People of South Asian ancestry have, on average, a higher risk of heart attack and stroke than most other groups, and heart disease tends to appear at a younger age. US cholesterol guidance has listed South Asian ancestry as a risk-enhancing factor for that reason.
This is a statement about large populations, not a prediction for any one person. Most of the extra risk traces back to familiar factors such as blood sugar, blood pressure and fat carried around the waist, and those can be measured and managed.
Key takeaways
- Large studies find roughly double the rate of heart attack and stroke in South Asian adults compared with adults of European ancestry.
- Standard risk calculators did not capture that difference in the largest study.
- Diabetes, high blood pressure and central body fat explain much of the gap, and they often show up at a lower body weight.
- Researchers have not found a risk factor unique to South Asian people.
Who the term covers
In heart research, South Asian usually means people whose families come from India, Pakistan, Bangladesh, Sri Lanka, Nepal, Bhutan or the Maldives. That is about a quarter of the world's population, with many languages, diets and ways of life.
The term is a research category. It is useful because it flags a pattern that would otherwise be hidden. An American Heart Association scientific statement points out that when all Asian Americans are counted as one group, the group looks lower risk, largely because of lower risk in East Asian populations. Looked at separately, South Asians have higher proportional death rates from artery disease than other Asian groups and non-Hispanic whites.1
What the population data show
The clearest numbers come from the UK Biobank, which followed 8,124 middle-aged adults of South Asian ancestry and more than 449,000 of European ancestry for a median of 11 years. None had known heart disease at the start.
Over that time, 6.8% of the South Asian participants had a heart attack, a stent or bypass procedure, or an ischemic stroke, compared with 4.4% of the European participants. After statistical adjustment, that worked out to about twice the risk.2
The higher relative risk was largely consistent across age groups, in men and women, and across clinical subgroups.
Earlier onset
Timing is part of the story. In the INTERHEART study, which compared heart attack patients in South Asian countries with patients in other parts of the world, the average age at a first heart attack was 53 in South Asian countries and about 59 elsewhere.
The researchers did not find a mysterious cause. The same nine risk factors explained most heart attacks in South Asians as in everyone else. The difference was that South Asian participants had more of those risk factors at younger ages. The authors concluded that this largely explains the earlier heart attacks.3
Why a risk calculator can read low
Here is the finding that matters most in a doctor's office. In the UK Biobank analysis, the 10-year risk predicted by standard US and UK calculators was nearly identical for South Asian and European participants, even though the observed risk was about twice as high.2
That gap is why guidelines add ancestry on top of the calculated number. The 2018 US cholesterol guideline included South Asian ancestry in its list of risk-enhancing factors, alongside items such as a family history of early heart disease and metabolic syndrome.4 A risk enhancer does not change the percentage. It is a reason for a clinician to look more closely when the number is borderline or intermediate.
The metabolic pattern
When the UK Biobank team looked at which factors accounted for the most risk, high blood pressure, diabetes and central adiposity, meaning fat carried around the abdomen, mattered more in South Asian participants than in European ones. The heart association statement reaches a similar view: most of the risk can be explained by known risk factors, especially those related to insulin resistance.1
Body weight can mislead here. A World Health Organization expert consultation concluded that a substantial share of Asian people are at high risk of type 2 diabetes and cardiovascular disease at a body mass index below 25, the usual cutoff for overweight.5 In plain terms, a weight that looks healthy on a standard chart does not rule out metabolic risk. Our page on insulin resistance explains what that term means and how it is assessed.
Lp(a)
Lipoprotein(a), or Lp(a), is an inherited cholesterol particle that a standard panel does not measure. In a seven-group analysis from INTERHEART, an Lp(a) level above 50 mg/dL was linked to about 48% higher odds of heart attack overall.
The share of heart attacks attributable to high Lp(a) was largest in South Asians, at 9.5%.6 Current US guidance is that every adult should have Lp(a) measured once. See our guide to the Lp(a) test for what the result means and what it cannot tell you.
What gets checked
| Check | Why it gets attention |
|---|---|
| Blood sugar and A1c | Diabetes carried more weight as a risk factor in South Asian adults in the UK Biobank study |
| Blood pressure | Also a larger contributor in the same study |
| Waist size, not only weight | Risk can be present at a lower body mass index |
| Cholesterol panel, with Lp(a) once | Lp(a) is inherited and missed by routine testing |
| Family history | A parent or sibling with early heart disease adds to the picture |
None of this is special testing. It is ordinary risk assessment done earlier and read with ancestry in mind. If relatives had heart disease young, see our guide to family history of early heart disease.
Your next step
If your calculated risk looks low but your ancestry or family history says otherwise, read our guide to the coronary calcium score, a scan clinicians sometimes use when a risk estimate is uncertain. The related reading below covers what a borderline or intermediate result means.
You can also answer the three quick questions in the screener on the Cardio Res-Q program page.
Are You a Candidate for Cardio Res-Q?
Three quick questions about the risk factors we screen for. Your answers stay between you and the clinic.
Frequently asked questions
Does this apply if I was born and raised in the United States?
The studies described here include people of South Asian ancestry living in the United Kingdom and the United States, not only people living in South Asia, and the higher risk was seen in them too. Where you grew up shapes diet, activity and access to care, so individual risk varies widely.
I am not overweight. Does the higher risk still apply to me?
It can. A World Health Organization expert group found that risk of type 2 diabetes and cardiovascular disease is substantial in Asian populations at a body mass index under 25. Waist size, blood sugar and blood pressure say more than the scale does.
Does South Asian ancestry mean I need cholesterol medication?
No. A risk-enhancing factor is a reason for a closer look, not an automatic prescription. Whether medication makes sense depends on your full risk picture and is a decision to make with your clinician.
Is there a gene that explains the higher risk?
No single cause has been identified. The American Heart Association statement says the biology of artery disease is no different in South Asians than in any other group, and that no risk factors unique to this population have been found.
Related reading
This article is for general education and is not medical advice. Decisions about testing and medication should be made with your clinician. If you have chest pain or other symptoms of a heart attack, call 911.
