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South Asians and coronary disease: is there discordance between effects on incidence and prognosis?
  1. M Justin S Zaman1,
  2. Pete Philipson1,
  3. Ruoling Chen1,
  4. Ahmed Farag2,
  5. Martin Shipley1,
  6. Michael G Marmot1,
  7. Adam D Timmis3,
  8. Harry Hemingway1
  1. 1Department of Epidemiology and Public Health, University College London, London, UK
  2. 2Department of Cardiology, Norfolk and Norwich University Hospital, Norwich, UK
  3. 3Department of Cardiology, Barts and The London School of Medicine and Dentistry, London, UK
  1. Correspondence to Dr M Justin S Zaman, Department of Epidemiology and Public Health, University College London, 1-19 Torrington Place, London WC1E 6BT, UK; justin.zaman{at}


Objective To determine whether the effect of South Asian ethnicity differs between studies of incidence and prognosis of coronary disease.

Design Systematic literature review and meta-analysis, and cohort analysis from a national acute coronary syndrome (ACS) registry linked to mortality (National Institute of Cardiovascular Outcomes Research/Myocardial Infarction National Audit Project).

Setting International for the review, and England and Wales for the cohort analysis.

Patients The numbers of South Asians included in the meta-analysis were 111 555 (incidence) and 14 531 (prognosis) of whom 8251 were from the ACS cohort.

Main outcome measures Incidence studies: non-fatal myocardial infarction or fatal coronary heart disease; prognostic studies: mortality; HRs for 1-year all-cause death in ACS cohort.

Results South Asians had higher incidence of coronary disease compared with white subjects (HR 1.35 95% CI 1.30 to 1.40) based on meta-analysis of nine studies. Among 10 studies on prognosis, South Asians had better prognosis compared with white subjects (HR 0.78 95% CI 0.74 to 0.82). In the ACS cohort, the impact of diabetes (42.4% of South Asians, 16.9% of white subjects) on 1-year mortality was stronger in South Asians than white subjects (age-adjusted HR 1.83 95% CI 1.59 to 2.11 vs 1.53 95% CI 1.49 to 1.57). However, prognosis was better in South Asians even among diabetics, older people and those living in areas of the highest social deprivation.

Conclusions South Asian ethnicity is associated with higher incidence of coronary disease, but lower mortality once coronary disease is manifest. The dissociation between effects on incidence and prognosis suggests that public health initiatives to reduce inequalities in mortality between South Asian and white populations should focus on primary prevention.

This is a CALIBER study with Identifier: NCT01163513.

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