Identification and Management of Atherosclerotic Cardiovascular Disease Risk in South Asian Populations in the U.S.

South Asians (SAs, individuals with ancestry from Bangladesh, Bhutan, India, Maldives, Nepal, Pakistan, and Sri Lanka) are among the fastest growing ethnic subgroups in the United States. SAs typically experience a high prevalence of diabetes, abdominal obesity, and hypertension, among other cardiovascular disease risk factors, which are often under recognized and undermanaged. The excess coronary heart disease risk in this growing population must be critically assessed and managed with culturally appropriate preventive services. Accordingly, this scientific document prepared by a multidisciplinary group of clinicians and investigators in cardiology, internal medicine, pharmacy, and SA-centric researchers describes key characteristics of traditional and nontraditional cardiovascular disease risk factors, compares and contrasts available risk assessment tools, discusses the role of blood-based biomarkers and coronary artery calcium to enhance risk assessment and prevention strategies, and provides evidenced-based approaches and interventions that may reduce coronary heart disease disparities in this higher-risk population.

[4] South Asians (individuals who trace their ancestry from Bangladesh, Bhutan, India, the Maldives, Nepal, Pakistan, and Sri Lanka) are diverse with regard to region of origin, cultural identity, religious practices, cuisine, and language use.Accordingly, while the atherosclerotic cardiovascular disease (ASCVD) risk for SA adults is roughly double that of White adults, [5][6][7] the risk of coronary heart disease (CHD) differs across SA subpopulations. 5][10][11][12] The clinical presentation of ASCVD among SAs generally occurs earlier in life (mean age 53 years), with a higher burden of atherosclerosis, even in the absence of symptoms or clinical findings. 9,13-15Despite recognition of elevated ASCVD risk 16 recommendations for risk, assessment, and stratification (a fundamental concept for the prevention of ASCVD), and subsequent management are not sufficiently tailored to the high ASCVD risk experienced by SA adults, largely because populationspecific risk calculators inadequately estimate risk in this population, particularly for those at borderline or intermediate risk ($5%-<20% by the pooled cohort equations [PCE]). 5,17rein, we aim to address the roles of traditional and nontraditional risk factors, and review emerging strategies for risk assessment and reclassification, such as blood-based biomarkers and coronary artery calcium (CAC), that may better inform primary prevention of premature ASCVD in SAs who reside in the United States.

SOUTH ASIANS ARE A HETEROGENOUS POPULATION
In the United States, understanding the health and disease patterns in specific Asian subpopulations has been challenging largely because Asian subgroups have frequently been aggregated into a single "Asian" category.The earliest SA immigrants (namely, from India and Pakistan) were regarded as 'other' when reporting US census data until 1920, followed by 'Hindu.' 18 The Luce-Celler Act of 1946 granted naturalization rights and extended immigration quotas allowing 100 people each from India and Pakistan to immigrate to the United States per year; these quotas were lifted in 1965, encouraging an influx of skilled professionals from all SA countries. 19Family reunification in the mid-1980s allowed further diversification of the SA population.Accordingly, the SA diaspora has spread across the United States with heavily concentrated pockets in California, the District of Columbia, Illinois, New Jersey, New York, Texas, and Virginia. 20The category 'Asian Indian' was the only SA subgroup identification available for immigrants on the US census card until 2010, after which 'other Asian' was introduced as an additional write-in category to encompass people from the remaining SA countries. 21,22 addition to more detailed U.S. Census and vital statistics race and ethnicity reporting, recent (Supplemental Table 1) and emerging (Supplemental Table 2a and 2b) research have focused specifically on SA health data.For example, CHD mortality rates are higher among SAs living in their native countries compared to those living in Western countries. 23,24milarly, immigrant SAs in Europe have higher CHD rates compared to local populations. 78U.S. Asian Indian men and women have persistently higher age-HIGHLIGHTS South Asians experience a higher burden of CHD compared with adults of other racial/ethnic groups.
Culturally adapted assessment and management of traditional and nontraditional risk factors is essential.
Available population ASCVD risk assessment tools may be unreliable, particularly for those at borderline and intermediate risk; CAC testing may help refine risk and personalize care.
