DR. kamlesh

Why traditional tests fail to predict cardiac risk in India

1. Burden of Heart Disease

Cardiovascular disease (CVD) remains the leading cause of mortality worldwide, accounting for approximately 32% of all global deaths. Coronary heart disease (CHD) constitutes the largest share of this burden.

South Asians are disproportionately affected. Atherosclerotic cardiovascular disease (ASCVD) occurs 5–10 years earlier, with higher mortality at lower BMI and LDL-C levels compared with Western populations.

Key insight: Traditional risk factors alone do not fully explain this excess risk in Indians. Metabolic risk is central.

2.Established (Classical) Risk Factors

2.1 Non-modifiable Risk Factors

Age
Male sex
Genetics / family history of premature coronary artery disease (CAD)

These factors determine baseline susceptibility but are not directly actionable.

2.2 Modifiable Traditional Risk Factors

Dyslipidaemia & Hypertension

Elevated LDL-C is causally linked to atherosclerosis
Non-HDL cholesterol and ApoB are superior predictors
Many Indians develop CAD despite “normal” LDL-C
Each 20 mmHg rise in systolic BP doubles cardiovascular mortality
Masked and nocturnal hypertension contribute to residual risk

3. Diabetes and Glycaemia

Diabetes confers a 2–4-fold higher coronary risk
Prediabetes and post-prandial hyperglycaemia increase ASCVD risk
HbA1c demonstrates a continuous risk relationship
Risk begins years before diabetes diagnosis

4. Insulin Resistance: The Missing Link

Precedes diabetes, hypertension, and dyslipidaemia
Drives visceral obesity and fatty liver
Promotes endothelial dysfunction and inflammation
Creates a prothrombotic state

Insulin Resistance–Based Indices

METS-IR

Associated with coronary artery calcification
Linked to carotid intima–media thickness
Predicts incident ASCVD events
Independent of LDL-C and HbA1c

TyG Index

Predicts major adverse cardiovascular events
Correlates with coronary plaque burden
Outperforms fasting glucose alone

Evidence-Aligned Preventive Framework

ASCVD risk score for event prediction
Insulin resistance markers (METS-IR or TyG)
Waist circumference and fat distribution assessment
Blood pressure and lifestyle evaluation
Lifetime cardiometabolic risk estimation

Heart disease is fundamentally a cardiometabolic disorder, driven by insulin resistance and visceral adiposity, with dyslipidaemia acting as a downstream mediator.

Heart Disease in Indians: Earlier, Deadlier, and Often Missed