Incidence and Progression of Coronary Artery Calcium in South Asians Compared With 4 Race/Ethnic Groups

Life's essential 8 and risk of subclinical atherosclerosis progression: a prospective cohort study

BACKGROUND

Previous studies have demonstrated the benefits of ideal cardiovascular health (CVH) in reducing cardiovascular risk. However, its role in subclinical atherosclerosis (SA) progression remains unclear. We aim to examine the association of CVH, estimated by the American Heart Association's new Life's Essential 8 (LE8), with the progression of SA.

METHODS

This prospective cohort study was conducted among 972 asymptomatic Chinese participants and followed up for 5.7 years. The LE8 score (range, 0-100) consisted of blood pressure, lipids, glucose, body mass index, smoking status, diet health, physical activity and sleep health was evaluated in 1998 and 2008-2009. Progression of SA was determined by carotid plaque and coronary artery calcification (CAC) in 2008-2009 and 2013-2014. Log-binomial regression model was used to estimate the association of LE8 score with SA progression.

RESULTS

Each 10 points increment in LE8 score was associated with 15.2% (RR: 0.848, 95% CI: 0.797-0.902), 17.7% (RR: 0.823, 95% CI: 0.766-0.884) and 12.0% (RR: 0.880, 95% CI: 0.845-0.916) lower risks of carotid plaque, CAC and overall SA progression, respectively. Compared with participants with non-ideal CVH at both visits, the participants with ideal CVH at both visits had 39.1% (RR: 0.609, 95% CI: 0.494-0.752), 41.0% (RR: 0.590, 95% CI: 0.456-0.764) and 29.7% (RR: 0.703, 95% CI: 0.598-0.825) lower risks of carotid plaque, CAC and overall SA progression, respectively.

CONCLUSIONS

Higher LE8 scores were associated with lower risks of SA progression. Besides, long-term maintenance of optimal CVH was more beneficial to prevent SA progression.

The utility of coronary artery calcium scoring to enhance cardiovascular risk assessment for South Asian adults

South Asian individuals represent a highly diverse population and are one of the fastest growing ethnic groups in the United States. This population has a high prevalence of traditional and non-traditional cardiovascular disease (CVD) risk factors and a disproportionately high prevalence of coronary heart disease. To reflect this, current national society guidelines have designated South Asian ancestry as a "risk enhancing factor" which may be used to guide initiation or intensification of statin therapy. However, current methods of assessing cardiovascular risk in South Asian adults may not adequately capture the true risk in this diverse population. Coronary artery calcium (CAC) scoring provides a reliable, reproducible, and highly personalized method to provide CVD risk assessment and inform subsequent pharmacotherapy recommendations, if indicated. This review describes the utility of CAC scoring for South Asian individuals.

Association of cardiovascular health with subclinical coronary atherosclerosis progression among five racial and ethnic groups: The MASALA and MESA studies

BACKGROUND AND AIMS

South Asian adults (SA) are at higher risk for atherosclerotic cardiovascular disease (ASCVD) compared with other racial/ethnic groups. Life's Simple 7 (LS7) is a guideline-recommended, cardiovascular health (CVH) construct to guide optimization of cardiovascular risk factors. We sought to assess if the LS7 metrics predict coronary artery calcium (CAC) incidence and progression in asymptomatic SA compared with four other racial/ethnic groups.

METHODS

We assessed the distribution of CVH metrics (inadequate: score 0-8, average: 9-10, optimal: 11-14, and per 1-unit higher score) and its association with incidence and progression of CAC among South Asians in the Mediators of Atherosclerosis in South Asians Living in America (MASALA) study compared with other race/ethnic groups from the Multiethnic Study of Atherosclerosis (MESA).

RESULTS

We included 810 SA, 2622 Non-Hispanic White (NHW), and 4192 Other adults (collectively 1893 Black, 1496 Hispanic and 803 Chinese American participants, respectively). SA and White participants compared to Other race/ethnicity groups were more likely to have optimal CVH metrics (26% SA vs 28% White participants vs 21% Other, respectively, p < 0.001). Similar to NHW and the Other race/ethnic group, SA participants with optimal baseline CVH were less likely to develop incident CAC on follow-up evaluation compared to participants with inadequate CVH metrics, optimal CVH/CAC = 0: 24% SA, 28% NHW, and 15% Other (p < 0.01). In multivariable linear and logistic regression models, there was no difference in annualized CAC incidence or progression between each race/ethnic group (pinteraction = 0.85 and pinteraction = 0.17, respectively). Optimal blood pressure control was associated with lower CAC incidence among SA participants [OR (95% CI): 0.30 (0.14-0.63), p < 0.01] and Other race and ethnicity participants [0.32 (0.19-0.53), p < 0.01].

CONCLUSIONS

Optimal CVH metrics are associated with lower incident CAC and CAC progression among South Asians, similar to other racial groups/ethnicities. These findings underscore the importance of optimizing and maintaining CVH to mitigate the future risk of subclinical atherosclerosis in this higher risk population.

Lipid Association of India 2023 update on cardiovascular risk assessment and lipid management in Indian patients: Consensus statement IV

OBJECTIVE

In 2016, the Lipid Association of India (LAI) developed a cardiovascular risk assessment algorithm and defined low-density lipoprotein cholesterol (LDL-C) goals for prevention of atherosclerotic cardiovascular disease (ASCVD) in Indians. The recent refinements in the role of various risk factors and subclinical atherosclerosis in prediction of ASCVD risk necessitated updating the risk algorithm and treatment goals.

METHODS

The LAI core committee held twenty-one meetings and webinars from June 2022 to July 2023 with experts across India and critically reviewed the latest evidence regarding the strategies for ASCVD risk prediction and the benefits and modalities for intensive lipid lowering. Based on the expert consensus and extensive review of published data, consensus statement IV was commissioned.

RESULTS

The young age of onset and a more aggressive nature of ASCVD in Indians necessitates emphasis on lifetime ASCVD risk instead of the conventional 10-year risk. It also demands early institution of aggressive preventive measures to protect the young population prior to development of ASCVD events. Wide availability and low cost of statins in India enable implementation of effective LDL-C-lowering therapy in individuals at high risk of ASCVD. Subjects with any evidence of subclinical atherosclerosis are likely to benefit the most from early aggressive interventions.

