Episode 8 - Heart Disease in South Asians

Join our special guest,  Dr. Santosh Menon from Christ Hospital in Cincinnati, for a practical discussion on the incidence, clinical presentation, and management of heart disease in South Asian populations. We discuss possible mechanisms for the high observed incidence of CVD, the role of screening, and practical management tips for therapy and lifestyle modification.   Please subscribe to receive updated episodes automatically! Visit https://www.ohioacc.org/cardiohio-podcast/.

For more information, see the AHA Clinical Statement on Heart Disease in South Asians, as well as the MASALA study website. 

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Please subscribe to receive updated episodes automatically! Visit https://www.ohioacc.org/cardiohio-podcast/.

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Transcript

0:04

Welcome to the Cardio Ohio Podcast, a production of the Ohio Chapter of the American College of Cardiology. This is Can Greyal in Columbus, Ohio. This is Ben Allen Cherry Cardiovascular Imaging fellow from Cleveland, Ohio. More information on the podcast, including past episodes, is available@ohioacc.org. And now for today's,

Kanny 0:30

So welcome back to the Cardio Ohio podcast. And we would like to welcome to our show, Dr. Santosh Menan from Cincinnati. He's a clinical cardiologist, a heart failure specialist as well at Christ Hospital, but he also is the medical director for the cardiovascular clinic for South Asias, which we're gonna hear much more about. Santos, welcome to the show.

Santosh 0:53

Hey, thank you Kenny. Thank you Ben and Gwen for having me. I'm really.

Kanny 0:58

Yeah, we appreciate you as well joining us. of course, just, two weeks ago you gave an excellent talk at. Statewide or highway C meeting with an overview, of heart disease in South Asians. So we kind of wanted to build off your presentation, maybe reinforce some of the key points and also get into more practical advice about how we can, manage. Some of our patients, role of screening as well. But we thought we'd start by just asking you how this became an area of interest for you. In other words, what was your path from, deciding to go into cardiology, to ultimately, having this position to start a clinic like this?

Santosh 1:35

Yes. Thank you so much. You know, I always loved cardiology. I mean, it's so, data driven. All the studies have done everything guideline driven. so I had a passion, cardiology from med school to residency. And then, you know, within cardiology, I really enjoyed doing heart failure l a and I did that for a few years. I evolved to do more, general cardiology, heart failure, of course, preventive cardiology. My interest with South Asia is really, I am ashamed to say, or maybe I should be proud to say that I read about it in the New York Times with the article about the Masala study from the front page of it. And that got me fascinated. And then when you talk to other people, you know, everybody has a family member, friend or someone as I've made representation. My wife's cousin had an MI at a very early age and that really tweaked my interest and I. You know, we look, we look different. we, we have very little smoking, very few risk factors, but we have this horrendous, cardiovascular risk and what is the basis of that? What are the studies? And what I found was that there really is not much studies, you know, initially most studies for Asians in lop everybody together, including South Asians. Chinese, Japanese, and the data was skewed because we were thought to have a low risk for cardiovascular disease. It's only recently that people started separating, separating the data out, especially, in England and I found that yes, south patients are a very high risk and masala study, which I thought was a great acronym. was, was really the icing on the cake to increase awareness, especially, for me and to get more interested in this. Yeah,

Kanny 3:13

and we're gonna get into details about the MESSALA study, which I think has definitely expanded our knowledge. So, you know, I've been practicing 25 years now. It's been 30 years since I started as a fellow. I remember in the late 1990s, some of those early articles that were first pointing out. The risk in South Asians. I know a lot came from, the United Kingdom in those days dealing with, South Asian immigrants. So in the last 20 years, have subsequent studies, kind of confirmed that there is both a higher, prevalence and incidents in South Asians, and also, uh, Confirm that perhaps the, the onset of diseases at a younger age as

Santosh 3:51

well. Yes. Apart from the masala study, there's been several studies of really demographic studies looking at South Asians as a separate population. And what they find is that it happens 10 years sooner than white counterparts. and also the risk of dying is four times greater when compared. a case controlled, Americans. there was the Mesa study, but that also again, lumped together, Chinese and, Hispanics and South Asians. And again, you, you found that when you break down the Mesa study that there was a high risk among South Asians for developing coronary calcium, which as you know, is a precusor to having a myocardial infarction.

