South Asians and Cardiovascular Risk

Obesity and Atherogenic Dyslipidemia

National-level differences in myocardial infarction (MI) quality of care among Asian patients in the United States are unclear. We assessed the quality of MI care in the 6 largest US Asian ethnic groups. Patients aged ≥18 years with ST-segment-elevation MI or non-ST-segment-elevation MI in the Get With The Guidelines-Coronary Artery Disease registry (711 US hospitals, 2015-2021) were assessed. The odds of MI-related quality of care and process outcomes were evaluated in Asian Indian, Chinese, Filipino, Japanese, Korean, Vietnamese, and other Asian adults compared with non-Hispanic White adults. Sex-stratified logistic regression models were adjusted for age and clinical characteristics. There were 5691 Asian patients (1520 Asian Indian, 422 Chinese, 430 Filipino, 114 Japanese, 283 Korean, 553 Vietnamese, and 2369 other Asian) and 141 271 non-Hispanic White patients, overall 30% female, and mean age of 66.5 years. Relative to non-Hispanic White adults, among patients with ST-segment-elevation MI, door-to-ECG time ≤10 minutes was less likely in Asian Indian (adjusted odds ratio [aOR], 0.64 [95% CI, 0.50-0.82]), Chinese (aOR, 0.65 [95% CI, 0.46-0.93]), and Korean (aOR, 0.57 [95% CI, 0.33-0.97]) men and in other Asian women (aOR, 0.61 [95% CI, 0.41-0.90]). Door-to-balloon time ≤90 minutes was less likely in Asian Indian men (aOR, 0.71 [95% CI, 0.56-0.90]) and Filipina women (aOR, 0.48 [95% CI, 0.24-0.98]). In patients with ST-segment-elevation MI or non-ST-segment-elevation MI, optimal medical therapy for MI was less likely in Korean men (aOR, 0.65 [95% CI, 0.47-0.90]) and more likely in Asian Indian men (aOR, 1.22 [95% CI, 1.06-1.40]) and women (aOR, 1.32 [95% CI, 1.04-1.67]) and Filipina women (aOR, 1.84 [95% CI, 1.27-2.67]). MI quality of care varies among US Asian patients with ST-segment-elevation MI and non-ST-segment-elevation MI. Quality improvement programs must identify and address the factors that result in suboptimal MI quality of care among US Asian patients.

“The pawn has been promoted to queen.”1 C-reactive protein (CRP), formerly considered solely as a biomarker for inflammation, is now viewed as a prominent partaker in endothelial dysfunction and atherosclerosis.2,3 Serving clinically for several years as a nonspecific marker for inflammatory processes, CRP, with the advent of high-sensitivity assays, has emerged as one of the most powerful independent predictors of cardiovascular disease.4,5 The Centers for Disease Control and Prevention and the American Heart Association issued a Class IIa recommendation for the screening of high-sensitivity (hs) CRP as a routine part of global cardiovascular risk assessment.6 However, several questions about CRP’s mechanism of action remain. In the present issue of Circulation , Khreiss et al7 provide evidence suggesting that native, pentameric CRP must undergo structural modification, forming monomeric subunits, before promoting a proinflammatory phenotype. This molecular finding may not only serve to influence basic molecular research examining CRP’s detrimental effect, but may also influence the clinical use of CRP as a prognostic marker. See p 2016 Compelling evidence exists to support CRP’s designation as a powerful independent predictor of future cardiovascular risk. CRP predicts cardiovascular risk in a wide variety of clinical settings, including men and women without overt cardiovascular disease,8,9 patients with stable angina or presenting with acute coronary syndromes,10,11 postmyocardial infarction patients, and those with the metabolic syndrome.12 Furthermore, CRP predicts not only incident myocardial infarction and cardiovascular death, but also the risk of ischemic stroke,13 sudden cardiac death,14 incident peripheral artery disease,15 and restenosis after percutaneous coronary intervention.16 In primary prevention, CRP confers additional prognostic value at all levels of Framingham risk and at all levels of the metabolic syndrome and blood pressure.17–19 In head-to-head comparisons with LDL cholesterol, CRP was found to be the …

Relation of central obesity and insulin resistance with high diabetes prevalence and cardiovascular risk in South Asians

