Risk Factors for Atherosclerotic Cardiovascular Disease in the South Asian Population
Although ASCVD rates in the United States and other developed countries have decreased by half in the past 30 years, rates in South Asians have doubled in the past 20 years.
Advanced practice clinicians need to be aware of the high rates of atherosclerotic cardiovascular disease (ASCVD) in the South Asian population. The most common cause of noncommunicable disease death worldwide is due to ASCVD,1 and ASCVD is a key driver of health disparities globally; 80% of the ASCVD burden occurs in low- and middle-income countries.2
South Asia is the fastest growing region in the world.3 The South Asian population — defined as those living in India, Nepal, Maldives, Bhutan, Afghanistan, Pakistan, Sri Lanka, and Bangladesh4 — constitute 20% of the world's population; people from these countries are at particular risk for ASCVD.1 Within the next 15 years, India is projected to become the most populous nation on Earth. South Asians have a greater prevalence of ASCVD than other ethnic groups and have disproportionately poorer health outcomes overall compared with other ethnic groups3; 50% of the population is more likely to die from coronary heart disease compared with those of European origin.5
It is important to note there are established differences in morbidity and mortality among different ethnic groups within the South Asian population.6 However, ASCVD death occurs 5 to 10 years earlier in all South Asian populations compared with Western populations.7 Although ASCVD rates in the United States and other developed countries have decreased by half in the past 30 years, the rates in South Asians have doubled in the past 20 years.1,7 The explanation for this increase in ASCVD may arise from complex interactions between genetic and environmental factors.3 South Asians exhibit the highest rates of ASCVD among all ethnic groups, and the highest prevalence in this disparity is seen in younger age groups.8 Up to 25% of myocardial infarctions in India occur in individuals under the age of 40 compared with 4% to 6% of individuals in Western Europe and North America.8 It is projected that within the next 10 years, South Asians will account for >20% of ASCVD deaths worldwide.9 This results in the highest loss of potentially productive years of life due to ASCVD.
Many risk factors are strongly linked to the development of ASCVD, including elevated blood glucose, obesity, smoking, elevated blood pressure, abnormal cholesterol levels, and a positive family history of ASCVD. However, these factors do not fully explain the disproportionately high ASCVD risk within the South Asian population. This residual risk suggests that additional, nonclassic risk factors contribute to ASCVD risk.
Attempting to reduce the excess morbidity and mortality of ASCVD requires a wide understanding of the collective risk factors associated with the disease state to facilitate treatment and attempt a reduction of risk across a population. However, population-specific risk factors among the South Asian population have been inadequately explored, leading to a significant gap in the ability to understand ASCVD risk factors within this population. The increasing global ASCVD burden in developing countries and the increasing cost of health care on local economies are cause for concern.
In addition to the risk of heart disease, other health issues exist specifically in South Asian populations. They are 3- to 4-times more likely to have type 2 diabetes than whites, have a faster progression of disease, be diagnosed at a younger age, and have more complications.10