideal fasting glucose criteria (p = 0.04), further underscoring the role of metabolic risk factors influenced by social and structural stressors (Caceres, Markovic, et al. 2019).

4.3.3. C‐Reactive Protein (CRP)

CRP, a known blood biomarker of systemic inflammation, has been associated with increased CVD risk in sexual minority populations. One included study by Simenson et al. (2020) conducted a longitudinal analysis using data from 483 women participating in the Epidemiologic Study of Health Risk in Women (ESTHER). Participants completed a baseline survey between 2003 and 2006 and a follow‐up survey in 2015 or 2016. The study found that, at baseline, lesbian participants were more likely than heterosexual women to have CRP levels above 3 mg/L (p < 0.05), indicating a potentially elevated risk for CVD (Ashley J Simenson et al. 2020).

4.3.4. Physical Factors

4.3.4.1. BMI, Overweight or Obesity

Eleven studies (Caceres et al. 2022; Caceres, Streed, et al. 2020; Caceres, Jackman, et al. 2020; Caceres, Markovic, et al. 2019; Caceres et al. 2023; Caceres, Veldhuis, et al. 2019; Caceres, Veldhuis, et al. 2019; Mijas et al. 2021; Morgan et al. 2019; Rosendale et al. 2024; Ashley J Simenson et al. 2020) reported that elevated BMI and obesity among LGBTQ+ populations are significantly associated with increased CVD risk. Caceres et al. (2022) examined racial and ethnic differences in physiological risk factors for CVD and found that lesbian and bisexual women had significantly higher BMI compared to heterosexual women (Caceres et al. 2022). This pattern was consistent across racial groups, with both White and Black lesbian women, as well as bisexual women from various minority backgrounds, exhibiting higher BMI than White heterosexual women. Similarly, Simenson et al. (2020) conducted a longitudinal analysis to explore disparities between lesbian and heterosexual women. Their findings revealed that lesbian participants experienced higher rates of obesity over time compared to their heterosexual counterparts, further highlighting the role of body weight in contributing to CVD risk among sexual minority populations (Ashley J Simenson et al. 2020).

4.3.4.2. Blood Pressure (BP)

Two studies (Caceres et al. 2022; Rosendale et al. 2024) reported that blood pressure is a significant factor influencing CVD risk among LGBTQ+ populations. In a cross‐sectional study, Caceres et al. (2022) found that bisexual women had higher systolic blood pressure (SBP) compared to heterosexual women, with Black bisexual women exhibiting the highest SBP among female subgroups (Caceres et al. 2022). In contrast, Latina women demonstrated lower diastolic blood pressure (DBP) than their heterosexual counterparts. Among men, both Black and Latino participants had higher SBP compared to White heterosexual men. Additionally, Black bisexual men showed elevated DBP relative to White heterosexual men, highlighting racial and sexual identity‐based disparities in blood pressure and associated CVD risk.

4.3.4.3. Older Age/Age

Two studies (Malhotra et al. 2022; Sherman et al. 2022) identified age as an important factor associated with cardiovascular disease (CVD) risk among sexual and gender minority populations. Malhotra et al. (2022) reported that older age was significantly associated with higher CVD risk among transgender and gender‐diverse individuals based on regression analyses (Malhotra et al. 2022). In a retrospective longitudinal study, Sherman et al. (2022) examined age‐related patterns of CVD diagnoses among LGBTQ+ populations and found that sexual minority women were diagnosed with high blood pressure, high cholesterol, stroke and heart attacks at younger ages compared with heterosexual women. Similarly, sexual minority men were more likely to receive a stroke diagnosis at a younger age than heterosexual men (Sherman et al. 2022). These findings suggest differences in the timing of CVD onset across sexual orientation and gender identity groups; however, the included studies did not formally test interaction effects between age and sexual orientation or gender identity.

