OBJECTIVES: To determine whether ethnic differences in diabetes, dyslipidaemia and ectopic fat deposition account for ethnic differences in incident cardiovascular disease. BACKGROUND: Coronary heart disease(CHD) risks are elevated in South Asians(SA) and lower in African Caribbeans(AfC) compared to Europeans. These ethnic differences map to lipid patterns and ectopic fat deposition. METHODS: Cardiovascular risk factors were assessed in 2049 Europeans, 1517 SA and 630 AfC in 1988-91(mean age 52.4±6.9). Fatal and non-fatal events were captured over a median 20.5 year follow-up. Subhazard ratios(SHRs) were calculated using competing risks regression. RESULTS: Baseline diabetes prevalence was over three times greater in SA and AfC than in Europeans. SA were more, and AfC less, centrally obese and dyslipidaemic than Europeans. Compared to Europeans CHD incidence was greater in SA and less in AfC. The age and sex adjusted SA versus European SHR(95% CI) was 1.70((1.52, 1.91),p<0.001) and remained significant (1.45(1.28,1.64),p<0.001) when adjusted for waist:hip ratio. The AfC vs European age and sex adjusted SHR of 0.64(0.52, 0.79), p<0.001 remained significant when adjusted for HDL and LDL cholesterol (0.74(0.60, 0.92),p=0.008). Compared to Europeans, SA and AfC experienced more strokes (age and sex adjusted SHRs:1.45(1.17,1.80), p=0.001 and 1.50(1.13, 2.00),p=0.005, respectively) and this differential was more marked in those with diabetes (age adjusted SHRs:1.97(1.16,3.35), interaction p=0.038) and 2.21(1.14, 4.30), interaction p=0.019). CONCLUSIONS: Ethnic differences in measured metabolic risk factors did not explain differences in CHD incidence. The apparently greater association between diabetes and stroke risk in SA and AfC compared with Europeans merits further study.