Abstract
Background
Premature coronary artery disease is increasingly observed in low- and middle-income countries; however, data on young adults undergoing invasive coronary evaluation in resource-limited settings remain scarce. This study assessed clinical presentation, angiographic findings, system-related delays, and in-hospital outcomes among young adults undergoing coronary angiography in a Sub-Saharan catheterization center.
Methods
We retrospectively analyzed consecutive patients aged ≤45 years who underwent coronary angiography, with or without percutaneous coronary intervention, for acute coronary syndromes (ST-elevation myocardial infarction [STEMI], non-ST-elevation myocardial infarction [NSTEMI], or unstable angina) and stable coronary artery disease between June 2021 and June 2025. Demographic data, cardiovascular risk factors, angiographic characteristics, and in-hospital outcomes were collected. The primary outcome was in-hospital mortality.
Results
A total of 121 patients were included (median age 41 years; 77.7% male). Acute coronary syndromes predominated, with ST-elevation myocardial infarction in 45.5%. Smoking (55.4%) and khat use (39.7%) were the most prevalent risk factors. System delays were substantial, with a median door-to-balloon time of 355 minutes and 79.3% exceeding 180 minutes. The left anterior descending artery was the most common culprit vessel, and multivessel disease was present in 36.4%. In-hospital mortality was 9.9% and was associated with cardiogenic shock, severely reduced left ventricular ejection fraction, no-reflow/slow-flow phenomena, khat use, and prolonged door-to-balloon time (p <0.05).
Conclusion
Young adults with acute coronary syndromes in resource-limited settings experience substantial early mortality associated with delayed reperfusion, high-risk presentation, and region-specific risk factors. Improving STEMI systems of care and targeting modifiable exposures such as smoking and khat use may help improve outcomes.
Keywords: young adults, acute coronary syndrome, coronary angiography, khat, door-to-balloon time, resource-limited setting
Introduction
Coronary artery disease (CAD) remains the leading cause of mortality worldwide, accounting for an increasing proportion of premature cardiovascular deaths despite advances in prevention and treatment strategies.1–3 Although CAD has traditionally been considered a disease of older adults, acute coronary syndromes (ACS) are being increasingly recognized among young individuals, particularly in low- and middle-income countries (LMICs). While the prevalence of CAD in individuals younger than 45 years is estimated to be relatively low, ranging between 5% and 10%, its clinical, economic, and societal consequences are substantial because it affects individuals during their most productive years of life.4–6
The clinical and angiographic profile of ACS in young adults differs significantly from that observed in older populations. Young patients are predominantly male and frequently exposed to modifiable lifestyle-related risk factors, particularly cigarette smoking, while chronic comorbidities such as long-standing hypertension and diabetes mellitus are less prevalent.6–9
Angiographic studies consistently demonstrate a predominance of single-vessel disease in this age group, most commonly involving the left anterior descending artery, with a lower burden of diffuse or calcified atherosclerosis compared with older patients.5–8 Nevertheless, young patients often present late and may experience extensive myocardial injury, cardiogenic shock, or severe left ventricular dysfunction, resulting in considerable morbidity and mortality.9–11
In Sub-Saharan Africa, the burden of cardiovascular disease is rising rapidly as a consequence of demographic transition, urbanization, and lifestyle changes, while health systems continue to face major constraints.12–14 Despite this growing burden, high-quality data describing ACS in young adults from resource-limited catheterization laboratories remain scarce. Most available evidence originates from high-income settings or well-resourced centers, where access to timely reperfusion therapy is more reliable and system-related delays are shorter, limiting the generalizability of these findings to low-resource environments.11,15–17 In Sub-Saharan Africa, femoral access remains the predominant approach, reported in approximately 70–90% of coronary procedures in many centers due to resource and training limitations.12–14
Beyond conventional cardiovascular risk factors, region-specific exposures may play an important role in premature CAD. Khat (Catha edulis), a psycho-stimulant widely used in East Africa and the Horn of Africa, has been associated with sympathetic activation, endothelial dysfunction, coronary vasospasm, platelet activation, and prothrombotic states.18–21 Several studies have linked khat use to acute myocardial infarction and increased severity of coronary artery disease, particularly among young male users.19–22 Prior work from our institution has further demonstrated increased complexity and severity of coronary lesions among khat users undergoing percutaneous coronary intervention, underscoring its potential role as an underrecognized but modifiable cardiovascular risk factor.22
Building on previous institutional experience in coronary angiography and heart failure research.23–25 and in the context of persistent system-related delays to reperfusion in LMICs.15–17,26–28
The present study aimed to describe the clinical presentation, angiographic characteristics, system-related delays, and in-hospital outcomes of young patients (≤45 years) undergoing coronary angiography in a resource-limited Sub-Saharan catheterization center. By integrating patient-level, angiographic, and health-system factors, this study seeks to provide context-specific evidence to inform strategies for improving outcomes among young adults with ACS.