CONCLUSIONS

This document presents the updated risk stratification and treatment algorithm and describes the rationale for each modification. The intent of these updated recommendations is to modernize management of dyslipidemia in Indian patients with the goal of reducing the epidemic of ASCVD among Indians in Asia and worldwide.

Diabetes in South Asians: Uncovering Novel Risk Factors With Longitudinal Epidemiologic Data: Kelly West Award Lecture 2023

South Asian populations have a higher prevalence and earlier age of onset of type 2 diabetes and atherosclerotic cardiovascular diseases than other race and ethnic groups. To better understand the pathophysiology and multilevel risk factors for diabetes and cardiovascular disease, we established the Mediators of Atherosclerosis in South Asians Living in America (MASALA) study in 2010. The original MASALA study cohort (n = 1,164) included 83% Asian Indian immigrants, with an ongoing expansion of the study to include individuals of Bangladeshi and Pakistani origin. We have found that South Asian Americans in the MASALA study had higher type 2 diabetes prevalence, lower insulin secretion, more insulin resistance, and an adverse body composition with higher liver and intermuscular fat and lower lean muscle mass compared with four other U.S. race and ethnic groups. MASALA study participants with diabetes were more likely to have the severe hyperglycemia subtype, characterized by β-cell dysfunction and lower body weight, and this subtype was associated with a higher incidence of subclinical atherosclerosis. We have found several modifiable factors for cardiometabolic disease among South Asians including diet and physical activity that can be influenced using specific social network members and with cultural adaptations to the U.S. context. Longitudinal data with repeat cardiometabolic measures that are supplemented with qualitative and mixed-method approaches enable a deeper understanding of disease risk and resilience factors. Studying and contrasting Asian American subgroups can uncover the causes for cardiometabolic disease heterogeneity and reveal novel methods for prevention and treatment.

Beyond the Basics: Unraveling the Complexity of Coronary Artery Calcification

Coronary artery calcification (CAC) is mainly associated with coronary atherosclerosis, which is an indicator of coronary artery disease (CAD). CAC refers to the accumulation of calcium phosphate deposits, classified as micro- or macrocalcifications, that lead to the hardening and narrowing of the coronary arteries. CAC is a strong predictor of future cardiovascular events, such as myocardial infarction and sudden death. Our narrative review focuses on the pathophysiology of CAC, exploring its link to plaque vulnerability, genetic factors, and how race and sex can affect the condition. We also examined the connection between the gut microbiome and CAC, and the impact of genetic variants on the cellular processes involved in vascular calcification and atherogenesis. We aimed to thoroughly analyze the existing literature to improve our understanding of CAC and its potential clinical and therapeutic implications.

Association of diabetes with coronary artery calcium in South Asian adults and other race/ethnic groups: The multi-ethnic study of atherosclerosis and the mediators of atherosclerosis in South Asians living in America study

PURPOSE

South Asian (SA) persons have increased risks for diabetes mellitus (DM) and atherosclerotic cardiovascular disease (ASCVD). We examined whether the association of DM with subclinical atherosclerosis assessed by coronary artery calcium (CAC) differs in SA versus other ethnic groups.

METHODS

We studied adults from the Multi-Ethnic Study of Atherosclerosis and the Mediators of Atherosclerosis in South Asians Living in America studies without ASCVD. CAC was examined among those normoglycemic, pre-DM and DM. Logistic regression examined pre-DM and DM with the odds of any CAC > 0 and CAC ≥ 100.

RESULTS

Among 7562 participants, CAC > 0 and CAC ≥ 100 in those with DM was highest in non-Hispanic White (NHW) (80% and 48%) and SA (72% and 41%) persons. Adjusted Ln (CAC + 1) was highest in NHW (3.68 ± 0.21) and SA (3.60 ± 0.23) (p < .01) DM patients. SA and NHW adults with DM (vs normoglycemic) had highest odds of CAC > 0 (2.13 and 2.27, respectively, p < .01). For CAC ≥ 100, SA and Chinese adults had the highest odds (2.28 and 2.27, respectively, p < .01). Fasting glucose and glycated hemoglobin were most strongly associated with CAC among SA.

CONCLUSIONS

Diabetes mellitus most strongly relates to any CAC in SA and NHW adults and CAC ≥ 100 in SA and Chinese adults, helping to explain the relation of DM with ASCVD in these populations.

A South Asian Mediterranean-style diet is associated with favorable adiposity measures and lower diabetes risk: The MASALA cohort

OBJECTIVE

The Mediterranean diet is associated with lower risks for type 2 diabetes (T2D) and cardiovascular disease in certain populations, although data among diverse groups are limited. This study evaluated cross-sectional and prospective associations between a novel South Asian Mediterranean-style (SAM) diet and cardiometabolic risk among US South Asian individuals.

METHODS

The study included 891 participants at baseline in the Mediators of Atherosclerosis in South Asians Living in America (MASALA) study. Culturally relevant foods were grouped into nine categories to construct the SAM score. The study examined associations of this score with cardiometabolic risk factors and incident T2D.

RESULTS

At baseline, higher adherence to the SAM diet was associated with lower glycated hemoglobin (-0.43% ± 0.15% per 1-unit increase in SAM score; p = 0.004) and lower pericardial fat volume (-1.22 ± 0.55 cm3 ; p = 0.03), as well as a lower likelihood of obesity (odds ratio [OR]: 0.88, 95% CI: 0.79-0.98) and fatty liver (OR: 0.82, 95% CI: 0.68-0.98). Over the follow-up (~5 years), 45 participants developed T2D; each 1-unit increase in SAM score was associated with a 25% lower odds of incident T2D (OR: 0.75, 95% CI: 0.59-0.95).

CONCLUSIONS

A greater intake of a SAM diet is associated with favorable adiposity measures and a lower likelihood of incident T2D.

