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Cardiologist Monzur Morshed discusses the article, “Why South Asians in the U.S. face a silent heart disease crisis.” Drawing from his direct experience treating the Bangladeshi-American community in New York City, Monzur explains why people from South Asia are disproportionately at risk for developing heart disease 5 to 10 years earlier than other populations, often despite having normal cholesterol levels. The conversation delves into specific, often overlooked risk factors like the “thin-fat” phenotype, genetic predispositions such as elevated lipoprotein(a), and cultural barriers including diet and the stigma around mental health. They provide actionable clinical tips for health care providers and patients, emphasizing that standard risk assessments are failing this vulnerable community. The key takeaway is a call for a paradigm shift: clinicians must treat South Asian patients as high-risk by default and utilize culturally sensitive, aggressive screening to close the equity gap in cardiovascular care.

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Transcript

Kevin Pho: Hi, and welcome to the show. Subscribe at KevinMD.com/podcast. Today we welcome Monzur Morshed. He’s a cardiologist. And today’s KevinMD article is “Why South Asians in the U.S. face a silent heart disease crisis.” Monzur, welcome to the show.

Monzur Morshed: Thank you. Thank you, Dr. Kevin, for having me. It is truly a privilege to be here.

Kevin Pho: All right. Thank you so much for writing and joining us. Tell us a little bit about your story and then the KevinMD article that you shared with us today.

Monzur Morshed: OK. I am a board-certified cardiologist practicing in New York. I’m originally from Bangladesh and have served a very diverse patient population, for example, immigrants, working-class men, and families under stress, for decades now. And during COVID, I did a lot of community education, including through Bangladeshi television like Time Television and TBN 24, and also public health outreach in underserved areas.

I came up with the article because when I see my patients where I practice right now in the Bronx, especially in the South Asian community, they have hypertension, palpitations, and chest pain. I see that they sometimes don’t have any of the risk factors we look for. However, they are still diagnosed with a lot of heart attacks, even though they don’t have traditional cardiac risk factors—they’re too young, too thin, and too quiet.

So then I thought I should write something about it. And right away, I thought about your podcast and your journal, which is very popular and reliable. I know when I was a medical student, I used to read your articles sometimes when I had time. So that’s how I came to your podcast today to talk about this issue.

Kevin Pho: So let’s jump straight into that article. You highlight that some South Asian groups develop heart disease five to ten years earlier than other groups. So talk about that genetic predisposition.

Monzur Morshed: Yes. You’re absolutely right, Dr. Kevin. South Asians are very vulnerable to certain genetic and biological factors like insulin resistance and central obesity, even with a normal BMI. Many South Asians have visceral fat—they are thin on the outside but fat on the inside. They also have dyslipidemia. They might have low HDL, high triglycerides, but quote-unquote normal bad cholesterol, like LDL. And recently, we are also talking about lipoprotein(a). South Asians are more likely to have higher lipoprotein(a) because it’s genetically determined and associated with early atherosclerosis.

They have a higher prevalence of diabetes and metabolic disease, even with a lower BMI, because of the central obesity. They have higher high-sensitivity CRP, which is a very pro-inflammatory marker. And also, Dr. Kevin, South Asians love rice, and they love high-carbohydrate, refined-grain, sugary diets. So, white rice and sweets can also contribute to metabolic disorders. Since their traditional cooking uses a lot of oil, they use trans fat, which can also contribute to abnormal cholesterol.

Regarding their lifestyle, most of them have low physical activity. They don’t like to go to the gym. They may or may not use tobacco. But the biggest thing I want to emphasize is psychosocial stress. For an immigrant family, they constantly worry about whether or not they’ll be deported, and they’re having stress in the family. Sometimes they go through a lot of stress, like divorce or not having a good job, in a society that does not acknowledge them as much as it should.

All this stress means increased cortisol, Dr. Kevin. And that cortisol creates a vicious cycle that stays in our system, and eventually, this chronic inflammatory system kicks in. So then we get early, aggressive atherosclerosis. The bottom line is, even though they look thin, even though they may not smoke, and even though they may have quote-unquote normal LDL, the combination of genetic biological markers and stress can lead to early heart disease.

Kevin Pho: Several things that you said got my attention. You talk about the high visceral fat, so sometimes a normal body mass index can be misleading for South Asian patients. And in your article, you also note that South Asians sometimes have a vegetarian diet, but because of these genetic factors you talked about, you call that a dietary illusion for many South Asians, right?

Monzur Morshed: Yes.

Kevin Pho: Now you also talk about lipoprotein(a), and we’ve talked about that sometimes on my podcast. And like you said, it’s a genetic predisposition for atherosclerotic risk. Going forward, to my knowledge, there isn’t really any treatment specifically to lower lipoprotein(a). Is that correct from your understanding?