Methodology
Study Design and Setting
This was a retrospective observational study conducted at the Mogadishu Somali–Türkiye Recep Tayyip Erdoğan Training and Research Hospital, a high-volume tertiary referral center providing 24-hour invasive cardiology services, including emergency coronary angiography and percutaneous coronary intervention (PCI).
Study Population
We retrospectively reviewed the medical records of consecutive patients aged ≤45 years who underwent coronary angiography, with or without PCI, between June 2021 and June 2025. Indications for coronary angiography included acute coronary syndromes—ST-elevation myocardial infarction (STEMI), non-ST-elevation myocardial infarction (NSTEMI), or unstable angina—as well as stable coronary artery disease, based on standard clinical practice.
To minimize selection bias, all eligible consecutive cases during the study period were included. Patients with prior coronary artery bypass graft surgery, known congenital or structural heart disease, or incomplete angiographic data were excluded. After applying eligibility criteria, 121 patients comprised the final study cohort.
Data Collection and Variables
Data were obtained from electronic and paper-based hospital records, catheterization laboratory databases, and procedural reports. Collected variables included demographic characteristics, cardiovascular risk factors, clinical presentation, electrocardiographic findings, laboratory parameters, angiographic features, procedural details, and in-hospital outcomes. Variables with incomplete documentation were recorded as missing and were not imputed, in keeping with the retrospective nature of the study.
Definitions
ST-elevation myocardial infarction (STEMI) was defined as ischemic chest pain accompanied by persistent ST-segment elevation on electrocardiography. Non-ST-elevation myocardial infarction (NSTEMI) was defined by ischemic symptoms with elevated cardiac troponin levels in the absence of ST-segment elevation. Unstable angina was defined as ischemic symptoms without biochemical evidence of myocardial necrosis.
Door-to-balloon (DTB) time was defined as the interval from hospital presentation to first intracoronary device activation during PCI. A DTB time >180 minutes was considered indicative of prolonged system-related delay, reflecting real-world logistical challenges in a resource-limited setting.
The culprit vessel was identified by the operating interventional cardiologist and categorized as the left anterior descending (LAD), right coronary artery (RCA), left circumflex artery (LCX), or left main/other. Multivessel coronary artery disease was defined as significant stenosis in two or more epicardial coronary arteries. Procedural success was defined as restoration of TIMI grade 3 flow with residual stenosis <30% and no immediate major procedural complications.
Outcome Measures
The primary outcome was in-hospital mortality. Secondary outcomes included cardiogenic shock, severely reduced left ventricular systolic function (LVEF <35%), heart failure, no-reflow or slow-flow phenomenon, and procedural success.
Statistical Analysis
Statistical analyses were conducted using IBM SPSS Statistics for Windows, version 26.0 (IBM Corp., Armonk, NY, USA). Continuous variables are presented as median (interquartile range) or mean ± standard deviation, as appropriate, while categorical variables are expressed as frequencies and percentages. Comparisons between survivors and non-survivors were performed using the Mann–Whitney U-test for continuous variables and the χ2 test or Fisher’s exact test for categorical variables, as appropriate. A multivariable logistic regression model was initially planned to identify independent predictors of in-hospital mortality. However, due to the limited number of outcome events and the presence of strong predictors such as cardiogenic shock and severely reduced left ventricular ejection fraction, quasi-complete separation was observed, precluding reliable estimation of adjusted odds ratios. Accordingly, multivariable modeling was not pursued further, and associations are presented using univariate analyses. All analyses were two-sided, and a p-value <0.05 was considered statistically significant.