4.3.5. Comorbidity

4.3.5.1. Metabolic Syndrome

Five studies (Caceres, Streed, et al. 2020; Caceres, Jackman, et al. 2020; Caceres, Veldhuis, et al. 2019; Caceres, Veldhuis, et al. 2019; Malhotra et al. 2022) identified metabolic syndrome as a significant contributor to CVD risk in LGBTQ+ populations, involving conditions such as diabetes, hypertension, chronic kidney disease and obesity. Caceres, Veldhuis, et al. (2019) reported that sexual minority women with adulthood or lifetime trauma had increased odds of hypertension and obesity (Caceres, Veldhuis, et al. 2019). Specifically, adulthood trauma was associated with higher odds of hypertension and obesity, while lifetime trauma was linked to both hypertension and obesity. Additionally, childhood trauma was significantly associated with increased odds of diabetes. In a related study, Caceres, Veldhuis, et al. (2019) found that Black sexual minority women reported higher rates of hypertension, obesity and diabetes compared to their White counterparts. Among lesbian women specifically, Black participants were more likely than White lesbian women to report a history of hypertension, diabetes and obesity (Caceres, Veldhuis, et al. 2019). These findings highlight the compounding effects of trauma, race and sexual identity on comorbid conditions contributing to elevated CVD risk in LGBTQ+ individuals.

4.3.5.2. Chronic Obstructive Pulmonary Disease (COPD)

A prospective cohort study (Malhotra et al. 2022) examined predictors of CVD among transgender men, transgender women and gender non‐conforming individuals in the United States. The findings indicated that COPD was an independent predictor of CVD in this population.

4.3.5.3. HIV Infection

Two studies (Puhr et al. 2019; Rosenson et al. 2020) identified HIV infection as a significant CVD risk factor. In a study by Puhr et al. (2019), HIV infection was associated with increased self‐reported diagnoses of heart disease, hypertension, stroke, diabetes and thrombosis (Puhr et al. 2019). Similarly, Rosenson et al. (2020) reported that HIV infection was linked to a higher hazard ratio for CVD outcomes, including myocardial infarction, stroke and lower extremity artery disease (Rosenson et al. 2020).

4.3.6. Psychological Factors

4.3.6.1. Positive Psychological Factors

Resilience. Resilience was found to be a protective factor influencing CVD risk among sexual minority populations (Jacklyn D Foley et al. 2022). Foley et al. (2022) examined the relationship between discrimination, resilience and CVD risk factors among sexual minority women. Higher resilience was associated with lower perceived stress, reduced hazardous alcohol use and less sedentary behaviour, each considered a proxy for reduced cardiovascular risk in this study.

Mastery. Mastery also emerged as a significant protective factor (Mereish and Goldstein 2020). Mereish and Goldstein (2020) assessed 670 sexual minority adults in the United States to explore how distal and proximal minority stressors impact CVD risk, with mastery evaluated as a mediating factor. Greater mastery was linked to lower CVD risk index scores, decreased likelihood of excess body fat and increased engagement in regular physical activity.

4.3.6.2. Negative Psychological Factors

Trauma. Trauma was identified as a notable contributor to CVD risk (Caceres, Veldhuis, et al. 2019; Solberg et al. 2023). For example, Caceres, Veldhuis, et al. (2019) found that childhood trauma was associated with higher odds of reporting diabetes, while adulthood and lifetime trauma were linked to increased odds of obesity and hypertension. These comorbid conditions serve as proxies for elevated cardiovascular risk among sexual minority women (Caceres, Veldhuis, et al. 2019).

Mental Distress. Mental distress, including symptoms of depression, was associated with increased CVD risk in five studies (Caceres, Jackman, et al. 2020; Caceres, Veldhuis, et al. 2019; Malhotra et al. 2022; Morgan et al. 2019; Ashley J Simenson et al. 2020). For example, Caceres, Veldhuis, et al. (2019) reported that Black and Latina sexual minority women had higher rates of lifetime depression compared to their White counterparts (Caceres, Veldhuis, et al. 2019). Morgan et al. (2019) found that depression was associated with elevated levels of inflammatory markers (CRP and IL‐6), both of which contribute to cardiometabolic risk in young sexual and gender minorities (Morgan et al. 2019).

Perceived Stress. Perceived stress was highlighted as a significant factor in one longitudinal cohort study (Morgan et al. 2019). Morgan et al. (2019) found that higher perceived stress was significantly associated with increased levels of IL‐6, an inflammatory biomarker contributing to elevated CVD risk among young sexual and gender minority individuals (Morgan et al. 2019).

