Abstract
Cardiovascular disease (CVD) represents a significant cause of global mortality and
morbidity. South Asians (SAs) have a particularly high burden of coronary artery disease
(CAD). This review describes current literature regarding the prevalence, incidence,
etiology, and prognosis of CVD in SA migrants to high-income nations. We conducted
a narrative review of CVD in the SA diaspora through a search of MEDLINE and PubMed.
We included observational studies, randomized clinical trials, nonsystematic reviews,
systematic reviews, and meta-analyses written in English. Of 15,231 articles identified,
827 articles were screened and 124 formed the basis for review. SA migrants have a
1.5-2 times greater prevalence of CAD than age- and sex-adjusted Europids. Increased
abdominal obesity and body fat and increased burden of type 2 diabetes mellitus and
dyslipidemia appear to be primary drivers of the excess CAD burden in SAs. Sedentary
lifestyle and changes in diet after immigration are important contributors to weight
gain and adiposity. Early life factors, physical activity patterns and, in some cases,
reduced adherence to medical therapy may contribute to increased CVD risks in SAs.
Novel biomarkers like leptin and adipokines may show distinct patterns in SAs and
provide insights into cardiometabolic risk determinants. In conclusion, SAs have distinct
CVD risk predispositions, with a complex relationship to cultural, innate, and acquired
factors. Although CVD risk factor management and treatment among SAs is improving,
opportunities exist for further advances.
Résumé
Les maladies cardiovasculaires (MCV) représentent une cause importante de mortalité
et de morbidité mondiales. Les Sud-Asiatiques (SA) ont un niveau particulièrement
élevé de maladie coronarienne. Cette revue compile la littérature actuelle concernant
la prévalence, l'incidence, l'étiologie et le pronostic des MCV chez les migrants
SA vers les pays à revenu élevé. Nous avons effectué un examen narratif des MCV dans
la diaspora SA via une recherche dans MEDLINE et PubMed. Nous avons inclus des études
d'observation, des essais cliniques randomisés, des revues non systématiques, des
revues systématiques et des méta-analyses écrites en anglais. À partir de 15 231 articles
identifiés, 827 articles ont été examinés et 124 ont formé la base pour la revue.
Les migrants SA ont une prévalence de maladie coronarienne 1,5 à 2 fois plus grande
que les europoïdes, ajusté pour l’âge et le sexe. L’augmentation de l'obésité abdominale
et du gras corporel, et l'augmentation de la charge du diabète de type 2 et la dyslipidémie
semblent être le principal moteur de la charge excessive de la maladie coronarienne
chez les SA. Un mode de vie sédentaire et des changements de régime alimentaire après
l'immigration sont d’importants contributeurs à la prise de poids et l'adiposité.
Des facteurs des stades précoces de l’existence, la façon de pratiquer une activité
physique et, dans certains cas, une observance réduite du traitement médical peuvent
contribuer à l'augmentation des risques de MCV chez les SA. De nouveaux biomarqueurs
telles la leptine et les adipokines peuvent montrer des modèles distincts chez les
SA et fournir des indications sur les déterminants du risque cardiométabolique. En
conclusion, les SA ont des prédispositions distinctes de risque de MCV, avec une intrication
complexe de facteurs culturels, innés et acquis. Bien que la gestion des facteurs
de risque des MCV et leur traitement chez les SA s’améliore, des possibilités demeurent
pour des avancées ultérieures.