At least 25% of coronary patients have sudden death or nonfatal myocardial infarction without prior symptoms.1 Therefore, the search for coronary patients with subclinical disease who could potentially benefit from intensive primary prevention efforts is critically important. The American Heart Association’s (AHA) Prevention V Conference, “Beyond Secondary Prevention: Identifying the High Risk Patient for Primary Prevention,” addressed ways to identify more patients who are asymptomatic and clinically free of coronary heart disease (CHD) but at sufficiently high risk for a future coronary event to justify more intensive risk reduction efforts.2 In this report, we amplify on key findings and recommendations of the AHA Prevention V conference, highlight new research since the conference, and propose an approach to the use of office-based testing and additional noninvasive procedures in selected patients to better define their coronary event risk. The recommendations are concordant with the recently released approach to risk assessment and management from the third report of the Adult Treatment Panel of the National Cholesterol Education Program (ATP-III).3 Enthusiasm for primary prevention and risk assessment in asymptomatic people has been spurred by recent advances in prevention research. Lipid-lowering trials demonstrated that primary prevention of coronary events is feasible, evidenced by the West of Scotland Coronary Primary Prevention Study (WOSCOPS) trial4 of hypercholesterolemic men and by the Air Force/Texas Coronary Atherosclerosis Prevention Study (AFCAPS/TexCAPS) trial5 in average or typical risk men and women with only moderate lipid abnormalities. Aspirin6 or ACE inhibitors7 can also reduce risk in selected asymptomatic, high-risk people. Emerging coronary risk factors have been described including inflammatory, infectious, and thrombotic markers,8 and there has been a steady flow of reports that focus attention on potential new ways of predicting coronary risk.9 In addition, noninvasive tests for subclinical atherosclerotic disease are available …

Urbanized South Asians' susceptibility to coronary heart disease: The high-heat food preparation hypothesis

C-reactive protein in young individuals: problems and implications for Asian Indians

Development and evaluation of cultural food frequency questionnaires for South Asians, Chinese, and Europeans in North America

This paper will focus on illustrating through qualitative personal narratives the lived realities of three South Asian Indian women in academia across the continuum of their experiences personally, professionally, and as academics within the field of Marriage and Family Therapy (MFT). The authors will speak to their South Asian identity, their acculturation experiences as Asian Indian women in the US professional and academic context, their different generational experiences in immigration journeys, their different academic and clinical journeys, and other contextual variables such as age, solidarity with other South Asian women in academia, peer mentorship experiences, and finding their own voices and empowerment through connections with other women with similar experiences. In addition to the lack of formal academic mentorship, the authors will describe how they as South Asian Indian women have grappled with the challenges of systemic gender and racial biases that undermined their development as academics and hindered their progress toward gender and racial equality in academic and clinical settings. The authors will situate their personal narratives within the frameworks of feminist solidarity and social justice through describing their mentorship experiences, as mentors and mentees, and how they still were able to establish their professional identities as professional, academic, South Asian women of color.

CRP-Marker or Maker of Cardiovascular Disease?Jan Nilsson C -reactive protein (CRP) has emerged as an interesting novel and potentially clinically useful marker for increased cardiovascular risk. 1,2This is an attractive concept because atherosclerosis is a disease characterized by chronic arterial inflammation 3,4 and suggests the possibility that subclinical states of atherosclerosis can be identified by an increase in circulating markers of inflammation before acute events occur.Based on data obtained primarily from in vitro studies it has also been proposed that CRP in itself is actively contributing to disease progression and that it should be considered as true risk factor and consequently as a target for intervention.However, in the present issue of Arteriosclerosis, Thrombosis, and Vascular Biology, two independent reports demonstrate that transgenic overexpression of CRP does not affect the development of atherosclerosis in mice, suggesting that this is not the case.