Evaluation of South Asian subpopulations will help characterize the contribution of social determinants, environmental influences, and genetic susceptibility on heterogenous cardiovascular disease burden.disease and heart failure when compared to non-Hispanic White (NHW) individuals. 3,6,25Compared to other SA subpopulations, however, the highest risk of CHD is seen among those of Bangladeshi origin, followed by Pakistani, then Indian adults: HR 3.66 (95% CI: 2.38-5.61),HR 2.45 (95% CI: 2.06-2.91),HR 1.83 (95% CI: 1.64-2.04),respectively. 5,26[29] TRADITIONAL RISK FACTORS Traditional risk factors explain a large proportion of ASCVD risk in SA adults. 5,8,9,30,31The timing for screening among SAs compared to other ethnicities is less clear.ASCVD risk assessment guidelines in New Zealand suggest traditional risk factor (TRF) assessment in SA at age 30 years for men and 40 years for women, considering higher rates of CHD in immigrant SA living there. 30The US Preventive Service Task Force recommends lipid screening for men   11 The age-adjusted prevalence of T2D using electronic health records (EHRs) for SA living in Northern California, New York City, and Atlanta were 29.1%, 10.7%, and 6.7%, respectively. 34,35The prevalence of T2D also varies among US and non-US community-dwelling SA subpopulations 36 : Bangladesh (10.4%-25%),Pakistani (11.6%-22.6%),Sri Lankan (7.8%-26.8%),Indian (7.1%-18.3%),[42][43] National Health Interview Survey data suggest that Asian Indian adults were diagnosed with T2D 5 years younger (46 years old; 95% CI: 43.9-48.5 years), P < 0.001) than NHW (51 years old; 95% CI: 50.4-51.9years), P < 0.001). 44Regional data using the California Health Interview Survey revealed that SAs were diagnosed with T2D 10.2 years earlier compared to NHW (mean age 44.9 vs 55.4, respectively). 45outh Asians are at high risk of T2D at a lower BMI compared to other ethnicities, even when accounting for other traditional risk factors. 40This is referred to as the 'thin-fat' or 'South Asian' phenotype of elevated fasting glucose, low high-density lipoprotein cholesterol (HDL-C), high triglycerides, and lower lean mass at normal ranges of BMI. 36,53rly and repeated screening for glucose intolerance and T2D may help identify at risk individuals.
Indeed, there was a high incidence rate of glycemic progression in the MASALA study, where 32% (95% CI: 27.6-35.9) of participants progressed either from normal glucose tolerance to prediabetes or T2D, or from prediabetes to T2D over 5 years of follow-up. 36commendations from the American Diabetes Association (ADA), World Health Organization (WHO), National Institute for Health and Care Excellence (United Kingdom), and South Asian Health Foundation suggest that a BMI of $23 kg/m 2 should trigger screening for diabetes in SA. [54][55][56][57][58] HYPERTENSION.In the United States, the ageadjusted prevalence of hypertension is 20 to 43% among studies of community-dwelling SA. 35,[59][60][61] These findings are consistent with the reported prevalence of 27% in a 2014 meta-analysis of observational studies from South Asian Association for Regional Cooperation member countries. 62Factors such as 2 , 2 0 2 3 length of U.S. residency and poor dietary habits influence the development of hypertension. 49,63pertension is a well-established independent risk factor for myocardial infarction (MI), stroke, and chronic kidney disease.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 guidelines 57 Obtain fasting glucose level, at any body mass index 73,74 Hypertension Screen for other ASCVD risk factors in adults with hypertension according to National guidelines 69,73 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). 80A reasonable walking goal is 7,000-10,000 steps per day. 81mily 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 adolescents 82 ; consider testing for Lp(a).
][92] Screen for diabetes if gestational diabetes was present.Obtain and manage blood pressure per available National guidelines. 71ep 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.
a Step 6 If available, refer to a South Asian cardiovascular and metabolic specialty program.the interplay of hypertension with other TRF, suggesting dietary and lifestyle enhancement, and explaining the value of pharmaceutical therapy if indicated. 71A summary of these recommendations is provided in Table 1.