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References
- Global and regional mortality from 235 causes of death for 20 age groups in 1990 and 2010: a systematic analysis for the Global Burden of Disease Study 2010.Lancet. 2012; 380: 2095-2128
- Global status report on noncommunicable diseases 2010.World Health Organization, Geneva2011 (Available at:) (Accessed September 13, 2014)
- Mortality from all causes and circulatory disease by country of birth in England and Wales 2001-2003.J Public Health (Oxf). 2007; 29: 191-198
- Cardiovascular risk and events in 17 low-, middle-, and high-income countries.N Engl J Med. 2014; 371: 818-827
- 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; 356: 279-284
- Trends for coronary heart disease and stroke mortality among migrants in England and Wales, 1979-2003: slow declines notable for some groups.Heart. 2008; 94: 463-470
- Coronary heart disease mortality for six ethnic groups in California, 1990-2000.Ann Epidemiol. 2004; 14: 499-506
- Coronary heart-attacks in East London.Lancet. 1975; : 833-838
- Diet and risk factors for coronary heart disease in Asians in Northwest London.Lancet. 1985; 65: 1086-1090
- Sizable variations in circulatory disease mortality by region and country of birth in six European countries.Eur J Public Health. 2013; 23: 594-605
- Risk factors for early myocardial infarction in South Asians compared with individuals in other countries.JAMA. 2007; 297: 286-294
- Variant metabolic risk factor profile leading to premature coronary disease: time to define the syndrome of accelerated atherocoronary metabolic syndrome in Asian Indians.Singapore Med J. 2009; 50: 949-955
Population Reference Bureau. 2013 world population data sheet. Available at: http://www.prb.org/pdf13/2013-population-data-sheet_eng.pdf. Accessed March 21, 2015.
Ministry of Overseas Indian Affairs. Population of non-resident Indians (NRIs): Country Wise 2012:1-4.
- South Asian diaspora.in: Ember M. Ember C.R. Skoggard I. Encyclopedia of Diasporas. Springer, New York2005: 285-296
The World Bank. Country and Lending Groups, 2015. Available at: http://data.worldbank.org/about/country-and-lending-groups#OECD_members. Accessed March 21, 2015.
- Caucasian.Br Med J. 1984; 288: 696-698
- Comparison of cardiovascular risk profiles among ethnic groups using population health surveys between 1996 and 2007.CMAJ. 2010; 182: E301-E310
- Cardiovascular risk among South Asians living in Canada: a systematic review and meta-analysis.CMAJ Open. 2014; 2: E183-E191
- South Asians and coronary disease: is there discordance between effects on incidence and prognosis?.Heart. 2013; 99: 729-736
- Effect of potentially modifiable risk factors associated with myocardial infarction in 52 countries (the INTERHEART study): case-control study.Lancet. 2004; 364: 937-952
- Cardiovascular disease mortality in Asian Americans.J Am Coll Cardiol. 2014; 64: 2486-2494
- Premature cardiovascular events and mortality in south Asians with type 2 diabetes in the United Kingdom Asian Diabetes Study— effect of ethnicity on risk.Curr Med Res Opin. 2010; 26: 1873-1879
- Mortality and morbidity from diabetes in South Asians and Europeans: 11-year follow-up of the Southall Diabetes Survey, London, United Kingdom.Diabet Med. 1998; 15: 53-59
- Association of cardiac and non-cardiac chronic disease comorbidity on glycaemic control in a multi-ethnic population with type 1 and type 2 diabetes.Postgrad Med J. 2011; 87: 763-768
- The use of BMI and waist circumference as surrogates of body fat differs by ethnicity.Obesity (Silver Spring). 2007; 15: 2817-2824
- Prevalence of coronary artery disease in Asian Indians.Am J Cardiol. 1992; 70: 945-949
- Increased burden of coronary artery disease in South-Asians living in North America. Need for an aggressive management algorithm.Atherosclerosis. 2009; 204: 1-10
- Long-term prognosis of South Asians following acute coronary syndromes.Can J Cardiol. 2008; 24: 585-587
- 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; 161: 2-8