The Indian Asian population accounts for a fifth of all global deaths from coronary heart disease (CHD). CHD deaths on the Indian subcontinent have doubled since 1990, and are predicted to rise a further 50% by 2030. Reasons underlying the increased CHD mortality among Indian Asians remain unknown. Although conventional cardiovascular risk factors contribute to CHD in Indian Asians as in other populations, these do not account for their increased risk. Type-2 diabetes, insulin resistance and related metabolic disturbances are more prevalent amongst Indian Asians than Europeans, and have been proposed as major determinants of higher CHD risk among Indian Asians. However, this view is not supported by prospective data. Genome-wide association studies have not identified differences in allele frequencies or effect sizes in known loci to explain the increased CHD risk in Indian Asians. Limited knowledge of mechanisms underlying higher CHD risk amongst Indian Asians presents a major obstacle to reducing the burden of CHD in this population. Systems biology approaches such as genomics, epigenomics, metabolomics and transcriptomics, provide a non-biased approach for discovery of novel biomarkers and disease pathways underlying CHD. Incorporation of these ‘omic’ approaches in prospective Indian Asian cohorts such as the London Life Sciences Population Study (LOLIPOP) provide an exciting opportunity for the identification of new risk factors underlying CHD in this high risk population.

Effectiveness of a community screening program for metabolic syndrome and cardiovascular risk factor identification in young South Asians adults

Cardiovascular disease (CVD) is a leading global cause of mortality, but South Asians experience a disproportionately high burden of disease, often developing CVD at younger ages and with lower body mass indices compared to other populations. This project explores the underlying genetic and lifestyle factors contributing to elevated cardiovascular risk in South Asians, aiming to highlight the need for targeted prevention strategies and policy reforms. A literature review was conducted using peer-reviewed studies, meta-analyses, and reviews published between 2007 and 2024. After screening 47 initial articles, 18 were selected for analysis based on their relevance to genetic and lifestyle risk factors in South Asian adults. The review identified several genetic markers associated with increased CVD risk, including variations in APOC3, LPA, APOA5, and others, which contribute to elevated triglyceride levels, central obesity, and insulin resistance. Lifestyle contributors such as high dietary saturated fat intake, low fruit consumption, and sedentary behavior were also strongly associated with increased CVD prevalence. The interplay between these genetic and environmental factors underscores the need for multifaceted interventions. Current cardiovascular guidelines often lack specificity for South Asians, which may lead to underdiagnosis and undertreatment. Evidence supports the implementation of culturally tailored public health initiatives, aggressive lipid and metabolic monitoring, and community-based programs to reduce risk in this population. This study emphasizes the importance of inclusive research and targeted healthcare strategies to address the unique cardiovascular risk profile of South Asians and improve health outcomes across diverse populations.

The Antihypertensive and Lipid-Lowering treatment to prevent Heart Attack Trial (ALLHAT) compared in >30 000 high-risk hypertensive patients the effects on coronary heart disease of 3 treatment strategies: (1) based on the diuretic chlorthalidone, (2) the calcium-channel blocker (CCB) amlodipine, and (3) the angiotensin converting-enzyme (ACE) inhibitor lisinopril, respectively.1 Sponsored by the National Heart, Lung, and Blood Institute, ALLHAT stands out because no differences occurred in the incidence of the primary end point that consisted of the combination of fatal coronary heart disease and acute myocardial infarction.1 Not surprisingly, the attention of the ALLHAT consortium shifted to secondary end points, such as stroke, or to loosely defined2 components of secondary end points, such as heart failure. At the end of the line, the ALLHAT investigators based their main conclusions on events that, at the initiation of the trial, they regarded as “soft data that will at best confirm or supplement the primary endpoint.”3 More importantly, what was not identical in the 3 treatment groups was the on-treatment blood pressure despite vigorous attempts to titrate and combine the study medications to achieve a blood pressure of <140 mm Hg systolic and 90 mm Hg diastolic.1 These salient features of ALLHAT should be kept in mind whenever one attempts to interpret the findings of this landmark trial. In this issue of Hypertension , Leenen et al4 published a post hoc analysis, in which they made a direct comparison of cardiovascular and other outcomes among the 18 102 ALLHAT participants randomly assigned to amlodipine or lisinopril. In line with previous reports,1 the incidence of the primary coronary end point and total and cardiovascular mortality were similar in both groups. However, the patients randomly assigned to lisinopril experienced higher risks of stroke, combined cardiovascular disease, gastrointestinal bleeding, …

Diabetes epidemic in the South Asian Diaspora: action before desperation