Friday , April 27 2018
Latest Article
Home / Abstracts / Coronary Artery Disease in South Asians
Coronary Artery Disease in South Asians

Coronary Artery Disease in South Asians

Disclosures: No relevant disclosures Address for Correspondence: Mintu P. Turakhia, M.D. M.A.S Palo Alto VA Health Care System Stanford University 3801 Miranda Ave – 111C Palo Alto CA 94304 Tel (650) 858-3932 Fax (866) 756-3025 E-mail: mintu@stanford.edu Sources of Funding: Dr. Turakhia was supported by a Veterans Health Services Research & Development Career Development Award (CDA09027-1) and an American Heart Association National Scientist Development Grant (09SDG2250647). Abstract Coronary heart disease is a leading cause of death worldwide, and has been shown to have a high prevalence among South Asians living on and off the Indian subcontinent. This has largely been attributed to both an increased prevalence of traditional risk factors as well as higher levels of novel markers and biomarkers of risk. Compared to Caucasians and most other racial groups, South Asians with coronary heart disease and myocardial infarction tend to present earlier, largely explained by a greater prevalence of risk factors at a younger age. Genetic factors, lifestyle, and urbanization have all been implicated as the reasons for this increased risk and high prevalence of heart disease. New programs aimed at screening younger South Asians have been successful at identifying risk factors for treatment and lifestyle modification. Practitioners should be aware of the increased cardiovascular risk in South Asians, screen for risk factors starting at a younger age, and recommend aggressive medical and lifestyle risk factor modification. Introduction Coronary heart disease(CHD) is a leading cause of death worldwide.1 When compared to other ethnicities, South Asians have a high prevalence of coronary artery disease and associated risk factors.1-3  South Asians are individuals originally from the countries comprising the Indian subcontinent including India, Pakistan, Nepal, Bangladesh and Sri Lanka. The World Health Organization (WHO) reports that CHD will be the largest cause of death and disability by 2020. South Asians make up 25% of the global population, but over 50% of the world’s cardiovascular deaths will be in persons of South Asians origin.1, 2 South Asians have a three to five fold increased risk of myocardial infarction.4 South Asians also present with more severe disease and at an earlier age than Caucasians.5 Because the South Asian population is growing rapidly not only in India, but also abroad, it is important to address and appropriately manage this increased cardiovascular risk.6 Prevalence of coronary disease in South Asians The prevalence of coronary artery disease (CAD) is high among native South Asians as well as migrant South Asians. Prevalence estimates over the last thirty years range from 7.6 to 11% (Table 1).1, 4, 7-10 The Chennai Urban Population Study, which studied subjects in two residential areas in southern India, found an overall CAD prevalence of 11.0%.11 A study of over 2000 subjects in Jaipur, India found an overall prevalence of 7.59% based on standardized questionnaire and electrocardiogram changes.12 A study in Delhi, India of over 13,000 subjects cited a prevalence of 9.7%.13 Similar rates have been reported in studies off the Indian subcontinent as well. The Canadian Study of Health assessment and Risk in Ethnic Groups (SHARE) that South Asians had a CAD prevalence of 10.7%, significantly greater than the prevalence of CAD in the European (4.6%) and Chinese populations (1.7%).14 Mortality attributable to coronary heart disease CHD mortality in South Asians is 40-60% higher compared to the population averages.15 One of the earliest reports of high coronary heart disease rates among South Asians was from Singapore in a study of 9,568 autopsies in the 1950s, which reported a seven-fold higher incidence of coronary heart disease among South Asians in comparison to the Chinese population.16 The 1994 WHO report stated that cardiovascular mortality in individuals less than 70 years of age was 52.2% in India compared to 26.5% in developed countries.17Similar results were found in an analysis of cause-specific death rates among Canadians of European, South Asian, and Chinese origin which showed that those of South Asian and European origin had significantly higher death rates from ischemic heart disease when compared to those of Chinese origin.18 This was confirmed by a study in the UK which reported higher mortality ratios from ischemic heart disease among South Asians compared to European controls.19 The Study of Health Assessment and Risk in Ethnic groups trial (SHARE) based in Canada compared individuals of South Asian, Chinese and European origin, and found subclinical atherosclerosis to be more prevalent among South Asians than the Chinese and European populations. South Asian origin was also an independent predictor of cardiovascular mortality.14  This has also been validated in the United States South Asian population. An analysis of the California Mortality Database between 1990 and 2000 found that both South Asian men and women had higher proportional mortality ratios when compared to six other ethnicities.20Furthermore, South Asians