- Risk factors, hospital management and outcomes after acute myocardial infarction in South Asian Canadians and matched control subjects.CMAJ. 2002; 166: 717-722
- Outcomes in young South Asian Canadians after acute myocardial infarction.Can J Cardiol. 2012; 28: 178-183
- Differences between South Asians and White Europeans in five year outcome following percutaneous coronary intervention.Int J Clin Pract. 2011; 65: 1259-1266
- Mortality in South Asians and Caucasians se United Kingdom: an observational cohort study of 279,256 patients from the BCIS (British Cardiovascular Intervention Society) National Database.JACC Cardiovasc Interv. 2014; 7: 362-371
- Outcomes after acute myocardial infarction in South Asian, Chinese, and white patients.Circulation. 2010; 122: 1570-1577
- The top 10 causes of death. Fact sheet no. 310., May 2014.World Health Organization, Geneva2012
- Risk factors for ischaemic and intracerebral haemorrhagic stroke in 22 countries (the INTERSTROKE study): a case-control study.Lancet. 2010; 376: 112-123
- Concomitant coronary artery disease among Asian ischaemic stroke patients.Ann Acad Med Singapore. 2008; 37: 573-575
- South Asian strokes: lessons from the St Mary’s stroke database.QJM. 2010; 103: 17-21
- The 1996 Leicestershire Community Stroke & Ethnicity Study: differences and similarities between South Asian and white strokes.Int J Epidemiol. 1999; 28: 853-858
- Risk factors, quality of care and prognosis in South Asian, East Asian and white patients with stroke.BMC Neurol. 2013; 13: 74
- Ethnicity and stroke risk in patients with atrial fibrillation.Heart. 2013; 99: 1087-1092
- Increased 5-year mortality in the migrant South Asian stroke patients with diabetes mellitus in the United Kingdom: the West Birmingham Stroke Project.Int J Clin Pract. 2008; 62: 197-201
- Ethnic South Asian ischaemic stroke patients have a higher prevalence of a family history of vascular disease compared with age, gender and diabetes-matched ethnic Chinese subjects.J Neurol Sci. 2009; 285: 118-120
- Secular trends in the cardiovascular risk profile and mortality of stroke admissions in an inner city, multiethnic population in the United Kingdom (1997-2005).J Hum Hypertens. 2008; 22: 18-23
- Acute heart failure syndromes: current state and framework for future research.Circulation. 2005; 112: 3958-3968
- Epidemiology and risk profile of heart failure.Nat Rev Cardiol. 2010; 8: 30-41
- Ethnic differences in the prevalence and aetiology of left ventricular systolic dysfunction in the community: the Harrow heart failure watch.Heart. 2005; 91: 595-600
- Prognosis for South Asian and white patients newly admitted to hospital with heart failure in the United Kingdom: historical cohort study.BMJ. 2003; 327: 526-531
- Ethnicity and variation in prognosis for patients newly hospitalised for heart failure: a matched historical cohort study.Heart. 2005; 91: 1545-1550
- Differences in the clinical characteristics of ethnic minority groups with heart failure managed in specialized heart failure clinics.JACC Heart Fail. 2014; : 2
- National, regional, and global trends in fasting plasma glucose and diabetes prevalence since 1980: systematic analysis of health examination surveys and epidemiological studies with 370 country-years and 2·7 million participants.Lancet. 2011; 378: 31-40
- Ethnic disparities in the association of impaired fasting glucose with the 10-year cumulative incidence of type 2 diabetes.Diabetes Res Clin Pract. 2014; 103: 127-132
- Prevalence of diabetes in New York City, 2002-2008: comparing foreign-born South Asians and other Asians with U.S.-born whites, blacks, and Hispanics.Diabetes Care. 2011; 34: 1791-1793
- Prevalence and correlates of diabetes in South Asian indians in the United States: findings from the metabolic syndrome and atherosclerosis in South Asians living in america study and the multi-ethnic study of atherosclerosis.Metab Syndr Relat Disord. 2010; 8: 157-164
- Age- and sex-related prevalence of diabetes mellitus among immigrants to Ontario, Canada.CMAJ. 2010; 182: 781-789
