Thread by @hyderabaddoctor

"My cholesterol is normal. How did I get a heart attack?"
This is one of the commonest questions I hear from patients.
The answer may explain why Indians develop heart disease 5-10 years earlier than many Western populations.
A thread. Repost for wider reach and bookmark for future reference.
1/n

🔸Many people believe: Normal cholesterol = No risk of heart attack.
🔸Unfortunately, this is not always true.
🔸A significant proportion of heart attacks occur in people whose routine lipid profile appears "normal."
2/n

Why are South Asians different?
Compared with many other populations, South Asians tend to develop:
🔸Heart disease at a younger age
🔸Diabetes at a younger age
🔸Insulin resistance
🔸Abdominal obesity
Often at lower body weights.
3/n

The problem is that traditional cholesterol tests do not always tell the whole story.
A person may have:
✅Normal LDL-C
but still have:
❌High numbers of atherogenic particles
that can enter artery walls and form plaques.
4/n

This is where ApoB becomes important.
Think of LDL-C as the amount of cholesterol being transported.
Think of ApoB as the number of vehicles carrying that cholesterol.
More vehicles = More opportunities to damage arteries.
5/n

Two people can have exactly the same LDL-C.

🔴Yet one may have substantially higher ApoB.
That person often carries a higher cardiovascular risk despite a "normal" LDL level.
6/n

Another clue is triglycerides.
Many South Asians have:
• Mildly elevated triglycerides
• Low HDL
• Insulin resistance
even when LDL appears acceptable.
This pattern is common and often overlooked.
7/n

The most dangerous fat is often not the fat you can see. It is the fat around internal organs.

▶️This "visceral fat" promotes:
• Insulin resistance
• Inflammation
• High triglycerides
• Higher cardiovascular risk
8/n

A person may look only mildly overweight and still carry significant visceral fat.
This is one reason why BMI alone can be misleading in South Asians.
9/n

What else increases risk?
• High blood pressure
• Smoking
• Diabetes
• Physical inactivity
• Poor sleep
• Chronic stress
• Family history of premature heart disease
10/n

Don't forget Lipoprotein(a) or Lp(a).
Lp(a) is largely inherited.
Many South Asians have elevated Lp(a), which increases the risk of heart attack, stroke and aortic valve disease, even when routine cholesterol levels are normal.
11/n

So what tests should people discuss with their doctor?
Besides a routine lipid profile, selected individuals may benefit from:
🔸ApoB
🔸Lipoprotein(a)
🔸Blood sugar/HbA1c/Fasting insulin
🔸High sensitivity CRP
🔸Blood pressure assessment
Particularly if there is a strong family history of heart disease.
12/n

The good news is that most cardiovascular risk is modifiable.
Focus on:
✅Exercise
✅Healthy body weight
✅Blood pressure control
✅Diabetes prevention
✅Smoking cessation
✅Healthy diet
✅Adequate sleep
13/n

Take-home message:
A normal cholesterol report does not always mean low cardiovascular risk.
▶️For South Asians, the bigger picture includes:
• ApoB
• Lp(a)
• Insulin resistance
• Visceral fat
• Blood pressure
• Family history

▶️Don't just ask: "What is my LDL?"
✅Also ask: "What is my overall cardiovascular risk?"

14/n (End)
Dr Sudhir Kumar @hyderabaddoctor