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Why Is It Important to Assess Asian Subgroups Individually for Cardiometabolic Risk?

  • Authors: News Author: Megan Brooks; CME Author: Charles P. Vega, MD
  • CME / ABIM MOC / CE Released: 6/9/2023
  • Valid for credit through: 6/9/2024, 11:59 PM EST
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Target Audience and Goal Statement

This activity is intended for primary care clinicians, cardiologists, nurses/nurse practitioners, pharmacists, physician assistants, and other clinicians who care for Asian American persons.

The goal of this activity is for learners to be better able to assess the cardiovascular risk (CV) for Asian American persons and means to help reduce this risk.

Upon completion of this activity, participants will:

  • Distinguish the risk for CV disease among Asian American adults
  • Assess means to improve CV outcomes among Asian American persons
  • Outline implications for the healthcare team


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News Author

  • Megan Brooks

    Freelance writer, Medscape


    Megan Brooks has no relevant financial relationships.

CME Author

  • Charles P. Vega, MD

    Health Sciences Clinical Professor of Family Medicine
    University of California, Irvine School of Medicine


    Charles P. Vega, MD, has the following relevant financial relationships:
    Consultant or advisor for: Boehringer Ingelheim Pharmaceuticals, Inc.; GlaxoSmithKline; Johnson & Johnson Pharmaceutical Research & Development, L.L.C.

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  • Leigh Schmidt, MSN, RN, CNE, CHCP

    Associate Director, Accreditation and Compliance, Medscape, LLC


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  • Amanda Jett, PharmD, BCACP

    Associate Director, Accreditation and Compliance, Medscape, LLC


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Why Is It Important to Assess Asian Subgroups Individually for Cardiometabolic Risk?

Authors: News Author: Megan Brooks; CME Author: Charles P. Vega, MDFaculty and Disclosures

CME / ABIM MOC / CE Released: 6/9/2023

Valid for credit through: 6/9/2024, 11:59 PM EST


Clinical Context

May is Asian American and Pacific Islander Heritage Month in the United States, so it is fitting that the American Heart Association (AHA) has published a guide to cardiovascular (CV) health for the Asian American community in the form of a new Scientific Statement. The statement also provides a review of data about the Asian American community and provides suggestions for clinicians to improve the CV health of Asian American adults.

In the 2020 Census, persons of Asian descent comprised 7.2% of the total US population; however, one challenge in describing the Asian American community is the wide difference in cultures -- and health outcomes -- within this population. Approximately 4.1 million people in the United States claim Chinese heritage, with a similar number of Asian Indians (4 million). The next most common countries of ancestry are the Philippines (2.9 million), Vietnam (1.8 million), and Korea (1.5 million). The average annual household income of Asian American families compares favorably with that of White families ($93,759 vs $69,823), but the authors of the current Scientific Statement noted that persons with a heritage from countries with more recently established migration patterns to the United States, such as Burma and Nepal, are more likely to have lower household income.

The current review breaks down data on CV risk factors and the epidemiology of cardiovascular disease (CVD) among East Asian (Chinese, Japanese, and Korean); South Asian (Asian Indian, Pakistani, Sri Lankan, Bangladeshi, Nepali, and Bhutanese); and Southeast Asian (Filipino, Vietnamese, Cambodian, Malaysian, Thai, Laotian, Indonesian, Hmong, and Singaporean) populations.

Study Synopsis and Perspective

In a new Scientific Statement, the AHA highlights the need to assess Asian American subgroups individually to get a more accurate picture of their risks for diabetes and heart disease.

Asian Americans have significant differences in genetics, socioeconomic factors, culture, diet, lifestyle, and acculturation levels based on the Asian region of their ancestry that likely have unique effects on their risk for type 2 diabetes (T2D) and heart disease, the statement notes.

"Examining Asian subgroups separately is crucial to better understand the distinctions among them, how these differences translate into their risk of [T2D] and atherosclerotic disease, and how healthcare professionals may provide care and support in a culturally appropriate manner," writing group chair Tak W. Kwan, MD, chief of cardiology, Lenox Health Greenwich Village, and clinical professor of medicine, Northwell Health, New York, New York, said in a news release.

