India's Unique CV Risk Profile: How to Decode the Role of Aspirin?

Cardiovascular disease remains one of the dominant non-communicable causes of death in India, contributing substantially to premature morbidity and mortality. (1)

Indian CV Risk Burden–Latest Evidence: The Indian population demonstrates an elevated cardiometabolic risk profile at younger ages 15-49), with a high prevalence of hypertension, diabetes, dyslipidemia, and central obesity. (2) The INTERHEART study highlighted that modifiable risk factors drive up to 90% of MI cases in India, prominently dyslipidemia. (3) CVDs account for nearly 25% of all deaths and 45% of mortality in those aged 40–69 years. (4)

Indian CV Risk Needs are Different from Western Population – Emphasis Spotlight: Indians develop CVD nearly a decade earlier than Western counterparts, with 25% of MIs before age 40 and 50% of CAD deaths under 50. Despite ~10 mg/dL lower LDL-C, they exhibit higher ASCVD risk due to atherogenic dyslipidemia: low and dysfunctional HDL-C, high triglycerides, elevated Apo B, and Lp(a) levels, necessitating intensified interventions.(3)

Stratifying Cardiovascular Risk in India: A Practical Perspective

Given the complex and early-onset nature of ASCVD in Indians, a practical risk assessment must address three key domains: cardio-metabolic abnormalities, non-modifiable traits, and lifestyle-related behaviors, each contributing uniquely to the overall burden.

Critical Cardio-Metabolic Risk Factors:

The Indian population faces a high cardiometabolic burden from a young age (20-30 years), with 47% having prediabetes, 61% overweight/obesity, and 19% hypertension, poor lipid control, insulin resistance, and central obesity, often under-recognized, compound ASCVD risk. (5) Despite known benefits, control remains poor, necessitating early, multi-factorial stratification using waist, BP, TG, HDL-C, and glucose. (6)

Non-Modifiable Risk Factors:

Non-modifiable CV risk factors in Indians include family history of ASCVD (30%), male gender (69%), and age over 40 years (70%). In addition, inherited atherogenic traits like low HDL-C, elevated Lp(a), and high Apo B significantly raise ASCVD risk, warranting early, ethnicity-specific lipid management—even in those with relatively low LDL-C. (7) As per a July 2025 published review, South Asian individuals have the highest global share of elevated Lp(a), with 469 million people, and the highest population attributable risk due to high Lp(a) for MI at 9.5%. (8) Around 25% of Indians have elevated Lp(a) levels (≥50 mg/dL), indicating its significant contribution as a CV risk factor in this population. (9)

Lifestyle and Habits:

Behavioral risk factors remain prominent—26% of Indian men and 3% of women reported smoking; alcohol use was similarly reported by 28% of men and 3% of women. Insufficient physical activity increased CVD risk by 36% (AOR 1.36), and second-hand smoke by 41% (AOR 1.41), with higher risk seen in men. (10)

Aspirin in Primary Prevention – Individualize

Amid this elevated and multifactorial risk landscape, aspirin continues to be explored for its preventive potential, particularly in high-risk individuals.

Aspirin reduces the first CV events by irreversibly inhibiting COX-1 in platelets, lowering thromboxane A2 and platelet aggregation. (11) It may also reduce Lp(a) levels by suppressing apo(a) mRNA in the liver. (12) Guidelines (including USPSTF, ESC, and AHA/ACC) suggested individualized decisions based on ASCVD risk, CAC scoring, and bleeding risk. Patients aged 40–59 with high and very high ASCVD risk and low bleeding risk may benefit. (10)

The more recent DCRM (2024) also suggested considering low-dose aspirin for primary prevention in individuals with two or more cardiovascular risk factors—such as elevated non-HDL-C, elevated LDL-C, elevated Lp(a), low HDL-C, diabetes, hypertension, CKD, smoking, family history of ASCVD, or a CAC score >100—provided the potential benefit outweighs the bleeding risk, which should be carefully assessed and monitored.(13)

Tools like AspirinGuide can help clinicians assess individual bleeding risk and guide shared decision-making regarding aspirin use.

Final Message

Early-onset, multifactorial ASCVD risk in Indians requires a tailored prevention strategy. Stratifying cardio-metabolic, non-modifiable, and lifestyle risks can guide individualized decisions, including aspirin use, in high-risk individuals.

Abbreviations: ASCVD – Atherosclerotic Cardiovascular Disease, CVD – Cardiovascular Disease, MI – Myocardial Infarction, LDL-C – Low-Density Lipoprotein Cholesterol, HDL-C – High-Density Lipoprotein Cholesterol, TG – Triglycerides, Apo B – Apolipoprotein B, Lp(a) – Lipoprotein(a), BP – Blood Pressure, COX-1 – Cyclooxygenase-1, CAC – Coronary Artery Calcium, CKD – Chronic Kidney Disease, DCRM – Diabetes, Cardiorenal, and/or Metabolic (platform/consensus), USPSTF – United States Preventive Services Task Force, ESC – European Society of Cardiology, AHA/ACC – American Heart Association / American College of Cardiology, AOR – Adjusted Odds Ratio