4.4. Social Factors

4.4.1. Discrimination Experiences

Our study found that experiences of discrimination among sexual minority populations significantly impact their cardiovascular risk (Jacklyn D Foley et al. 2022). A study by Foley et al. (2022) examined the relationship between discrimination, resilience and cardiovascular disease risk factors among sexual minority women. The results showed that experiences of discrimination were significantly associated with a higher likelihood of tobacco use in the past month and hazardous drinking levels, both of which serve as proxies for CVD risk in this study (Jacklyn D Foley et al. 2022).

4.4.2. Loneliness

Loneliness has been identified as a social factor contributing to CVD risk among sexual minority populations. Ross et al. (2024) studied 103 sexual minority men in the United States, with and without HIV, during the COVID‐19 era. Loneliness was negatively associated with total and LDL cholesterol in the cardiometabolic subsample. Those who used methamphetamine or screened positive for a stimulant use disorder had significantly higher loneliness scores. Notably, negative associations between loneliness and lipid levels were observed only among methamphetamine users (Emily J Ross et al. 2024).

4.4.3. Marital Status

One of the studies included in our review highlights marital status as a significant determinant of CVD risk across sexual orientation and gender groups (Solazzo et al. 2020). Using regression models that examined health outcomes among heterosexual, lesbian, gay and bisexual men and women, Solazzo et al. (2020) found that married individuals generally exhibited the lowest probability of developing CVD compared with those who were formerly or never married. In contrast, heterosexual women who were formerly married showed higher CVD risks, and the strength of associations between marital status and CVD risk varied by sexual orientation and gender (Solazzo et al. 2020).

5. Discussion

This systematic review synthesized evidence from 20 studies examining determinants of CVD risk among sexual minority populations. Overall, the included studies demonstrated moderate to high methodological quality and were predominantly conducted in high‐income countries. The findings indicate that CVD risk is shaped by multiple factors across six domains: behavioural, blood biomarker, physical, comorbid, psychological and social factors. Common risks included tobacco use, adverse metabolic profiles, obesity, hypertension and comorbid conditions such as HIV and metabolic syndrome. Importantly, psychosocial and structural determinants, particularly minority stress, discrimination and loneliness, were consistently associated with increased CVD risk, underscoring the need for integrated and equity‐oriented approaches to prevention and care.

5.1. Behavioural Factors

Among sexually diverse populations, behavioural factors such as nicotine use, health habits and substance use are key contributors to cardiovascular disease (CVD) risk. These behaviours are linked to established CVD mechanisms, including endothelial dysfunction, inflammation and metabolic dysregulation (Schmidt‐Trucksäss et al. 2024). Nicotine promotes vascular impairment by increasing vasoconstrictors like endothelin‐1 and suppressing vasodilators such as nitric oxide (Whitehead et al. 2021) and accelerates atherosclerosis through oxidative stress and inflammasome activation (Mao et al. 2021). Elevated tobacco use among gay men and sexual minority women (SMW), especially Black SMW, may result from social stressors like discrimination and minority stress (Caceres, Jackman, et al. 2020), emphasizing the need for tailored cessation programs. Diet and physical activity also vary within these groups. Gay men generally report better dietary habits than heterosexual men (B. A. Caceres et al. 2023), potentially influenced by sociocultural norms around masculinity and health (Velzeboer et al. 2024).

Prestemon et al. (2022) similarly found higher dietary quality among gay and bisexual men compared to their heterosexual counterparts (Prestemon et al. 2022). However, exercise engagement is less consistent. Transgender women and gender nonconforming individuals report lower activity levels, potentially due to barriers such as discrimination or a lack of safe environments (Caceres, Streed, et al. 2020; Lightner et al. 2024). SMW, including lesbians and bisexual women, demonstrate higher activity rates (Caceres, Jackman, et al. 2020), potentially offering protection against CVD. Substance use—including heavy alcohol and stimulant use—is another significant CVD risk factor in this population (Caceres, Jackman, et al. 2020; E. J. Ross et al. 2024). Alcohol contributes to elevated blood pressure, obesity and arrhythmia risk (Hoek et al. 2022). Stimulants heighten cardiovascular strain through increased heart rate, blood pressure and arrhythmic potential (Dominic et al. 2022). Higher alcohol use among SMW may stem from minority stress and cultural norms within LGBTQ+ spaces (Zollweg et al. 2023). These findings support the need for integrated, culturally informed interventions addressing both substance use and mental health.

