How is high cholesterol treated if I am Asian-American?

The 2018 American Heart Association (AHA)/American College of Cardiology (ACC) Guideline on the Management of Blood Cholesterol recommends healthy lifestyle practices and statins for adults with atherosclerotic cardiovascular disease (ASCVD), high cholesterol (low density lipoprotein cholesterol [LDL-C] ≥190 mg/dL), or an elevated risk of ASCVD, including Asian-Americans.¹  

Prevalence of Dyslipidemia Among Asian-Americans

The primary data source for US prevalence rates of dyslipidemia is the National Health and Nutrition Examination Survey which has very limited data from Asian-Americans.² However, heart disease and stroke statistics from the AHA indicate that cardiovascular disease is one of the leading causes of death among Asians who live in the US.³ Generally, the risk of heart disease among Asian-Americans (6.0%) is lower than among non-Hispanic whites (11.1%). However, the risk among Asian Indian adults (9%) is more than twice as high as among Korean Americans (4%). Asians differ from each other in culture, genetic ancestry, and environmental exposures, all factors that can influence cardiovascular risk.^4,5

Based on data from 53,125 Asian-American primary care patients in Northern California, there is considerable variability of dyslipidemia rates among the six ethnic subgroups studied (Asian Indians, Chinese, Filipinos, Japanese, Koreans, Vietnamese).⁶ Highest rates of dyslipidemia (LDL-C ≥ 130 mg/dL or ever taking LDL-lowering medication) were seen among Filipino men and women (73.1% and 63.0%, respectively). Lowest rates occurred among Chinese men and women (55.3% and 45.8%, respectively). By comparison, in the same database of primary care patients (total n= 169,430), rates of dyslipidemia among non-Hispanic white men and women were 62.2% and 52.6%, respectively; rates among Black American men and women were 63.1% and 57.2%, respectively.

Treatment of High Cholesterol in Asian Americans

The 2018 AHA/ACC cholesterol guidelines recommend a heart-healthy diet that is consistent with ethnic and cultural preferences for Asian-Americans.¹ According to nutritional guidelines of the AHA and the ACC, a heart-healthy lifestyle includes a diet that is rich in vegetables, fruits, whole grains, legumes, non-tropical vegetable oils, and healthy proteins.^7,8 These guidelines also recommend limiting the intake of sweets, sugar-sweetened beverages, and red meat. Caloric requirements should be determined by the need to avoid weight gain or to lose weight if you are overweight in order to minimize risk for ASCVD. Physical exercise is also important to heart health and adults generally benefit from 40 minutes of aerobic physical activity three to four times per week.¹   

Lipid-lowering medication, particularly statins, are recommended for individuals whose LDL-C is 190 mg/dL or higher, including Asian-Americans, for primary prevention of ASCVD.¹ The 2018 AHA/ACC guideline also recommends statins for people with LDL-C <190 mg/dL based on an assessment of their risk for future ASCVD events. The rate of ASCVD events is generally lower among Asian-Americans when compared to non-Hispanic whites.³ Asians were not included in the 2013 AHA-ACC ASCVD derivation cohort used to calculate cardiovascular risk and the calculator has not been validated in this population which reduces its potential predictive power in an Asian population.⁹ DeFilippis et al. evaluated the accuracy of the 2013 AHA-ACC ASCVD risk calculators in the Multi-Ethnic Study of Atherosclerosis (MESA) and found that the risk calculator over-estimated the risk in Chinese Americans.¹⁰ For 371 Chinese men in the MESA study, 49.7 ASCVD events were predicted compared to 12 observed. For 392 Chinese women in the MESA study, 31.7 ASCVD events were predicted and nine were observed.

Because the variables that best predict risk vary somewhat by race and because the available risk calculators have not been thoroughly studied with respect to their accuracy in Asian-Americans, the 2018 cholesterol guidelines recommend that Asians use the risk calculator called the Pooled Cohort Equation (PCE) for whites. However, this approach may underestimate risk in South Asians (from Bangladesh, India, Nepal, Pakistan, and Sri Lanka) and over-estimate risk in East Asians (from Japan, Korea, and China).^1,5,11

The amount statins can benefit an individual depends to some degree on how much the cholesterol levels decline in response to statins.¹² A reduction of about 40 mg/dL in LDL-C causes a 20% to 25% drop in heart and blood vessel-related events, such as myocardial infarction (MI), coronary deaths, strokes, and coronary revascularizations, for each year statins are taken. This is true even in people with lower levels of cholesterol to start with. The clinical trial data used to estimate the effectiveness of statins, however, was derived from disproportionately white populations. 