A multilevel framework to investigate cardiovascular health disparities among South Asian immigrants in the United States

PURPOSE

Prior studies of cardiovascular health (CVH) disparities among immigrants of South Asian origin in the United States have examined South Asians as one homogenous group, focused primarily on Indian-origin immigrants, and examined risk at the individual level.

METHODS

We present current knowledge and evidence gaps about CVH in the three largest South Asian-origin populations in the United States-Bangladeshi, Indian, and Pakistani-and draw on socioecological and lifecourse frameworks to propose a conceptual framework for investigating multilevel risk and protective factors of CVH across these groups.

RESULTS

The central hypothesis is that CVH disparities among South Asian populations exist due to differences in structural and social determinants, including lived experiences like discrimination, and that acculturation strategies and resilience resources (e.g., neighborhood environment, education, religiosity, social support) ameliorate stressors to act as health protective factors.

RESULTS

Conclusions: Our framework advances conceptualization of the heterogeneity and drivers of cardiovascular disparities in diverse South Asian-origin populations. We present specific recommendations to inform the design of future epidemiologic studies on South Asian immigrant health and the development of multilevel interventions to reduce CVH disparities and promote well-being.

Leveling the playing field: The utility of coronary artery calcium scoring in cardiovascular risk stratification in South Asians

South Asian (SA) individuals, particularly those that reside in the United States and other Westernized countries, are at an elevated risk for ASCVD and mortality related to ASCVD. The 2018 ACC/AHA/Multi-society Cholesterol guideline listed SA as a high-risk ethnicity, underscoring the importance of treating modifiable risk factors to reduce ASCVD burden. Coronary artery calcium (CAC), a highly specific marker of subclinical atherosclerosis, may be a useful test to improve risk stratification among SA individuals. CAC testing is a cost-effective, highly reproducible, and specific marker of subclinical atherosclerosis, shown to improve ASCVD risk assessment across all racial/ethnic groups, thereby serving as a guide for initiating or deferring preventive therapies. In this White Paper we will discuss the use of CAC scoring to optimize risk stratification and delivery of preventive therapies to individuals of SA ethnicity.

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.

Comparing the pooled cohort equations and coronary artery calcium scores in a symptomatic mixed Asian cohort

Background

The value of pooled cohort equations (PCE) as a predictor of major adverse cardiovascular events (MACE) is poorly established among symptomatic patients. Coronary artery calcium (CAC) assessment further improves risk prediction, but non-Western studies are lacking. This study aims to compare PCE and CAC scores within a symptomatic mixed Asian cohort, and to evaluate the incremental value of CAC in predicting MACE, as well as in subgroups based on statin use.

Methods

Consecutive patients with stable chest pain who underwent cardiac computed tomography were recruited. Logistic regression was performed to determine the association between risk factors and MACE. Cohort and statin-use subgroup comparisons were done for PCE against Agatston score in predicting MACE.

Results

Of 501 patients included, mean (SD) age was 53.7 (10.8) years, mean follow-up period was 4.64 (0.66) years, 43.5% were female, 48.3% used statins, and 50.0% had no CAC. MI occurred in 8 subjects while 9 subjects underwent revascularization. In the general cohort, age, presence of CAC, and ln(Volume) (OR = 1.05, 7.95, and 1.44, respectively) as well as age and PCE score for the CAC = 0 subgroup (OR = 1.16 and 2.24, respectively), were significantly associated with MACE. None of the risk factors were significantly associated with MACE in the CAC > 0 subgroup. Overall, the PCE, Agatston, and their combination obtained an area under the receiver operating characteristic curve (AUC) of 0.501, 0.662, and 0.661, respectively. Separately, the AUC of PCE, Agatston, and their combination for statin non-users were 0.679, 0.753, and 0.734, while that for statin-users were 0.585, 0.615, and 0.631, respectively. Only the performance of PCE alone was statistically significant (p = 0.025) when compared between statin-users (0.507) and non-users (0.783).

Conclusion

In a symptomatic mixed Asian cohort, age, presence of CAC, and ln(Volume) were independently associated with MACE for the overall subgroup, age and PCE score for the CAC = 0 subgroup, and no risk factor for the CAC > 0 subgroup. Whilst the PCE performance deteriorated in statin versus non-statin users, the Agatston score performed consistently in both groups.

The Correlation between the Vascular Calcification Score of the Coronary Artery and the Abdominal Aorta in Patients with Psoriasis

Psoriasis is known as an independent risk factor for cardiovascular disease due to its chronic inflammation. Studies have been conducted to evaluate the progress of atherosclerotic plaques in psoriasis. However, inadequate efforts have been made to clarify the relationship between atherosclerosis progress in coronary arteries and other important blood vessels. For that reason, we investigated the correlation and development of the coronary artery calcification score (CACS) and the abdominal aortic calcification score (AACS) during a follow-up examination. Eighty-three patients with psoriasis underwent coronary computed tomography angiography (CCTA) for total CACS and abdominal computed tomography (AbCT) for total AACS. PASI score, other clinical features, and blood samples were collected at the same time. The patients' medical histories were also retrieved for further analysis. Linear regression was used to analyze the CACS and AACS associations. There was a moderate correlation between CACS and AACS, while both calcification scores relatively reflected the coronary plaque number, coronary stenosis number, and stenosis severity observed with CCTA. Both calcification scores were independent of the PASI score. However, a significantly higher CACS was found in psoriatic arthritis, whereas no similar phenomenon was recorded for AACS. To conclude, both CACS and AACS might be potential alternative tests to predict the presence of coronary lesions as confirmed by CCTA.

Shock Wave Intravascular Lithotripsy: Shock the Rock

Complex coronary artery disease with severe coronary calcification can be challenging to treat, with a higher risk of procedural complications and major adverse cardiac events. Intravascular lithotripsy (IVL) is a pioneering technology for the treatment of critically calcified coronaries. IVL utilizing localized pulsatile sonic pressure waves at low pressure provides a novel approach for lesion preparation of severely calcified plaques. The deliverability and ease of use are also likely to increase access and use of IVL, and combination therapy with other devices shows promise.

