Non-HDL Cholesterol as a Predictor of Coronary Atherosclerosis in South Asians: A Narrative Review.

PURPOSE OF REVIEW: To examine the role of non-HDL cholesterol (non-HDL-C) as a predictor of coronary atherosclerosis and atherosclerotic cardiovascular disease (ASCVD) risk in South Asians, and its utility relative to LDL-C and apolipoprotein B for risk stratification and lipid-lowering therapy in this high-risk population.

RECENT FINDINGS: South Asians experience a disproportionate and premature burden of ASCVD that is not fully explained by conventional risk factors and is underestimated by most established risk calculators. They exhibit a characteristic atherogenic dyslipidemia - elevated triglycerides, low HDL-C, and a predominance of small dense LDL and remnant particles, often with only modestly elevated LDL-C - that is inadequately captured by LDL-C but well reflected in non-HDL-C. Non-HDL-C demonstrates a graded association with ASCVD, correlates with atherosclerotic plaque burden across imaging modalities (coronary artery calcium, coronary CT angiography, and intravascular ultrasound), and has outperformed LDL-C for risk prediction in large meta-analyses. Recent US and Indian guidelines now incorporate non-HDL-C as a coprimary treatment target, with the Lipid Association of India providing South Asian-specific thresholds. Non-HDL-C is an inexpensive, non-fasting lipid measure that better captures the atherogenic lipoprotein burden of South Asians than LDL-C alone and may improve risk stratification and treatment in this group. Data specific to non-HDL-C in South Asians remain limited; future work should define population-specific thresholds, clarify its relationship with apolipoprotein B and lipoprotein(a), and address the under-representation of South Asians in clinical trials and persistent barriers to preventive care.