Kanny 4:32

And is it true, do you think studies have confirmed that the risk is high, both in Native South Asians and their home countries as well as those that have immigrated to western countries?

Santosh 4:44

Absolutely. as you know, diabetes med, especially type two diabetes med or insulin resistance, is at almost epidemic proportions in the South Asian countries. A lot of it is due to diet, lack of exercise. And probably a genetic component. And that does not change when you migrate to the United States or Canada or England, it follows you. So just moving to a country where, let's just say that maybe medical care is more advantage, more access, it does not change your risk. We carry that with us. Yeah, that's perfect, Dr.

Ben 5:21

Menden. And, and for our, for our listeners, this messala study we talked about, this is the mediators of atherosclerosis in South Asians living in America. It's by Dr. Kana from, U C S F, in collaboration with docs from, Northwestern, and it kind of focused on South Asians living in America, trying to detail. Almost in a descriptive fashion, what, what is the rates of coronary disease, but also what are some of the contributors? And, and that's kind of where I wanted to plug you in here. You know, you, you have this clinic in Cincinnati where you're seeing the patients and in the study from some of the papers from the Masalas study, they, they talk about, you know, the BMI cut point for South Asians for obesity. Is around 27 and a half lower than any of the other races. Do you see this where you have, kind of coronary disease that's out of proportion to the bmi, meaning people are what we call skinny fat.

Santosh 6:15

Yes. the BMIs have to be dropped for South Asians was, we don't fit. the criteria that is for obesity and we tend to hide our obesity, what we callal obesity or, visceral obesity, which is much more arthrogenic and that is not picked up in a bmi. For instance, in my South Asian clinics, I use wasted hip ratio, which is, which we think is much more accurate to see which patients are obese

Ben 6:43

You know, beyond the obesity differences and body, body composition differences, people have brought up coronary size. Coronary diameter. has that been something you've seen in, in either the literature in your, in your practice that has contributed?

Santosh 7:00

What I see a lot and what the studies support is that we get extensive atherosclerosis. So it's not the typical proximal L A D 90%, which can easily be stented. It tends to be long diffuse ratty, something with diabetics would get. But a lot of these patients are not diabetic. They're not by, by, criteria. They may be insulin resistant, but they're not diabetics. They tend to be diffused, they tend to be more distal, the lesions, and they tend, they tend to be, dense, lipid plaques and a very high calcium scores suggesting, a lot of plaque burden at a very young age and at a very low b.

Ben 7:36

Yeah, that, that's an interesting point and I'll, I'll transition to candy here on a topic. He, is near to end dear to his heart cuz he's an avid golfer and still really active. You know, the indie masala study, I think South Asians were, were like very significantly lower in terms of how much exercise they did each day. Is, is that something you're seeing as well? And, and how have you kind of used that in the management tool to, to encourage South Asian patients to, to kind of get out there and get moving?

Santosh 8:07

So, that's a great point. I, the study shows the ma sub-study that compared to, white counterparts, we tend to walk about 4,000, 5,000 steps less using a pedometer and I think that is a tremendous risk factor. There are many factors for that. One, as you know, as South Asians, it is ingrained in us to study, work hard and. Spend too much time exercising, or doing sports and stuff like that. but also there are social barriers, especially in female studies have shown that females of South Asian descent, especially those that have only been in this country for a few years, have barriers. Not just basically, you know, getting to a gym, but going to a gym, working. out in front of other people walking in the street and stuff like that. Moving is difficult for them because of these barriers. And a lot of females who also have a very high risk of heart disease amongst South Asians, they are the, the key players in the families. That means they do all the cooking, that they, the kids have no time to look after themselves. I mean, I see it a lot in my South Asian patients. Sometimes the husband and the wife come together to see me when the wife is my. The husband does all the talking for them and explaining the situation. So there are many reasons as to why South Asians are just not that active and one of them being it's ingrained in us. Number two is that I believe that there's a lot of social barriers to exercise. Yeah,

Ben 9:32

Santosh. I think those are, those are great points. I will say. As a South Indian and a 33 year old who still plays basketball once a week, I'm waiting for my call up from the calves to be their 13th man. So don't wreck my dreams.

