Indian Asians account for one-fifth of all cardiovascular deaths worldwide. Cardiovascular mortality in Indian Asians overseas is higher than in indigenous populations. Diabetes, insulin resistance, and related metabolic disturbances are more common among Indian Asians than Europeans and may account for up to 70% of major Q wave ECG abnormalities in Asians. Previous studies provide evidence that genetic and environmental factors, the latter including intrauterine growth retardation, reduced physical activity, increased weight, and dietary intake, contribute to the high prevalence of diabetes and insulin resistance in Asians. The importance of conventional coronary risk factors is emphasized by studies showing higher prevalence of cigarette smoking, hypertension, and hypercholesterolemia in migrant and urban Indians compared with rural Indians. Recent studies suggest that new risk factors, including C-reactive protein, homocysteine, and lipoprotein(a), are increased among Indian Asians compared with Europeans and may contribute to part of the excess cardiovascular risk in Asians. Further work is needed to identify the precise genetic and environmental mechanisms underlying increased vascular risk in Indian Asians. Clinical strategies must be developed that identify Indian Asians at increased risk and assess the effectiveness of treatment for insulin resistance, and other cardiovascular risk factors, in this racial group.