5.2. Blood Biomarkers

Lipid profiles, glucose regulation and inflammation markers offer critical insights into CVD risk among LGBTQ+ populations. Cholesterol levels, particularly non‐HDL cholesterol, were associated with higher CVD risk in bisexual men and women (Caceres et al. 2022; Caceres et al. 2023), due to their role in vascular inflammation and atherosclerosis (Lampsas et al. 2023). Some racial differences were noted—White lesbian and Black bisexual women had lower total cholesterol (Caceres et al. 2022). Fasting glucose and HbA1c levels were also elevated in sexual minority individuals, especially those identifying as “not sure,” and among Black and Latino groups (Caceres et al. 2022; Caceres, Markovic, et al. 2019). HbA1c is linked to CVD through mechanisms like oxidative stress and inflammation (Prasad 2018). SMW were less likely to meet ideal fasting glucose thresholds, pointing to metabolic challenges shaped by social and structural stressors (Caceres, Markovic, et al. 2019; Kosmas et al. 2023). CRP, an inflammatory marker, was higher in lesbian women than in heterosexual women (Ashley J. Simenson et al. 2020), contributing to endothelial dysfunction and atherosclerosis (Chia and Ang 2025). These findings highlight the need for targeted interventions addressing inflammation and metabolic health in LGBTQ+ populations.

5.3. Physical Factors

Physical factors, such as elevated BMI, obesity, blood pressure and age, significantly contribute to CVD risk among sexual minority populations. Higher BMI and obesity are consistently associated with increased CVD risk, while elevated blood pressure remains a critical risk factor. Additionally, aging is linked to reduced cardiac function, yet younger LGBTQ+ populations are more likely to receive early diagnoses of hypertension, hypercholesterolemia, stroke and myocardial infarction. A previous study by Tian et al. (2023) found that obesity and high blood pressure are key metabolic drivers of CVD across age groups (Tian et al. 2023). Among boys, overweight status correlated with elevated blood pressure and abnormal lipid profiles; among girls, higher triglycerides and lower HDL‐C levels were observed. These risks were evident across all age groups, with adolescent boys facing greater odds of high systolic BP and total cholesterol, and girls showing similar risks for triglycerides and HDL‐C (Lee et al. 2023). These patterns emphasize the importance of addressing the unique health needs of LGBTQ+ populations, who often experience barriers to care and psychosocial stress that compound cardiovascular risk. Future longitudinal studies are needed to explore how physical, behavioural and social factors interact over time. Culturally sensitive interventions that reduce discrimination, promote mental well‐being and ensure access to inclusive healthcare are essential to mitigating CVD risk in these populations.

5.4. Comorbidity

Comorbid conditions such as metabolic syndrome, COPD, HIV infection and chronic kidney disease significantly increase CVD risk among LGBTQ+ individuals. These risks are compounded by trauma, race and minority stress, resulting in complex health disparities that require holistic, culturally sensitive care. A previous study highlighted a higher prevalence of hypertension and diabetes in LGBTQ+ populations and ethnic minorities, including Hispanic, Black and Southeast Asian groups (Muncan 2018). LGBTQ+ individuals face a greater risk of metabolic syndrome due to chronic stress from discrimination and stigma, which elevates cortisol, promotes insulin resistance and leads to obesity and diabetes (Corliss et al. 2018; Flentje et al. 2020). Elevated cortisol also mimics aldosterone, disrupting fluid balance and increasing hypertension risk (Taweh and Moreira 2023). Chronic kidney disease contributes to CVD through hormonal and hemodynamic changes that damage cardiac tissue (Jankowski et al. 2021). COPD risk is also higher in LGBTQ+ individuals, particularly due to elevated smoking rates and limited healthcare access stemming from discrimination (Maniar and Drummond 2024; Pinnamaneni et al. 2022). HIV‐positive LGBTQ+ individuals often experience higher stress, increased smoking and lipid alterations from antiretroviral therapy—factors that further elevate CVD risk (Policarpo et al. 2019). Overall, LGBTQ+ individuals face heightened cardiovascular vulnerability due to intersecting comorbidities and social determinants. Addressing these disparities requires integrated care approaches that prioritize stigma reduction, trauma‐informed practices and equitable access to health services.

