Objectives <p>The study aimed to investigate a non-invasive biomarker for predicting coronary heart disease by analyzing fecal sulfatide levels.</p> Methods <p>A retrospective study was conducted on 593 patients with coronary heart disease, divided into acute myocardial infarction (AMI), unstable angina pectoris (UAP), and stable angina pectoris groups (SAP), and a control group of 200 healthy adults. General information was collected for analysis, and fecal sulfatide levels were compared among groups. Binary logistic regression analysis assessed the correlation between fecal sulfatide levels and coronary heart disease. Statistical analyses were performed to evaluate the risk factors, and predictive value was assessed using receiver operating characteristic (ROC) curves.</p> Results <p>Statistically significant differences were observed in the characteristics of age, complete blood cell count, high-density lipoprotein cholesterol, low-density lipoprotein cholesterol between the group of patients with coronary heart disease and the control group (<i>P</i> &lt; <i>0.05</i>). Noteworthy, fecal sulfatide levels were notably higher in coronary heart disease groups. Furthermore, fecal sulfatide levels in AMI group significantly exceeded those in SAP and UAP groups (<i>P</i> &lt; <i>0.05</i>). Multivariate logistic regression analysis identified fecal sulfatide as an independent risk factor for coronary heart disease, with an area under the ROC curve of 0.893 (95% CI 0.869, 0.921), indicating strong predictive value.</p> Conclusions <p>Fecal sulfatide may serve as a novel, non-invasive biomarker for early coronary heart disease prediction and risk stratification. However, the retrospective and single-center design of this study limits the generalizability of the results, and future large-scale, multi-center prospective studies are needed to validate these findings.</p>