First-time incidence of ischemic heart disease among immigrants in Sweden: variation by country of origin, duration of residence, and immigrant generation in a nationwide cohort study

Q: What is the clinical evidence from this study?

Study design: Cohort. Population: Ischemic heart disease (IHD) (n=8536717). Intervention: First-generation (G1) and second-generation (G2) immigrant status (stratified by country of origin, duration of residence, and immigration period) vs. Swedish-born individuals (including G2 for G1 comparisons; native Swedes with two Swedish-born parents for G2 comparisons). Primary outcome: First-time recorded diagnosis of ischemic heart disease (IHD; ICD-9 410-414, ICD-10 I20-I25) (HR 1.16 in G1 women (HR 1.14 in G1 men), 95% CI 1.14-1.17).

Q: What does this research mean for the field?

First-generation immigrants in Sweden, particularly recent arrivals and those from the Middle East, Nordic countries, and South Asia, have an elevated risk of first-time ischemic heart disease compared with Swedish-born individuals, with risk decreasing as duration of residence increases. Novelty: ClaimNovelty.INCREMENTAL. Consensus alignment: ConsensusAlignment.NEUTRAL.

Daniel Nigusse Tollosa; Kazem Zendehdel; Sol Juárez; Alexander Miething; Andrea C. Dunlavy; Mikael Rostila

doi:10.1093/eurpub/ckag192

October 9, 2026European Journal of Public HealthOpen Access

First-time incidence of ischemic heart disease among immigrants in Sweden: variation by country of origin, duration of residence, and immigrant generation in a nationwide cohort study

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Key result

First-generation immigrant status linked to ~16% higher risk of ischemic heart disease vs. Swedish-born individuals.

HR 1.16 in G1 women (HR 1.14 in G1 men)
95% CI 1.14-1.17
n=8,536,717

Figures

Why the study?

With an increasingly diverse immigrant population in Sweden and rising cardiovascular disease risk factors in many countries of origin, understanding disparities in ischemic heart disease among immigrants and their descendants has become increasingly important.

Does immigrant status (by country of origin, duration of residence, and generation) influence the incidence of first-time ischemic heart disease compared with Swedish-born individuals in Sweden?

Key Points

To investigate disparities in first-time ischemic heart disease incidence among immigrants and their descendants in Sweden across country of origin, duration of residence, and generation.
Nationwide registry-based cohort study of 8 536 717 individuals aged 35–85 years (50.1% women; 18.2% first-generation [G1] and 9.4% second-generation [G2] immigrants) followed from 1993 to mid-2023.
First-time ischemic heart disease (IHD) was ascertained from the Swedish National Patient Register using ICD-9 and ICD-10 codes.
Adjusted Cox regression models estimated hazard ratios (HRs) controlling for income quintile, education, occupation, marital status, and healthcare region.
During follow-up, 703 212 first-time IHD events occurred, with G1 immigrants showing higher risk than Swedish-born individuals (fully adjusted HR 1.16, 95% CI: 1.14–1.17 in women; HR 1.14, 95% CI: 1.13–1.15 in men).
Risk was highest among G1 immigrants with 5–15 years duration of residence (HR 3.67, 95% CI: 3.53–3.82 in women; HR 4.13, 95% CI: 4.03–4.25 in men), generally declining with longer residence.
Marked regional variation occurred: Middle Eastern immigrants (HR 1.18, 95% CI: 1.14–1.22 in women; HR 1.47, 95% CI: 1.44–1.50 in men) and Pakistani immigrants (HR 1.79 in women; HR 1.93 in men) had significantly elevated risks, whereas second-generation immigrants generally showed no elevated risk except those of Nordic parental origin.

Study Design

Type

Cohort (n=8,536,717)

Multicenter

Yes

Structured PICO

Does immigrant status (by country of origin, duration of residence, and generation) influence the incidence of first-time ischemic heart disease compared with Swedish-born individuals in Sweden?

P

Population

8,536,717 adults aged 35-85 years in Sweden (50.1% women; 18.2% first-generation and 9.4% second-generation immigrants) followed in a nationwide registry cohort from 1993 to mid-2023.

E

Exposure

Immigrant status and migrant-related exposures: first-generation immigrants (G1, born outside Sweden) and second-generation immigrants (G2, born in Sweden with ≥1 foreign-born parent), categorized by country/region of origin, duration of residence (5–15, 16–30, ≥31 years), and calendar period of arrival.

C

Comparator

Swedish-born individuals (including G2) as the reference group for G1 comparisons; native Swedes (born in Sweden to two Swedish-born parents) as the reference group for G2 comparisons.