present with myocardial infarction and coronary disease up to 10 years earlier than Caucasians and other racial groups further contributing to increased prevalence in this group.3, 21, 22 There are two leading explanations for the high disease burden in South Asians. The first is that South Asians have a high prevalence of traditional risk factors, which leads to developing coronary disease at a young age. The second is that South Asians have novel risk factors, usually biomarker based, that account for the variation in risk independent of traditional risk factors. Traditional Risk factors While it is well established that South Asians have a higher burden of cardiovascular mortality, studies attribute this increased prevalence to an increased prevalence of cardiovascular risk factors including age, hypertension, hyperlipidemia, diabetes and smoking, based on the Framingham population. However, the Framingham risk score, when applied to South Asians, results in underestimation of cardiovascular risk among South Asians because of the statistical bias towards age when calculating the Framingham score. South Asians present with coronary artery disease at a younger age than their ethnic counterparts, largely explained by increased prevalence of risk factors at a young age.21 In Western populations, it has been found that CAD occurs up to 10 years earlier in South Asians when compared to the general population.3, 21-23 Acute myocardial infarction (AMI) has also been reported at a younger age in South Asian emigrants vs. South Asian natives largely explained by the increased prevalence of risk factors at an earlier age among South Asians.9, 22, 24 25 Absence of risk factors during adolescence, and rapid development of risk factors during ages 30-39 suggesting a need for active screening of South Asians early to prevent disease.26 Another study by Ismail et al found similar results, attributing the increased prevalence of myocardial infarction at a younger age in South Asians to an increased prevalence of cardiovascular risk factors including tobacco use, ghee intake, elevated fasting glucose, high cholesterol, paternal history of cardiovascular disease, low income and low level of education.22 The INTERHEART case control study analyzed risk factors for acute myocardial infarction (AMI) in 52 countries across various ethnicities including South Asians. Compared to controls, in patients with AMI across all regions, 90% of the attributable risk of MI was from nine risk factors including:  smoking, increased apolipoprotein B/apolipoprotein A-I ratio, hypertension, diabetes mellitus, abdominal obesity, and psychosocial stress. The study concluded that >90% of the global risk of cardiovascular disease is preventable by appropriately managing these nine risk factors.9 Furthermore because these risk factors were more prevalent at an earlier age this can partially explain the increased prevalence of AMI in a younger age among South Asians. Diabetes and Metabolic Syndrome Diabetes mellitus has a high prevalence among South Asians and is a predictor of cardiovascular mortality.27, 28 A study of urban South Indians found that diabetic subjects had twofold higher mortality rates when compared to those without diabetes.29 The SHARE study found glucose intolerance or diabetes in one-third of the South Asian population studied, markedly higher than other ethnicities.14 A study in Atlanta, Georgia found that type II diabetes was prevalent in 18.3% of South Asian immigrants which was significantly greater than the local Caucasian, African American and Hispanic populations.30 South Asians in the UK are three to five-fold more likely to have diabetes than their ethnic counterparts.31 Furthermore South Asian diabetics are thought to have a two to four-fold greater mortality than European diabetics.32, 33 Metabolic syndrome has been recognized as a set of risk factors for CAD including dyslipidemia, low HDL, hypertension, glucose intolerance, and abdominal obesity.34, 35 Metabolic syndrome has been associated with a twofold greater risk of CAD and a five-fold greater risk of developing diabetes.36 South Asians have a strikingly high prevalence of metabolic syndrome and glucose intolerance both on the Indian subcontinent and off the subcontinent.25, 28, 37, 38 In India the prevalence of metabolic syndrome was 41.1% in a study of 475 individuals aged 20-75 years of age.39 A study in the UK showed that metabolic syndrome among British South Asians was 39%, significantly greater than the 20% prevalence noted in British Caucasians.40 A study of South Asians living in California found a 27% prevalence of metabolic syndrome.28 The high prevalence of metabolic syndrome among South Asians can be explained by the “adipose tissue overflow hypothesis” which suggests that subcutaneous adipose tissue is less developed in South Asians causing earlier utilization of visceral adipose tissue resulting in an increased atherogenic profile at similar BMIs when compared to Caucasians.9, 41, 42 Dyslipidemia An abnormal lipid profile is a strong predictor of cardiovascular disease. Increased total cholesterol, increased LDL levels, increased triglycerides, and low levels of HDL increase cardiovascular risk. 17, 43 Total cholesterol levels correlate with increased risk of cardiovascular