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. Author manuscript; available in PMC: 2023 Dec 12.
Published in final edited form as: JACC Adv. 2023 Mar 31;2(2):100258. doi: 10.1016/j.jacadv.2023.100258

TABLE 1.

Primary Prevention Management Considerations for Individuals of South Asian Ancestry72

Step 1 Inquire about country of origin (ASCVD risk is highest among those from Bangladesh and Pakistan) and length of residency in America, if applicable.
Step 2 Assess key risk factors.
Risk factor Screening/Testing, if applicable.
Prediabetes and type 2 diabetes

  • Screening suggested at 35 y of age according to available National guidelines57

  • Obtain fasting glucose level, at any body mass index73,74
Hypertension

  • Screen for other ASCVD risk factors in adults with hypertension according to National guidelines69,73: smoking, diabetes, dyslipidemia, excessive weight, low fitness, unhealthy diet, psychosocial stress, and sleep apnea; testing may include fasting blood glucose, complete blood cell count, lipids, basic metabolic panel, thyroid-stimulating hormone, urinalysis, electrocardiogram with optional echocardiogram, uric acid, and urinary albumin-to-creatinine ratio.
Dyslipidemia
Common patterns:
1) ‘Atherogenic dyslipidemia,’ characterized by:
↓ HDL-C,
↑ triglycerides, and
↑ total cholesterol;
2) ‘HDL paradox’ defined as dysfunctional HDL-C, even at higher values.

  • In setting of increased risk of coronary heart disease, screen for lipid disorders in men 20-35 y old and women 20-45 y old according to available National guidelines32; consider testing for Lp(a), and/or apolipoprotein B-100 for further ASCVD risk stratification.

  • Emphasize diet and lifestyle modifications.
Tobacco use

  • Inquire about traditional (eg, cigarettes, cigars, electronic cigarettes, snuff) and cultural tobacco products: smokeless (eg, gutkha, naswar, paan, paan masala, zarda) and smoked (eg, bidi, hookah, shisha, chilam).

  • Encourage cessation using pharmacotherapy and behavioral interventions in line with National guideline recommendations.73,75,76
Overweight and obesity

  • Fasting blood glucose; screen for metabolic syndrome; target BMI ≤23 kg/m2.

  • Management can include behavioral, pharmacologic, and surgical interventions if indicated.77,78
Physical activity

  • Encourage a minimum of 150 min of moderate-intensity exercise per week,79 tailored to beliefs, norms, and modesty; consider gender-specific programs and culturally specific activities.

  • Walking is a common form of exercise and should be encouraged (including with spouse, family, and friends, for example).80 A reasonable walking goal is 7,000-10,000 steps per day.81
Family history of coronary artery disease (premature or any first-degree relative)

  • Screening lipid panel; selective lipid screening on the basis for family history in children and adolescents82; consider testing for Lp(a).
Diet and nutrition

  • Provide culturally tailored educational material; emphasize moderation and encourage a diet rich in healthy plant-based foods (ie, whole grains, fresh fruits and vegetables, nuts, seeds, lentils, and legumes), liquid plant-based oils (ie, olive, canola, sunflower, and soybean), foods containing polyunsaturated fats (omega-3 and omega 6), viscous fibers (ie, oats, barley, flax seeds), and lean protein (ie, beans, legumes, fish, and chicken)73.83-89

  • Refer to nutritionist specializing in South Asian cuisine/diet, if available.
Women’s reproductive health

  • Inquire about a history of gestational diabetes, hypertensive disorders of pregnancy (preeclampsia, eclampsia), or polycystic ovarian syndrome.90-92

  • Screen for diabetes if gestational diabetes was present.

  • Obtain and manage blood pressure per available National guidelines.71
Step 3 Offer languages concordant with the patient’s ethnicity (eg, translator service), provide educational material written and translated into languages native to South Asian countries, provide and encourage education on cultural beliefs and practices for all team members of the healthcare team.
Step 4 Risk assess: Calculate cardiovascular risk using the 2013 PCE; ‘South Asian’ ethnicity is a risk-enhancing factor for those at borderline and intermediate risk by the PCE.
Step 5 Risk stratify: Consider use of CAC scoring to further stratify risk, particularly for those at borderline or intermediate risk (≥5%-<20% by the PCE), or those who are low risk by the PCE (<5%) with a family history of coronary heart disease.82,88,93,a
Step 6 If available, refer to a South Asian cardiovascular and metabolic specialty program.94
a

Particularly for Asian Indian adults based on available data.

ASCVD = atherosclerotic cardiovascular disease; BMI = body mass index; CAC = coronary artery calcium; HbA1c = hemoglobin A1c; HDL-C = high-density lipoprotein cholesterol; PCE = pooled cohort equations.