5.5. Psychological Factor

Psychological factors play a significant role in CVD risk among sexual minority populations. Positive traits like resilience and mastery are protective. Foley et al. (2022) found that greater resilience was linked to lower hazardous alcohol use and less sedentary behaviour in sexual minority women (J. D. Foley et al. 2022). Similarly, resilience has been associated with CVD‐protective behaviours in diverse older women (Springfield et al. 2020). Mastery—a sense of control over life—also correlates with reduced CVD risk and improved cardiometabolic health, though research in LGBTQ+ groups remains limited (Mereish and Goldstein 2020; Roepke and Grant 2011). Enhancing resilience and mastery may be effective in reducing CVD risk in this population. Conversely, negative psychological experiences such as trauma and distress contribute to increased CVD risk. Childhood trauma, especially sexual abuse, is linked to obesity in sexual minority women (Wood et al. 2017) often due to maladaptive coping behaviours that lead to elevated BMI (Katz‐Wise et al. 2014). Routine screening for trauma history and trauma‐informed interventions are essential in clinical care. Mental distress is also prevalent. Sexual minority adults report higher levels of depression and anxiety, which are associated with a 50% increased risk of CVD (Caceres, Brody, et al. 2017; Wu et al. 2018). Psychological distress significantly affects cardiovascular health across both heterosexual and LGBTQ+ populations (Satti et al. 2025), necessitating mental health strategies tailored to LGBTQ+ populations. Perceived stress, strongly linked to the inflammatory marker IL‐6, is another important factor. Stress scores are higher among sexual and gender minority adults than in the general population (Gordián‐Arroyo et al. 2022; McElroy et al. 2016; Morgan et al. 2019), and elevated stress responses contribute to inflammation and metabolic dysregulation (Jurgens et al. 2023). Future research should explore interventions targeting inflammatory processes to reduce CVD risk.

5.6. Social Factors

Social determinants such as discrimination, loneliness, marital status and structural health disparities were consistently identified as key contributors to elevated CVD risk. Experiences of discrimination were shown to increase unhealthy coping behaviours such as smoking and hazardous alcohol use, both well‐established proxies for cardiovascular risk (Jacklyn D Foley et al. 2022). These findings are consistent with the minority stress theory, which posits that chronic exposure to stigma and prejudice can lead to physiological dysregulation and poor health outcomes (Meyer 2003). Moreover, loneliness—particularly among sexual minority men—was associated with altered lipid profiles and higher psychological distress, further linking social isolation to cardiometabolic vulnerability (Emily J Ross et al. 2024).

The impact of marital status emerged as another significant social factor. While marriage has traditionally been associated with improved cardiovascular outcomes, our review found that this benefit is not equally distributed across sexual orientation groups. Specifically, formerly married bisexual women exhibited higher CVD risk, a finding that may reflect intersectional disadvantages related to gender, sexual identity and marital disruption (Solazzo et al. 2020). These patterns highlight the inadequacy of one‐size‐fits‐all approaches to cardiovascular risk assessment and support the need for more nuanced, identity‐informed healthcare strategies.

6. Study Limitation

This systematic review has several limitations that should be acknowledged. First, the majority of included studies were conducted in the United States, which may limit the generalizability of findings to other cultural and healthcare contexts. Second, most studies employed cross‐sectional designs, which restrict the ability to infer causal relationships between identified risk factors and cardiovascular disease.

Third, variation in how sexual orientation and gender identity were defined, measured and reported across studies may have introduced inconsistencies and limited comparability. In addition, although the search strategy included terms related to gender‐diverse populations, the available literature more frequently reported sexual orientation than gender identity, which may have limited the systematic capture of gender‐diverse populations. Fourth, several studies grouped diverse sexual and gender minority identities into broad categories, potentially obscuring subgroup‐specific risks and experiences.

Fifth, publication bias is possible, as studies published in languages other than English were not included. Finally, the review may have missed relevant grey literature or unpublished data, which could contribute to a more comprehensive understanding of the topic. In addition, this systematic review was not prospectively registered; however, the study was conducted and reported in strict accordance with the PRISMA guidelines to ensure methodological rigour and transparency.