Santosh 9:44

that and here really. Taken this and are really taking care of themselves, at least exercising a lot more. But it's the other generation. Our parents generations who came here worked hard to get here, and studies are shown the more senior you become in your company or in your institution, or you become a professor. More sedentary becomes also stress is a very important, Mental stress is a huge factor in South Asian. If you talk to all South Asians, even the young ones who work in it, they're stressed to the max. And that also is very ProART, I think. Yeah, I'm glad you

Kanny 10:22

brought that up, Santos. I do think that's, a commonality I see in my patients as well, one point about exercise that's very interesting is that you do see a lot of, young, extremely athletic patients who still develop atherosclerotic disease. and so that exercise, even though it can be protective, it certainly doesn't prevent you from. Aro scribe disease because sometimes people are actually becoming more active because of their family history or because they already had other risk factors. Do you see that as well? Hmm,

Santosh 10:51

absolutely. and that is one thing I'd recommend is at least you can't negate maybe the genetics, but you can Sure negate other risk factors such as sedentary lifestyle. One thing I do tell them is, Whatever it takes. Get down to get, get down to your ideal body weight. Get rid of the fat, and I think your insulin intolerance and your and your type two diabetes will get better automatically. It'll help your stress. There absolutely is no downside. I think in South Asian or any population, but especially South Asians to exercising. Our muscle mass is less so we tend to hold onto the weight in our. Abdomen and our arms tend to be thin and as you know, you need muscle to absorb, glucose and to store it. And less muscle mass means less, less, less glucose storage. and, and I, so I tell my patients, Aerobic is great, but you also have to, use weights and would do resistance training. That's very important.

Kanny 11:48

Yeah, absolutely. Before we move on to talk a little bit more about management and screening. You mentioned early on about the diabetes, about the explosion and the incidents, but is there anything we can learn about the presentation of glucose intolerance in South Asians that may be different than general populations? is there anything different in terms of, a screening regimen, in terms of like what cut points you might use to consider someone pre-diabetic, for example?

Santosh 12:14

I, I, from what I've seen in all my, almost all of my south, even some of them that are runners are, they tend to be glucose intolerant. That means that they're fasting. Glucoses tend to be not of the diabetes range, but they are. Moderately elevated suggesting insulin resistance. Sometimes I, you know, some people recommend some of the studies they recommend to an insulin level. I've done that in a couple of young patients. but really in my policy now with South Asian, especially ones who are really motivated, Get their numbers down, almost everything to normal. So an a1c less than 5.7, 5.5, LDL less than 60, 75. Those numbers have to blood pressures that have to be perfect. As you know, in the MASALA study, they found that we had a higher incidence of high blood pressure, and increased fasting glucoses and type two diabetes. And, and elevated calcium levels. So really you gotta get these numbers down to normal in most patients.

Kanny 13:15

Yeah. Well, that's a great, I think that's a great way to transition a little more into screening and targets. so let's just take a theoretical patient, you know, a 35 or 40 year old, South Asian professional. Maybe they have, family history of coronary disease or other cardiac events and relative. they don't have any history themselves, but they haven't really been the most. thorough about, tracking their primary prevention measures and they're coming in to see you for risk assessment. So, you know, we're all, general cardiologists and we understand, you know, the, the bread and butter things we're gonna recommend to every patient, but, What are the things you would tell them to focus on if they're coming to see you for the first time they're asymptomatic, in terms of where they should be, what targets they should be shooting for, for things like lipids, blood pressure, stress reduction, and so

