Guest Post: Should Race Continue to Be Used as a Cardiovascular Risk Factor?

Akshay Pendyal, MD, MHS, FACC
Posted on September 3, 2024

Dr. Pendyal is Assistant Professor of Medicine at Duke University School of Medicine and Associate Director of the Duke National Clinician Scholars Program.

These are interesting times to be in the business of atherosclerotic cardiovascular disease (ASCVD) prevention. Our risk refinement tools are more sensitive than ever. We have a keen understanding of lipoproteins and their role in atherogenesis. Imaging modalities such as coronary calcium scoring allow us to assess plaque burden with stunning clarity. And statins, one of the most potent pharmacologic public health interventions of the last 40 years, are widely available and well tolerated.

Paradoxically, though, we still somehow find ourselves resorting to the same modes of risk stratification that we’ve been using for centuries. Despite the emergence of techniques that allow us to trace molecular ancestry (and therefore transcend phenotypic classification schemes), the promise of “personalized medicine” in mitigating disease risk has yet to materialize. Hence, the stubborn persistence of the category of race in modern medicine.

Drs. Asha Shajahan and Saavia Girgla do an admirable job in their recent editorial of outlining the heightened ASCVD risk that South Asian patients face. As they rightly note, this heightened risk is likely due to this group’s higher probability of possessing traditional risk factors—including obesity and metabolic syndrome—rather than any sort of genetically mediated mechanism.

The question, then, becomes what use “race” (or the crude proxy of physical appearance and country of family origin) has in augmenting the risk calculus that, as clinicians, we perform every time we see an individual patient. What value does race have over and above those socially modulated risk factors that, after decades of study, are known to be atherogenic?

I contend that the answer may be “not much.” South Asians are a huge, heterogenous group, with varying social positions and health behaviors. From a public health standpoint, focusing on factors that we know increase ASCVD risk (e.g., dietary patterns, smoking, comorbid conditions such as diabetes mellitus), rather than nebulous concepts such as shared ancestry and cultural practices, might make more sense.

More research on ASCVD in South Asian populations is needed; however, we should prepare ourselves for the possibility that such research is exceedingly unlikely to uncover a distinct causative agent. If so, the residual risk conferred by the racial category “South Asian” as an explanatory variable is likely to remain small.