Monzur Morshed: Yes, yes. That is a very good question, Dr. Kevin. Since lipoprotein(a) is almost 90 percent genetically determined, typical statin therapy like atorvastatin or rosuvastatin probably won’t play a significant role. We cannot change our age; we cannot change our genetic component. However, if we screen for it early—let’s say you screen somebody with lipoprotein(a) at least once in their lifetime so you know that patient’s status—we can work on other environmental components within our control. Plus, we can possibly use a PCSK9 inhibitor, Dr. Kevin. Nowadays, injection-type medications like inclisiran, Repatha, or Praluent also play a significant role, especially for this type of patient.

Kevin Pho: In terms of screening, you said you have a large immigrant population. What role do you use lipoprotein(a) for? Do you have any clinical symptoms that point you towards ordering lipoprotein(a)? Do you just simply screen everybody as a cardiologist? What are your triggers for ordering that test?

Monzur Morshed: Right. Again, that’s a very good question. Typically, we order tests like a lipid panel, and then we plug the numbers into the ASCVD risk calculation. A risk of less than 5 percent is a very low chance of having cardiac disease, while the 5 percent to 7.5 percent range is a critical one. For a typical American, if you don’t have a family history of heart disease, you can probably manage that risk with diet and lifestyle modification. However, I think for South Asians, even with a risk number considered normal in western medicine, they should have a lipoprotein(a) screening at least once in their lifetime to see whether or not they carry a significant risk for future heart disease. That way, we can consider other tests like a coronary calcium score for this type of borderline-risk South Asian patient. They should have this type of screening so that we can diagnose them early.

Kevin Pho: So you get the basic lipid profile, plug it into the 10-year cardiovascular risk calculator, and if you get a borderline result between 5 and 7.5 percent in a South Asian patient, then you would order a lipoprotein(a) test to look for a genetic predisposition. If it is elevated, then you could look at a specific test like the coronary artery calcium score. Am I getting that right?

Monzur Morshed: Exactly, exactly, Dr. Kevin. Yes.

Kevin Pho: And in terms of age and how they present with coronary artery disease, are we seeing people being diagnosed at a younger-than-normal age? What kind of ages are we talking about?

Monzur Morshed: In my clinical practice, I see people who are around 35 or 40 years old, with no other risk factors, who still end up with CABG bypass surgery. To give you one example, I have another patient with no obvious risk factors. But he was so afraid to talk, and as I tried to dig more into his history, I found out that he’s a very educated person, but he has a tremendous fear that his wife is going to leave him. He is getting a lot of stress from his divorce.

Eventually, he ended up with a quote-unquote acute heart attack. We then found out it was takotsubo cardiomyopathy, which, as you know, Dr. Kevin, is a stress-related cardiomyopathy. The symptoms are exactly like a heart attack, but in the cath lab, everything, especially the coronary vessels, is normal. So those are the things I see; at a young age, they are getting a lot of cardiac issues.

Kevin Pho: You mentioned the psychosocial stressors, especially in that immigrant population. As a cardiologist, how do you address those social factors for the patients who come to see you in your cardiology clinic?

Monzur Morshed: Even when results are quote-unquote normal, I still try to dig into the patient’s history to see whether or not they are having any other issues or if they have a family history. Many of them don’t even know, because sudden cardiac death is common, especially back in Bangladesh, where most people could not even make it to a hospital. So they probably don’t know the cause of death.

Whenever a patient comes to me, I screen them like a typical American. Then I try to go a little bit deeper, looking at where they stand on our ASCVD chart and what their BMI is. A BMI that is considered normal in American culture may not be normal for them. Those are the things I need to focus on more so I can screen in greater detail to see whether they will have heart disease in the future.

Kevin Pho: As you know, there are many tests where we could indirectly measure coronary artery disease. You mentioned a coronary artery calcium score. So why choose that test versus, say, an imaging stress test, a nuclear stress test, or an exercise stress test? Take us through the decision process for someone without symptoms who has an elevated lipoprotein(a). Why a coronary artery calcium score?

Monzur Morshed: Yes. A coronary calcium score will tell you something, even in, let’s say, a 35-year-old man with normal labs. I have to learn to trust my instinct and the data. So, I need to know what his calcium score is—whether it is zero, between 1 and 100, or over 100—so that I can decide whether to start statin therapy or order other tests. This allows me to order tests earlier.

Kevin Pho: In a primary care setting, where I see a lot of South Asian patients myself, tell us about some of the things I need to look out for to consider some of these tests you’re ordering in your cardiology clinic. Is there anything in the history that would get my antenna up to look for potential early heart disease?