Ethical Considerations
The study protocol was approved by the Ethics Committee of Mogadishu Somali–Türkiye Recep Tayyip Erdoğan Training and Research Hospital (Decision No. 1101, dated 21 October 2024). Owing to the retrospective design and use of anonymized patient data, the requirement for informed consent was waived.
Results
Study Population and Baseline Characteristics
A total of 121 young patients (≤45 years) who underwent coronary angiography during the study period were included in the final analysis. The median age was 41 years (IQR 38–44), and the cohort was predominantly male (77.7%). Smoking and qat use were the most frequently observed cardiovascular risk factors. The majority of patients presented with acute coronary syndromes, with ST-elevation myocardial infarction (STEMI) representing the most common clinical presentation. Baseline demographic and clinical characteristics are summarized in Table 1.
Table 1.
Baseline Characteristics of the Study Population (n = 121)
| Variable | Value |
|---|---|
| Age, years, median (IQR) | 41 (38–44) |
| Male sex, n (%) | 94 (77.7) |
| Body mass index, kg/m2, mean ± SD | 27.5 ± 4.2 |
| Low socioeconomic status, n (%) | 67 (55.4) |
| Current smoking, n (%) | 67 (55.4) |
| Qat use, n (%) | 48 (39.7) |
| Hypertension, n (%) | 30 (24.8) |
| Diabetes mellitus, n (%) | 22 (18.2) |
| Hyperlipidemia, n (%) | 36 (29.8) |
| Family history of premature CAD, n (%) | 34 (28.1) |
| ST-elevation myocardial infarction (STEMI), n (%) | 55 (45.5) |
| Non-ST-elevation myocardial infarction (NSTEMI), n (%) | 17 (14.0) |
| Unstable angina, n (%) | 17 (14.0) |
| Stable coronary artery disease, n (%) | 32 (26.4) |
Notes: Values are presented as median (interquartile range), mean ± standard deviation, or number (percentage), as appropriate.
System-Related Delay and Angiographic Findings
Marked system-related delays were observed. The median door-to-balloon (DTB) time was 355 minutes (IQR 290–420), with nearly four-fifths of patients (79.3%) experiencing DTB times exceeding 180 minutes. Femoral access was the predominant vascular approach for coronary angiography and intervention.
From an angiographic perspective, the left anterior descending artery (LAD) was the most frequently identified culprit vessel, followed by the right coronary artery (RCA) and left circumflex artery (LCX). Comprehensive angiographic and procedural characteristics are presented in Table 2, and the distribution of culprit vessels is illustrated in Figure 1.
Table 2.
Cath-Lab and Angiographic Characteristics (n = 121)
| Variable | Value |
|---|---|
| System and procedural characteristics | |
| Door-to-balloon time, min, median (IQR) | 355 (290–420) |
| DTB >180 min, n (%) | 96 (79.3) |
| Femoral access, n (%) | 109 (90.1) |
| Radial access, n (%) | 12 (9.9) |
| Angiographic characteristics | |
| Culprit vessel – LAD, n (%) | 58 (47.9) |
| Culprit vessel – RCA, n (%) | 39 (32.2) |
| Culprit vessel – LCX, n (%) | 19 (15.7) |
| Left main / other, n (%) | 5 (4.1) |
| High thrombus burden (≥4), n (%) | 31 (25.6) |
| No-reflow / slow flow, n (%) | 18 (14.9) |
| Procedural outcomes | |
| Procedural success, n (%) | 103 (85.1) |
Notes: Values are presented as median (interquartile range) or number (percentage). Percentages are calculated based on available data.
Abbreviation: Cath Lab, cardiac catheterization laboratory.
