Melanie Cole, MS (Host): Welcome to AHN Med Talks, an informative resource for physicians across various specialties as we delve into the latest medical insights and best practices, ensuring you stay at the forefront of your field. I'm Melanie Cole. And today, we're highlighting AHN's New South Asian Heart Clinics. Joining me is Dr. Anita Radhakrishnan. She's a cardiologist with AHN Cardiovascular Institute specializing in cardiology and advanced cardiac imaging.

Dr. Radhakrishnan, thank you so much for joining us today. Start by telling us why South Asians are at a higher risk for heart disease, even when they appear healthier—in some cases, look younger—and even eat healthier in many cases. Tell us about the unique biological risk factors such as insulin resistance and visceral adiposity, elevated Lp(a) There's so many of these different risk factors and why traditional risk assessment may underestimate the risk in this population.

Dr. Anita Radhakrishnan: Thank you so much for having me. So, South Asians are people with ancestry from India, from Pakistan, from Sri Lanka, Bangladesh, Nepal, and they actually have one of the highest risks of cardiovascular disease globally. And what's special about this population or what's unique is that they develop heart disease at much younger ages with higher intensity, but they're very difficult to identify as high risk.

And as you said, they appear healthy. And so, this appearing healthy can be very misleading. Many patients that are South Asians, when you look at them, oftentimes have a normal BMI, which means they appear in normal weight and height. But still internally, they have a very adverse cardiometabolic profile. So, the key issues with South Asians is they develop visceral adiposity, which is basically development of fat on organs, and they have insulin resistance, diabetes, more advanced diabetes. They have dyslipidemia and they have unique artherogenic risk factors such as elevated lipoprotein A. So, they have lower body weight, but the risks are pretty high internally.

And when you look at them, traditionally, they look thin. And so, automatically, as most providers, we think, "Oh, they must be low risk as well because of their low BMI." But when you actually do an assessment, they oftentimes have higher abdominal fat, they have higher triglycerides, lower HDL; smaller, dense LDL particles. Their diabetes onset may be younger and their vascular biology is just high risk. So, the main message is that you don't let normal BMI be a visual indicator for cardiac risk, because this population will definitely not be screened in that scenario.

Talking about unique risk factors is important. But I think the bigger conversation is that our current risk calculators in the United States, such as the ASCVD risk or the PREVENT calculator, which looks at blood pressure and the general traditional lipid panel to identify their risks. It also looks at smoking and diabetes presence. We will oftentimes miscalculate or create a lower risk panel profile in South Asians. And that's mainly because it doesn't really include the family history, the South Asian ancestry, the Lp(a), the ApoB, the visceral adiposity, the metabolic syndrome, the inflammatory risk, all this that is high in South Asians. So, that's why they oftentimes are considered low risk. And so, we're not aggressive in our primary prevention in this population. And so, disease starts at younger ages, and we oftentimes pick it up after a cardiac event occurs.

Melanie Cole, MS: Wow, that really is interesting. And I'd like to talk about some of those gaps. But going back to your answer for a second. You mentioned smoking. I mentioned in my intro and my first question about diet when we think of South Asian foods, lentils and spices and seasonings. And when we think of these gaps, you mentioned that it does take into account smoking, but are they missing some of these other things? Do these come into the picture? Is this mostly genetic as we look at that visceral adiposity and those things that you were just discussing.

Dr. Anita Radhakrishnan: Yeah. So, the things that are genetic is predominantly their lipid profile and their insulin resistance. I agree that lifestyle, just like it is in the western world, can contribute to heart disease. But I would say that their Lp(a) is a genetically determined marker. And recent studies have shown that the South Asian cohort have significantly elevated Lp(a). And I think that every single South Asian should have an Lp(a) tested at least once in their life. And ApoB, which gives us a better idea of the number of atherogenic particles in their body, which includes all of the LDL particles, along with Lp(a). This also can be extremely helpful, and it's not routinely checked in regular patients.

But the other thing that South Asians have in terms of lifestyle is their diet. And South Asians, we're pretty diverse and we're fairly healthy in our activities, but our diet really does compose of a lot of refined carbohydrates like white rice. And you may have heard of naan or idli or dosa, a lot of fried snacks, and a lot of sugar in the food that we eat. And a lot of South Asians are vegetarian as well, which tend to be lower in protein and fiber, and they tend to be higher in unsaturated fats.

Physical activity is another major issue. I think South Asians are academically and professionally very driven, but structured exercise is not something that's very typically built in the day-to-day life, because they are so career-driven. And women tend to prioritize work and family, and also put physical exercise as our last prerogative. And so, physical activity is not up to ideal American Heart Association goals. And their diet contributes to the increased risk as well.

Melanie Cole, MS: Wow. So as we're talking about these gaps in the existing tools, the need for more tailored risk stratification approaches for this population, what inspired the creation of the South Asian Heart Center? Tell us about the clinical need, personal motivation, and the vision behind developing such a specialized center.

Dr. Anita Radhakrishnan: Well, the inspiration really does come from a personal understanding of South Asian. I am a South Asian. I have many friends and families that have had heart disease with sudden death at young ages. I also trained in India, so I've seen a lot of heart disease in the young population there. But that, along with my clinical experience here in the United States, as well as the community need, is where the inspiration comes from.

I was repeatedly seeing South Asian patients who did not fit this classic risk model, because their BMI was normal and because their traditional lipid panel was normal and things were borderline. And because things were borderline, they were left alone, or they just said, "Continue, we'll keep an eye on it." And then, the next thing is they come in with a massive cardiac event such as a heart attack. So, it's really from this clinical story that we are seeing over and over again. And that's really why American Heart Association and ACC has identified South Asians now as a unique high-risk race of their own.