Cardiovascular risk-enhancing factors and coronary artery calcium in South Asian American adults: The MASALA study

Objectives

The 2018 and 2019 U.S. guidelines for the management of cholesterol and primary prevention of atherosclerotic cardiovascular disease (ASCVD) recommend consideration of cardiovascular risk-enhancing factors (REFs), including South Asian ancestry, to refine ASCVD risk estimation. However, the associations of REFs with atherosclerosis are unclear in South Asian American adults, who have a disproportionately elevated premature coronary heart disease risk. In the Mediators of Atherosclerosis in South Asians Living in America (MASALA) cohort, we investigated associations of individual REFs, or the number of REFs, with coronary artery calcium (CAC).

Methods

Using baseline and follow-up data from MASALA, we evaluated the association of REFs (family history of ASCVD, low-density lipoprotein cholesterol ≥160 mg/dL, triglycerides ≥175 mg/dL, lipoprotein(a) >50 mg/dL, high-sensitivity C-reactive protein [hsCRP] ≥2.0 mg/dL, ankle-brachial index <0.9, chronic kidney disease, metabolic syndrome), individually and combined, with baseline prevalent CAC, any CAC progression (including incident CAC and CAC progression), and annual CAC progression rates using multivariable logistic regression and generalized linear models.

Results

Among 866 adults, mean age was 55 [SD 9] years and 47% were female. There were no significant associations of REFs with baseline prevalent CAC or any CAC progression (incident CAC and CAC progression at Exam 2) after adjustment. Among the 56% of participants who had any CAC progression, having 3+ REFs was associated with a significantly higher annual CAC progression rate (adjusted rate ratio [aRR] 1.94, 95% CI 1.39-2.72) vs. having 0 REFs. The annual CAC progression rate was 20% higher per additional REF (aRR 1.20, 95% CI 1.09-1.32). Findings were similar after excluding statin users, and among those with low 10-year ASCVD risk (<5%).

Conclusions

Among South Asian American adults, we found no association of REFs with prevalent CAC at baseline or having any CAC progression. Among those with any CAC progression, a higher number of REFs was associated with higher annual CAC progression rates.

South Asian ethnicity: What can we do to make this risk enhancer a risk equivalent?

South Asians account for around 25% of the global population and are the fastest-growing ethnicity in the US. This population has an increasing burden of atherosclerotic cardiovascular disease (ASCVD) which is also seen in the diaspora. Current risk prediction equations underestimate this risk and consider the South Asian ethnicity as a risk-enhancer among those with borderline-intermediate risk. In this review, we discuss why the South Asian population is at a higher risk of ASCVD and strategies to mitigate this increased risk.

Coronary artery calcium incidence and changes using direct plaque measurements: The MASALA study

BACKGROUND AND AIMS

We aimed to identify predictors of change in direct measures of coronary artery calcium (CAC) volume and density in South Asian participants.

METHODS

We used data from participants in the Mediators of Atherosclerosis in South Asians Living in America (MASALA) study with prevalent CAC and direct measures of CAC by serial computed tomography (CT) exams (2010-2013, 2016-2018). We examined the distribution of incident CAC volume and peak density, as well as progression and identified risk factors for progression of change in volume and density in multivariable models.

RESULTS

The study cohort consisted of 102 participants with incident CAC and 285 with CAC progression. CAC volume and density were highest, and incident CAC was most common in the left anterior descending artery (LAD). The greatest progression in volume was in the right coronary artery and the greatest change in density was in the left main. In linear regression models for CAC progression adjusted for baseline density, volume, risk factors, smoking (β +190.1, p = 0.02), baseline volume (β +0.24 per mm³, p < 0.01), and scan interval (β +0.15 per day, p = 0.01) were associated with change in total volume whereas Lp(a) (β +0.81 per mg/dL, p = 0.03), exercise (β +0.19 per 10 MET-min/week, p = 0.01), and baseline volume (β +0.15 per mm³, p < 0.01) and density (β -0.55 per unit, p < 0.01) were associated with change in total density.

CONCLUSIONS

In this South Asian cohort, smoking was associated with CAC volume progression, while Lp(a) and exercise were associated with progression of peak CAC density.

A healthy plant-based diet is favorably associated with cardiometabolic risk factors among participants of South Asian ancestry

BACKGROUND

Plant-based diets are recommended for chronic disease prevention, yet there has been little focus on plant-based diet quality among participants of South Asian ancestry who consume a predominantly plant-based diet.

OBJECTIVES

We evaluated cross-sectional and prospective associations between plant-based diet quality and cardiometabolic risks among participants of South Asian ancestry who are living in the United States.

METHODS

We included 891 participants of South Asian ancestry who completed the baseline visit in the Mediators of Atherosclerosis in South Asians Living in America (MASALA) study. The prospective analysis included 735 participants who completed exam 2 (∼5 years after baseline). The plant-based diet quality was assessed using 3 indices: an overall plant-based diet index (PDI) that summarizes the consumption of plant foods, a healthy PDI (hPDI) that measures consumption of healthy plant foods, and an unhealthy PDI (uPDI) that reflects consumption of less healthy plant foods.

RESULTS

At baseline, the PDI score was inversely associated with fasting glucose. We observed inverse associations between PDI and hPDI scores and HOMA-IR, LDL cholesterol, weight, and BMI (all P values < 0.05). Higher scores on the hPDI, but not PDI, were associated with lower glycated hemoglobin, higher adiponectin, a smaller visceral fat area, and a smaller pericardial fat volume. Each 5-unit higher hPDI score was associated with lower likelihoods of fatty liver (OR: 0.76; 95% CI: 0.64, 0.90) and obesity (OR: 0.88; 95% CI: 0.80, 0.97). There were no associations between uPDI scores and cardiometabolic risks. Prospectively, after covariate adjustment for baseline values, each 5-unit higher hPDI score was associated with an 18% lower risk of incident type 2 diabetes (OR: 0.82; 95% CI: 0.67, 1.00).

CONCLUSIONS

A higher intake of healthful plant-based foods was associated with a favorable cardiometabolic risk profile. Dietary recommendations to lower chronic disease risks among participants of South Asian ancestry should focus on the quality of plant-based foods.