DYSLIPIDEMIA.Atherogenic dyslipidemia among SAs is characterized by higher levels of triglycerides and total cholesterol, lower/similar low-density lipoprotein-cholesterol (LDL-C), and lower levels of HDL-C compared to NHW. [95][96][97] Compared to other racial/ ethnic groups, SAs also may have higher levels of apolipoprotein (Apo)-B100 and non-HDL-C, lipoprotein(a) [Lp(a)], and low levels of Apo-A1, although more data are required. 9,98-100For example, in the INTERHEART study, Asian Indians had the lowest HDL-C, the highest ratios for total cholesterol/HDL-C and Apo-B/Apo-A1, respectively, across all LDL-C categories compared to other ancestral groups.Importantly, all of these parameters predicted future coronary artery disease, respectively. 23e prevalence of HDL-C <40 mg/dL in males and <50 mg/dL in females has been reported as high as 52% and 54% of Asian Indian men and women using EHR data in Northern California, respectively. 101The cardioprotective effect of HDL-C may be blunted in SAs compared to other East Asian subgroups: the OR for 1 SD increase in HDL-C among SAs was 0.87 (95% CI: 0.72-1.06),vs 0.77 (95% CI: 0.70-0.85) in other East Asians at the time of the first MI. 31is may be explained by a higher concentration of smaller HDL-C particles that contribute proinflammatory and prooxidant effects and are unable to participate in effective reverse cholesterol transport. 102,103Higher Apo-A1 (principal structural and functional protein component of HDL-C) levels in SAs are associated with a lower risk of MI. 31 Lp(a) is genetically determined and highly atherogenic.Lp(a) is estimated to be elevated (>50 mg/dL or >125 nmol/L) in 25% of SA globally. 104,105The population attributable risk of MI was highest for SA when Lp(a) was >50 mg/dL. 106Compared to other racial/ ethnic groups, the association of Lp(a) concentrations and MI in a case-control study was highest in SA (OR: 2.14, 95% CI: 1.59-2.89,P < 0.001). 106Prospective data suggest an association between elevated Lp(a) and ASCVD (HR: 1.31, 95% CI: 1.04-1.64,P ¼ 0.023). 5Lp(a) levels were not associated with CAC prevalence (P ¼ 0.98), common carotid atherosclerosis (P ¼ 0.97), or aortic valve calcification (P ¼ 0.64) in the MASALA study. 107,108SAs tend to have lower Lp(a) levels than Black adults, which may signal the need for ethnic specific Lp(a) thresholds to select truly higher risk individuals. 105,107uth Asian men and women have similar or lower LDL-C levels compared to other racial/ethnic groups. 96,109Among SA subgroups, Pakistani adults had higher mean LDL-C values compared to North Indian (120 mg/dL vs 109 mg/dL, respectively; P ¼ 0.02), although no difference was found between North and South Indian (P ¼ 0.49) or between South Indian and Pakistani adults (P ¼ 0.06). 110 ticles with a higher concentration of ApoB. 31This indicates a larger atherogenic particle load that may account for the elevated risk of ASCVD, even at lower LDL-C concentrations. 31,111 the absence of randomized controlled or prospective data, the National Lipid Association has provided expert opinion recommendations regarding the optimal primary prevention targets for lipid profiles in SAs, based on risk profile (high ¼ PCE 10 years 20%-29%, very high ¼ PCE 10 years 30%-39%, and extreme ¼ PCE >40%). 88For example, LDL-C (mg/dL) goals for the 3 risk categories are <70, <50, and <30, respectively.
The ideal triglycerides target is <150 mg/dL, and HDL-C (mg/dL) is suggested to be >40 in men and >50 in women.
OVERWEIGHT AND OBESITY STATUS.Body composition and fat distribution are important determinants of CVD risk in SAs who tend to have a higher percentage of body, liver, and visceral fat compared to other ancestral groups. 10,112Hence, BMI calculations in SAs may be unreliable considering this body fat distribution.As such, the ADA and WHO recommended lowering BMI cut points to encourage public health action, with a focus on weight reduction and increased physical activity. 10,55,56Accordingly, the prevalence of obesity in SAs varies between studies.