- Insulin resistance and truncal obesity as important determinants of the greater incidence of diabetes in Indian Asians and African Caribbeans compared with Europeans: the Southall And Brent REvisited (SAsBRE) cohort.Diabetes Care. 2013; 36: 383-393
- Defining obesity cut points in a multiethnic population.Circulation. 2007; 115: 2111-2118
- Characteristics of glucose metabolism in Nordic and South Asian subjects with type 2 diabetes.PLoS One. 2013; 8: e83983
- Early evidence of ethnic differences in cardiovascular risk: cross sectional comparison of British South Asian and white children.BMJ. 2002; 324: 1-6
- Mortality of South Asian patients with insulin-treated diabetes mellitus in the United Kingdom: a cohort study.Diabet Med. 2004; 21: 845-851
- Ethnic differences in myocardial infarction in patients with hypertension: effects of diabetes mellitus.QJM. 2008; 101: 231-236
- Cardiovascular complications and mortality after diabetes diagnosis for South Asian and Chinese patients: a population-based cohort study.Diabetes Care. 2013; 36: 2670-2676
- Outcomes in a diabetic population of South Asians and whites following hospitalization for acute myocardial infarction: a retrospective cohort study.Cardiovasc Diabetol. 2010; 9: 4
- Obesity and the risk of myocardial infarction in 27,000 participants from 52 countries: a case-control study.Lancet. 2005; 366: 1640-1649
- Obesity as a cardiovascular risk factor.Am J Med. 2003; 115: 37-41
- Overweight and obesity as determinants of cardiovascular risk.Arch Intern Med. 2002; 162: 1867
- Measures of body fat in South Asian adults.Nutr Diabetes. 2013; 3: e69
- Deriving ethnic-specific BMI cutoff points for assessing diabetes risk.Diabetes Care. 2011; 34: 1741-1748
- Ethnicity-specific obesity cut-points in the development of Type 2 diabetes—a prospective study including three ethnic groups in the United Kingdom.Diabet Med. September 2015; 32: 226-234
- Defining obesity cut-off points for migrant South Asians.PLoS One. 2011; 6: e26464
- Relation of central obesity and insulin resistance with high diabetes prevalence and cardiovascular risk in South Asians.Lancet. 1991; 337: 382-386
- Waist circumference and waist-to-hip ratio as predictors of cardiovascular events: meta-regression analysis of prospective studies.Eur Heart J. 2007; 28: 850-856
- Adipocyte hypertrophy, fatty liver and metabolic risk factors in South Asians: the Molecular Study of Health and Risk in Ethnic Groups (mol-SHARE).PLoS One. 2011; 6: e22112
- Visceral adipose tissue accumulation differs according to ethnic background: results of the Multicultural Community Health Assessment Trial (M-CHAT).Am J Clin Nutr. 2007; 86: 353-359
- Elevation in cardiovascular disease risk in South Asians is mediated by differences in visceral adipose tissue.Obesity (Silver Spring). 2012; 20: 1293-1300
- Abdominal visceral and subcutaneous adipose tissue compartments: association with metabolic risk factors in the Framingham Heart Study.Circulation. 2007; 116: 39-48
- American College of Cardiology/American Heart Association Task Force on Practice Guidelines. 2013 ACC/AHA guideline on the treatment of blood cholesterol to reduce atherosclerotic cardiovascular risk in adults: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines.Circulation. 2014; 129: S1-45
- C-reactive protein as a screening test for cardiovascular risk in a multiethnic population.Arterioscler Thromb Vasc Biol. 2004; 24: 1509-1515
- Lipids, lipoproteins, and apolipoproteins as risk markers of myocardial infarction in 52 countries (the INTERHEART study): a case-control study.Lancet. 2008; 372: 224-233
- Lipid profile, plasma apolipoproteins, and risk of a first myocardial infarction among Asians: an analysis from the INTERHEART Study.J Am Coll Cardiol. 2009; 53: 244-253
- Dyslipidemia in South Asians living in a western community.J Clin Lipidol. 2009; 3: 14-18
- Lipid and carbohydrate metabolic risk markers for coronary heart disease and blood pressure in healthy non-obese premenopausal women of different racial origins in the United Kingdom.Metabolism. 1996; 45: 328-333