Ten things to know about ten cardiovascular disease risk factors - 2022

The American Society for Preventive Cardiology (ASPC) "Ten things to know about ten cardiovascular disease risk factors - 2022" is a summary document regarding cardiovascular disease (CVD) risk factors. This 2022 update provides summary tables of ten things to know about 10 CVD risk factors and builds upon the foundation of prior annual versions of "Ten things to know about ten cardiovascular disease risk factors" published since 2020. This 2022 version provides the perspective of ASPC members and includes updated sentinel references (i.e., applicable guidelines and select reviews) for each CVD risk factor section. The ten CVD risk factors include unhealthful dietary intake, physical inactivity, dyslipidemia, pre-diabetes/diabetes, high blood pressure, obesity, considerations of select populations (older age, race/ethnicity, and sex differences), thrombosis (with smoking as a potential contributor to thrombosis), kidney dysfunction and genetics/familial hypercholesterolemia. Other CVD risk factors may be relevant, beyond the CVD risk factors discussed here. However, it is the intent of the ASPC "Ten things to know about ten cardiovascular disease risk factors - 2022" to provide a tabular overview of things to know about ten of the most common CVD risk factors applicable to preventive cardiology and provide ready access to applicable guidelines and sentinel reviews.

Relation of Menopause With Cardiovascular Risk Factors in South Asian American Women (from the MASALA Study)

The menopausal transition is a time of accelerating risk of cardiovascular disease (CVD), and promoting cardiovascular health during midlife is an important period of time to prevent CVD in women. The association of menopause with cardiovascular risk factors or subclinical atherosclerosis has not previously been evaluated in South Asian American women, a population with a disproportionately higher CVD burden compared with other race/ethnic groups. The objective of this study was to evaluate the association of menopause with CVD risk factors and subclinical cardiometabolic disease markers. We studied women aged 40 to 84 years from the Mediators of Atherosclerosis in South Asians Living in America study. The association of self-reported menopausal status with multiple demographic and clinical variables was assessed with linear and logistic regression adjusted for age and cardiovascular health behaviors. In a secondary ("age-restricted") analysis, postmenopausal participants outside the age range of premenopausal participants were excluded. In the age-restricted sample, menopause was associated with a higher adjusted odds of hypertension (odds ratio = 1.19, 95% confidence interval [CI] 1.02 to 1.41), and higher systolic blood pressure (β = 6.34, 95% CI 0.82 to 11.87), and significantly higher subcutaneous fat area (β = 42.8, 95% CI 5.8 to 91.4). No significant associations between menopause and ectopic fat deposition, coronary artery calcium, or carotid intima-media thickness were observed. In South Asian American women in the Mediators of Atherosclerosis in South Asians Living in America study, menopause was associated with cardiovascular risk factors and higher subcutaneous fat deposition. Menopausal status is an important factor to examine and address CVD risk factors.

The Morphology of Coronary Artery Disease in South Asians versus White Caucasians and its Implications

South Asians (SAs) experience a higher prevalence and earlier onset of coronary artery disease and have worse outcomes relative to White Caucasians (WCs) following invasive revascularization procedures, a mainstay of coronary artery disease (CAD) management. We sought to review the differences in the CAD pattern and risk factors between SA and WC patients and discuss their potential impact on the development of coronary disease, acute coronary syndrome and revascularization outcomes. SAs have a more diffuse pattern with multi-vessel involvement compared to WCs. However, less is known about other morphological characteristics such as calcification of atherosclerotic plaque and coronary diameter in SA populations. Despite a similar coronary calcification burden, higher non-calcified plaque composition, elevated thrombosis and inflammatory markers likely contribute to the disease pattern. While the current evidence on the role of coronary vessel size remains inconsistent, smaller coronary diameters in SAs could play a potential role in the higher disease prevalence. This is especially important given the impact of coronary artery diameter on revascularization outcomes. In conclusion, SAs have a unique CAD risk profile comprised of traditional and novel risk factors. Our findings highlight the need for additional awareness of healthcare professionals of this specific risk profile and potential therapeutic targets, as well as the need for further research in this vulnerable population.

Evaluating the Coronary Artery Disease Consortium Model and the Coronary Artery Calcium Score in Predicting Obstructive Coronary Artery Disease in a Symptomatic Mixed Asian Cohort

Background

The utility of a given pretest probability score in predicting obstructive coronary artery disease (CAD) is population dependent. Previous studies investigating the additive value of coronary artery calcium (CAC) on pretest probability scores were predominantly limited to Western populations. This retrospective study seeks to evaluate the CAD Consortium (CAD2) model in a mixed Asian cohort within Singapore with stable chest pain and to evaluate the incremental value of CAC in predicting obstructive CAD.

Methods and Results

Patients who underwent cardiac computed tomography and had chest pain were included. The CAD2 clinical model comprised of age, sex, symptom typicality, diabetes, hypertension, hyperlipidemia, and smoking status and was compared with the CAD2 extended model that added CAC to assess the incremental value of CAC scoring, as well as to the corresponding locally calibrated local assessment of the heart models. A total of 522 patients were analyzed (mean age 54±11 years, 43.1% female). The CAD2 clinical model obtained an area under the curve of 0.718 (95% CI, 0.668–0.767). The inclusion of CAC score improved the area under the curve to 0.896 (95% CI, 0.867–0.925) in the CAD2 models and from 0.767 (95% CI, 0.721–0.814) to 0.926 (95% CI, 0.900–0.951) in the local assessment of the heart models. The locally calibrated local assessment of the heart models showed better discriminative performance than the corresponding CAD2 models (P<0.05 for all).

Conclusions

The CAD2 model was validated in a symptomatic mixed Asian cohort and local calibration further improved performance. CAC scoring provided significant incremental value in predicting obstructive CAD.