For example, in SA, the prevalence of obesity (defined as BMI $27.5 kg/m 2 ) was 39.3% in men and 36.8% in women in a Northern California EHR cohort. 34National survey data indicated the overall prevalence of obesity may be higher at 77.6% (defined as BMI $23 kg/m 2 in this study). 63National data also suggest that compared to other Asian subgroups, SAs have the one of the highest prevalence of overweight/ obesity status. 113,114mpared with European Whites, SAs have a relatively greater amount of abdominal adipose tissue. 115Central adiposity is associated with insulin resistance and metabolic syndrome, contributes to hypertension, high cholesterol, lower HDL-C, and independently predicts acute ischemic heart disease in Asian Indians. 64inicians should be aware of cultural beliefs regarding body habitus considering self-perceived underestimates of weight status and the effect of weight on the risk for chronic diseases. 116,117Age at immigration and duration of residence in the United States are also correlated with a higher prevalence of overweight/obese status. 118,119SA infants have higher visceral and subcutaneous adipose tissue deposits compared to NHW, falsely capturing a healthy weight status even in the setting of higher metabolic risk. 120imordial prevention efforts including a greater emphasis on maternal health during pregnancy may be necessary, considering SA children (ages 5-7) are more likely to be overweight/obese compared to children of other race/ethnicities. 121e ADA Diabetes Guidelines suggest annual BMI screening with a cut point value of $23 kg/m 2 in SAs to define overweight status. 57In addition to encouraging a "healthy meal plan" and increased physical activity, obesity guidelines from the American College of Endocrinology also suggest annual screening (same BMI cut point as ADA) and define abdominal obesity in SA as a waist circumferences of $85 cm in men and $74 cm in women 57,78 ; this is lower than SA waist circumference recommendations by the International Diabetes Federation Epidemiology Task Force Consensus Group ($90 cm in men; $80 cm in women). 122The large-scale utility of other measurements such as adiposity (eg, bioelectric impedance, magnetic resonance imaging, and air/water displacement plethysmography) is limited considering the lack of outcome data. 78ET.4][125] In SA, a longer residence in the United States is directly associated with higher intake of saturated and trans fats, dietary cholesterol, and alcohol, for example (P < 0.05). 126This is consistent with the dietary habits of SAs after migration to European countries. 127Examples of deleterious cooking and dietary habits include: 1) high heat cooking and deep frying; 2) using reheated oil high in trans fats and advanced glycosylation end product; 3) using oils with high saturated fats (partially hydrogenated vegetable oil, palmolein oil); 4) lower quantity and quality of protein intake; and 5) high intake of sugar and refined carbohydrates. 128,129ternatively, a diet higher in fruit, vegetables, nuts, and legumes is associated with a lower prevalence of hypertension and metabolic syndrome. 49A healthy plant-based diet was associated with a lower incidence of T2D, lower odds of fatty liver, and a better metabolic risk factor profile in MASALA. 85ditionally, a Mediterranean-type diet that incorporates traditional SA food is associated with a lower likelihood of obesity, fatty liver, and T2D. 85gher attainment of cardiovascular health metrics  TOBACCO.The prevalence of tobacco use among American SAs is lower compared with other racial/ ethnic groups, including other Asian ethnic groups. 156,157For example, the prevalence of current smoking was 12.4% among Filipinos, 5.9% among Chinese, and 18.5% among NHW compared with 5.1% among Asian Indians. 59,158In the MASALA study (with majority first-generation immigrants), 5% of men and 1% of women were current smokers.
Commonly used questionnaires used to assess tobacco use typically do not capture cultural forms of tobacco, and therefore the prevalence of regular use of these products among SAs is not well understood and may be underestimated. 159 addition to combustible cigarette use, there are other forms of tobacco use specific to SA culture including smokeless (gutkha, naswar, paan, paan masala, zarda) and smoked products (bidi, hookah, shisha, chilam). 160,161Asking product-specific questions revealed high rates of alternative tobacco use in a New York City study among Bangladeshi and Gujurati adults. 162Tobacco use patterns may differ by gender as men were more likely to smoke while women were more likely to chew tobacco. 163SAs place emphasis on using culturally specific tobacco products during celebrations and social functions as a tribute to their heritage and a means of hospitality. 161,164There may also be inaccuracies in perceptions of the health effects and potential harms of tobacco products, which can further complicate their use. 164e prevalence of tobacco use may also differ among first generation compared with later generations.For example, among SA immigrants in the Northeast U.S., nearly half of female cigarette smokers were first-generation immigrants. 165Clinicians and public health officials should address the use and cardiovascular effects of these products using cultural-specific messaging.Available Center for Disease Control Asian-centric resources for smoking cessation are offered in non-South Asian languages. 166This is similar to other national antitobacco organizations. 167Pharmacotherapy and behavioral interventions to aid tobacco cessation should be offered to help curb use of these products, in line with national consensus recommendations. 75NTRADITIONAL RISK FACTORS FAMILY HISTORY.Family history of premature ASCVD (FamHx) (traditionally defined as age <55 for men and <65 for women) is a non-modifiable, established risk factor, that carries a temporal relationship for the development of future ASCVD (larger influence of shared, genetic component for premature events, and a more balanced contribution of environmental and acquired CVD risk factors for later onset events). 168Observational data suggest that the prevalence of FamHx in SAs ranges between 40% to 60%. 5, [169][170][171] The presence of a FamHx is associated with CHD, OR ranging from 1.45 (95% CI: 1.30-1.60)to 1.71 (95% CI: 1.21-2.42),depending on the study population and self-reported definition used. 5,170,172wever, this is similar to other racial/ethnic groups. 169A one-time screening Lp(a) value in the presence of a FamHx may be useful to help further stratify ASCVD risk. 88,173A positive FamHx should promote a screening lipid panel for familial lipid disorders in adults older than age 20. 82

MARKERS OF INFLAMMATION.
