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Atherosclerotic cardiovascular disease remains a leading cause of morbidity and mortality, with South Asians experiencing a disproportionately high burden. This excess risk is not fully explained by conventional risk factors, highlighting the need for a more nuanced understanding. However, progress has been hindered by a paucity of South Asian-specific research, limited validation studies, and under-representation in clinical trials. Emerging evidence points to a complex interplay of genetic predisposition, cardiometabolic dysfunction, lifestyle, and socioeconomic influences driving this heightened susceptibility. This review synthesizes recent advancements in genomics, lipid metabolism, biomarkers, imaging, and composite risk calculators, aiming to refine risk stratification in clinical practice. Additionally, we discuss key limitations in current research and explore future directions to bridge knowledge gaps. A deeper understanding of these factors is essential to developing targeted interventions and identifying novel therapeutic strategies to attenuate the elevated atherosclerotic cardiovascular disease risk.