Knowledge Gaps, Challenges, and Opportunities in Health and Prevention Research for Asian Americans, Native Hawaiians, and Pacific Islanders: A Report From the 2021 National Institutes of Health Workshop

Asian Americans (AsA), Native Hawaiians, and Pacific Islanders (NHPI) comprise 7.7% of the U.S. population, and AsA have had the fastest growth rate since 2010. Yet the National Institutes of Health (NIH) has invested only 0.17% of its budget on AsA and NHPI research between 1992 and 2018. More than 40 ethnic subgroups are included within AsA and NHPI (with no majority subpopulation), which are highly diverse culturally, demographically, linguistically, and socioeconomically. However, data for these groups are often aggregated, masking critical health disparities and their drivers. To address these issues, in March 2021, the National Heart, Lung, and Blood Institute, in partnership with 8 other NIH institutes, convened a multidisciplinary workshop to review current research, knowledge gaps, opportunities, barriers, and approaches for prevention research for AsA and NHPI populations. The workshop covered 5 domains: 1) sociocultural, environmental, psychological health, and lifestyle dimensions; 2) metabolic disorders; 3) cardiovascular and lung diseases; 4) cancer; and 5) cognitive function and healthy aging. Two recurring themes emerged: Very limited data on the epidemiology, risk factors, and outcomes for most conditions are available, and most existing data are not disaggregated by subgroup, masking variation in risk factors, disease occurrence, and trajectories. Leveraging the vast phenotypic differences among AsA and NHPI groups was identified as a key opportunity to yield novel clues into etiologic and prognostic factors to inform prevention efforts and intervention strategies. Promising approaches for future research include developing collaborations with community partners, investing in infrastructure support for cohort studies, enhancing existing data sources to enable data disaggregation, and incorporating novel technology for objective measurement. Research on AsA and NHPI subgroups is urgently needed to eliminate disparities and promote health equity in these populations.

Barriers to Follow Up Care in the South Asian Immigrant Population at High Risk of Acute Coronary Syndrome at Elmhurst Hospital Center

We studied South Asian immigrant patients who did not return to Elmhurst Hospital Center (EHC) after emergent cardiac catheterization in order to propose interventions to improve follow up care. We identified 74 eligible patients, interviewed 30 about follow up practices, and analyzed findings. Most patients are Bangladeshi and 77% preferred a foreign language. Some were visiting the US during the admission without intent to follow up. Half were dissatisfied with EHC providers, complications, and inadequate care at follow up appointments. Some patients were unaware of scheduled appointments or the necessity of follow up. Most follow with private providers due to language accessibility, availability, and proximity. We found that language barriers contribute to loss to follow up and the true loss to follow up rate is lower than reported at EHC. This can inform practices at hospitals with immigrant populations, minimize resource waste, and improve quality of care.

Evolution of Coronary Calcium Screening for Assessment of Atherosclerotic Cardiovascular Disease Risk and Role in Preventive Cardiology

PURPOSE OF REVIEW

Coronary artery calcium (CAC) is an important measure of subclinical atherosclerosis and strongly predicts atherosclerotic cardiovascular disease (ASCVD) outcomes. The purpose of this review is to discuss the key studies that have helped to establish its role as an important screening tool and its place in preventive cardiology.

RECENT FINDINGS

Epidemiologic studies document a strong relation of age, race/ethnicity, and risk factors with the prevalence and extent of CAC. Large-scale registry and prospective investigations show CAC to be the strongest subclinical disease predictor of ASCVD outcomes, with higher CAC scores associated with successively higher risks and those with a CAC score of 0 having a long-term "warranty" against having events. Moreover, CAC is associated with greater initiation of preventive health behaviors and therapy. Current US guidelines utilize CAC to inform the treatment decision for statin therapy. Further study is underway to document whether CAC screening will ultimately improve clinical outcomes. CAC is well established as the most important subclinical cardiovascular disease measure for prediction of future ASCVD outcomes and can be used for informing the treatment decision for preventive therapies.

JCL roundtable: South Asian atherosclerotic risk

South Asian risk for atherosclerotic cardiovascular disease (ASCVD) has received special emphasis in the 2018 US AHA/ACC/Multisociety Cholesterol Guidelines. The term "South Asian" refers specifically to the countries of India, Pakistan, Nepal, Bhutan, Bangladesh, Sri Lanka, and Maldives and to the worldwide diaspora of families from these countries. With this definition, approximately 25% of the world's population is South Asian, but about 50% of ASCVD occurs in this group. In this JCL Roundtable, we discuss the roles of visceral adiposity, diabetes, and features of the metabolic syndrome; lipoprotein(a); and diet and lifestyle, including the transition of both diet and lifestyle over the past 40 to 50 years. Genetic and/or hidden risk is an area of ongoing research. Individual patient assessment and intervention should recognize the earlier onset of ASCVD and the value of screening for traditional risk factors as well as waist circumference, coronary artery calcium scoring, and lipoprotein(a) assay. Culturally acceptable dietary strategies are available, although not widely implemented or evaluated as yet. In very-high-risk cases of secondary prevention, one should consider combining medications to drive low-density lipoprotein cholesterol much lower than 70 mg/dL. Our discussion concludes by insisting that the signal of alarm must be accompanied by decisive action.

Intravascular Lithotripsy for Vessel Preparation in Severely Calcified Coronary Arteries Prior to Stent Placement - Primary Outcomes From the Japanese Disrupt CAD IV Study

BACKGROUND

Intravascular lithotripsy (IVL) delivers acoustic pressure waves to modify calcium, enhance vessel compliance and optimize stent deployment. The objective of this study was to assess the safety and effectiveness of IVL treatment of de novo stenoses involving severely calcified coronary vessels in a Japanese population.

METHODS AND RESULTS

Disrupt CAD IV (NCT04151628) was a prospective, multicenter study designed for Japanese regulatory approval of coronary IVL (SWM-1234). The primary safety endpoint was freedom from major adverse cardiac events (MACE) at 30 days. The primary effectiveness endpoint was procedural success (residual stenosis <50% by QCA without in-hospital MACE). Noninferiority analyses for the primary endpoints were performed by comparing the CAD IV cohort with a propensity-matched historical IVL control group. Patients (intent-to-treat, n=64) were enrolled from 8 centers in Japan. Severe calcification by core laboratory assessment was present in all lesions, with a calcified length of 49.8±15.5 mm and a calcium angle of 257.9±78.4° by optical coherence tomography. Primary endpoints were achieved with non-inferiority demonstrated for freedom from 30-day MACE (CAD IV: 93.8% vs. Control: 91.2%, P=0.008), and procedural success (CAD IV: 93.8% vs. Control: 91.6%, P=0.007). No perforations, abrupt closures, or slow/no-reflow events occurred at any time during the procedures.