The statement was published online May 8 in the journal Circulation.[1]

Impact on Health Outcomes

Asian American subgroups are broadly categorized by the geographic region of Asian descent and include South Asia (India, Pakistan, Sri Lanka, Bangladesh, Nepal, or Bhutan); East Asia (Japan, China, or Korea); Southeast Asia (Philippines, Vietnam, Thailand, Cambodia, Laos, Indonesia, Malaysia, Singapore, Hmong); and Hawaii/Pacific Islands (Hawaii, Guam, Samoa, or other Pacific islands).

Asian Americans make up the fastest growing racial and ethnic group in the United States. Together, T2D and atherosclerotic cardiovascular disease (ASCVD) are the leading causes of illness and death among Asian American adults; yet, there is significant variability in prevalence and risk factors within the different subgroups, the writing group pointed out.

For example, based on available data, rates of coronary artery disease (CAD) among Asian American individuals indicate an overall prevalence of 8% in men and about 3% in women; however, available data for subgroups suggest higher CAD rates among Asian Indian Americans (13% for men and 4.4% for women) and Filipino Americans (about 9.2% and 4.3%, respectively).

Available data on T2D among Asian American subgroups also show varied prevalence and risk.

A study from California found overall, AsA adults had higher rates of T2D (range, 15.6%-34.5%) compared with non-Hispanic White adults (12.8%). Among Chinese American adults, the rate was 15.8%. Among Korean American and Japanese American adults, rates were about 18% to 19% and among American adults with Filipino ancestry, the rate was nearly 32%; yet, most studies to date aggregate Asian American persons in a single group and do not examine the subgroups individually, which is a challenge to providing evidence-based recommendations, the writing group said.

"Particular attention should focus on the T2D and ASCVD risk differences among the different [Asian American] subgroups because they may affect the precision in clinical and health outcomes," they suggested.

"Culturally specific recommendations and interventions across the different [Asian American] subgroups related to T2D and ASCVD will help improve primary and secondary prevention and health outcomes in this population," they added.

The writing group also noted that existing CVD risk calculators -- which are based on data validated in non-Hispanic Black adults and non-Hispanic White adults and less extensively studied in Asian American adults -- may underestimate the risk for T2D and heart disease in South Asian adults, persons of lower socioeconomic status, or persons with chronic inflammatory diseases.

On the other hand, these tools may overestimate CVD risk among East Asian adults, persons with higher socioeconomic status, or persons who are already participating in preventive healthcare services.

Advances in epidemiology and data analysis and the availability of larger, representative cohorts will allow for refinement of pooled cohort equations to better gauge ASCVD risk in AsA subgroups, they said.

Filling in the Gaps

The writing group outlined several key areas to consider for strengthening the data about Asian American adults. Chief among them is the need to include disaggregated data on Asian American subgroups in clinical trials and government-sponsored studies.

Another is to standardize ways of collecting ethnic and subgroup data for Asian American adults for national health systems, surveys, and registries. National surveillance surveys should also consider oversampling Asian American persons to increase representation for the various subgroups, the writing group suggested.

"All of us -- healthcare professionals, policymakers, community leaders and patients -- must advocate for more health research funding for [Asian American persons] and demand inclusion of Asian American subgroup information in clinical trials and government-sponsored research," Kwan said.

"Having a platform to share and disseminate data on [Asian American persons] for the scientific and research community would also be an asset for the health care professionals who care for this population," Kwan added.

The new Scientific Statement is a follow-up to a 2010 AHA "call to action"[2] to seek data on health disparities among Asian American subgroups, as reported by Medscape Medical News,and a 2018 scientific statement[3] addressing CVD risk in South Asian persons (Asian Indian, Pakistani, Sri Lankan, Bangladeshi, Nepali, or Bhutanese).