Inflammation is an important pathophysiological mechanism responsible for the initiation and progression of atherothrombosis. 174C-reactive protein is a marker of systemic inflammation that is typically elevated in Asian Indians compared with Whites and is associated with traditional risk factors and prevalent CVD. 175,176[183] MATERNAL RISK FACTORS.Adverse pregnancy outcomes are related to an increased risk for ASCVD.
Gestational diabetes mellitus (GDM) is a particularly important risk factor for ASCVD among SA American adults. 184Compared with NHW, non-Hispanic Black, Hispanic, and other Asian groups, nulliparous SA (Asian Indian) American women at first live birth experienced the highest rate of GDM in 2019 (129.1 per 1,000 live births), with a significant 4.4% per year increase in GDM rates between 2011 and 2019. 185Between 2014 and 2019, GDM rates were higher among Asian Indian women born outside the United States (122.7 per 1,000 live births) compared with those born in the United States (75.5 per 1,000 live births). 186SA American women in the MASALA study who reported a history of GDM had 3.2 times higher odds of having T2D, compared with women without GDM. 187Given the disproportionate burden of GDM experienced in SA American women, the American College of Obstetrics and Gynecology recommends screening for GDM early in pregnancy for SA (and other Asian American) women. 90GDM is known to have consequences for both the mother and offspring, although the available data are generally not from South Asian populations.GDM increases the risk of subsequent ASCVD in midlife 188 and also increases the risk for premature ASCVD in the offspring. 189Confirming these findings and quantifying the magnitude of risk conferred among SA women remains to be evaluated.
Hypertensive disorders of pregnancy (HDP), which include pregnancy-induced hypertension and preeclampsia, are another important adverse pregnancy outcome that increases risk for ASCVD.In 2019, HDP rates among nulliparous Asian Indian women at first live birth were 54.1 per 1,000 live births, and HDP rates increased on average 9.0% per year between 2011 and 2019. 190HDP rates were higher among Asian Indian women born inside the United States (64.4 per 1,000 live births), compared with Asian Indian women born outside the United States (52.9 per 1,000 live births). 186ile HDP is associated with a higher risk of subsequent premature mortality among other populations in the United States, 191 the role of HDP and several other adverse pregnancy outcomes on the risk for ASCVD in SA American adults remains to be characterized.Differences in adverse pregnancy outcomes including GDM and HDP in subgroups of SA Americans (eg, Pakistani, Bangladeshi) have not been evaluated to date.
BARRIERS TO ACCESSING HEALTH CARE.As the SA population in the United States grows, public health strategies must adapt to meet their needs. 192Identifying a racial group as "high risk" may serve to improve and/or provide health care resources to vulnerable populations, but also has the potential to thwart health-seeking behavior, engagement in care, and adherence to therapy. 193Furthermore, it does not account for disparities in care provision and process, socioeconomic position, neighborhood environment, sociocultural factors, and racial discrimination. 2,194ecific health challenges that impact cardiovascular health in SA and proposed opportunities to overcome these barriers are listed in Table 2.

ASCVD risk management considerations for South
Asians are depicted in the Central Illustration and described in Table 1.

RISK ASSESSMENT
Risk assessment is fundamental for ASCVD risk reduction counseling.However, risk prediction, discrimination, and calibration in SA adults remain challenging for the following reasons: 1) available guidelines recommended risk algorithms have not been derived from or prospectively validated in SA adults; 2) limited considerations have been given for native vs migrant populations; and 3) there is paucity of disaggregated data, which masks meaningful ASCVD health differences in SA subgroups.As such, available population-specific risk assessment tools unreliably estimate risk in SA at large and among subgroups 5,17,27,214-221 (Table 3).