CONCLUSIONS

Coronary IVL demonstrated high procedural success with low MACE rates in severely calcified lesions in a Japanese population.

Coronary artery disease in East and South Asians: differences observed on cardiac CT

Epidemiological studies have observed East Asians (EAs) are significantly less likely to develop or die from coronary artery disease (CAD) compared with Caucasians. Conversely South Asians (SAs) develop CAD at higher rate and earlier age. Recently, a range of features derived from cardiac CT have been identified which may further characterise ethnic differences in CAD. Emerging data suggest EAs exhibit less coronary calcification and high-risk, non-calcified plaque compared with Caucasians on CT, with no difference in luminal stenosis. In contrast, SAs exhibit similar to higher coronary calcification and luminal stenosis, smaller luminal dimensions and more high-risk, non-calcified plaque than Caucasians. Beyond demonstrating ethnic differences in CAD, cardiac CT may enhance and individualise cardiovascular risk stratification in EAs and SAs. While data thus far in EAs have demonstrated calcium score and CT-derived luminal stenosis may incrementally predict cardiovascular risk beyond traditional risk scores, there remains a paucity of data assessing its use in SAs. Future studies may clarify the prognostic value of cardiac CT in SAs and investigate how this modality may guide preventative therapy and coronary intervention of CAD in EAs and SAs.

Coronary artery calcium scoring: an evidence-based guide for primary care physicians

Primary care physicians often must decide whether statin therapy would be appropriate (in addition to lifestyle modification) for managing asymptomatic individuals with borderline or intermediate risk for developing atherosclerotic cardiovascular disease (ASCVD), as assessed on the basis of traditional risk factors. In appropriate subjects, a simple, noninvasive measurement of coronary artery calcium can help clarify risk. Coronary atherosclerosis is a chronic inflammatory disease, with atherosclerotic plaque formation involving intimal inflammation and repeated cycles of erosion and fibrosis, healing and calcification. Atherosclerotic plaque formation represents the prognostic link between risk factors and future clinical events. The presence of coronary artery calcification is almost exclusively an indication of coronary artery disease, except in certain metabolic conditions. Coronary artery calcification can be detected and quantified in a matter of seconds by noncontrast electrocardiogram-gated low-dose X-ray computed tomography (coronary artery calcium scoring [CACS]). Since the publication of the seminal work by Dr. Arthur Agatston in 1990, a wealth of CACS-based prognostic data has been reported. In addition, recent guidelines from various professional societies conclude that CACS may be considered as a tool for reclassifying risk for atherosclerotic cardiovascular disease in patients otherwise assessed to have intermediate risk, so as to more accurately inform decisions about possible statin therapy in addition to lifestyle modification as primary preventive therapy. In this review, we provide an overview of CACS, from acquisition to interpretation, and summarize the scientific evidence for and the appropriate use of CACS as put forth in current clinical guidelines.

Ten things to know about ten cardiovascular disease risk factors

Given rapid advancements in medical science, it is often challenging for the busy clinician to remain up-to-date on the fundamental and multifaceted aspects of preventive cardiology and maintain awareness of the latest guidelines applicable to cardiovascular disease (CVD) risk factors. The "American Society for Preventive Cardiology (ASPC) Top Ten CVD Risk Factors 2021 Update" is a summary document (updated yearly) regarding CVD risk factors. This "ASPC Top Ten CVD Risk Factors 2021 Update" summary document reflects the perspective of the section authors regarding ten things to know about ten sentinel CVD risk factors. It also includes quick access to sentinel references (applicable guidelines and select reviews) for each CVD risk factor section. The ten CVD risk factors include unhealthful nutrition, physical inactivity, dyslipidemia, hyperglycemia, high blood pressure, obesity, considerations of select populations (older age, race/ethnicity, and sex differences), thrombosis/smoking, kidney dysfunction and genetics/familial hypercholesterolemia. For the individual patient, other CVD risk factors may be relevant, beyond the CVD risk factors discussed here. However, it is the intent of the "ASPC Top Ten CVD Risk Factors 2021 Update" to provide a succinct overview of things to know about ten common CVD risk factors applicable to preventive cardiology.

Dyslipidemia and Cardiovascular Disease Prevention in South Asians: A Review and Discussion of Causes, Challenges and Management Strategies

BACKGROUND

South Asians are at a significantly increased risk of atherosclerotic cardiovascular disease (ASCVD). For a major portion of the South Asian population, the cardiovascular disease events occur at a relatively younger age, are associated with worse outcomes, and have potentially more severe socioeconomic implications compared to their western counterparts.

METHODS

The term "South Asian" typically constitutes individuals from India, Pakistan, Nepal, Bhutan, Bangladesh, Sri Lanka, and Maldives, including expatriates as well as their families from these countries. Based on this, South Asians form approximately 25% of the world's population, with a high ASCVD burden in this group. In this review, we discuss the pathophysiological factors underlying ASCVD in South Asians, the dyslipidemia types and management, and discuss approaches to improve the overall ASCVD prevention efforts in this large subset population of the world. Although the pathophysiological mechanisms underlying the excess risk of cardiovascular disease in South Asians are multifactorial, dyslipidemia is a primary risk factor for the incidence and prevalence of this disease. The traditional "South Asian" dyslipidemia pattern includes levels of low-density lipoprotein cholesterol (LDL-C) in the normal range with a high concentration of LDL particles, elevated triglycerides, low levels of high-density lipoprotein cholesterol (HDL-C) with dysfunctional HDL particles, and high levels of lipoprotein(a).

CONCLUSION

While combined efforts to study the expatriate South Asians in western countries have been able to identify South Asian specific dyslipidemias, causal associations and optimal management remain relatively less explored. Larger scale studies are needed to better quantify the relationship of each lipid parameter with ASCVD risk among South Asians as well as optimal lipid targets and management strategies to reduce morbidity and mortality in this high-risk group.

