South Asian Americans are at high risk of CVD and stroke, AHA reports

South Asians living in the United States have a higher risk for atherosclerotic cardiovascular disease (CVD) than other Asian groups and non-Hispanic whites in America, according to a recent scientific statement from the American Heart Association published in Circulation.

More than 3.4 million people in the United States identify themselves as South Asians, according to the US Census. About 80% come from India. Others are from Bangladesh, Bhutan, the Maldives, Nepal, Pakistan, and Sri Lanka.

“Overall, Asians are at a lower risk for heart disease and stroke compared to people of European ancestry. But when you look at South Asians—both immigrants and people of South Asian ancestry born in the United States—their risk for heart disease and stroke is higher than people from East Asia and people of European ancestry,” said Annabelle S. Volgman, MD, chair of the statement’s writing group and medical director, Rush Heart Center for Women, and professor of medicine, Rush Medical College, Chicago, IL.

Compared to people of European ancestry, South Asian Americans:

• Have a greater risk of severe atherosclerosis.
• Are more likely to have multiple segments of their arteries narrowed by atherosclerosis.
• Have higher levels of LDL cholesterol and triglycerides and lower levels of HDL cholesterol.
• Have a higher level of calcium deposits if they are of Indian ancestry and older than age 60.
• Have at least a two-fold higher prevalence of type 2 diabetes, a higher incidence of new-onset diabetes, and a higher prevalence of impaired glucose tolerance.

Evidence to date has confirmed the higher burden of CVD in South Asians in the United States, particularly ischemic heart disease, noted the statement’s authors. A majority of the cardiovascular risk in South Asians can be explained by the increased prevalence of known risk factors, especially those related to insulin resistance.

Diet is a key factor, they pointed out. Many South Asians, even those who are vegetarians, consume saturated fats from tropical oils—such as palm and coconut oil—and refined carbohydrates—such as sugar, white bread, and highly processed foods. Ongoing studies are investigating improving diet quality among South Asians by reintroducing traditional whole grains, which were once a mainstay of diet in the region, and by replacing ghee (butter with all the water removed) with monounsaturated oils such as olive, corn, or other oils.

South Asian Americans also engage in less physical activity than other minority group members, according to the statement. “As health-care providers, we need to do a better job of helping our South Asian patients understand the importance of exercise, because many don’t realize how important it is to their health,” Dr. Volgman said.

South Asians need to be better informed about their risk for CVD and illness, how to access health-care services to reduce and manage those risks, and the benefits of prevention. The statement’s authors offered several recommendations to clinicians based on their findings:

• Calculate atherosclerotic CVD risk using guidelines recommended by the American Heart Association/American College of Cardiology pooled cohort equations.
• Consider using the UK QRISK2 calculator (bearing in mind that it is based specifically on the South Asian population in the United Kingdom).
• Use primary and secondary CVD prevention guidelines.
• Use the International Diabetes Federation race-specific cut points for diagnosing metabolic syndrome. Recommended cut points are waist circumference >90 cm (35.4 in) in South Asian men and >80 cm (31.5 in) in South Asian women.
• Closely follow up women with gestational diabetes for the development of diabetes.
• Increase educational efforts by targeting community gathering areas, including temples and cultural and health fairs.
• Help raise awareness as a key effort to improve knowledge of the increased CVD risk in this population.
• Demonstrate at the individual doctor-patient level “cultural competency” in understanding the increased risk of atherosclerotic CVD in South Asian patients. Provide South Asian-specific recommendations on medications, diet, and lifestyle modifications.

Regarding the last recommendation, community programs that encourage South Asians to exercise and reduce stress through yoga, Bollywood dancing, or other culturally specific physical activities are likely to be more successful than other forms of physical activity, the authors noted.

“It is the hope of the authors of this statement that atherosclerotic CVD mortality will decrease in the US South Asian population through increased awareness of the higher risk of atherosclerotic CVD in South Asians and implementation of the actionable recommendations included in this statement,” they wrote.