For example, the National Institute for Health and Care Excellence (NICE) guidelines recommended a crude adjustment factor to the Framingham Risk Score (FRS) for SAs (FRS multiplied by 1.4 for men; no recommendation for women). 241The FRS and UK

Prospective Diabetes Study underestimates risk in
SAs compared to a White European population. 240ISK2 underestimates risk in SA women. 233The 3rd Joint British Societies' CVD risk calculator accounts for SA ethnicity; however, underestimates risk considering the small proportion (2.3%) of SA adults included in the cohort. 232ISK3 (5.25% SAs), ETHRISK (46% SAs), NORRISK-2 SADia (12% SAs) are not yet incorporated into any national guidelines. 238,239The 2019 WHO risk charts (estimates risk in Bangladesh, Bhutan, India, Nepal, and Pakistan) misclassify higher-risk SAs to low-risk categories. 242The INTERHEART Modifiable Risk-Score has been internally and externally validated for the prediction of future ASCVD risk in SAs; however, its application is limited considering casecontrol data used to develop the risk calculator. 236e 2013 AHA/ACC PCE recommend using "White" race for SA adults, resulting in risk underestimation.Racial and cultural discrimination 195,196 Racial/cultural discrimination experienced when seeking health care services may be related to poor self-rated health status and quality of life. 197,198isting cultural attitudes regarding health care Fatalistic beliefs (all events are predetermined and therefore inevitable), cultural, and social norms influence selfmanagement and illness beliefs. 199,200culturation In MASALA, 3 acculturation strategies were identified: separation (preference for South Asian culture over US culture), assimilation (preference for US culture over South Asian culture), and integration (similar level of preference for South Asian and US cultures).Length of stay in the US, English proficiency, and higher household income influenced assimilation or integration strategies. 201Those in the integration and assimilation strategies had better cardiometabolic risk factors than those in the separation class. 202igher levels of acculturation influence health-seeking behaviors and higher self-reported health in a positive fashion. 203cioeconomic status Lack of health insurance and high out-of-pocket expense for appointments and prescriptions. 204alth literacy Health literacy is closely associated with English proficiency and cultural health beliefs; limited literacy associated with a poor understanding of available health services, underutilization of available medical care, and lower levels of self-rated health status and diabetes care in SAs.205,206 Geography -distance from healthcare center, extended wait times, child care responsibilities, and lack of access to transportation Transportation is especially problematic for elders who cannot drive or/and speak English and those who live in multigenerational homes. 207nguage 207,208 Effective healthcare use requires native language accessibility to explain symptoms, and understand diagnosis and treatment, for example.
Children can help facilitate interpretation; however, this method is prone to incorrect or incomplete communication when children lack the appropriate medical terminology, lending itself to delay of care in the elderly. 209ower rates of English proficiency are a predictor for higher traditional health practices. 210alth care practices do not align with modern Western or allopathic medicine South Asian patients question the need and efficacy of modern medication.In parallel with medical therapy use, they may use traditional remedies, perceived to be more efficacious and nontoxic.Family and friends can serve as important in decisions to use alternative medicines. 43

Opportunities Comments
Culturally sensitive educational materials Education material is written and translated into common languages native to South Asian countries.
Educational material offers culturally specific information (eg, dietary recommendations that name foods common to a SA diet, or healthcare recommendations during religious obligations such as Ramadan fasting) 83,134 .
Language/Health literacy Patient experience is improved in practice settings that offer a language concordant with the patient's ethnicity. 208gagement of cultural/religious organizations and social networks.
Partnering with places of worship or community events to promote healthy lifestyle education, healthy eating habits, increased physical activity, and combat the effect of discrimination and racism. 148,211,212ltural competency Systemic education on cultural behaviors and practices for all members of the healthcare team. 213saggregation of health data Disaggregation will help refine our understanding of health care disparities among South Asian subpopulations, considering broad genetic, cultural, and socioeconomic characteristics.3 MASALA ¼ Mediators of Atherosclerosis in South Asians Living in America; SA ¼ South Asians.
origin, generation of immigration, and acculturation. 98While European observations appear to mirror those observed in SAs residing within the United States, additional studies are imperative to filling in knowledge gaps that exist within this group.