events. Serum cholesterol levels are relatively high in the economically privileged in India, and are higher in South Asian migrants when compared to Caucasian controls.15, 44 In the SHARE study, total cholesterol levels were found to be significantly higher in South Asians, when compared to the Chinese and European controls.14 High LDL is a risk factor for cardiovascular disease, however LDL levels in South Asians are comparable to other populations.4, 45 The SHARE study found slightly increased LDL levels in South Asians when compared to Europeans and Chinese. Small dense LDL particles are also an important risk factor for atherogenesis.46-48 Elevated levels of small, dense LDL are associated with a two to threefold higher risk of cardiovascular disease and atherogenesis.48Among South Asians, the prevalence of small dense LDL particles ranges from 35-45%.44, 46, 49 While Kulkarni et al found elevated levels of small, dense LDL particles in South Asians when compared to their ethnic counterparts, another study found no statistically significant difference.44, 46 This data must be validated with further studies given conflicting studies. Patients with high triglyceride levels also may be at increased risk for cardiovascular disease. High triglycerides promote elevated levels of small, dense LDL, which are atherogenic.50 Patel et al reported that elevated triglycerides are associated with a more atherogenic lipid profile, with higher cholesterol levels, lower HDL levels, and smaller and denser LDL particles.51 South Asians have higher triglyceride levels when compared to other ethnicities.43, 44, 52-55  In Fiji, South Asians had 30% higher triglyceride levels in comparison to the native population.56 HDL is a lipid subparticle thought to participate in reverse cholesterol transport. Low levels of HDL have been defined as a cardiovascular risk factor.14, 45 South Asians have lower HDL when compared to their ethnic counterparts potentially explaining increased atherogenesis in this population.3, 4, 14, 27, 57, 58 Anand et alfound significantly lower levels of HDL in South Asians when compared to the European  and Chinese populations.14 High levels of small, less protective HDL have also been seen among South Asians, and is cited as a possible explanation for increased cardiovascular risk seen among South Asians.4, 44 Smoking Smoking is widely prevalent among South Asians, especially on the Indian subcontinent. More than one-third of South Asian native men, a few percent of women use tobacco, and there are estimated to be 120 million smokers in India.59 A recent national study found a strikingly high prevalence of smoking and attributed smoking to be the cause of death in 5% of women and 20% of men in India.60 A study by Pais et al found cigarette smoking to be the strongest predictor of first acute myocardial infarction on the Indian subcontinent.61 However, the prevalence of CAD remains high in South Asian migrants despite decreased prevalence of smoking when compared to their ethnic counterparts, suggesting the need to study other risk factors.1, 3, 17 Emerging Risk Factors In addition to traditional risk factors, over the last two decades several biomarkers thought to predict cardiovascular risk and myocardial infarction have been identified. These biomarkers include lipoprotein(a), apolipoprotein B100, and CRP levels. These biomarkers have been primarily studied among Caucasians, however there are have been some reports of increased prevalence of these novel risk factors in the South Asian population. Lipoprotein(a) has identified as an independent risk factor for early development of coronary artery disease independent of diet.2, 4, 62-65It has also been cited as a predictor of development of premature coronary artery disease.62 South Asians off the Indian subcontinent have been found to higher levels of lipoprotein(a) when compared to their ethnic counterparts.58, 66, 67 South Asian migrants have higher lipoprotein(a) levels than South Asian natives.58 Apolipoprotein-B100 to apolipoprotein-AI ratio can predict atherogenesis, and is more prevalent in South Asians vs. other ethnicities.68, 69 In the INTERHEART study, Joshi et al found that the prevalence of elevated apolipoprotein-B100 to apolipoprotein –AI ratio to be higher among South Asians with MI when compared to subjects from other countries (61.5% vs. 48.3%).21 Elevated CRP has been shown to be a marker of atherogenesis and vascular inflammation, as well as a predictor of plaque rupture and cardiovascular risk.2, 70, 71 CRP levels are higher in South Asians vs. Caucasian patients suggesting a pro-inflammatory state. A study in the UK of over 1,000 healthy adults found increased levels of CRP among South Asians vs. European whites; furthermore, the study suggested that increased levels of CRP were also associated with traditional cardiovascular risk factors.72  This was validated by a study in Canada which found CRP levels to be significantly elevated in South Asians vs. Chinese and European populations in a study of 1250 subjects in Canada.14 Lifestyle factors Urbanization and lifestyle factors may contribute to increased incidence of CAD and risk factors. It was observed as early as 1962 that there is an increased prevalence of disease and risk factors in urban