AMI in young adults represents a growing and distinct clinical entity, characterized by specific epidemiological, clinical, and angiographic features that clearly differentiate it from myocardial infarction occurring in older populations [2,3]. In the present study, we observed a strong male predominance and a mean age in the early 40s, findings consistent with contemporary international registries and reflecting early exposure of young men to high-risk behaviors [1,4]. The marked male predominance likely reflects both higher rates of tobacco and cannabis use and a potential protective effect of female sex hormones in premenopausal women [5].

One of the most striking findings of our study is the overwhelming predominance of behavioral cardiovascular risk factors, particularly cigarette smoking and cannabis use. Tobacco use affected nearly two-thirds of patients, reinforcing its central role in premature coronary artery disease through endothelial dysfunction, enhanced platelet activation, and accelerated atherothrombosis [6]. Cannabis use was also highly prevalent, affecting more than one quarter of patients, and has been increasingly implicated in the pathogenesis of acute coronary syndromes in young adults [7]. Experimental and clinical data suggest that cannabis may promote coronary vasospasm, increase myocardial oxygen demand, and induce prothrombotic states, thereby acting as a potent trigger for AMI in susceptible individuals [8,9]. In regions such as Morocco, where cannabis consumption remains relatively common among young adults, these findings underscore the need for stronger public health policies addressing both tobacco and cannabis use as major cardiovascular risk factors.

From an angiographic standpoint, our results confirm the predominance of single-vessel coronary disease in young patients with STEMI, with a marked involvement of the left anterior descending artery. This pattern is consistent with previous studies reporting less diffuse atherosclerosis and more localized culprit lesions in younger individuals [3,10]. Such angiographic features are often associated with plaque erosion or rupture in otherwise minimally diseased coronary arteries, as well as with transient thrombotic occlusions [11]. This limited coronary involvement likely contributes to the relatively favorable short-term prognosis observed in young patients, including lower in-hospital mortality rates compared with older populations.

Nevertheless, the identification of MINOCA in nearly 10% of patients highlights the heterogeneity of mechanisms underlying myocardial infarction in this age group. MINOCA represents a diagnostic and therapeutic challenge, as it encompasses a wide range of pathophysiological processes, including coronary vasospasm, SCAD, coronary embolism, and microvascular dysfunction [12-14]. In young patients, particularly women, these mechanisms may be more prevalent than classic atherothrombotic disease [13]. The limited access to advanced diagnostic tools such as early cardiac magnetic resonance imaging, intracoronary imaging with optical coherence tomography or intravascular ultrasound, and vasoreactivity testing may lead to underdiagnosis or misclassification of these entities in routine clinical practice, especially in low- and middle-income countries [12].

Although short-term outcomes in our cohort were generally favorable, with a high rate of successful reperfusion and low in-hospital mortality, a substantial proportion of patients developed left ventricular systolic dysfunction or cardiogenic shock. These complications carry important prognostic implications and emphasize that young age does not confer protection against severe manifestations of myocardial infarction [15]. Moreover, the long-term prognosis of these patients remains a major concern, as continued exposure to modifiable risk factors such as tobacco and cannabis is associated with recurrent ischemic events, progressive coronary disease, and impaired quality of life [9,16].

Taken together, our findings highlight the urgent need for comprehensive prevention and management strategies tailored to young adults with myocardial infarction. Beyond optimizing acute reperfusion strategies and reducing system delays, particular emphasis should be placed on aggressive secondary prevention, including structured smoking and cannabis cessation programs, early initiation of evidence-based pharmacotherapy, and access to age-adapted cardiac rehabilitation [15,17]. In addition, the implementation of standardized diagnostic pathways for MINOCA and other non-atherosclerotic causes of myocardial infarction may improve etiological diagnosis and guide personalized management in this challenging population [12].

Limitations

This study has several limitations that should be acknowledged. First, its retrospective and single-center design limits the ability to establish causal relationships and may reduce the generalizability of the findings to other populations or healthcare settings. Second, the relatively small sample size may have limited the statistical power to detect associations between risk factors and clinical outcomes, particularly in subgroup analyses.

Third, data collection relied on retrospective medical records, which may be subject to incomplete or missing information, especially regarding lifestyle factors such as the duration, intensity, and timing of tobacco and cannabis use. Fourth, advanced diagnostic investigations, including early cardiac magnetic resonance imaging, intracoronary imaging (optical coherence tomography/intravascular ultrasound), and systematic vasoreactivity testing, were not routinely available. As a result, some non-atherosclerotic mechanisms of myocardial infarction, particularly within the MINOCA spectrum, may have been underdiagnosed or potentially misclassified.

Finally, this study focused on in-hospital outcomes, and no long-term follow-up data were available. Therefore, conclusions regarding recurrent events, long-term mortality, and adherence to secondary prevention strategies could not be assessed.