Premature myocardial infarction in a transitional middle-income country: Clinical phenotype, risk burden, invasive management, and early mortality in an 11-year national cohort

Background Premature myocardial infarction (MI) represents a major public health concern, particularly in transitional healthcare systems where risk factor control remains suboptimal. However, contemporary large-scale data on premature MI from Southeast Europe are limited. Aim To evaluate clinical characteristics, risk factor burden, management patterns, and in-hospital mortality among patients with premature MI in Kosovo over an 11-year period. Methods We analyzed 13,099 consecutive patients admitted with acute MI between 2014 and 2024 at our University Clinical Centre. Premature MI was defined as age <55 years in men and <65 years in women; very young MI as <45 years. Baseline characteristics, invasive management, and in-hospital outcomes were compared with non-premature MI. Logistic regression identified predictors of in-hospital mortality. Results Premature MI accounted for 3,708 cases (28.3%), including 639 (4.9%) very young patients. Compared with non-premature MI, premature MI patients were more frequently male (100% men <55; women <65), active smokers (39–71%), and had a strong family history of cardiovascular disease (≈46–52%) (all p<0.001). Very young MI patients had particularly high smoking prevalence (71%) but lower diabetes rates (14.6%). Hypertension (72.8%) and diabetes (40.4%) were highly prevalent among premature MI women, whereas smoking predominated in men (71%). STEMI presentation was common, particularly among very young patients (62.8%, p<0.001). In-hospital mortality was significantly lower in premature compared with non-premature MI (6.1% vs. 11.1%, p<0.001) and lowest in very young MI (2.0%). Independent predictors of mortality in premature MI included diabetes mellitus, left bundle branch block, reduced LVEF (<50%), cardiogenic shock, and absence of PCI (all p<0.001). Conclusions Nearly one-third of all AMI cases in Kosovo occur prematurely. Premature MI is characterized by an alarming burden of modifiable risk factors, particularly smoking and hypertension. Although short-term mortality is lower than in older patients, high-risk clinical features such as cardiogenic shock and LV dysfunction strongly determine outcome. These findings highlight the urgent need for aggressive primary prevention and early risk factor control in younger populations within transitional healthcare systems.