India when compared to rural India.8-10, 73, 74 This suggests that urbanization may contribute to increased cardiovascular risk as evidenced by the increased prevalence of disease and cardiovascular risk factors in urban vs. rural India including increased BMI, low HDL, high triglycerides, diabetes, hypertension and lifestyle factors including exercise and calorie intake.7, 13, 75, 76 Studies showed lower rates of diabetes mellitus among rural South Asians vs. urban South Indians as well.30, 77 In a review of studies reporting serum cholesterol levels,  high average serum cholesterol values were more prevalent in urban South Asians of a high socioeconomic strata vs. a low socioeconomic strata and in South Asians overseas vs. South Asians on the Indian subcontinent.15 Hypertension however, was reported as having a consistently high prevalence between urban and rural South Asian patients.78 Generally, however this increased prevalence of cardiovascular risk factors in urban South Asians holds true in South Asian migrants as well. Furthermore South Asians tend to be more physically inactive than their ethnic counterparts. Physical inactivity is another risk factor highly prevalent among South Asians.9  In a study based in Delhi of 276 newly diagnosed CHD patients, sedentary lifestyle was characteristic of 97% of the cohort.79 In a study based in the UK, South Asian patients were more likely to be sedentary vs. white patients (47.0% vs. 28.1%), and this physical inactivity explained >20% of excess coronary heart disease mortality among South Asians after adjustment for confounders.80 Advances to address public health burden Risk scores to estimate short and long-term risk of heart disease or cardiovascular events have been derived to estimate risk at point of clinical care. The Framingham Risk Score is the most commonly used of these.81The risk score is a weighted sum of age, gender, total cholesterol, HDL cholesterol, smoking status and systolic blood pressure and can estimate the 10-year risk of CHD. However, the Framingham score markedly underestimates cardiovascular risk in South Asians, primarily because of the statistical bias towards advanced age. Therefore, South Asian individuals below age 50 or 60 have a marked underestimation of CHD risk, even though they have a high prevalence of CHD risk factors at younger ages. Recognizing this risk, Bainey et alproposed an algorithm to actively screen for CAD among South Asians living off the Indian subcontinent by addressing the need for modification of the traditional Framingham risk factors, and by advocating that the Framingham score be multiplied by 1.4 to accurately assess cardiovascular risk.17 The South Asian Heart Center (SAHC), located in the Bay Area in California is an organization dedicated to addressing this strikingly high prevalence of cardiovascular disease South Asians face.  Through education, lifestyle changes, risk factor screening, and consistent follow up, SAHC aims to provide cardiovascular care catered to the Bay Area South Asian population. Awareness is the first step to addressing this epidemic, and more organizations like SAHC are needed to appropriately treat and prevent heart disease among South Asians.28 There is a high prevalence of cardiovascular disease and cardiovascular risk factors among South Asians. In order to prevent premature disease and decrease the prevalence of disease, both awareness and action is necessary.  Thus, to prevent CAD among South Asians, preventative measures such as education, dietary and lifestyle modification, screening for metabolic syndrome, cardiovascular risk factor reduction and regular follow up with care providers is paramount.17, 21, 82

References

  1. Yusuf S, Reddy S, Ounpuu S, Anand S. Global burden of cardiovascular diseases: Part II: variations in cardiovascular disease by specific ethnic groups and geographic regions and prevention strategies. Circulation. 2001 Dec;104(23):2855-64.
  2. Palaniappan LP, Araneta MR, Assimes TL, et al. Call to action: cardiovascular disease in Asian Americans: a science advisory from the American Heart Association. Circulation. 2010 Sep;122(12):1242-52.
  3. Enas EA, Garg A, Davidson MA, Nair VM, Huet BA, Yusuf S. Coronary heart disease and its risk factors in first-generation immigrant Asian Indians to the United States of America. Indian Heart J. 1996 1996 Jul-Aug;48(4):343-53.
  4. Gupta M, Singh N, Verma S. South Asians and cardiovascular risk: what clinicians should know. Circulation. 2006 Jun;113(25):e924-9.
  5. Gupta M, Doobay AV, Singh N, et al. Risk factors, hospital management and outcomes after acute myocardial infarction in South Asian Canadians and matched control subjects. CMAJ. 2002 Mar;166(6):717-22.
  6. Ivey SL, Mehta KM, Fyr CL, Kanaya AM. Prevalence and correlates of cardiovascular risk factors in South Asians: population-based data from two California surveys. Ethn Dis. 2006;16(4):886-93.
  7. Gupta R. Recent trends in coronary heart disease epidemiology in India. Indian Heart J. 2008 2008 Mar-Apr;60(2 Suppl B):B4-18.
  8. Vaidya A, Pokharel PK, Nagesh S, Karki P, Kumar S, Majhi S. Prevalence of coronary heart disease in the urban adult males of eastern Nepal: a population-based analytical cross-sectional study. Indian Heart J. 2009 2009 Jul-Aug;61(4):341-7.