Santosh 14:01

forth. I tend to look at their risk. I try to stratify them. Look at that course like you said, the family history, their, was of hip ratio. Their blood pressure. Are they, are they obese? and really, I try to target to them really getting their blood pressure down to normal. The glucose is completely back to normal. and, and the lipids now at, at the age of 35 and 40, unless they have tremendous risk of coronary disease, that means that they have glucoses. The hdl, which is commonly low in South Asians, and the triglycerides rather, they have a family history. I'll do a calcium score early in these people. Cause you'll see even specs of calcium is a risk factor, as you know, for coronary. and I've seen a lot in my patients at a very early age, rampant, heavy coronary calcifications. And the maas did show that the coronary calcium scores tends to be higher compared to white counterparts. It was a more dense, calcification of these plaques, at a much early age. So sometimes South Asians need some convincing that, yes, you need to take a statin, you need to take aspirin, you need to exercise, watch your diet, and so on. And a calcium score is a great way, I think, of, convincing them that yes, it's a wake up call that you need to get something done and start acting on it now.

Kanny 15:17

So even below age 40, you don't have any, qualms about recommending, a calcium score if the risk profile would indicate that it can help your decision.

Santosh 15:26

below 40. You know, I may hesitate, but like I said, those that are, that I think are just, you know, very, type two diabetic or, appear to be insulin resistance. Insulin resistance, or the metabolic syndrome, whatever family history. I'll get that as a baseline and I'll follow that carefully. Understand that they could have soft plaque. That could be this. I don't do stress testing these people unless they have symptoms. I don't do coronary, CTAs unless I'm really, really concerned, that they have, that they have angina. Now some people come with a coronary counseling score that they had done through their physician or through a health fair or. Or, or bring carotid studies, you know, carotid doper, vascular screening, and that'll show some plaque. But, above, below 40 there really have, I really have to have more evidence before I do it.

Ben 16:13

Yeah, that's, that's totally understandable. Suno and, mm-hmm. just piggybacking off that, so say, just like Candy had said in that young patient who comes in, has risk factors, has all the primary prevention indications, you start'em on statin therapy, control their blood pressure monitor. If there's diabetes, you treat. What, how aggressive are you because, you know, these are young patients. How aggressive are you in jumping to a second lipid lowering management. How often are you using pcsk nine, Zetia, et cetera. And these young patients,

Santosh 16:45

as you know, South Asians tend to be, intolerant of statins for the most part. these are a chunk of South Asians that have a gene that, that, reduces their, tolerance of statins. So you can't really go on high doses. I don't have a lot of patients on, let's say 80 of Lipitor, but I tend to go to Crestor first. And if you look at the guidelines, they do recommend Superstatin for these patients, and I think that helps get their hdl. and I will target, if they have some coronary calcium, I'll go to below 70, 75 and then maybe even follow the European guidelines down to five. And the one thing about South Asia, which there's no data to support this, I if they have more modern calcium, I will repeat the calcium score in about two to three years. I won't wait the five years that it's recommended. The guidelines, and I will add Edia. Zei has very well tolerated these patients because, you know, their max dose of Rosuvastatin, they've lost some weight, but the HDL is low. The LDL still the nineties. I'll add Zeti and I've had good results. with that. I've only have a couple of patients, a couple of patients who already have for secondary prevention, PCSK nine inhibitor, and they seem to tolerate that well. Of course, I will check vitamin D levels of these and use U 10 with them because our U 10 levels tend to be low, in South Asians.

Ben 18:04

Yeah, that's an interesting point. especially here in Cleveland. I think everyone, regardless of your ethnicity or anything, your vitamin D levels are, are quite low. So that's often something we target when we're starting statins. yeah. You know, looking at it from the fellow perspective, I know there are, there are a lot of fellows in training who are listening and it's quite a unique path. You took, doing heart failure and then starting a, a South Asian clinic in a major. Can, can you just share a little bit, I know you, you talked a little about the motivation, but just how it's been starting like a very specialized clinic where, like in Cleveland we don't have this clinic. just how it's been, how the growing pains and how you've recruited people and how follow up has been to get patients to buy in.

