Introduction:
Acute coronary syndrome (ACS) in young adults represents an important growing clinical challenge worldwide. This study aimed to evaluate the clinical characteristics and predictors of premature ACS, with particular emphasis on sex differences and cardiovascular risk factors.

Material and methods:
We retrospectively analyzed 2,909 patients with ACS treated at the University Clinical Centre of Kosovo. Of these, 587 had premature ACS (men <55 years; women <65 years). Data on CV risk factors, electrocardiographic, echocardiographic, angiographic findings and medications, were collected from medical records.

Results:
Patients with premature ACS had a higher prevalence of hypercholesterolemia (35.2 vs. 25.1%; p<0.001), uncontrolled hypercholesterolemia (40.4 vs. 26.9%; p<0.001), current smoking (41.1 vs. 22.9%; p<0.001) and family history of CAD (46.2 vs. 32.4%; p<0.001), but a lower prevalence of diabetes, hypertension, and uncontrolled diabetes (all p<0.001) compared with older patients. Among premature ACS patients, women had lower smoking, alcohol use, and uncontrolled hypercholesterolemia, but higher diabetes and hypertension than men. In multivariable analysis, smoking (OR 1.59), uncontrolled hypercholesterolemia (OR 1.71), and family history (OR 1.66) independently predicted premature ACS (all p<0.001). These associations were consistent across sexes: in women, uncontrolled diabetes (OR 1.51) and hypertension (OR 1.49) were additional predictors, whereas in men, smoking (OR 1.63) and uncontrolled hypercholesterolemia (OR 1.73) predominated.

Conclusions:
Premature ACS, diagnosed in every 5th patients in Kosovo, is mainly associated with uncontrolled hypercholesterolemia and smoking, while diabetes, hypertension, and hyperglycemia are less common than in older patients. Clear sex differences observed, with a more cardiometabolic profile in women and lifestyle-related risk factors in men.