  9. Yusuf S, Hawken S, Ounpuu S, et al. Effect of potentially modifiable risk factors associated with myocardial infarction in 52 countries (the INTERHEART study): case-control study. Lancet. 2004 2004 Sep 11-17;364(9438):937-52.
  10. Latheef SA, Subramanyam G. Prevalence of coronary artery disease and coronary risk factors in an urban population of Tirupati. Indian Heart J. 2007 2007 Mar-Apr;59(2):157-64.
  11. Mohan V, Deepa R, Rani SS, Premalatha G, No.5) CUPSC. Prevalence of coronary artery disease and its relationship to lipids in a selected population in South India: The Chennai Urban Population Study (CUPS No. 5). J Am Coll Cardiol. 2001 Sep;38(3):682-7.
  12. Gupta R, Prakash H, Majumdar S, Sharma S, Gupta VP. Prevalence of coronary heart disease and coronary risk factors in an urban population of Rajasthan. Indian Heart J. 1995 1995 Jul-Aug;47(4):331-8.
  13. Chadha SL, Radhakrishnan S, Ramachandran K, Kaul U, Gopinath N. Epidemiological study of coronary heart disease in urban population of Delhi. Indian J Med Res. 1990 Dec;92:424-30.
  14. Anand SS, Yusuf S, Vuksan V, et al. Differences in risk factors, atherosclerosis, and cardiovascular disease between ethnic groups in Canada: the Study of Health Assessment and Risk in Ethnic groups (SHARE). Lancet. 2000 Jul;356(9226):279-84.
  15. McKeigue PM, Miller GJ, Marmot MG. Coronary heart disease in south Asians overseas: a review. J Clin Epidemiol. 1989;42(7):597-609.
  16. DANARAJ TJ, ACKER MS, DANARAJ W, WONG HO, TAN BY. Ethnic group differences in coronary heart disease in Singapore: an analysis of necropsy records. Am Heart J. 1959 Oct;58:516-26.
  17. Bainey KR, Jugdutt BI. Increased burden of coronary artery disease in South-Asians living in North America. Need for an aggressive management algorithm. Atherosclerosis. 2009 May;204(1):1-10.
  18. Sheth T, Nair C, Nargundkar M, Anand S, Yusuf S. Cardiovascular and cancer mortality among Canadians of European, south Asian and Chinese origin from 1979 to 1993: an analysis of 1.2 million deaths. CMAJ. 1999 Jul;161(2):132-8.
  19. Balarajan R, Bulusu L, Adelstein AM, Shukla V. Patterns of mortality among migrants to England and Wales from the Indian subcontinent. Br Med J (Clin Res Ed). 1984 Nov;289(6453):1185-7.
  20. Palaniappan L, Wang Y, Fortmann SP. Coronary heart disease mortality for six ethnic groups in California, 1990-2000. Ann Epidemiol. 2004 Aug;14(7):499-506.
  21. Joshi P, Islam S, Pais P, et al. Risk factors for early myocardial infarction in South Asians compared with individuals in other countries. JAMA. 2007 Jan;297(3):286-94.
  22. Ismail J, Jafar TH, Jafary FH, White F, Faruqui AM, Chaturvedi N. Risk factors for non-fatal myocardial infarction in young South Asian adults. Heart. 2004 Mar;90(3):259-63.
  23. Reddy KS. Cardiovascular disease in non-Western countries. N Engl J Med. 2004 Jun;350(24):2438-40.
  24. Gupta R, Joshi P, Mohan V, Reddy KS, Yusuf S. Epidemiology and causation of coronary heart disease and stroke in India. Heart. 2008 Jan;94(1):16-26.
  25. Misra A, Khurana L. The metabolic syndrome in South Asians: epidemiology, determinants, and prevention. Metab Syndr Relat Disord. 2009 Dec;7(6):497-514.
  26. Gupta R, Misra A, Vikram NK, et al. Younger age of escalation of cardiovascular risk factors in Asian Indian subjects. BMC Cardiovasc Disord. 2009;9:28.
  27. Enas EA, Mohan V, Deepa M, Farooq S, Pazhoor S, Chennikkara H. The metabolic syndrome and dyslipidemia among Asian Indians: a population with high rates of diabetes and premature coronary artery disease. J Cardiometab Syndr. 2007;2(4):267-75.
  28. Flowers E, Molina C, Mathur A, et al. Prevalence of metabolic syndrome in South Asians residing in the United States. Metab Syndr Relat Disord. 2010 Oct;8(5):417-23.
