(119) Reframing Menopause Care: Cardiovascular Disease Prevention for South Asian Women

Abstract Introduction South Asian women experience a disproportionate burden of atherosclerotic cardiovascular disease across the lifespan. During the menopausal transition, adverse cardiometabolic shifts such as higher blood pressure, central adiposity, and atherogenic lipid changes intersect with South Asian predominant risks: earlier and more frequent diabetes at lower BMIs, greater visceral fat at a given BMI, and genetically influenced factors such as elevated lipoprotein(a). In diaspora communities, language barriers, cultural incongruence, and uneven access to prevention combine with midlife caregiver responsibilities in multigenerational households, amplifying psychosocial stressors linked to microvascular ischemia. Objective To synthesize evidence on how menopause contributes to cardiovascular risk among South Asian women and how sociocultural and healthcare access factors, including caregiver burden in multigenerational households, increase risk. Methods We conducted a narrative review of peer-reviewed literature in major biomedical databases. Eligible studies included observational cohorts, meta-analyses, and qualitative or implementation studies on menopause, South Asian ethnicity, cardiovascular risk factors or outcomes, and sociocultural or access determinants in diaspora settings. We prioritized sex-specific analyses, midlife age groups, and outcomes spanning blood pressure, adiposity, glycemia, lipids and lipoprotein(a), subclinical atherosclerosis, ischemia with no obstructive coronary arteries (INOCA), and cardiac rehabilitation uptake. Results Among South Asian midlife women, postmenopausal versus premenopausal status is associated with higher odds of hypertension (odds ratio≈1.2), higher systolic blood pressure (≈6 mmHg), and greater subcutaneous fat. Associations with coronary artery calcium and carotid intima media thickness are not consistent after age restriction. Across multiethnic meta-analyses, premature or early menopause (age 45) is linked to higher risks of coronary heart disease (relative risk≈1.5), cardiovascular mortality (≈1.2), and all-cause mortality (≈1.1). Independent of menopausal status, South Asians develop type 2 diabetes earlier and at lower BMI. Screening at BMI 23 kg/m2 or higher captures risk missed by conventional cut points. HbA1c defined dysglycemia is common and often precedes diabetes, supporting perimenopausal screening. Elevated lipoprotein(a), largely genetically determined and prevalent in South Asians, adds risk beyond LDL cholesterol. Psychosocial stress and caregiving demands in midlife are linked to coronary microvascular dysfunction and stress induced ischemia, which can present as INOCA. Qualitative studies in diaspora communities highlight barriers to prevention and cardiac rehabilitation, including language, modesty norms, family and work role constraints, and cultural incongruence. Multigenerational living can intensify caregiver load, increasing stress and competing demands. Conclusions Menopause is a pivotal period when cardiometabolic risk intensifies among South Asian women. Menopause functions as a risk multiplier superimposed on high susceptibility to earlier diabetes at lower BMI, visceral adiposity, and elevated lipoprotein(a). Sociocultural and structural factors, including multigenerational caregiving and under engagement with preventive and cardiac rehabilitation services, further exacerbate risk. Priority actions include earlier midlife screening for blood pressure, fasting lipids with apoB and lipoprotein(a), and HbA1c or oral glucose tolerance testing. Screening should use lower BMI thresholds, culturally adapted lifestyle and pharmacologic interventions, and structured pathways to evaluate and manage microvascular ischemia and INOCA. Disclosure No.