South Asian heart risk: why a 9 per cent result can count as high

The patient in one published case vignette is a woman of 56, originally from Goa in India, who has had diabetes for 15 years. She is seen for routine medications soon after a hospital stay for an acute coronary syndrome (ACS), the term that covers heart attack and unstable angina. Her risk score before that event is given as 9 per cent. In Australia’s heart risk guideline, that is intermediate, one percentage point short of high.

That level, together with her ethnicity, “warranted reclassification to high risk”, the authors write. Had this risk estimation been done, extra treatment to lower her blood pressure and modify her blood lipids would have been recommended, “and perhaps the ACS event avoided or delayed”.

The vignette appears in a peer-reviewed article in the October 2024 issue of Cardiology Today. Its authors are described there as Mark Nelson, a GP and professor of general practice in Hobart, and Garry Jennings, a Melbourne cardiologist and the Heart Foundation’s Chief Medical Advisor. They are also the first and last authors of the Medical Journal of Australia’s April 2024 summary of the 2023 Australian guideline for assessing and managing cardiovascular disease risk. Their vignette turns on the part of that guideline dealing with South Asian heart risk.

Seven ethnicities in one bracket

The guideline, developed by the Heart Foundation and three other non-government health organisations, was launched on 20 July 2023 with the Aus CVD Risk Calculator and is published at cvdcheck.org.au. Inside it, seven South Asian ethnicities share one bracket: Indian, Pakistani, Bangladeshi, Sri Lankan, Nepali, Bhutanese and Maldivian.

Whatever your ethnicity, the calculator’s percentage does not take it into account. The calculator requires age, sex, smoking, blood pressure, cholesterol, diabetes and any use of cardiovascular medicines in the past six months, with postcode and a diagnosis of atrial fibrillation as optional extras, and more for people with diabetes. Ethnicity comes in afterwards, as a judgement, at a separate step where the calculator asks the clinician to consider reclassification factors.

For someone of South Asian ethnicity whose estimated risk sits close to the threshold for a higher category, the guideline asks clinicians to consider reclassifying that risk into the higher category. It says the same for Māori and Pacific Islander people. For people of East Asian ethnicity, who have a bracket of their own, it suggests considering a move down near a lower threshold. Both recommendations are graded conditional, and the evidence behind them is rated moderate in certainty.

The guideline acknowledges a practical gap: “In Australian healthcare, there is no standard or accepted practice for collecting data on ethnicity among non-Indigenous people”. Ethnicity, it adds, can be self-reported.

Heart risk close to the line

Simplified, as the guideline puts it, the calculator’s result is the probability of a heart attack, stroke or vascular disease in the next five years. Under 5 per cent is low, 10 per cent or more is high, and anything in between is intermediate.

Reclassification matters most near a threshold, the guideline says, because a small shift in the estimate can put a person in a different category.

Ethnicity is one of five reclassification factors. A family history of premature cardiovascular disease, meaning coronary heart disease or stroke in a mother, sister or daughter under 65 or a father, brother or son under 55, is a reason to consider a higher category. For people without diabetes whose kidney function is impaired, the wording is firmer: “strongly consider”. Severe mental illness, as the guideline defines it, is another reason. The fifth is a coronary artery calcium score.

Numbers from across the Tasman

The calculator’s equation was developed from a large New Zealand cohort, then recalibrated and modified for Australia. “The best performed algorithms are those based on local, contemporary populations,” Nelson and Jennings write, opening their account of why a new calculator was needed. A suitable Australian dataset, they add, did not exist.

The ethnicity figures the guideline cites come from New Zealand too, from a study of about 400,000 adults with no known cardiovascular disease, aged 30 to 74 when first assessed between 2002 and 2015. After adjusting for other risk factors, the guideline reports, the five-year risk of a major cardiovascular event for people of Indian ethnicity was 34 per cent higher in men and 13 per cent higher in women than for people of European ethnicity. It rates this evidence as moderate in certainty because the data have limited application to Australian populations.

Australia’s own figures have gaps. The Australian Institute of Health and Welfare lists information on culturally and linguistically diverse populations among current gaps in national data on heart, stroke and vascular disease, in a section last updated in May 2026. Its analysis of the 2021 Census, which asked whether a doctor or nurse had told people they had heart disease, found age-standardised figures of 4.6 per cent each for the Pakistan-born and the Bangladesh-born and 3.9 per cent for the Sri Lanka-born, against 3.6 per cent for the Australian-born. Its written findings give no figure for people born in India.

At least 20 minutes with a GP

The guideline recommends a risk assessment from 45 to 79 for everyone without known cardiovascular disease, and from 35 to 79 if they have diabetes. The Medicare item starts at a younger age than either. MBS Online lists item 699, a heart health assessment by a GP at consulting rooms, for patients aged 30 and over, lasting at least 20 minutes and claimable once in a 12-month period. Its schedule fee, last updated on 1 July 2026, is A$87.10, and the Medicare benefit is 100 per cent of that fee.

On its own, 9 per cent is an intermediate result. Whether it would have counted as high for the woman in the vignette depended on something left out of that percentage, and on a clinician choosing to weigh it.