And so, while we know there are a unique high-risk race, there is still a lot of work that needs to be done to identify how do we take care of this population? How do we risk stratify this population and provide a good prevention model? And that's really why the South Asian Heart Center here at Allegheny Health Network has been started. We do have many South Asians in the community. More than 10% of the Pittsburgh population is South Asians. We have physicians here with South Asian background that are focused on prevention and imaging and health equity. And so because of that, we've all been able to come together with this common interest to serve the community. And that's really why we've pursued this. And also, it's a great opportunity to provide an opportunity for research and data collection in this high-risk population as well, so that we can come up with ways to help tailor the treatment to the South Asians.

Melanie Cole, MS: Dr. Radhakrishnan. As you're speaking to other providers, you've mentioned a few of the markers like Lp(a), AboB, these inflammatory markers. Speak a little bit about those and the role of advanced imaging in detecting subclinical disease and what other providers should be looking for, if they're primary care providers or specialists, what you want them to pay special attention to.

Dr. Anita Radhakrishnan: I do want to emphasize when we talk about heart's disease in South Asians, we're talking about coronary artery disease. So, we're talking about plaque buildup in the arteries that's leading to heart attacks and leading to cardiac events.

So, to identify who is at risk, using our current risk models are not very helpful. But if they do have family history, if they do have an elevated Lp(a), if they have family history for heart disease, if they have an elevated Lp(a), if they're borderline in terms of diabetes or hypertension, there should be a very low threshold to consider coronary artery calcium scoring.

Right now, coronary artery calcium scoring in American guidelines is really for people that are intermediate risk. And I would say that South Asians, with these other unique risk factors. if they have that, they should consider a coronary calcium. It's a very powerful tool. And it detects subclinical atherosclerosis, but it only detects coronary calcium. So, that means the plaque has to be there for a while.

I would also say as an advanced cardiac imager, there is a great role for coronary CTA in this population as well. It's a slippery slope, because we don't want to do it on everybody, But in patients that have symptoms, that even if they appear atypical and they have these risk factors, a coronary CTA would be an excellent test to actually visually see the degree of plaque, how much of plaque is. noncalcified versus calcified so that we can understand the plaque burden and the plaque phenotype and appropriately be aggressive in risk management.

Melanie Cole, MS: Yeah, that's so important. So, tell us how the South Asian Heart Center is different from traditional cardiology clinics. I'd like you to speak about the comprehensive care model, including early detection as we've mentioned, advanced imaging as we've mentioned, and culturally tailored prevention strategies. I think that that's so important and certainly the multidisciplinary comprehensive approach.

Dr. Anita Radhakrishnan: Yeah. So, a traditional cardiology clinic oftentimes sees patients after an event or after a risk is already declared itself. Usually, they come in with symptoms, they come in with abnormal testing. But here, we're really trying to move this upstream, right? The focus is very early identification and deeper risk stratification, and a very culturally tailored preventive model.

So. We're not only looking at LDL and blood pressures, we're looking at these unique risk factors that I mentioned. We're getting a detailed family history, pregnancy risk-related factors in women is extremely important. Understanding the inflammatory risk and lifestyle pattern is important. And then, also, getting imaging evidence of subclinical atherosclerosis. It's going to be different, because we are going to take care of South Asian patients and they're oftentimes, I'm hoping, are going to be coming to see us when they're a lot younger, maybe in their 30s or 40s to help risk stratify them.

One of the major things that we're excited about is the collaboration we have with a South Asian lifestyle coaching program, which specifically is going to give culturally tailored care regarding diet advice and their recipes and their exercise, and those kind of recommendations that are very, very specific to the way South Asians live, so that it can be effective and patients can actually carry out and it can be a lifelong learning process. This collaboration will be for a year at a time for our patients, and we are going to provide that along with the routine care that we will be providing in clinics. These South Asian clinics are all over the city. We're going to where South Asians are, so we have it in Wexford at Allegheny General. We have it in North Fayette. We have it in Peters. We'll be going to Jefferson. We'll be in multiple areas where we have pockets of South Asians so that it's easy access for them as well.

Melanie Cole, MS: That's just wonderful news. And Dr. Radhakrishnan, as we wrap up. What have we missed? What would you like final thoughts and key takeaways to be for other providers that are looking to AHN's New South Asian Heart Clinics for referrals and information? What would you like them to know?

Dr. Anita Radhakrishnan: Yeah. I would like them to know that the service is available, You know, so that's first and foremost, especially for our providers that are in some of our peripheral centers, that we are here to take care of this population, and we're here to take care of them with you. We're not here to replace your care by any means, but we will be offering this culturally tailored care.

We will have a specific diabetologist as well as part of the South Asian clinic. So, we're here really to optimize care for this population. And there will be registry data so we can see that there's an improvement in outcome with our efforts. And we want to know that we are doing everything we can for the community.

And so, just bringing awareness that we're here for this high-risk group and that it's very much needed for the Pittsburgh community and having our providers at AHN and other facilities as well know that we're here is important, and we're looking forward to working with them to take care of our patients.

Melanie Cole, MS: Thank you so much, Doctor, for joining us today and sharing your expertise in telling us about this unique community. So, thank you again. And to learn more or to refer your patient, please call 844-MD-REFER, or you can visit findcare.ahn.org. Thank you so much for joining us on this edition of AHN Med Talks with the Allegheny Health Network. I'm Melanie Cole.