Coronary computed tomography angiography for cardiovascular risk assessment in South Asians.

BACKGROUND: South Asians represent one of the world's largest and fastest-growing ethnic groups and experience a disproportionately high burden of premature atherosclerotic cardiovascular disease (ASCVD). OBJECTIVE: Conventional risk calculators consistently underestimate true risk, largely because of unique metabolic, genetic, and inflammatory factors that accelerate atherosclerosis at younger ages. Coronary computed tomography angiography (CCTA) provides a comprehensive assessment of coronary atherosclerosis and offers an accurate method of detecting subclinical disease in this population. South Asians frequently demonstrate high rates of noncalcified plaque (NCP) despite low calculated risk and even in the presence of a coronary artery calcium score of 0. METHODS: Multiple cohort studies-including Mediators of Atherosclerosis in South Asians Living in America, DIL Wellness and Arterial Health Longitudinal Evaluation, and international registries-show that South Asians exhibit greater total plaque volume, higher proportions of NCP, and more high-risk plaque features compared with other ethnic groups. CCTA enables detailed quantification of plaque burden, characterization of high-risk morphologic features, and assessment of perivascular inflammation through the fat attenuation index. RESULTS: CCTA can better predict adverse cardiovascular events and refine preventive strategies beyond coronary artery calcium scoring. In younger South Asians (age 25-45 years), CCTA can detect early NCP that would otherwise remain undetected by calcium scoring. Integrating CCTA findings into therapeutic algorithms supports more aggressive low-density lipoprotein cholesterol lowering, targeted use of anti-inflammatory therapy, and personalized follow-up based on plaque burden and biology. CONCLUSION: This review summarizes the epidemiology, pathophysiology, and imaging-based risk stratification among South Asians, highlights key data demonstrating CCTA's prognostic value, and proposes a precision-prevention framework that leverages advanced CCTA techniques to address this population's elevated atherosclerotic cardiovascular disease risk.