  29. Mohan V, Shanthirani S, Deepa R, Premalatha G, Sastry N, Saroja R. Intra-urban differences in the prevalence of the metabolic syndrome in southern India — the Chennai Urban Population Study (CUPS No. 4). Diabet Med. 2001 Apr;18(4):280-7.
  30. Venkataraman R, Nanda NC, Baweja G, Parikh N, Bhatia V. Prevalence of diabetes mellitus and related conditions in Asian Indians living in the United States. Am J Cardiol. 2004 Oct;94(7):977-80.
  31. McKeigue PM, Pierpoint T, Ferrie JE, Marmot MG. Relationship of glucose intolerance and hyperinsulinaemia to body fat pattern in south Asians and Europeans. Diabetologia. 1992 Aug;35(8):785-91.
  32. Chaturvedi N, Fuller JH. Ethnic differences in mortality from cardiovascular disease in the UK: do they persist in people with diabetes? J Epidemiol Community Health. 1996 Apr;50(2):137-9.
  33. Mather HM, Chaturvedi N, Fuller JH. Mortality and morbidity from diabetes in South Asians and Europeans: 11-year follow-up of the Southall Diabetes Survey, London, UK. Diabet Med. 1998 Jan;15(1):53-9.
  34. Alberti KG, Eckel RH, Grundy SM, et al. Harmonizing the metabolic syndrome: a joint interim statement of the International Diabetes Federation Task Force on Epidemiology and Prevention; National Heart, Lung, and Blood Institute; American Heart Association; World Heart Federation; International Atherosclerosis Society; and International Association for the Study of Obesity. Circulation. 2009 Oct;120(16):1640-5.
  35. Grundy SM. Obesity, metabolic syndrome, and coronary atherosclerosis. Circulation. 2002 Jun;105(23):2696-8.
  36. Enas E, Mohan V, Deepa M, Farooq S, Pazhoor S, Chennikkara H. The metabolic syndrome and dyslipidemia among Asian Indians: a population with high rates of diabetes and premature coronary artery disease. J Cardiometab Syndr. 2007;2(4):267-75.
  37. Misra A, Chowbey P, Makkar BM, et al. Consensus statement for diagnosis of obesity, abdominal obesity and the metabolic syndrome for Asian Indians and recommendations for physical activity, medical and surgical management. J Assoc Physicians India. 2009 Feb;57:163-70.
  38. Sawant A, Mankeshwar R, Shah S, et al. Prevalence of metabolic syndrome in urban India. Cholesterol. 2011;2011:920983.
  39. Ramachandran A, Snehalatha C, Satyavani K, Sivasankari S, Vijay V. Metabolic syndrome in urban Asian Indian adults–a population study using modified ATP III criteria. Diabetes Res Clin Pract. 2003 Jun;60(3):199-204.
  40. Ajjan R, Carter AM, Somani R, Kain K, Grant PJ. Ethnic differences in cardiovascular risk factors in healthy Caucasian and South Asian individuals with the metabolic syndrome. J Thromb Haemost. 2007 Apr;5(4):754-60.
  41. Sniderman AD, Bhopal R, Prabhakaran D, Sarrafzadegan N, Tchernof A. Why might South Asians be so susceptible to central obesity and its atherogenic consequences? The adipose tissue overflow hypothesis. Int J Epidemiol. 2007 Feb;36(1):220-5.
  42. Raji A, Seely EW, Arky RA, Simonson DC. Body fat distribution and insulin resistance in healthy Asian Indians and Caucasians. J Clin Endocrinol Metab. 2001 Nov;86(11):5366-71.
  43. Enas EA. Rapid angiographic progression of coronary artery disease in patients with elevated lipoprotein(a). Circulation. 1995 Oct;92(8):2353-4.
  44. Bhalodkar NC, Blum S, Rana T, et al. Comparison of levels of large and small high-density lipoprotein cholesterol in Asian Indian men compared with Caucasian men in the Framingham Offspring Study. Am J Cardiol. 2004 Dec;94(12):1561-3.
  45. Gordon DJ, Probstfield JL, Garrison RJ, et al. High-density lipoprotein cholesterol and cardiovascular disease. Four prospective American studies. Circulation. 1989 Jan;79(1):8-15.
  46. Kulkarni KR, Markovitz JH, Nanda NC, Segrest JP. Increased prevalence of smaller and denser LDL particles in Asian Indians. Arterioscler Thromb Vasc Biol. 1999 Nov;19(11):2749-55.
  47. Austin MA, Breslow JL, Hennekens CH, Buring JE, Willett WC, Krauss RM. Low-density lipoprotein subclass patterns and risk of myocardial infarction. JAMA. 1988 Oct;260(13):1917-21.