CORONARY ARTERY CALCIUM
Considering unreliable ASCVD-risk estimation methods and the absence of a validated SA-specific risk calculator, the use of CAC may be a useful test to improve risk stratification and guide primary preventive efforts. 17CAC testing is a cost-effective, highly reproducible, and specific marker of subclinical atherosclerosis. 247 men and women with a 10-year predicted risk of >7.5% by the PCE were found to have a high CAC burden. 59Although formal validation is required, the PCE may adequately predict risk among SAs at low risk and high risk (<5% and >20%). 248However, the extent of ASCVD-risk overestimation using the PCE was greater among SA adults considered at low-and intermediate-risk compared to among NHWs. 17 with CAC >100. 70[261] Considering a high prevalence of prediabetes (not an indication for statin therapy) in SA adults, the presence of CAC may also influence statin initiation; alternatively if CAC ¼ 0, statin therapy may be deferred/avoided in lieu of ongoing prudent lifestyle interventions. 88,248,262nsidering the interplay of TRF and CAC and risk of early ASCVD events, an emphasis on the simultaneous appraisal of TRF and CAC in SA may be of clinical importance. 263In adults #45 years old of other racial/ethnic groups, the presence of CAC increases with the number of TRF, OR: 4.5 (95% CI: 2.7-7.3), in patients with >3 vs 0 TRF. 253Notably, SAs and NHW men have similar CAC burden (men age 58 AE 9 years vs 63 AE 10 years) but higher CAC burden compared to other racial/ethnic groups (mean age 62 AE 10). 109SA men have similar rates of CAC progression to NHW (interscan time 4.8 AE 0.8 years). 264[267] Among those with CAC ¼ 0 at baseline, the timing of repeat CAC scanning has not yet been defined specifically for SAs; however, a 3-to 5-year interval has been suggested for those at borderline or intermediate risk by the PCE, and 3 years for those with diabetes. 268Notably, among SA adults with no CAC at baseline in the MASALA study, the age-adjusted CAC incidence was 8.8% (95% CI, 6.8%-10.8%) in men and 3.6% (95% CI, 2.5%-4.8%) in women on repeat CAC measurement after 4.8 AE 0.8 years. 264Despite favorable outcome data in the absence of CAC, 247 a potential limitation of the CAC score lies in its inability to detect the entire spectrum of plaque morphology and burden. 269Coronary computed tomography angiography (CCTA) can evaluate coronary anatomy, stenosis, and characterize atherosclerotic plaques beyond the ability of CAC.Among multiethnic, asymptomatic populations that did not include SA, the prevalence of noncalcified plaque by CCTA ranges between 5.5% and 16% in patients with no CAC (% participants CAC ¼ 0, 23%-59%) [269][270][271][272] (NCT03920176).
Although long-term outcome data are expected to confirm the clinical significance of these findings, a clinical practice statement from the American Society for Preventive Cardiology suggests judicious use of CCTA as an alternative to CAC in asymptomatic highrisk populations (eg, family history of premature ASCVD, familial hypercholesterolemia, diabetes, and those of SA descent with strong family history among others). 273Other major scientific societies have not embraced CCTA for ASCVD risk assessment in asymptomatic patients, highlighting the role of early and aggressive risk factor identification and management as a reasonable approach.This may be particularly applicable to those at the highest ASCVD risk, such as low-income, low-education, low rates of acculturation, and those with poor access to health care, for example.
mass index BP = blood pressure CAC = coronary artery calcium CHD = coronary heart disease CVD = cardiovascular disease EHR = electronic health record GDM = gestational diabetes mellitus HDL-C = high-density lipoprotein cholesterol HDP = hypertensive disorders of pregnancy LDL-C = low-density lipoprotein-cholesterol MI = myocardial infarction NHW = non-Hispanic White PCE = pooled cohort equations SA = South Asian T2D = type 2 diabetes WHO = World Health Organization standardized mortality rates from ischemic heart aged 20 to 35 and women 20 to 45, if they are at an increased risk of CHD (defined as: diabetes, history of previous CHD or atherosclerosis, family history of CVD, tobacco use, hypertension, and obesity (body mass index [BMI] $30 kg/m 2 )); however, they do not specify ethnicity/race.

TABLE 1
Primary Prevention Management Considerations for Individuals of South Asian Ancestry 72 180

TABLE 2
Barriers and Opportunities to Improve Cardiovascular Health in South Asian Adults

Table 4 .
169,170,[248][249][250][251][252][253]Overall, ASCVD event data are required to confirm the importance of these find- 69,70xample, intermediate-risk SA have a 73% higher odds of CAC ¼ 0 (low short-term risk strata) compared to NHWs (95% CI: 1.00, 2.99).When considering SA ethnicity as a 'risk-enhancing factor' according to the 2018 AHA/ACC Blood Cholesterol Guidelines (ie, sys-ACC/AHA Blood Pressure guideline, CAC scoring may help identify those SA adults who would best qualify for aggressive lifestyle optimization and antihypertensive pharmacotherapy.69,70Forexample, the proportion of SA participants that would qualify for antihypertensive pharmacotherapy per the ACC/AHA, but not by JNC7 guidelines, was higher among those CENTRAL ILLUSTRATION Primary Prevention Cardiovascular Risk Assessment and Management Considerations for the South Asian Populations in the United States Agarwala A, et al.JACC Adv.2023;2(2):100258.*Data available mostly for Asian Indian adults.