- Elevated cholesteryl ester transfer protein (CETP) activity, a major determinant of the atherogenic dyslipidemia, and atherosclerotic cardiovascular disease in South Asians.Eur J Prev Cardiol. 2015; 22: 468-477
- Body composition and the apoB/apoA-I ratio in migrant Asian Indians and white Caucasians in Canada.Clin Sci (Lond). 2006; 111: 201-207
- Elevated lipoprotein (a) and apolipoprotein B to AI ratio in South Asian patients with ischaemic stroke.Int J Clin Pract. 2007; 61: 1824-1828
- Neuroendocrine mechanisms regulating food intake and body weight.Obes Rev. 2000; : 37-46
- Adiponectin: a novel adipokine linking adipocytes and vascular function.J Clin Endocrinol Metab. 2004; 89: 2563-2568
- Ethnic variation in adiponectin and leptin levels and their association with adiposity and insulin resistance.Diabetes Care. 2010; 33: 1629-1634
- Relationship of serum adiponectin and resistin to glucose intolerance and fat topography in South-Asians.Cardiovasc Diabetol. 2006; 5: 10
- Raised leptin concentrations among South Asian patients with chronic heart failure.Int J Cardiol. 2007; 122: 34-40
- The relationship between insulin sensitivity and serum adiponectin levels in three population groups.Horm Metab Res. 2005; 37: 695-701
- Total and high molecular weight adiponectin and ethnic-specific differences in adiposity and insulin resistance: a cross-sectional study.Cardiovasc Diabetol. 2013; 12: 170
- Altered lipid profile, leptin, insulin, and anthropometry in offspring of South Asian immigrants in the United States.Metabolism. 2001; 50: 1197-1202
- Biological, clinical, and population relevance of 95 loci for blood lipids.Nature. 2010; 466: 707-713
- Coronary Artery Disease (C4D) Genetics Consortium. A genome-wide association study in Europeans and South Asians identifies five new loci for coronary artery disease.Nat Genet. 2011; 43: 339-344
- The South Asian Genome.PLoS One. 2014; 9: 102645
- Genetic information and the prediction of incident type 2 diabetes in a high-risk multiethnic population: the EpiDREAM genetic study.Diabetes Care. 2013; 36: 2836-2842
- Does genetic heterogeneity account for the divergent risk of type 2 diabetes in South Asian and white European populations?.Diabetologia. 2014; 57: 2270-2281
- Diabetes mellitus: a “thrifty” genotype rendered detrimental by “progress.”.Am J Hum Genet. 1962; 14: 353-362
- A critical evaluation of the fetal origins hypothesis and its implications for developing countries early life origins of insulin resistance and type 2 diabetes in India and other Asian countries.J Nutr. 2009; 5: 205-210
- Amerind ancestry, socioeconomic status and the genetics of type 2 diabetes in a Colombian population.PLoS One. 2012; 7: e33570
- Thrifty genes for obesity and the metabolic syndrome—time to call off the search?.Diab Vasc Dis Res. 2006; 3: 7-11
- Neonatal anthropometry: the thin-fat Indian baby. The Pune Maternal Nutrition Study.Int J Obes Relat Metab Disord. 2003; 27: 173-180
- Differences in body composition between infants of South Asian and European ancestry: the London Mother and Baby Study.Int J Epidemiol. 2012; 41: 1409-1418
- Neonatal anthropometry: thin-fat phenotype in fourth to fifth generation South Asian neonates in Surinam.Int J Obes (Lond). 2009; 33: 1326-1329
- Differences in body composition and metabolic status between white U.K. and Asian Indian children (EarlyBird 24 and the Pune Maternal Nutrition Study).Pediatr Obes. 2012; 7: 347-354
- Dietary patterns and the risk of acute myocardial infarction in 52 countries: results of the INTERHEART study.Circulation. 2008; 118: 1929-1937
- Application of ethnic food composition data for understanding the diet and nutrition of South Asians in the United Kingdom.Food Chem. 2013; 140: 436-442
- South Asian dietary patterns and their association with risk factors for the metabolic syndrome.J Hum Nutr Diet. 2013; 26: 145-155
- Carbohydrate intake and HDL in a multiethnic population.Am J Clin Nutr. 2007; 85: 225-230
- The association between acculturation and dietary patterns of South Asian immigrants.PLoS One. 2014; 9: e88495
- Evolution of atherogenic diets in South Asian and Italian women after migration to a higher risk region.J Hum Nutr Diet. 2005; 18: 33-43
