South Asian Cardiovascular Risk

South Asians (SAs) experience a disproportionately high burden of premature atherosclerotic cardiovascular disease, yet conventional risk assessment algorithms often underestimate their cardiovascular risk. This review highlights the evolving role of atherosclerosis imaging, namely, coronary artery calcium scoring and coronary computed tomographic angiography (CTA), as complementary tools for earlier detection and refined risk stratification in SAs. The authors review evidence demonstrating earlier appearance and greater coronary plaque burden in SAs, often accompanied by higher risk plaque features and inflammation, even in the setting of a zero or low coronary artery calcium score. Advances in coronary CTA, including artificial intelligence–enabled plaque quantification, perivascular fat attenuation index, and computed tomography–derived fractional flow reserve, enable the characterization of high-risk vascular biology and may guide targeted preventive therapies. Coronary artery calcium scoring can refine risk in SAs as broadly as in other ethnic groups. However, in younger SAs who may not yet have developed calcified plaque, the selective and judicious application of coronary CTA to visualize noncalcified plaque in targeted high-risk individuals offers an evolving strategy for earlier and personalized initiation of aggressive preventive therapies.