O

Outcome

First-time recorded diagnosis of ischemic heart disease (IHD, both acute and chronic, identified from the Swedish National Patient Register via ICD-9 codes 410–414 and ICD-10 codes I20–I25) from 1993 to mid-2023.hard clinical

Main Result

Hazard Ratio: 1.16 (95% CI 1.14–1.17)

Absolute Event Rate: 363.8% vs 314.1%

First-generation immigrants in Sweden—especially recent arrivals with 5–15 years of residence and those from the Middle East, South Asia, and Nordic countries—face a significantly elevated risk of incident ischemic heart disease that challenges the classical healthy-migrant hypothesis and warrants targeted early cardiovascular prevention.

Limitations

Cannot completely exclude individuals who experienced an IHD event before 1990 when complete National Inpatient Register data became available, or prior to migration.
Registers lacked individual-level data on lifestyle (e.g., smoking, alcohol, physical activity) and clinical risk factors (e.g., hypertension, diabetes), leaving potential residual confounding.
Ethnicity is not recorded in Swedish national registers; country of birth and parental country of birth were used as proxies.
Inability to completely exclude prevalent IHD events occurring before 1990 (when complete National Inpatient Register coverage began) or prior to immigration despite a 5-year buffer period.
Lack of individual-level data on lifestyle behaviors (smoking, alcohol consumption, physical activity) and clinical cardiovascular risk factors (hypertension, diabetes, dyslipidaemia), resulting in potential residual confounding.
Absence of self-identified ethnicity in Swedish national registers, requiring the use of country of birth and parental country of birth as proxies.

Ask about this paper

Answers are grounded in this paper and cite their sources.

Implication

May inform early risk assessment in recent immigrants; challenges healthy-migrant hypothesis and extends migration-CVD research.

Abstract

As Sweden’s immigrant population has become increasingly diverse and many countries of origin have undergone an epidemiological transition with rising cardiovascular disease (CVD) risk factors, understanding disparities in ischemic heart disease (IHD) among immigrants and their descendants has become increasingly important. This nationwide registry-based cohort study included over 8.5 million individuals aged 35–85 years [50.1% women; 18.2% first-generation (G1) and 9.4% second-generation (G2) immigrants] who followed from 1993 to mid-2023. Adjusted Cox regression models were used to examine associations between migrant-related factors—including country of origin, duration of residence, period of immigration, and immigrant generation—and first-time IHD incidence. During follow-up, 703 212 first-time IHD events occurred. Compared with Swedish-born individuals, G1 immigrants from the Nordic countries, the Middle East, and selected Asian countries (Afghanistan, Pakistan, India, and Sri Lanka), as well as G2 individuals with Finnish parental origin, had a higher risk of IHD. The highest risks were observed among recent immigrants from the Middle East and among immigrants with the shortest duration of residence. Risk generally declined with increasing duration of residence and became lower than that of the reference population in many immigrant groups. Although age-standardized IHD incidence rates declined over the past three decades, the pace of decline varied across immigrant groups and was slowest among Asian immigrants. In conclusion, most immigrant groups, particularly recent immigrants from the Middle East and immigrants with the shortest duration of residence, had a higher risk of IHD. Tailored cardiovascular prevention strategies are essential to reduce these disparities among immigrants in Sweden.

Discussion

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Cite This Study

Tollosa et al. (2026) conducted a cohort in Ischemic heart disease (IHD) (n=8,536,717). First-generation (G1) and second-generation (G2) immigrant status (stratified by country of origin, duration of residence, and immigration period) vs. Swedish-born individuals (including G2 for G1 comparisons; native Swedes with two Swedish-born parents for G2 comparisons) was evaluated on First-time recorded diagnosis of ischemic heart disease (IHD; ICD-9 410-414, ICD-10 I20-I25) (HR 1.16 in G1 women (HR 1.14 in G1 men), 95% CI 1.14-1.17). First-generation immigrants in Sweden had a higher risk of first-time ischemic heart disease than Swedish-born individuals (HR 1.16 in women; HR 1.14 in men), peaking at 5-15 years of residence.

synapsesocial.com/papers/6af0e9a6de503f3774140ac9 https://doi.org/10.1093/eurpub/ckag192

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First-time incidence of ischemic heart disease among immigrants in Sweden: variation by country of origin, duration of residence, and immigrant generation in a nationwide cohort study

Figures

Key Points

Study Design

Structured PICO

Main Result

Limitations

Ask about this paper

Implication

Abstract

Discussion

Cite This Study

First-time incidence of ischemic heart disease among immigrants in Sweden: variation by country of origin, duration of residence, and immigrant generation in a nationwide cohort study

Figures

Key Points

Study Design

Structured PICO

Main Result

Limitations

Ask about this paper

Implication

Abstract

Discussion

Cite This Study

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