Table 10.

Racial/Ethnic Issues in Evaluation, Risk Decisions, and Treatment of ASCVD Risk

	Racial/Ethnic Groupings
	Asian AmericansS4.5.1-4,S4.5.1-13*	Hispanic/Latino AmericansS4.5.1-7–S4.5.1-11†	Blacks/African AmericansS4.5.1-14	Comments
Evaluation
ASCVD issues informed by race/ethnicity	ASCVD issues informed by race/ ethnicity ASCVD risk in people of South Asian and East Asian origin varies by country of origin; individuals from South Asia (see below) have increased ASCVD risk.	Race/ethnicity and country of origin, together with socioeconomic status and acculturation level, may explain risk factor burden more precisely (eg, ASCVD risk is higher among individuals from Puerto Rico than those from Mexico).	ASCVD risk assessment in black women shows increased ASCVD risk compared with their otherwise similar white counterparts	There is heterogeneity in risk according to racial/ethnic group and within racial/ethnic groups. Native American/ Alaskan populations have high rates of risk factors for ASCVD compared with non-Hispanic whites.S4.5.1-12
Lipid issues informed by race//ethnicityS4.5.1-15,S4.5.1-16	Asian Americans have lower levels of HDL-C than whites.	Hispanic/Latino women have higher prevalence of low HDL-C compared to Hispanic/ Latino men.	Blacks have higher levels of HDL-C and lower levels of triglycerides than non-Hispanic whites or Mexican Americans.	All ethnic groups appear to be at greater risk for dyslipidemia, but important to identify those with more sedentary behavior and less favorable diet.
	There is higher prevalence of LDL-C among Asian Indians, Filipinos, Japanese, and Vietnamese than among whites. An increased prevalence of high TG was seen in all Asian American subgroups.
Metabolic issues informed by race/ethnicity S4.5.1-3,S4.5.1-17, S4.5.1-1	Increased MetS is seen with lower waist circumference than in whites.	DM is disproportionately present compared with whites and blacks. There is increased prevalence of MetS and DM in Mexican Americans compared with whites and Puerto Ricans.	There is increased DM and hypertension.	There is increased prevalence of DM. Features of MetS vary by race/ethnicity. Waist circumference, not weight, should be used to determine abdominal adiposity when possible.
	DM develops at a lower lean body mass and at earlier ages.S4.5.1-19–S4.5.1-21 Majority of risk in South Asians is explained by known risk factors, especially those related to insulin resistance.S4.5.1-13
Risk Decisions
PCS4.5.1-22–S4.5.1-25	No separate PCE is available; use PCE for whites. PCE may underestimate ASCVD risk in South Asians. PCE may overestimate risk in East Asians.S4.5.1-26	No separate PCE is available; use PCE for non-Hispanic whites. If African-American ancestry is also present, then use PCE for blacks.	Use PCE for blacks.S4.5.1-10	Country-specific race/ ethnicity, along with socioeconomic status, may affect estimation of risk by PCE.
CAC scoreS4.5.1-27-S4.5.1-30	In terms of CAC burden, South Asian men were similar to non- Hispanic white men, but higher CAC when than blacks, Latinos, and Chinese Americans. South Asian women had similar CAC scores to whites and other racial/ethnic women, although CAC burden higher in older age.S4.5.1-31	CAC predicts similarly in whites and in those who identify as Hispanic/Latino.	In MESA, CAC score was highest in white and Hispanic men, with blacks having significantly lower prevalence and severity of CAC.	Risk factor differences in MESA between ethnicities did not fully explain variability in CAC. However, CAC predicted ASCVD events over and above traditional risk factors in all ethnicities.S4.5.1-32
Treatment
Lifestyle counseling (use principles of Mediterranean and DASH diets)	Use lifestyle counseling to recommend a hearthealthy diet consistent with racial/ethnic preferences to avoid weight gain and address BP and lipids.	Use lifestyle counseling to recommend a hearthealthy diet consistent with racial/ ethnic preferences to avoid weight gain and address BP and lipids.	Use lifestyle counseling to recommend a hearthealthy diet consistent with racial/ ethnic preferences to avoid weight gain and address BP and lipids.	Asian and Hispanic/ Latino groups need to be disaggregated because of regional differences in lifestyle preferences. Challenge is to avoid increased sodium, sugar, and calories as groups acculturate.
Intensity of statin therapy and response to LDL-C lowering	Japanese patients may be sensitive to statin dosing. In an open-label, randomized primaryprevention trial, Japanese participants had a reduction in CVD events with low- intensity doses of pravastatin as compared with placebo.S4.5.1-33 In a secondary-prevention trial, Japanese participants with CAD benefitted from a moderate-intensity dose of pitavastatin.S4.5.1-34	No sensitivity to statin dosage is seen, as compared with non-Hispanic white or black individuals.	No sensitivity to statin dosage is seen, as compared with non-Hispanic white individuals.	Using a lower statin intensity in Japanese patients may give results similar to those seen with higher intensities in non-Japanese patients.
Safety	Higher rosuvastatin plasma levels are seen in Japanese, Chinese, Malay, and Asian Indians as compared with whites.S4.5.1-35–S4.5.1-37 FDA recommends a lower starting dose (5 mg of rosuvastatin in Asians vs. 10 mg in whites). Caution is urged as dose is uptitrated	There are no specific safety issues with statins related to Hispanic/Latino ethnicity.S4.5.1-38	Baseline serum CK values are higher in blacks than in whites.S4.5.1-39 The 95th percentile race/ethnicity-specific and sexspecific serum CK normal levels are available for assessing changes in serum CK.	Clinicians should take Asian race into account when prescribing dose of rosuvastatin (See package insert). In adults of East Asian descent, other statins should be used preferentially over simvastatin.S4.5.1-5

^*The term Asian characterizes a diverse portion of the world’s population. Individuals from Bangladesh, India, Nepal, Pakistan, and Sri Lanka make up most of the South Asian group.^S4.5.1-26 Individuals from Japan, Korea, and China make up most of the East Asian group.

^†The term Hispanics/Latinos in the United States characterizes a diverse population group. This includes white, black, and Native American races. Their ancestry goes from Europe to America, including among these, individuals from the Caribbean, Mexico, Central and South America.

ASCVD indicates atherosclerotic cardiovascular disease; BP, blood pressure; CAC, coronary artery calcium; CAD, coronary artery disease; CK, creatine kinase;CVD, cardiovascular disease; DASH, Dietary Approaches to Stop Hypertension; DM, type 2 diabetes mellitus; FDA, US Food and Drug Administration; HDL-C, high-density lipoprotein cholesterol; LDL-C, low-density lipoprotein cholesterol; MESA, Multi-Ethnic Study of Atherosclerosis; MetS, metabolic syndrome; and PCE, pooled cohort equations.