- Dietary patterns in Asian Indians in the United States: an analysis of the metabolic syndrome and atherosclerosis in South Asians Living in America study.J Acad Nutr Diet. 2014; 114: 238-243
- Lipid profiles and associated gene polymorphisms in young Asian Indian patients with acute myocardial infarction and the metabolic syndrome.Metab Syndr Relat Disord. 2009; 7: 571-578
- How physically active are South Asians in the United Kingdom? A literature review.J Public Health (Oxf). 2004; 26: 250-258
- Levels of physical activity and relationship with markers of diabetes and cardiovascular disease risk in 5474 white European and South Asian adults screened for type 2 diabetes.Prev Med (Baltimore). 2010; 51: 290-294
- Variation in mode of physical activity by ethnicity and time since immigration: a cross-sectional analysis.Int J Behav Nutr Phys Act. 2010; 7: 75
- The association of leisure-time physical activity and active commuting with measures of socioeconomic position in a multiethnic population living in the Netherlands: results from the cross-sectional SUNSET study.BMC Public Health. 2012; 12: 815
- Body fatness, physical activity, and nutritional behaviours in Asian Indian immigrants to New Zealand.Asia Pac J Clin Nutr. 2007; 16: 663-670
- Regional variations in deitary intake and body mass index of first-generation Asian-Indian immigrants in the United States.J Am Diet Assoc. 2002; 102: 1286-1289
- Exercise and coronary heart disease risk markers in South Asian and European men.Med Sci Sports Exerc. 2013; 45: 1261-1268
- Lower cardiorespiratory fitness contributes to increased insulin resistance and fasting glycaemia in middle-aged South Asian compared with European men living in the United Kingdom.Diabetologia. 2013; 56: 2238-2249
- Physical activity behaviour and coronary heart disease mortality among South Asian people in the United Kingdom: an observational longitudinal study.Heart. 2011; 97: 655-659
- Effectiveness of statin prescribing on reducing mortality in South Asian, Chinese, and White patients with diabetes.Can J Cardiol. 2013; 29: 920-926
- Cardiac medication prescribing and adherence after acute myocardial infarction in Chinese and South Asian Canadian patients.BMC Cardiovasc Disord. 2011; 11: 56
- Prescribing patterns and adherence to medication among South-Asian, Chinese and white people with type 2 diabetes mellitus: a population-based cohort study.Diabet Med. 2014; 31: 1586-1593
- Antihypertensive medication adherence and mortality according to ethnicity: a cohort study.Can J Cardiol. 2014; 30: 925-931
- South Asians’ cardiac medication adherence.Eur J Cardiovasc Nurs. 2013; 13: 357-368
- Patient characteristics, compliance, and exercise outcomes of South Asians enrolled in cardiac rehabilitation.J Cardiopulm Rehabil Prev. 2007; 27: 212-218
- Association of physical activity, smoking, and alcohol intake with CVD-related hospital discharge in people of European, South Asian, or African descent.Eur J Prev Cardiol. 2013; 20: 80-88
- South Asian men have different patterns of coronary artery disease when compared with European men.Int J Cardiol. 2008; 129: 406-413
- Cardiovascular risk factor profiles of recent immigrants vs long-term residents of Ontario: a multi-ethnic study.Can J Cardiol. 2012; 28: 20-26
- Screening for the metabolic syndrome using simple anthropometric measurements in south Asian and white Europeans: a population-based screening study. The Leicester Ethnic Atherosclerosis and Diabetes Risk (LEADER) Study.Prim Care Diabetes. 2010; 4: 25-32
- South Asians and cardiovascular risk: what clinicians should know.Circulation. 2006; 113: e924-e929
- Ethnic variations in heart failure: Scottish Health and Ethnicity Linkage Study (SHELS).Heart. 2012; 98: 468-473
Article info
Publication history
Published online: June 17, 2015
Accepted:
June 11,
2015
Received:
March 19,
2015
Footnotes
Please see page 1146 for disclosure information.
Identification
Copyright
© 2015 Canadian Cardiovascular Society. Published by Elsevier Inc. All rights reserved.
