Analyzing 14.8 million adults across 80.9 million person-years in England's primary care database, this large population-based cohort study found dramatic variation in premature coronary artery disease (CAD, onset ≤45) hidden within broad ethnic categories. Bangladeshi men carried the steepest burden — nearly 2.8 times the incidence of White European men — while Indian men showed a more modest 1.39-fold excess. Crucially, elevated risk appeared as early as ages 18–26. Black men showed a protective pattern overall (IRR 0.64), lowest in African men. Among women, no aggregate South Asian excess emerged, yet Pakistani women faced a 1.56-fold elevated risk — masked by the broader grouping. The male-to-female ratio in Bangladeshi individuals reached 8.4:1 versus 3.3:1 in White Europeans, signaling an extraordinary sex-interaction effect.
This preprint, not yet peer-reviewed, carries significant public health weight despite that caveat. The findings challenge a core assumption of UK cardiovascular screening: that NHS Health Checks beginning at age 40 reach high-risk groups in time. For Bangladeshi and Pakistani men, risk accumulates a decade or more earlier. The study's scale — the largest disaggregated analysis of its kind in England — lends statistical credibility, though residual confounding from diet, stress, and socioeconomic factors within subgroups cannot be fully excluded. Mechanistically, higher rates of insulin resistance and central adiposity in South Asian subpopulations are established contributors, but this study underscores that policy aggregating ethnicity obscures who actually needs earlier intervention. If confirmed after peer review, these results argue strongly for ethnicity- and sex-stratified cardiovascular screening starting well before 40.
