Preventive Cardiology

Why South Asian risk is different

South Asian populations develop coronary artery disease earlier, at lower body mass indices, and with more diffuse involvement than the Western populations in which most risk calculators were derived. Applying those calculators unadjusted systematically under-estimates risk in Indian patients — a person told they are low risk at 40 may be nothing of the kind.

Lipoprotein(a), an inherited and largely diet-independent risk factor, is also more prevalent, and is not measured on a standard lipid panel unless specifically requested.

What a proper risk assessment includes

A detailed family history, including the ages at which relatives had events. A full lipid profile with apolipoprotein B or non-HDL cholesterol rather than LDL alone. HbA1c rather than fasting glucose in isolation. Blood pressure measured properly, and confirmed with ambulatory monitoring where readings are borderline or inconsistent.

Where risk is intermediate and the decision to treat is genuinely uncertain, coronary calcium scoring can reclassify a patient decisively in either direction — including downwards, which spares people decades of unnecessary medication.

What actually changes outcomes

Lipid lowering to a target appropriate to the level of risk, not to a nominal cut-off. Blood pressure control. Complete tobacco cessation, which is the single highest-yield change available to a smoker. Regular aerobic activity. Weight and glycaemic management where relevant.

These are unglamorous and they work. The evidence that medical therapy holds its own against intervention in stable disease is, read another way, evidence of how powerful this regimen is when it is delivered properly.

Who should be screened, and when

Anyone with a first-degree relative who had a cardiac event before 55 in men or 65 in women. Anyone with diabetes, hypertension, or a history of smoking. Anyone with a strong family history of sudden death. In the absence of risk factors, a baseline assessment in the fourth decade is reasonable for South Asian patients, which is earlier than most international guidance suggests.