This Scientific Statement was prepared by the volunteer writing group on behalf of the AHA Council on Epidemiology and Prevention; the Council on Lifestyle and Cardiometabolic Health; the Council on Arteriosclerosis, Thrombosis and Vascular Biology; the Council on Clinical Cardiology; the Council on Cardiovascular and Stroke Nursing; and the Council on Genomic and Precision Medicine.

Study Highlights

  • A large study found that the age- and sex-weighted prevalence rates of diabetes in different Asian American communities were as follows:
    • South Asian: 23.3%
    • Southeast Asian: 22.4%
    • East Asian: 14%
  • These rates exceed the prevalence of diabetes among White adults (12.8%). The American Diabetes Association recommends screening for diabetes among Asian American persons with a body mass index of ≥ 23 kg/m2 who have ≥ 1 additional risk factor, such as sedentary behavior or a family history.
  • In one study based in New York, the prevalence rates of self-reported hypertension were 27.1% for immigrants from South Asia compared with rates of 23.1% and 22.9% for resident White and Chinese immigrant adults, respectively.
  • Meanwhile, rates of self-reported dyslipidemia were highest among immigrants from Southeast Asia (33.4%) compared with persons from the Indian subcontinent (20.8%), East Asia (21.9%), and resident White adults (31.7%).
  • Among Asian American adults, Asian Indian men have the highest prevalence of CAD (13%), followed by Filipino men (9.2%), and Korean women (1.7%) have the lowest prevalence of CAD. South Asian men have higher coronary calcium scores compared with Black, Latino, or Chinese American men and similar levels compared with White men.
  • Asian Indian adults are 33% more likely to die due to ischemic heart disease compared with White adults, but Vietnamese adults have ~ 20% lower mortality related to heart disease.
  • The pooled cohort equations to estimate the risk for CVD may underestimate this risk in South Asian adults but overestimate the CV risk of East Asian adults.
  • Stroke is more prevalent in Asian American vs White populations. In particular, hemorrhagic stroke is more common among Asian American adults, possibly due to higher rates of hypertension. Among Asian American adults, Filipinos have the highest rate of stroke, followed by Chinese and Asian Indian persons.
  • Still, rates of peripheral artery disease are generally lower in Asian American vs other racial/ethnic groups.
  • Higher degrees of acculturation in the United States have generally been associated with an increased risk for CVD; however, foreign-born South Asian and Chinese adults have higher rates of CAD compared with US-born adults with South Asian or Chinese backgrounds. The opposite is true for Filipino adults: US-born Filipinos have higher rates of CAD.
  • Elements of the dietary pattern of Asian cultures may improve the risk for CVD, such as drinking unsweetened tea; however, dietary patterns from Asia can also rely on highly refined grains, such as rice, and may include too much sodium, along with large amounts of animal protein and organ meat. Fruit and vegetable consumption is variable but generally lower in Southeast Asian and South Asian cultures.
  • Social networks, especially within the family, are important for many Asian cultures. Efforts to engage these networks in promoting healthy lifestyle changes, such as smoking cessation, have been demonstrated to be effective.
  • Available evidence suggests that Asian American adults are less physically active compared with other racial/ethnic groups. Asian American adults, like other racial/ethnic minorities, are also at higher risk for sleep disorders and short sleep duration, which contribute to CVD.
  • Metformin use is common in Asia to treat T2D; however, Asian American patients at elevated risk for CVD may preferentially receive treatment with glucagon-like peptide-1 (GLP-1) agonists or sodium-glucose cotransporter 2 inhibitors.
  • Statins appear similarly effective among South Asian and White adults.

Implications for the Healthcare Team

  • Among Asian American adults, Asian Indian persons carry the most risk for CAD.
  • Strategies to improve the CV health of Asian American adults include discouraging negative elements from Asian diets; use of social networks, especially family, to engage in lifestyle change; replacement of metformin with drugs such as GLP-1 agonists; and application of statins.
  • The healthcare team should not treat all Asian American patients as a singular monolithic group but instead get to know health risks and advantages for individuals.


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