Objective: Hormone therapy in transgender people might be associated with increased risk of cardiovascular disease (CVD). We aimed to investigate whether the risk of CVD is increased in transgender people compared with people of the same birth sex.

Design and methods: PubMed, Cochrane, Embase, and Google Scholar were searched until July 2022. Studies evaluating cardiovascular events in transgender women or men were included. Primary outcomes were stroke, myocardial infarction (MI), and venous thromboembolism (VTE). Risk for transgender women versus cisgender men, and for transgender men versus cisgender women were analysed through random-effects meta-analysis.

Results: Twenty-two studies involving 19,893 transgender women, 14,840 transgender men, 371,547 cisgender men, and 434,700 cisgender women were included. The meta-analysis included ten studies (79% of transgender women, 76% of transgender men). In transgender women, incidence of stroke was 1.8%, which is 1.3 (95%CI 1.0-1.8) times higher than in cisgender men. Incidence of MI was 1.2%, with a pooled effect of 1.0 (95%CI 0.8-1.2). VTE incidence was 1.6%, which is 2.2 (95%CI 1.1-4.5) times higher. Stroke occurred in 0.8% of transgender men, which is 1.3 (95%CI 1.0-1.6) times higher compared with cisgender women. Incidence of MI was 0.6%, with a pooled effect of 1.7 (95%CI 0.8-3.6). For VTE this was 0.7%, being 1.4 (95%CI 1.0-2.0) times higher.

Conclusions: Transgender people have a 40% higher risk of CVD compared with cisgender people of the same birth sex. The increased risk in both groups suggests potential influence of socioeconomic and lifestyle factors, emphasising the importance of cardiovascular risk management.