Santosh 18:47

Yeah, I mean, it's been fantastic. I mean, you know, helping people, especially our community, I spend a lot of time on educating, the masses, as well as my patients. and I try to see them through, you know, if they have a, if they need some kind of, Coronary angio with something I, you know, help them. But what you'll see is that South Asians like seeing patient, doctors who look like them. So most of my patients, if they're South Asian, their primary care tends to be South Asian. and you know, for the most part, they tend to be very compliant. They've not heard all the stuff that I've told them about. I spend a lot of time on. And how to change your diet, how to exercise within your, your, your constraints, how to deal with stress and social isolation. How to deal with depression and things like that. And actually I have a South Asian physician who's a psychiatrist, a young girl, and her dad died of a sudden, cardiac death when she was the resident of Christ. who helps me with some of my South Asian patients. I, you have to approach it from their, from their side. You can't just tell them, Yeah, take this pill, come back and see me in a year. They just won't do it. So I discussed, What is your, plan, What is the barriers? What is your barriers to a really good diet? And I'm not a dietician, but I do recommend to them, for the most part, think about something like a Mediterranean type of diet. and once in a while, eating South Asian food is fine cause that is a attachment to our culture. But you can't eat it all the time. Was the, I suspect that is a common factor. As to why we develop all this ity. but it's been great. I mean, you know, they're, they're wonderful patients to take care of. some, some can be frustrating, of course, cause a lot of them have medical people in their families who, who wanna give an opinion, about, about their dads and moms care, or they want me to get them on the phone and stuff. But, they're grateful. They follow up. they show up. and they try to do what they can, but I, I try to tailor it to each one of them, and I think they feel more comfortable talking to, someone who looks like them, talks to them, understands where they're coming from. so it's been great. You know, it's, it's not, you know, it's not like it's, it's not like bursting from the scenes, but I'm getting there. I always recommend to my patients that if you have a very good primary care physician, very good cardiologist, and you're happy, they're taking good. See them, you know, I can, I can help you out once I can give you recommendation, you can take it back to them, that you should be on these kind of medications with these kind of targets. but, but, but I think I spend a lot of time educating and doing also free care for, as you know, there's a big population of, undocumented South Asians in the Midwest who, you know, who work, but they're not documents or. They don't have insurance and things like that. So we helped them out. A lot of educating, checking blood pressures, EKGs, and doing free echoes for the, for these, refugee population and undocumented people. So, but as you know, South Asians are, you know, they're different, different cultures and different ways of, of approaching them. But, but so far, so far so good. It's, it's been really great. It's been very satisfy. Yeah.

Ben 21:47

I think it's inspiring, you know, regardless of whatever discipline you're interested in, I know you run a busy heart failure practice at a major hospital, but even to, to have the time and the dedication to, to, to promote your time in this area is, is it's awesome to see and it's inspiring for, for us fellows.

Kanny 22:05

Santos, that's a great story to hear. I'm glad you brought up the diet because we didn't have a chance to ask you about that earlier in our discussion. But, obviously a lot of South Asians are vegetarian, but would you agree that that doesn't necessarily mean that they're eating a heart healthy diet? And as a follow up to that, what advice do you give some of the first generation or even the immigrants who are still holding on. South Asian type diet, what advice can we give them on changes they can make, you know, to make it a little more healthier?

