ESOC 2026 | The coronary artery disease paradox may be due to biological differences in ethnicity

So the research itself is part of a bigger project to try to understand the specificities of stroke and other cardiovascular or cerebrovascular diseases in ethnic minorities that have been really understudied in all aspects of research. So we wanted to specifically investigate or find out if what is commonly referred to as the coronary artery disease paradox is a true difference between white people and other ethnic minorities or if it is just a consequence of a bias in terms of access to healthcare or reporting of diseases or even willingness to participate in research. So basically, the coronary artery disease paradox was defined in the U.S. as this observation that people from ethnic minorities have a higher burden of vascular risk factors, hypertension, diabetes, obesity, but they paradoxically have a lower incidence of obstructive coronary acute disease, myocardial infarction, cardiovascular death, and so on. So the hypothesis usually even to explain that is that in the US, because black people have low access to healthcare, this might just be diagnosed less often on their report. So we thought that if the hypothesis is true, it will look at data in the UK where access to healthcare is more equitable due to the NHS, which is National Health Service, really at the point of access, we shouldn’t observe the same difference. But if we observe the coronary artery disease paradox, it will mean that potentially there is something to find in the susceptibility aspect of the disease. So to investigate that, we went to look at the data from the stroke vascular study. So it’s a study, prospective cohort study, that recruits all patients with suspected acute stroke in the UK and follows them up to identify or to record their outcome, but also systematically records data about their risk factors or past medical history using various sources or record linkage. So in that dataset, we had approximately 7,000 people, including about 300 people from ethnic minorities. And what we found is that black people had approximately 70% less coronary artery disease or history of coronary artery disease compared with white people, while there was no difference between Asian people and white people. And when we did adjusted analysis, because one concern in previous studies is that they have reported unadjusted analysis, but when we did adjusted analysis, adjusted for all the other risk factors, smoking, age, hypertension, diabetes, atrial fibrillation, we found that this difference was, or the odds ratio was 0.5, meaning that black people are approximately 50% less likely to have coronary artery disease when compared to white. And this magnitude of, the magnitude of this difference was confirmed in the meta-analysis, where we included not only Oxford’s data, but also data from other studies that have been published on the topic in the UK, including data from the South London Stroke Registry. So in conclusion, we think that the coronary artery disease paradox is a reflection of a true biological difference between black people and whites. And in the future, we need to investigate this further to understand the mechanisms. So this implies that studying ethnic minorities more often or more inclusively, including them in trials or in research, could help find out mechanisms that lead to lower susceptibility to coronary artery disease, which would in turn benefit the white people too, because if you find the mechanism, we can apply it to them.

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