Figure 1.
Distribution of culprit coronary vessels among patients undergoing coronary angiography, demonstrating predominance of the left anterior descending artery.
In-Hospital Outcomes
Overall, in-hospital mortality was 9.9% (n = 12). Adverse in-hospital events included cardiogenic shock, severely reduced left ventricular systolic function (LVEF <35%), heart failure, and no-reflow or slow-flow phenomena. Despite these complications, procedural success was achieved in the majority of cases. The distribution of key in-hospital outcomes across selected high-risk subgroups is depicted in Figure 2.
Figure 2.
Distribution of in-hospital outcomes across high-risk clinical subgroups, including cardiogenic shock, reduced left ventricular ejection fraction (<35%), and prolonged door-to-balloon time (>180 minutes).
Comparison Between Survivors and Non-Survivors
When outcomes were stratified by survival status, non-survivors were more likely to present with cardiogenic shock, severely reduced LVEF (<35%), high thrombus burden, and no-reflow/slow-flow phenomena. Importantly, all non-survivors experienced prolonged DTB times (>180 minutes). In contrast, age, sex, vascular access site, and the presence of multivessel coronary disease did not differ significantly between survivors and non-survivors. Detailed comparisons are provided in Table 3.
Table 3.
In-Hospital Outcomes and Comparison Between Survivors and Non-Survivors
| Variable | Survivors (n = 109) | Non-Survivors (n = 12) | p-value |
|---|---|---|---|
| Age, years, median (IQR) | 41 (38–44) | 42 (39–45) | 0.48 |
| Male sex, n (%) | 84 (77.1) | 10 (83.3) | 0.72 |
| Smoking, n (%) | 57 (52.3) | 10 (83.3) | 0.03 |
| Khat use, n (%) | 40 (36.7) | 8 (66.7) | 0.04 |
| STEMI presentation, n (%) | 46 (42.2) | 9 (75.0) | 0.06 |
| Cardiogenic shock, n (%) | 7 (6.4) | 8 (66.7) | <0.001 |
| DTB >180 min, n (%) | 82 (75.2) | 12 (100) | 0.01 |
| High thrombus burden (≥4), n (%) | 24 (22.0) | 7 (58.3) | 0.02 |
| No-reflow / slow flow, n (%) | 13 (11.9) | 5 (41.7) | 0.01 |
| LVEF <35%, n (%) | 9 (8.3) | 9 (75.0) | <0.001 |
| Multivessel disease, n (%) | 38 (34.9) | 6 (50.0) | 0.29 |
| Femoral access, n (%) | 98 (89.9) | 11 (91.7) | 0.85 |
Notes: Values are presented as median (interquartile range) or number (percentage). Categorical variables were compared using χ2 test or Fisher’s exact test as appropriate; continuous variables were compared using the Mann–Whitney U-test. p-values <0.05 were considered statistically significant.
Discussion
In this retrospective observational study, we evaluated the clinical characteristics, angiographic patterns, and in-hospital outcomes of young adults undergoing coronary angiography in a resource-limited Sub-Saharan catheterization center. Several important observations emerged. First, ACS—particularly ST-elevation myocardial infarction—was the predominant mode of presentation. Second, system-related delays to reperfusion were profound, with most patients experiencing door-to-balloon times far exceeding guideline-recommended thresholds. Third, despite relatively limited angiographic disease in many patients, in-hospital mortality and severe complications remained clinically important and were associated with cardiogenic shock, severely reduced left ventricular ejection fraction, and delayed reperfusion.