Comparisons of different statins in South Asians found that rosuvastatin and atorvastatin are well tolerated and effective in this population, although the treatment duration was brief (six weeks).¹³ There is some evidence that some Asian subgroups metabolize statins more slowly compared to non-Hispanic whites.² Compared to Caucasians exposed to similar doses of rosuvastatin, Japanese, Chinese, Filipino, Korean, Vietnamese, and Asian Indians were found to have higher plasma levels of the drug.¹⁴ As a result, the Food and Drug Administration recommends a lower starting dose of this drug when prescribed in Asians.^1,15 Lower starting doses may be warranted until further data on safety and efficacy in Asian populations is conducted.¹⁶ Lower doses of statins may also cause a greater reduction in CVD events in Asians than is seen in white populations taking the same dose.¹⁷

^References

1. Grundy SM, Stone NJ, Bailey AL, et al. 2018 AHA/ACC/AACVPR/AAPA/ABC/ACPM/ADA/AGS/APhA/ASPC/NLA/PCNA Guideline on the management of blood cholesterol. J Am Coll Cardiol 2018.
2. Pu J, Romanelli R, Zhao B, et al. Dyslipidemia in special ethnic populations. Cardiol Clin 2015; 33 (2): 325-333.
3. Mozaffarian D, Benjamin EJ, Go AS, et al. Executive summary: Heart disease and stroke statistics — 2016 update: a report from the American Heart Association. Circulation 2016: 133 (4): 447-454.
4. Palaniappan LP, Araneta MRG, Assimes TL, et al. Call to action: cardiovascular disease in Asian Americans. A science advisory from the American Heart Association. Circulation 2010; 122 (12): 1242-1252.
5. Volgman A, Palaniappan L, Aggarwal N. Atherosclerotic cardiovascular disease in South Asians in the United States: epidemiology, risk factors, and treatments. Circulation 2018; 138 : e1-34.
6. Frank ATH, Zhao B, Jose PO, Azar KMJ, Fortmann SP, Palaniappan LP. Racial/ethnic differences in dyslipidemia patterns. Circulation 2014; 129 (5): 570-579.
7. Eckel R, Jakicic J, Ard, JD et al. 2013 AHA / ACC guideline on lifestyle management to reduce cardiovascular risk. J Am Coll Cardiol 2014; 63 (25).
8. Jensen MD, Ryan DH, Apovian CM, et al. 2013 AHA / ACC / TOS guideline for the management of overweight and obesity in adults. J Am Coll Cardiol 2014; 63 (25): 2985-3023.
9. Goff DCJ, Lloyd-Jones DM, Bennett G, et al. 2013 ACC/AHA guideline on the assessment of cardiovascular risk: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. J Am Coll Cardiol 2014; 63 (25 Pt B): 2935-2959.
10. DeFilippis AP, Young R, McEvoy JW, et al. Risk score overestimation: the impact of individual cardiovascular risk factors and preventive therapies on the performance of the American Heart Association-American College of Cardiology-Atherosclerotic Cardiovascular Disease risk score in a modern multi-ethnic cohort. Eur Heart J 2017; 38 (8): 598-608.
11. Kandula NR, Kanaya AM, Liu K, et al. Association of 10-year and lifetime predicted cardiovascular disease risk with subclinical atherosclerosis in South Asians: findings from the Mediators of Atherosclerosis in South Asians Living in America (MASALA) study. J Am Hear Assoc 2014; 3:1-9.
12. Collins R, Reith C, Emberson J, et al. Interpretation of the evidence for the efficacy and safety of statin therapy. Lancet 2016; 388 (10059): 2532-2561.
13. Deedwania PC, Gupta M, Stein M, Ycas J, Gold A. Comparison of rosuvastatin versus atorvastatin in South-Asian patients at risk of coronary heart disease (from the IRIS Trial). Am J Cardiol 2007; 99 (11): 1538-1543.
14. Birmingham BK, Bujac SR, Elsby R, et al. Rosuvastatin pharmacokinetics and pharmacogenetics in Caucasian and Asian subjects residing in the United States. Eur J Clin Pharmacol 2015; 71 (3): 329-340.
15. Rosuvastatin [package insert]. Wilmington DE: AstraZeneca Pharmaceticals.
16. Liao JK. Safety and efficacy of statins in Asians. Am J Cardiol 2007; 99 (3): 410-414.
17. Nakamura H, Arakawa K, Itakura H, et al. Primary prevention of cardiovascular disease with pravastatin in Japan (MEGA Study): a prospective randomised controlled trial. Lancet 2006; 368 (9542): 1155-1163.