Heart attacks in Indians explained: Why risk remains even with normal cholesterol levels

What’s happening:
Doctors say a growing number of Indians are suffering heart attacks despite having “normal” cholesterol levels in routine blood tests, pointing to hidden cardiovascular risk factors that standard screenings often miss.

Why it matters now:
Heart disease is India’s leading cause of death, accounting for over 25% of all fatalities. Alarmingly, heart attacks and strokes are increasingly affecting younger adults, particularly in urban areas and among higher-income groups.

What experts are saying:
According to cardiologists, cholesterol numbers alone do not provide a complete picture of heart health in Indians.

“Indians have a unique lipid pattern,” said Dr Vaibhav Dedhia, Consultant Cardiologist at Jaslok Hospital and Research Centre. Even when total cholesterol and LDL (bad cholesterol) are within normal ranges, many Indians have low HDL (good cholesterol) and high triglycerides — a combination known as atherogenic dyslipidemia, which significantly increases heart disease risk.

Hidden risk factors beyond cholesterol:

• Cholesterol quality, not just quantity:
  Routine tests measure LDL levels but not particle type. Indians are more prone to small, dense LDL particles, which penetrate artery walls more easily and accelerate plaque buildup, even at normal LDL levels.

• Insulin resistance:
  Common in Indians due to abdominal obesity, prediabetes and type 2 diabetes, insulin resistance causes chronic inflammation and damages blood vessels. This accelerates atherosclerosis without necessarily raising cholesterol levels.

• High blood sugar damage:
  Elevated glucose levels stiffen arteries, narrow blood vessels and create inflammatory conditions that encourage plaque formation, restricting blood flow to the heart.

• Elevated lipoprotein(a):
  Lipoprotein(a), or Lp(a), is a genetically determined cholesterol particle frequently found at high levels in Indians. “High Lp(a) significantly increases heart attack risk but is not included in routine lipid profiles,” Dr Dedhia said.

  Elevated Lp(a) promotes clot formation, inflammation and plaque buildup, increasing the risk of heart attacks, strokes and aortic valve disease — even when other cholesterol markers appear normal.

What this means for people:
Doctors stress that relying solely on standard cholesterol reports can give a false sense of security. Comprehensive risk assessment — including triglycerides, HDL levels, blood sugar control, waist circumference and Lp(a) testing — is crucial, especially for Indians with a family history of heart disease.