Although cardiovascular disease (CVD) is the world’s largest cause of mortality, its burden varies by ethnicity. People from South Asia, including Bangladesh, Sri Lanka, Nepal, India, and Pakistan, are among the groups most at risk for developing coronary artery disease too soon. However, this population frequently receives standard risk assessments in clinical practice across the U.S. that do not take ethnic-specific risk factors into consideration, which results in underdiagnosis and undertreatment.

I have direct experience with the way that lifestyle, genetics, and cultural barriers combine to cause a silent epidemic of cardiovascular disease among South Asians as a practicing cardiologist in New York City, where I treat a sizable Bangladeshi-American community. Key clinical factors that all providers should be aware of are outlined in this article.

Early onset and genetics. Despite having normal or slightly raised LDL levels, South Asians are more likely than other populations to develop coronary artery disease (CAD) and to have symptoms 5–10 years earlier. Even in those who are not fat, the prevalence of insulin resistance, increased lipoprotein(a), and tiny dense LDL particles is much higher in this group.

Clinical tip: Use aggressive screening. Even in patients without conventional high-risk profiles, take into account CAC score and advanced lipid tests, particularly in males over 30 and females over 35.

Dietary illusions. Vegetarianism is popular among South Asians, although it’s not always heart-healthy. Diets that include fried foods, a lot of carbohydrates, and trans fats from ghee or leftover cooking oil are common. Insulin resistance and metabolic syndrome are exacerbated by a high glycemic load.

Clinical tip: Consult a nutritionist who is sensitive to cultural differences. Promote little substitutions, such as using brown rice instead of white, baking instead of frying, and being mindful of portion proportions.

The “thin-fat” phenotype and central obesity. South Asian patients frequently have normal BMIs but larger waist circumferences and visceral fat, particularly in men from Bangladesh and Pakistan. These people frequently experience early-onset diabetes and hypertension, sometimes going undiagnosed until a heart attack.

Clinical tip: BMI isn’t enough. For all persons over 30, use the waist-to-hip ratio and think about screening for insulin resistance.

Statin and preventive therapy underutilization. South Asians benefit from starting statins early, even if they may be more statin-sensitive. However, poor adherence to statins and antihypertensives is frequently caused by cultural opposition, ignorance, and language problems.

Clinical tip: To increase health literacy, use interpreters and visual aids. Handle your “fears” with empathy. In this population, a shared-decision model is more effective than directive therapy.

Legal and psychosocial stress. Numerous immigrants, particularly first-generation South Asian men, deal with ongoing stress, unstable employment, or even legal disputes, all of which increase cardiovascular risk by prolonged sympathetic overdrive. Silent ischemia and early myocardial infarction are made worse by the cultural stigma associated with seeking mental health treatment.

Clinical tip: Check for stress and mental health. Collaborate with primary care physicians or therapists who are attentive to cultural differences. When South Asian males exhibit unusual chest pain or palpitations, don’t undervalue the emotional toll they are carrying.

Cultural barriers to care access. I’ve seen patients in NYC avoid care because of religious fasting (such as during Ramadan), linguistic challenges, or immigration anxieties. Due to cultural modesty or a lack of control over their health care choices, female patients may postpone appointments.

Clinical tip: Reach is important.

Conclusion

Clinicians need to understand that South Asians are not covered by “normal” risk calculators. By default, treat them as high-risk. Underestimating comes at too great a cost.

Additionally, we must go beyond statistics by comprehending the barriers, culture, and behavior that are particular to this dynamic but vulnerable community. To narrow the equity gap in preventive and care, cardiologists, primary care physicians, and nurse practitioners must collaborate.

Monzur Morshed is a cardiologist. Kaysan Morshed is a medical student.