  48. Lamarche B, Tchernof A, Moorjani S, et al. Small, dense low-density lipoprotein particles as a predictor of the risk of ischemic heart disease in men. Prospective results from the Québec Cardiovascular Study. Circulation. 1997 Jan;95(1):69-75.
  49. Superko HR, Enas EA, Kotha P, Bhat NK, Garrett B. High-density lipoprotein subclass distribution in individuals of Asian Indian descent: the National Asian Indian Heart Disease Project. Prev Cardiol. 2005;8(2):81-6.
  50. Griffin BA, Freeman DJ, Tait GW, et al. Role of plasma triglyceride in the regulation of plasma low density lipoprotein (LDL) subfractions: relative contribution of small, dense LDL to coronary heart disease risk. Atherosclerosis. 1994 Apr;106(2):241-53.
  51. Patel JV, Caslake MJ, Vyas A, et al. Triglycerides and small dense low density lipoprotein in the discrimination of coronary heart disease risk in South Asian populations. Atherosclerosis. 2010 Apr;209(2):579-84.
  52. Whitty CJ, Brunner EJ, Shipley MJ, Hemingway H, Marmot MG. Differences in biological risk factors for cardiovascular disease between three ethnic groups in the Whitehall II study. Atherosclerosis. 1999 Feb;142(2):279-86.
  53. Chandalia M, Mohan V, Adams-Huet B, Deepa R, Abate N. Ethnic difference in sex gap in high-density lipoprotein cholesterol between Asian Indians and Whites. J Investig Med. 2008 Mar;56(3):574-80.
  54. Hemmings S, Conner A, Maffulli N, Morrissey D. Cardiovascular disease risk factors in adolescent British South Asians and whites: a pilot study. Postgrad Med. 2011 Mar;123(2):104-11.
  55. Miller GJ, Beckles GL, Byam NT, et al. Serum lipoprotein concentrations in relation to ethnic composition and urbanization in men and women of Trinidad, West Indies. Int J Epidemiol. 1984 Dec;13(4):413-21.
  56. Sicree RA, Tuomilehto J, Zimmet P, et al. Electrocardiographic abnormalities amongst Melanesian and Indian men of Fiji: prevalence and associated factors. Int J Cardiol. 1988 Apr;19(1):27-38.
  57. Dodani S. Excess coronary artery disease risk in South Asian immigrants: can dysfunctional high-density lipoprotein explain increased risk? Vasc Health Risk Manag. 2008;4(5):953-61.
  58. Anand SS, Enas EA, Pogue J, Haffner S, Pearson T, Yusuf S. Elevated lipoprotein(a) levels in South Asians in North America. Metabolism. 1998 Feb;47(2):182-4.
  59. Rani M, Bonu S, Jha P, Nguyen SN, Jamjoum L. Tobacco use in India: prevalence and predictors of smoking and chewing in a national cross sectional household survey. Tob Control. 2003 Dec;12(4):e4.
  60. Jha P, Jacob B, Gajalakshmi V, et al. A nationally representative case-control study of smoking and death in India. N Engl J Med. 2008 Mar;358(11):1137-47.
  61. Pais P, Pogue J, Gerstein H, et al. Risk factors for acute myocardial infarction in Indians: a case-control study. Lancet. 1996 Aug;348(9024):358-63.
  62. Bostom AG, Cupples LA, Jenner JL, et al. Elevated plasma lipoprotein(a) and coronary heart disease in men aged 55 years and younger. A prospective study. JAMA. 1996 Aug;276(7):544-8.
  63. Hoogeveen RC, Gambhir JK, Gambhir DS, et al. Evaluation of Lp[a] and other independent risk factors for CHD in Asian Indians and their USA counterparts. J Lipid Res. 2001 Apr;42(4):631-8.
  64. Bozbaş H, Yildirir A, Pirat B, et al. Increased lipoprotein(a) in metabolic syndrome: is it a contributing factor to premature atherosclerosis? Anadolu Kardiyol Derg. 2008 Apr;8(2):111-5.
  65. Danesh J, Collins R, Peto R. Lipoprotein(a) and coronary heart disease. Meta-analysis of prospective studies. Circulation. 2000 Sep;102(10):1082-5.
  66. Banerjee D, Wong EC, Shin J, Fortmann SP, Palaniappan L. Racial and Ethnic Variation in Lipoprotein (a) Levels among Asian Indian and Chinese Patients. J Lipids. 2011;2011:291954.