A meta‐analysis was not conducted due to substantial heterogeneity across studies in terms of study design, populations (e.g., racial and ethnic), definitions of cardiovascular risk factors and outcome measurements, which limited the feasibility of quantitative synthesis. Future research should prioritize the systematic inclusion and explicit reporting of gender identity, alongside sexual orientation, adopt longitudinal designs, use standardized definitions of sexual and gender identities, and include more diverse geographic, racial/ethnic compositions and cultural settings to improve the applicability of findings.

7. Conclusion

This systematic review demonstrates that LGBTQ+ populations are generally at greater risk of cardiovascular disease compared with non‐LGBTQ+ individuals. Elevated risk was consistently associated with both traditional cardiovascular risk factors, such as hypertension, dyslipidaemia, obesity and comorbid conditions, and non‐traditional determinants, including psychosocial stressors, mental health conditions and social and structural inequities. These findings underscore the need for inclusive, identity‐informed prevention and management strategies, as well as future research that addresses structural determinants to reduce cardiovascular health disparities in LGBTQ+ populations.

8. Implications for Nursing Practice and Policy

The findings of this systematic review highlight the essential role of nurses in mitigating cardiovascular disease risk among sexual minority populations through both clinical practice and health policy engagement. At the practice level, nurses are uniquely positioned to provide inclusive, culturally competent care that recognizes the intersectional influences of sexual orientation, gender identity, psychosocial stressors and structural inequities on cardiovascular health. Routine nursing assessments should incorporate identity‐informed screening for behavioural risk factors (e.g., tobacco use, diet, alcohol and substance use), biological markers (e.g., BMI, blood pressure, HbA1c, lipid profiles) and psychosocial determinants (e.g., trauma history, perceived stress, resilience). Nurses should also employ strength‐based approaches that foster resilience and mastery, which were identified as protective psychological factors and integrate trauma‐informed care into both preventive and therapeutic services.

From a policy perspective, the evidence underscores the urgent need to reduce structural barriers and health disparities that disproportionately affect sexual minority populations. Nursing leaders and professional organizations should advocate for policies that expand access to equitable cardiovascular prevention and management services, particularly for populations affected by stigma, discrimination and healthcare exclusion. Policies that mandate the collection of sexual orientation and gender identity (SOGI) data in health records are critical to inform surveillance, guide resource allocation and monitor progress toward health equity. Additionally, integrating LGBTQ+ health content into nursing curricula and continuing education programs is imperative to ensure that future and current nurses possess the competencies required to deliver affirming care.

Overall, advancing cardiovascular health equity in sexual minority populations requires a dual approach: practice‐level strategies that provide personalized, identity‐informed care and policy‐level initiatives that dismantle structural inequities and promote inclusive healthcare systems. By addressing both dimensions, nursing practice and policy can collectively contribute to reducing CVD risk and improving long‐term health outcomes for LGBTQ+ communities.

Author Contributions

Sriprasong S., Sukumanukoon K., Ruksakulpiwat S: conceptualization and study design. Sriprasong S., Sukumanukoon K., Chantab N., Chaosangkate N., Ruksakulpiwat S: literature retrieval. Sriprasong S., Sukumanukoon K., Chantab N., Chaosangkate N., Ruksakulpiwat S: literature screening and data extraction. Sriprasong S., Sukumanukoon K., Chantab N., Chaosangkate N., Ruksakulpiwat S: data analysis. Sriprasong S., Ruksakulpiwat S: Study supervision. Sriprasong S., Sukumanukoon K., Chantab N., Chaosangkate N., Ruksakulpiwat S: manuscript writing (original draft). Sriprasong S., Sukumanukoon K., Ruksakulpiwat S: writing – review and editing. Sriprasong S., Sukumanukoon K., Ruksakulpiwat S: critical revisions for important intellectual content. All authors reviewed and approved the final version of the manuscript.

Funding

The authors have nothing to report.

Ethics Statement

The authors have nothing to report.

Conflicts of Interest

The authors declare no conflicts of interest.

Supporting information

Table S1: Search Strategies by Database.

Table S2: Summary Table.

Data Availability Statement

The data that support the findings of this study are available in the Supporting Information of this article.