To Improve CV Care in US South Asians, Understand Unique ASCVD Risks: ACC

Aiming to shed light on the heterogeneity of cardiovascular risk among South Asians in North America and, a new American College of Cardiology (ACC) expert panel document explores how the healthcare community can better manage atherosclerotic cardiovascular disease (ASCVD) in this population.

Prior research has shown that South Asians—those with ancestry from Bangladesh, Bhutan, India, Maldives, Nepal, Pakistan, and Sri Lanka—tend to have an elevated risk of ASCVD, but also that targeted community programs have had success in, for example, lowering blood pressure for South Asians in the United States.

This kind of a paper singling out the South Asian community is important, especially because of how diverse it is, senior author Jaideep Patel, MD (Johns Hopkins Ciccarone Center for the Prevention of Cardiovascular Disease, Baltimore, MD), told TCTMD. “Having more representation [in the literature] is certainly helpful so that you can further characterize this national and cultural heterogeneity,” he said.

In addition to mitigating the higher risk of ASCVD in South Asians, another goal of this paper, Patel said, “is to provide education for patients also and the healthcare team at large to help navigate cultural, religious, social, geographic, and economic barriers that this population encounters as it comes to seek high quality care.”

Traditional, Nontraditional Risk Factors

For the expert panel document, published last month in JACC: Advances, Anandita Agarwala, MD (Baylor Scott and White Health Heart Hospital Baylor Plano, TX), Patel, and colleagues outline the available evidence about ASCVD risk in South Asian populations in the United States, pointing to the higher prevalence of prediabetes, diabetes, obesity, and hypertension, and lower levels of physical activity among South Asians compared with other racial/ethnic groups.

Additionally, they note, population-specific risk calculators like the ACC/American Heart Association (AHA) pooled cohort equation (PCE) “inadequately estimate risk in this population, particularly for those at borderline or intermediate risk.”

For physicians caring for South Asian patients, what has been missing were “actionable, guideline-driven recommendations to help identify risk in this population,” Patel said.

Some nuances to be aware of, he highlighted, are that while it is important to identify traditional risk factors, like smoking, these may be also be slightly different—tobacco, for example, in this population is less likely to be smoked but rather chewed or vaped. Moreover, less-common risk factors may play a larger role in ASCVD in South Asians, including physical inactivity and maternal risk factors like gestational hypertension and diabetes, alongside some “lipid nuances” like atherogenic dyslipidemia, low HDL levels, and elevated Lp(a), according to Patel.

And because the PCE may not accurately capture risk in this population, clinicians may consider coronary artery calcium testing more often in South Asians to help further refine risk, he said. “That may be something novel that perhaps noncardiology physicians may not be aware of.”

While the content in the statement is important for cardiologists, Patel said he also hopes family physicians and OB-GYN clinicians also take note. “The goal of this is to continue to raise awareness that there is a higher risk of cardiovascular disease in this population, but a lot of their risk is driven mainly by traditional risk factors, which are easily identified at time of the physician visit,” he said. “Certainly [all] the team members . . . have a role when it comes to directing at least patients into the right direction to help manage some of these risks.”

In addition, Patel hopes this statement will propel future research studies looking specifically at South Asian populations and ASCVD risk, particularly looking at topics such as the effects of immigration duration, ASCVD risk in second- and third-generation South Asians in the United States, as well as ethnically mixed families. He also would like to see studies examine how the role coronary vascular characteristics might play into future ASCVD risk in South Asians, as some have thought that smaller vessel dimensions can accelerate atherosclerosis..

“South Asians make up a quarter of the world's population, and South Asians are one of the fastest growing minorities in this country,” he concluded. “This is certainly a group that is going to be facing healthcare disparities, or probably already are, in addition to of some of the other underrepresented and minority groups, and so it is important to be aware of some of the nuances that affect this group.”