  67. Renges HH, Wile DB, McKeigue PM, Marmot MG, Humphries SE. Apolipoprotein B gene polymorphisms are associated with lipid levels in men of South Asian descent. Atherosclerosis. 1991 Dec;91(3):267-75.
  68. Dhawan J, Bray CL. Relationship between angiographically assessed coronary artery disease, plasma insulin levels and lipids in Asians and Caucasians. Atherosclerosis. 1994 Jan;105(1):35-41.
  69. Sharobeem KM, Patel JV, Ritch AE, Lip GY, Gill PS, Hughes EA. Elevated lipoprotein (a) and apolipoprotein B to AI ratio in South Asian patients with ischaemic stroke. Int J Clin Pract. 2007 Nov;61(11):1824-8.
  70. Pearson TA, Mensah GA, Alexander RW, et al. Markers of inflammation and cardiovascular disease: application to clinical and public health practice: A statement for healthcare professionals from the Centers for Disease Control and Prevention and the American Heart Association. Circulation. 2003 Jan;107(3):499-511.
  71. Mazer SP, Rabbani LE. Evidence for C-reactive protein’s role in (CRP) vascular disease: atherothrombosis, immuno-regulation and CRP. J Thromb Thrombolysis. 2004 Apr;17(2):95-105.
  72. Chambers JC, Eda S, Bassett P, et al. C-reactive protein, insulin resistance, central obesity, and coronary heart disease risk in Indian Asians from the United Kingdom compared with European whites. Circulation. 2001 Jul;104(2):145-50.
  73. Shrivastava P, Som D, Nandy S, et al. Profile of postmortem cases conducted at a morgue of a tertiary care hospital in Kolkata. J Indian Med Assoc. 2010 Nov;108(11):730-3.
  74. PADMAVATI S. Epidemiology of cardiovascular disease in India. II. Ischemic heart disease. Circulation. 1962 Apr;25:711-7.
  75. Gupta R. Burden of coronary heart disease in India. Indian Heart J. 2005 2005 Nov-Dec;57(6):632-8.
  76. Gupta SP, Malhotra KC. Urban–rural trends in the epidemiology of coronary heart disease. J Assoc Physicians India. 1975 Dec;23(12):885-92.
  77. McKeigue PM. Disturbances of insulin in British Asian and white men. BMJ. 1989 Nov;299(6708):1161-2.
  78. Gupta PC, Gupta R, Pednekar MS. Hypertension prevalence and blood pressure trends in 88 653 subjects in Mumbai, India. J Hum Hypertens. 2004 Dec;18(12):907-10.
  79. Bhasin SK, Dwivedi S, Dehghani A, Sharma R. Conventional risk factors among newly diagnosed coronary heart disease patients in Delhi. World J Cardiol. 2011 Jun;3(6):201-6.
  80. Williams ED, Stamatakis E, Chandola T, Hamer M. Physical activity behaviour and coronary heart disease mortality among South Asian people in the UK: an observational longitudinal study. Heart. 2011 Apr;97(8):655-9.
  81. Wilson PW, D’Agostino RB, Levy D, Belanger AM, Silbershatz H, Kannel WB. Prediction of coronary heart disease using risk factor categories. Circulation. 1998 May;97(18):1837-47.
  82. Misra A, Misra R, Wijesuriya M, Banerjee D. The metabolic syndrome in South Asians: continuing escalation & possible solutions. Indian J Med Res. 2007 Mar;125(3):345-54.
  83. Sarvotham SG, Berry JN. Prevalence of coronary heart disease in an urban population in northern India. Circulation. 1968 Jun;37(6):939-53.
  84. Gupta R, Gupta VP, Sarna M, et al. Prevalence of coronary heart disease and risk factors in an urban Indian population: Jaipur Heart Watch-2. Indian Heart J. 2002 2002 Jan-Feb;54(1):59-66.

Table 1: Prevalence of Coronary Heart Disease in South Asians*

Author Year Location Prevalence
Padmavati S74 1962 Delhi, India 1.04%
Sarvotham SG83 1968 Chandigarh 6.60%
Chadha SL13 1990 Delhi, India 9.67%
Gupta R12 1995 Jaipur, India 7.59%
Mohan V29 2001 Chennai, India 11.00%
Gupta R84 2002 Jaipur, India 8.12%
Anand SS14 2000 Canada 10.7%

*Adapted from Gupta, et al24

About hfm

Leave a Reply

Your email address will not be published. Required fields are marked *

*

You may use these HTML tags and attributes: <a href="" title=""> <abbr title=""> <acronym title=""> <b> <blockquote cite=""> <cite> <code> <del datetime=""> <em> <i> <q cite=""> <s> <strike> <strong>