On a humid Tuesday morning in Thiruvananthapuram, 34-year-old software engineer Mithun Kumar collapsed on his treadmill during a routine morning workout. The shock rippled through his family and coworkers, who had long considered him the picture of fitness. He was a marathon runner. He ate a strict plant-based diet. He didn’t smoke, and he had none of the usual red flags — no hypertension, no obesity, no diabetes.
Yet when he was rushed to the emergency department of a tertiary care centre in the city, a diagnostic coronary angiography revealed a near-total 95% blockage in the primary artery supplying blood to his heart. Just six months earlier, his executive health checkup had shown an exemplary total cholesterol level of 160 mg/dL, with LDL cholesterol sitting comfortably at 92 mg/dL. His family and his doctors were baffled: how does a heart attack happen to someone with such clean numbers? Subsequent specialised lipid testing, ordered after his angioplasty, found the answer. His Lipoprotein(a) — a largely inherited variant of LDL — measured 140 nmol/L, nearly triple the threshold for severe cardiovascular risk.
Mithun’s case is not an isolated one. It’s a warning sign of a critical gap in routine medical screening, one that continues to claim thousands of young lives across India every year.
This is part of a larger shift in how heart disease shows up in clinics today. Dr Chirag D, consultant in interventional cardiology at Aster Whitefield Hospital in Bengaluru, says the old assumption — that heart disease is an older person’s problem — no longer holds. “It is a very well-established fact that the incidence of atherosclerosis-related heart disease or vascular events has increased significantly in the younger population,” he explains. “Over the past decade, the incidence of heart attack has gone up significantly in young individuals. We are seeing many young patients coming with high lipids, as well as patients with no previously documented high lipids coming with heart attacks, only for us to discover very high cholesterol levels when we cross-check.”
Part of the problem is that standard risk models don’t fit South Asian bodies well. These models were built using western patient data, and they consistently underestimate how early and how aggressively vascular disease can progress across the Indian subcontinent. Recent joint guidelines from the American Heart Association and the American College of Cardiology have acknowledged this gap. They now list South Asian ethnicity as an independent “risk-enhancer” — a factor that on its own justifies earlier and more thorough lipid screening, with lower thresholds for treatment.
One clear recommendation stands out: every adult should have their Lp(a) measured at least once in their lifetime, since it captures a genetic risk that ordinary lipid panels miss entirely. For decades, though, routine checkups in Indian hospitals have relied almost solely on basic panels measuring total cholesterol and LDL. The result is a false sense of security — young professionals walk away with pristine reports while arterial blockages quietly build underneath.
So what makes Lp(a) so dangerous? Think of it as an invisible accelerant in the bloodstream. A standard cholesterol test only measures the general volume of fat circulating in your blood. But Lp(a) carries something extra — a sticky component that clings to the walls of blood vessels. It weakens the body’s natural defences there and speeds up plaque formation, even when overall cholesterol looks normal. Left undetected, this steady, microscopic damage builds fragile plaques over years. And those plaques can suddenly rupture with no prior chest pain and no warning at all.
Applying these international guidelines to India’s healthcare system means adapting them to local realities. Dr Sibu Mathew, professor in the cardiology department at Government Medical College, Thiruvananthapuram, explains how this plays out on the ground. “While global bodies like the American Heart Association have evolved their risk stratification to include a baseline, once-in-a-lifetime Lp(a) assay, universal screening for the entire population isn’t practical or clinically necessary,” he says. “In India, we rely on guidelines from the Lipid Association of India, built specifically around our population. LDL remains the primary target for treatment. But we also know that South Asians tend to develop coronary artery disease a full decade earlier than western populations. That’s why starting aggressive statin therapy early — when LDL is elevated — matters so much. It helps blunt the cumulative risk before silent disease has a chance to take root.”
There’s also a financial case for catching this early. An Lp(a) test costs somewhat more than a routine lipid profile at private diagnostic centres, but it’s a one-time investment — unlike ongoing prescription costs, or the far higher costs of emergency procedures like stenting and bypass surgery. And as medicine shifts from measuring short-term, 10-year risk toward understanding lifetime cardiovascular exposure, catching these genetic markers early lets doctors correct the picture for South Asian patients — people who would otherwise be flagged as low-risk by western calculators.
KNOW YOUR LAB REPORT
Total Cholesterol
This is the sum of all the cholesterol in your blood — LDL, HDL, and a portion from triglycerides
LDL (‘Bad’ Cholesterol)
LDL is the cholesterol that gets deposited into artery walls, where it can build up into plaques over time. This is the single most important number for treatment decisions in India. The Cardiological Society of India and Lipid Association of India (LAI) both treat LDL-C as the primary target, with the greatest emphasis placed on controlling it first
HDL (‘Good’ Cholesterol)
HDL helps clear excess cholesterol out of the bloodstream and back to the liver, so higher HDL is generally protective
Triglycerides
These are a different type of fat in the blood, mostly from diet, that supply energy but raise heart risk when chronically elevated
The Indian twist: Elevated triglycerides paired with low HDL is a particularly common and Indian-specific pattern
Lab reference points
Normal LDL cholesterol (Bad Cholesterol): below 100 mg/dL (optimal)
Normal total cholesterol:
below 200 mg/dL
Lp(a) desirable range: below 50 nmol/L (or <30 mg/dL, depending on lab units)
Lp(a) high-risk threshold: above 50 nmol/L