TABLE 3
Select Risk Assessment Calculators and Guideline Considerations Specific to South Asian Adults Continued on the next page European Atherosclerosis Society; ESC ¼ European Society of Cardiology; FRS ¼ Framingham Risk Score; MI ¼ myocardial infarction; N/A ¼ not applicable; NICE ¼ National for Health and Clinical Excellence; UK ¼ United Kingdom; USA ¼ United States of America; WHO ¼ World Health Organization.
a If applicable.ACC ¼ American College of Cardiology; AHA ¼ American Heart Association; CVD ¼ cardiovascular disease; EAS ¼

TABLE 4
255mary of Advanced Measures of CAC in South Asian AdultsKanaya et al109MASALA, MESA South Asian and NHW men have similar CAC burden (mean age 58 AE 9 y vs 63 AE 10 y), but higher CAC burden compared to other race/ethnic groups (mean age 62 AE 10y).CAC scores were similar for South Asian women compared to all women of other racial/ethnic groups; however, South Asian women >70 y had a higher prevalence of any CAC than most other racial/ethnic groups.wasdirectlyassociatedwithCACdensityandwaist circumference was inversely associated with CAC density (P < 0.05).Body mass index, hypertension status, statin use, diabetes, and HOMA-IR were all directly associated with CAC volume (P < 0.05).Kanaya et al264MASALA, MESA Age-adjusted CAC incidence was similar in South Asian men compared with White, Black, and NHW men, but significantly higher than Chinese men (11.1% vs 5.7%, P ¼ 0.008).There was no difference in CAC incidence or progression between South Asian women and women of other racial/ethnic groups.Bhatia et al255MASALA CAC volume and density were highest, and incident CAC was most common in the left anterior descending artery.Highest volume change was in the right coronary artery.Highest change in density was in the left main coronary artery.Smoking is associated with CAC volume progression.Lipoprotein(a) and exercise are associated with CAC density progression.Patel et al 169 MASALA, MESA Compared to other racial/ethnic groups, the presence of an FamHx in South Asian adults is associated with CAC > 300, OR (95% CI): 2.82 (1.6-4.93).The presence of an FamHx provides significant information for the prediction and reclassification of severe CAC in South Asians: c-statistic increase from 0.853 to 0.863 (P ¼ 0.001), net reclassification improvement 38.9% (95% CI: 14.6%-62.6%].¼ coronary artery calcium; CI ¼ confidence interval; FamHx ¼ family history of CHD; HOMA-IR ¼ homeostatic model assessment for insulin resistance; MASALA ¼ Mediators of Atherosclerosis in South Asians Living in America;NHW ¼ non-Hispanic White; OR ¼ odds ratio; PCE ¼ pooled cohort equations; SABRE ¼ South Hall and Brent Revisited study; T2D ¼ type 2 diabetes. CAC Holmboe-Ottesen G, Wandel M. Changes in dietary habits after migration and consequences for health: a focus on South Asians in Europe.Food Nutr Res.2012;56:1-12.128.Kakde S, Bhopal RS, Bhardwaj S, Misra A. Urbanized South Asians' susceptibility to coronary heart disease: the high-heat food preparation hypothesis.Nutrition.2017;33:216-224.129.Gupta N, Shah P, Goel K, et al.Imbalanced dietary profile, anthropometry, and lipids in urban Asian Indian adolescents and young adults.J Am Coll Nutr.2010;29(2):81-91.130. Singh PN, Arthur KN, Orlich MJ, et al.Global epidemiology of obesity, vegetarian dietary patterns, and noncommunicable disease in Asian Indians.Am J Clin Nutr.2014;100 Suppl 1:359S-364S.131.Jin Y, Kanaya AM, Kandula NR, Rodriguez LA, Talegawkar SA.Vegetarian diets are associated with selected cardiometabolic risk factors among middle-older aged South Asians in the United States.J Nutr. 2018;148(12):1954-1960. 132.Akhtar AM, Ghouri N, Chahal CAA, et al.