Incident Cardiovascular Disease (CVD) within the South Asian Diaspora has failed to decline in parallel with other migrant groups. Rates of coronary disease in middle-aged South Asians, 50% higher than UK background, are concerning and place a growing socio-economic burden on communities and health-care providers. Concerted efforts to recognise and manage early CVD-risk within this highly susceptible group are essential if persistent health inequalities are to be adequately addressed. Significant variation in CVD implies differential interaction of risk factors across populations or the presence of additional factors accounting for increased risk. Metabolic conditions prevalent in South Asians and characterised by insulin resistance, glucose disorders and dyslipidaemia may be key to addressing observed CVD differences. Type 2 Diabetes Mellitus (T2DM) develops early in South Asians and once established carries a high risk of vascular mortality. Prediabetes is more common in South Asians and associate independently with vascular and diabetes-risk. Ethnic pre-disposition to central obesity and its metabolic consequences is clearly important in determining CVD risk, but even when combined with other factors (e.g. social-economic deprivation, smoking, blood pressure) fails to entirely account for observed variation in vascular events between groups. Assumptions that cultural incompatibility and medication compliance influence CVD outcomes are largely unsubstantiated, implying unidentified factors contribute to increased risk in South Asians.