Association of Alcohol Consumption and Ideal Cardiovascular Health Among South Asians: The Mediators of Atherosclerosis in South Asians Living in America (MASALA) Study

BACKGROUND

Observational studies have shown that alcohol consumption above the recommended limit is associated with increased cardiovascular disease (CVD), although its association in South Asians is unclear. Less is known regarding the association between alcohol consumption and cardiovascular health (CVH), assessed by the American Heart Association's Life's Simple 7 (LS7) health metrics among those with South Asian ancestry.

METHODS

This analysis included 701 participants without CVD from the Mediators of Atherosclerosis in South Asians Living in America (MASALA) cohort (2015 to 2018). Based on a personal history questionnaire, participants were divided into never, former, and current drinkers. The current drinking category was further classified into 1 to 3 drinks/wk, 4 to 7 drinks/wk, and >7 drinks/wk. The consumption of 5 or more drinks on 1 occasion in the past month was defined as binge drinking. Each LS7 component was given a point score of 0, 1, or 2. The total score was categorized into 0 to 6, 7 to 10, and 11 to 14 to represent poor, intermediate, and ideal CVH, respectively. We use multinomial logistic regression to examine the association between alcohol consumption and CVH.

RESULTS

In the MASALA cohort (mean age = 59 years, 43% female), participants consuming >7 drinks/wk had the lowest mean CVH score. Compared with never drinkers, male participants consuming >7 drinks/wk were less likely to have intermediate CVH (0.44 [0.08, 0.91]) and ideal CVH (0.23 [0.03, 0.96]). Binge drinking was associated with significantly lower odds of ideal CVH compared with never drinkers.

CONCLUSION

We found evidence of an inverse association of moderate to heavy alcohol consumption and ideal CVH in South Asian men. These findings further underscore the important relationship between alcohol consumption and CVH in this unique population of South Asians.

Incidence and Progression of Coronary Artery Calcium in South Asians Compared With 4 Race/Ethnic Groups

Background

South Asians have a relatively high prevalence of coronary artery calcium (CAC) compared with other race/ethnic groups. We determined CAC incidence and progression among South Asians, and compared them with 4 race/ethnic groups.

Methods and Results

Data from the MASALA (Mediators of Atherosclerosis in South Asians Living in America) study were used to calculate CAC incidence and progression rates and any CAC change. Data from the MESA (Multi‐Ethnic Study of Atherosclerosis) were used to compare the CAC incidence and progression rates. A total of 698 South Asians had repeat CAC measurements after 4.8±0.8 years. Among those with no CAC at baseline, the age‐adjusted CAC incidence was 8.8% (95% CI, 6.8–10.8%) in men and 3.6% (2.5–4.8%) in women. The median annual CAC progression was 26 (interquartile range, 11–62) for men and 13 (interquartile range, 4–34) for women. Compared with MESA, age‐adjusted CAC incidence was similar in South Asian men compared with white, black, and Latino men, but significantly higher than Chinese men (11.1% versus 5.7%, P=0.008). After adjusting for age, diabetes mellitus, hypertension, and statin medication use, Chinese, black, and Latino men had significantly less CAC change compared with South Asian men, but there were no differences between South Asian and white men. There was no difference in CAC incidence or progression between South Asian women and women in MESA.

Conclusions

South Asian men had greater CAC change than Chinese, black, and Latino men but similar change to that of whites after adjusting for traditional risk factors.

The Burden of Atherosclerotic Cardiovascular Disease in South Asians Residing in Canada: A Reflection From the South Asian Heart Alliance

South Asians (SAs), originating from the Indian subcontinent (India, Pakistan, Sri Lanka, Bangladesh, Nepal, and Bhutan), represent one quarter of the global population and are the largest visible minority in Canada. SAs experience the highest rates of coronary artery disease in Canada. Although conventional cardiovascular risk factors remain predictive in SA, the excess risk is not fully explained by these risk factors alone. Abdominal obesity, metabolic syndrome, and insulin resistance likely contribute a greater risk in SAs than in other populations. The South Asian Heart Alliance has been recently formed to investigate and recommend the best strategies for the prevention of cardiometabolic disease in SAs in Canada. This topic review represents a comprehensive overview of the magnitude of cardiovascular disease in SAs in Canada, with a review of conventional and novel risk markers in the SA population. Both primary and secondary prevention strategies are suggested and when possible, adapted specifically for the SA population. The need for SAs and their healthcare professionals to be more aware of the problem and potential solutions, along with the need for population-specific research, is highlighted.

Lipids in South Asians: Epidemiology and Management

Purpose of Review

This review focuses on lipoprotein abnormalities in South Asians (SA) and addresses risk stratification and management strategies to lower atherosclerotic cardiovascular disease (ASCVD) in this high-risk population.

Recent Findings

South Asians (SAs) are the fastest growing ethnic group in the United States (U.S) and have an increased risk of premature coronary artery disease (CAD). While the etiology may be multifactorial, lipoprotein abnormalities play a key role. SAs have lower low-density lipoprotein cholesterol (LDL-C) compared with Whites and at any given LDL-C level, SA ethnicity poses a higher risk of myocardial infarction (MI) and coronary artery disease (CAD) compared with other non-Asian groups. SAs have lower high-density lipoprotein cholesterol (HDL-C) with smaller particle sizes of HDL-C compared with Whites. SAs also have higher triglycerides than Whites which is strongly related to the high prevalence of metabolic syndrome in SAs. Lipoprotein a (Lp(a)) levels are also higher in SAs compared with many other ethnic groups. This unique lipoprotein profile plays a vital role in the elevated ASCVD risk in SAs. Studies evaluating dietary patterns of SAs in the U.S show high consumption of carbohydrates and saturated fats.

Summary

SAs have a high-risk lipoprotein profile compared with other ethnicities. Lipid abnormalities play a central role in the pathogenesis of CAD in SAs. More studies are needed to understand the true impact of the various lipoproteins and their contribution to increasing ASCVD in SAs. Aggressive lowering of LDL-C in high-risk groups using medications, such as statins, and lifestyle modification including dietary changes is essential in overall CAD risk reduction.