South Asian Ethnicity as a Risk Enhancer for Heart Disease

By Parag Joshi, M.D.

Associate Professor of Internal Medicine

People of South Asian ancestry are increasingly recognized as being at high risk of myocardial infarction. A session at #AHA21 focused on this, with several talks centered on South Asians and cardiometabolic disease. I had the privilege of presenting a lecture on how best to identify those who are at high risk of heart disease in this population, noting earlier preventive therapies and how their implementation might be improved.

One current challenge in clinical care is the lack of a South Asian-specific risk estimator. The current guideline-recommended approach to risk estimation for heart attacks and strokes is to use the pooled cohort equations, which were developed from and validated among white and Black men and women. When estimating risk in South Asian individuals, it is recommended to use the estimate for white individuals. However, a recent large study from the United Kingdom suggested that individuals with South Asian ancestry had twice the risk of heart attacks and strokes as individuals with European ancestry, despite similar estimated risk by the pooled cohort equations. Further, traditional risk factors did not fully explain the risk in South Asian individuals. It is likely that diabetes and visceral adiposity played a strong role, but more research is needed to better understand the reasons for these discrepancies.

For this reason, a coronary artery calcium (CAC) score may help to better understand a patient’s risk in the near term (i.e., the next 10 years). The Mediators of Atherosclerosis in South Asians Living in the United States (MASALA) study has provided valuable information suggesting there is significant heterogeneity in the burden of plaque estimated by calcium scores and the risk estimate by the pooled cohort equations. As part of a National Lipid Association work group tasked with providing a clinical perspective on preventing heart attacks in South Asians, we recommended CAC scoring to improve identification of high-risk individuals in this group as the first step to providing more aggressive preventive strategies.

Email: parag.joshi@utsouthwestern.edu

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