80% of Indians who passed the test suffered heart attack

New Delhi: He has no red flags. There is no “high risk” label. By standard medical calculators, he wasn’t the kind of patient to worry doctors. Then the heart attack occurred suddenly and without warning. Doctors say the condition is no longer uncommon. A major study from India suggests this may be the norm.In a retrospective analysis of more than 5,000 Indian patients, a widely used global heart disease risk calculator failed to identify most people at risk, with about 80% of first-time heart attack patients not previously labeled as high risk. Researchers led by Dr Mohit Dayal Gupta of GB Pant Hospital in Delhi said Western models ignore risk patterns unique to India, often placing patients in low or moderate categories despite potential dangers.Doctors use these models to decide who needs treatment, but studies have found that they often misclassify risk and sometimes give conflicting results. Across models, only 11%-20% of patients were labeled as high risk, although all eventually developed heart disease.“Indian patients and populations behave completely differently. We have different risk factors, different patterns, so Western scores may not always be appropriate,” Dr. Gupta said.

The core of the problem is a mismatch. Most of these risk calculators are designed with Western populations in mind, where heart disease tends to develop later in life. In India, heart attacks occur earlier and manifest differently – the average age of patients was only 54, the study found, highlighting the premature onset of heart disease.Researchers say Indians exhibit a unique “South Asian phenotype.” Heart disease risk appears earlier, often with diabetes and insulin resistance, even at normal weight. Cholesterol patterns are misleading—HDL is low, triglycerides are high, and LDL may not be very high. Many people, despite appearing thin, have hidden fat in their abdomens, a risk that body mass index-based assessments miss. Smoking and psychosocial stress, as well as traditional risk factors such as diabetes, smoking, and dyslipidemia, further exacerbate this hidden burden.This is why Western risk scores underperform. They relied heavily on age and LDL cholesterol, leading to an underestimation of younger Indians. As a result, many patients fall into the “moderate risk” category—a gray area where preventive treatment is often delayed. Crucially, these models ignore key drivers such as insulin resistance, lipoprotein(a), ApoB, central obesity and chronic kidney disease.The impact is huge. These scores determine who gets preventive medication and closer monitoring. When risks are underestimated, intervention is often only initiated after a major event has occurred.As the Indian population remains poorly represented in global datasets, these findings renew calls for customized risk scores. Experts say that until such tools are developed, risk calculators must be used along with clinical judgment, including family history, diabetes, psychosocial stress and early screening.