Monzur Morshed: OK. Very good question. First, as we know, Dr. Kevin, we listen to the patient and the symptoms they’re describing. But besides the symptoms, is anything else going on in their family or their life? Is there stress? Is there a family history of heart disease? So again, we do basic tests like an EKG and various lab tests. In addition, we can do more specific tests, like I said: lipoprotein(a), apolipoprotein B, and a high-sensitivity CRP test.

Then, look into their BMI to see if it fits. We look at the ASCVD risk to see whether it’s borderline or higher. We also have to educate the patient about their diet and lifestyle, in addition to controlling their other chronic issues and managing psychosocial factors. Those are the things we need to address.

Kevin Pho: You mentioned apolipoprotein B, which is a test many physician influencers mention. Tell us a little bit about that specific test.

Monzur Morshed: Yes, those are very new tests nowadays, so we have to focus on them. Lipoprotein(a) and apolipoprotein B are two markers to consider in addition to bad cholesterol, or LDL. If these tests are elevated, you know the patient is going in the wrong direction, toward having heart disease in the future. So we have to act quickly so that this patient will not have a heart attack or cardiac event in the near future.

And we also sometimes look at the ratio—what is the LDL to HDL ratio? For many South Asians, as I mentioned, LDL could be low or normal, but their HDL could also be low. We have to know what their ratios are so we can manage those patients appropriately.

Kevin Pho: When it comes to statin medications, I sometimes feel they have a stigma attached to them. Many patients have talked to others on statins who have muscle aches or elevated liver enzymes, and they’re very hesitant to go on them despite all the data supporting how they reduce the risk of cardiac events. So when patients are hesitant about starting a statin, even when it’s indicated, what do you tell them?

Monzur Morshed: OK, that’s a very good question. Yes, a lot of patients are hesitant to start statin therapy because of muscle aches. Sometimes they hear things on social media that they might get dementia. But again, not everybody will get muscle aches. If they do, it’s usually a proximal muscle ache, and it can be temporary. We can lower the dose, take a holiday break from the medicine, or switch to another medication so the patient can adjust.

They have to know that while they might get a little muscle ache, they will likely get used to it. And as I said, if someone gets a muscle ache, we have all these options to eliminate it. But they have to understand that a cardiac event can be deadly. It might only happen one time, and he or she might not survive. So this is very important because we can reduce atherosclerosis with this medication. It’s a revolutionary medicine, and new medications are coming out every day.

If somebody doesn’t want to take an oral pill, we can reassess their cardiac profile to see if they can get an injection every one or two weeks. Or even, Dr. Kevin, the PCSK9 inhibitor inclisiran can be given every three or six months. We can manage this, especially for somebody who has already had a cardiac event or has a stent. They have to get their LDL lower than 55. To achieve that, we can sometimes order medications like Repatha, Praluent, or even inclisiran in addition to statin therapy to lower the LDL even further. This is very crucial.

So, talk to your primary care physician or your cardiologist if you have any muscle ache. We can manage it in other ways. There are a lot of options we can use to eliminate that muscle ache or any other minor side effect you might have.

Kevin Pho: We’re talking with Monzur Morshed. He’s a cardiologist, and today’s KevinMD article is “Why South Asians in the U.S. face a silent heart disease crisis.” Monzur, let’s end with some take-home messages you want to leave with the KevinMD audience.

Monzur Morshed: So, my take-home messages. First of all, I want to talk to my fellow clinicians.

• Reassess your risk models: Traditional calculators often fail South Asian patients.
• Do not wait for symptoms: Many South Asians with severe disease are asymptomatic.
• Look beyond the labs: Consider waist circumference, lipoprotein(a), and the triglyceride-to-HDL ratio.
• Acknowledge the stress: Legal trouble, immigration, divorce, and loneliness can all play a role.
• Partner with community leaders: If you need to, go to a temple, mosque, or church. South Asian associations can be a great avenue for spreading awareness.
• Create safety in your exam room: Minority men often don’t feel safe being vulnerable.
• Expand your definition of risk: Write and speak about it when you can.

I also want to say that heart disease is sometimes a very silent suffering among minority men. They are probably battling legal issues, broken families, and unspoken fears, which can drive heart disease. We must treat the emotional wounds, not just the physical ones. So I will ask my fellow clinicians to listen harder, ask deeper, and treat the patient, not just the pathology. Because sometimes the most dangerous arrhythmia is a heart that has been silenced for too long.

Kevin Pho: Monzur, thank you so much for sharing your perspective and insight, and thanks again for coming on the show.

Monzur Morshed: Thank you for having me.