The demographic and risk factor profile observed in our cohort, characterized by male predominance and high rates of cigarette smoking, is consistent with reports from South Asia, Eastern Europe, and Sub-Saharan Africa.5–9,12–14 These findings reinforce the central role of lifestyle-related risk factors in premature CAD. Importantly, khat use was highly prevalent in our population, representing a region-specific exposure that distinguishes this cohort from those reported in non-khat-using regions. Experimental and clinical data suggest that khat induces coronary vasoconstriction, endothelial dysfunction, platelet activation, and prothrombotic states, mechanisms that may predispose users to large infarcts and adverse outcomes.18–21 Our findings are concordant with previous studies demonstrating increased coronary disease severity and procedural complexity among khat users undergoing PCI, emphasizing the need to recognize khat use as a modifiable cardiovascular risk factor in regional prevention strategies.21,22
Angiographically, left anterior descending artery involvement and single-vessel disease predominated, consistent with observations from studies conducted in Nepal, Pakistan, India, and Kenya.5–9,12–14 These patterns likely reflect the pathophysiology of premature atherosclerosis, where focal plaque rupture rather than diffuse multivessel disease predominates. Nevertheless, the presence of multivessel disease in a substantial proportion of patients suggests that aggressive atherosclerosis can occur even at a young age, particularly in the context of smoking, dyslipidemia, and substance use.
One of the most concerning findings of this study was the magnitude of system-related delays. The median door-to-balloon time greatly exceeded international recommendations, and all non-survivors experienced prolonged delays. Previous studies have consistently demonstrated a strong association between delayed reperfusion and increased infarct size, cardiogenic shock, and mortality, regardless of patient age.15–17,26–28 In resource-limited settings, such delays are often multifactorial, reflecting delayed patient presentation, limited emergency medical services, interfacility transfer delays, and catheterization laboratory availability. Our findings underscore that, in young patients, favorable coronary anatomy alone is insufficient to mitigate the adverse impact of delayed reperfusion.
In-hospital mortality in our cohort was higher than that reported in many high-income settings but comparable to outcomes described in other LMICs.6,9,12–14 Mortality clustered among patients presenting with cardiogenic shock and severely reduced left ventricular systolic function, suggesting the prognostic importance of early hemodynamic compromise. These observations are consistent with prior institutional studies demonstrating the strong association between ventricular dysfunction and adverse outcomes across acute cardiac conditions.23–25
Limitations
Several limitations warrant consideration. The retrospective, single-center design inherently limits causal inference and generalizability. Some variables were incompletely documented, reflecting real-world practice in resource-limited settings and introducing the potential for information bias. Data on procedural complications such as bleeding, stroke, and acute kidney injury were not consistently available and could not be analyzed. Additionally, long-term outcomes were not available, restricting assessment to in-hospital events. The relatively small number of mortality events resulted in quasi-complete separation during multivariable modeling, precluding reliable identification of independent predictors; accordingly, findings should be interpreted as associative rather than causal. Given multiple statistical comparisons, there remains a potential for type I error; therefore, the results should be interpreted as exploratory and hypothesis-generating. Despite these limitations, this study provides valuable insight into an underrepresented population and highlights important patient-level and system-level determinants of outcome.
Conclusion
Young adults presenting with ACS in resource-limited Sub-Saharan catheterization centers experience substantial morbidity and mortality despite relatively favorable coronary anatomy. High-risk clinical presentation, khat use, and prolonged system-related delays are important factors associated with adverse outcomes. Targeted public health interventions addressing smoking and khat use, alongside strengthening regional STEMI systems of care, may help reduce the growing burden of premature coronary artery disease in this population. These findings should be interpreted in the context of the study limitations.
Funding Statement
No funding was received for this study.
Data Sharing Statement
The datasets generated and/or analyzed during the current study are available from the corresponding author upon reasonable request.
Ethics Approval and Consent to Participate
The research protocol was approved by the Ethics Committee of Mogadishu Somali–Türkiye Recep Tayyip Erdoğan Training and Research Hospital (Decision No. 1101, Reference No. MSTH/19892, dated 21 October 2024) and was conducted in accordance with the ethical principles of the Declaration of Helsinki. Due to the retrospective nature of the study and the use of anonymized data, the requirement for informed consent was waived by the Ethics Committee.
Consent for Publication
The study is retrospective in nature and involves anonymized data.
Disclosure
The authors declare that they have no competing interests in this work.
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Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Data Availability Statement
The datasets generated and/or analyzed during the current study are available from the corresponding author upon reasonable request.