Santosh 22:37

Absolutely. Yeah. I, I think the diet is our biggest part. I mean, we eat high carb, low fiber diets where the blood sugar goes up immediately in our bodies, our insulin levels go up even higher to, to overcome this, hyperglycemia and that gets stored as fat in our bellies, and that can be hidden very. but it is a, it is a link to our culture. So what I tell my patients is, and I ask them about diet very much in detail, and they like talking about their diet. Cause you understand the word that they use China, you know, RO and stuff like that, which, a western Dr. May not understand. And what I tell them is that you don't have a choice anymore. Especially those that have, Calcium score, they've had a heart attack or they've had bypass surgery. Those, unfortunately, those days are long gone. When our ancestors ate this kind of few food, first of all, they don't eat only one meal a day and they would walk everywhere. And studies are shown that those, South Asians that live the rural area have a 50% reduced, BMI and a hip wasted hip ratio and a lower risk for cardiovascular disease. We're eating the same foods, but we're not as active. So you gotta change your diet. You don't have a. And the I, I just keep it simple again, because I'm not a dietician. I tell them, You really have to eat a Mediterranean type of diet. Being a vegetarian, it's a vegetarian Paradox in the studies have shown, and I think in the also 40% of the patients were vegetarians are large numbers. And we're vegetarians for religious reasons, whereas the Western population is vegetarian for health reasons. So I tell them, Be a vegetarian for health reasons, don't eat Indian food rights and all that. And Chip was, you will eat more carbs to overcome the lack of protein and that will make your risk even higher in terms of having cardiovascular problems. And studies are shown that there is a vegetarian paradox. you know, you try not to insult anybody cause it is religious, but I tell. You know, Mediterranean is essentially vegetarian and if you're a meat there, there's meat in, in a, in a Mediterranean type of diet. So instead of using rice, use quinoa. and once a once a week you can cheat, you know, But if you eat it every day, even if you, unless you work at four to six hours a day, it's just going to gonna be a problem. This problem will continue to be a, escalate. And I tell them, you know, your forties, your kids are in the 10, 15 years old. If they see what you eat and how you exercise, they will pick up those habits. And, and, and we don't know, the massage study has a second arm to a third arm to it, looking at second generation South Asians, what is their risk for cardiovascular disease? so diet I think is very, very, very important. And adjusting it, is also, is also very crucial for long-term survival for these.

Kanny 25:22

Well, Santos, thanks so much. we have just a few minutes left. so it sounds like if I could summarize what you've been telling us, the best way we're gonna attack this, kind of explosion in, in the incidence of, of vascular disease in this group is a combination of maybe earlier detection, more aggress. Detection of risk factors and perhaps more aggressive therapy of risk factors to tighter, targets. And then perhaps a role for screening with a calcium scoring. And other modalities to detect a disease at an earlier stage. Is that a fair, summary so far?

Santosh 25:59

Absolutely. That's

Kanny 26:00

perfect. And of course, tremendous lifestyle changes, like you mentioned to exercise, diet, weight loss, et cetera. I thought we would wrap up just by asking you what you think some of the future directions are gonna be. you know, I've followed this literature for 20 years, just like you. And as you said, there's a real posity of well done studies that really are helping to guide us in terms of, understanding this better and managing our patients. it's nice to see the MESSALA study, which of course is ongoing and is gonna yield some good information. But what do you think are some of the unanswered questions that hopefully, will, get, some answers? As we expand the, evidence base in the next, you know, five or 10 years,

Santosh 26:41

I think what we need, what what is lacking is interventional studies. So we don't even know what statins do or which, or PCSK nine. What about fish oil? you know, vapo, you know, those kind of things. So, you know, randomized trial amongst South Asians. In a, we're almost at 5 million South Asians in this, in this country, and it's amazing that there's, there's not been a randomized trial for South Asians now. Yes, Masala is gonna have about 500 patients in their database and they're looking at interventions. Si. Which is where the, daughter and the mother exercise together, diet together, to see it reduces cardiovascular risk. So there's many studies to come, but you, you know, but there has to be randomized clinical trials. I mean, so many South Asians are cardiologists. We should all get together and put these things together. So many, some of them are in leading institutions such as Cleveland Clinic and all and all that. but without randomized trials, we're just extrapolating all the information. By a lot of it is just, you know, experience from other, other South Asian centers is what we go by a lot of.

Kanny 27:47

Well, we definitely look forward to learning more about your ongoing experience with your clinic and hopefully a chance to collaborate a bit on this, growing population, that we all are encountering. I just wanna thank you again for taking some time to chat with Ben and I about this problem and give us some, real, practical management tips. Thanks.

Santosh 28:08

Absolutely. It's been a pleasure. Nice work guys. Thank you so much.

28:11

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