Background/Objectives: Limited research has evaluated the association between the triglyceride-to-high-density lipoprotein (TG/HDL) ratio and premature coronary artery disease (PCAD), particularly in Saudi Arabia. Therefore, this study aimed to investigate the association of the TG/HDL ratio with PCAD and to assess its sensitivity and specificity in a young Saudi population. Methods: This comparative retrospective case–control study utilized data collected from patients’ electronic medical records at King Saud University Medical City (KSUMC) between 2015 and 2023. The vessel score and Gensini score were used to evaluate the severity of coronary occlusion. The study population was divided into two groups: (1) a healthy control group consisting of blood bank donors, selected to exclude individuals with chronic diseases such as metabolic disorders and hypertension, with no evidence of coronary artery disease and aged ≤50 years (as confirmed by a cardiologist to rule out cardiovascular disease); and (2) patients with PCAD, aged ≤51 years, who underwent selective coronary angiography using the standard hospital procedure (right femoral artery approach). Coronary angiographic images were evaluated using right and left oblique views with cranial and caudal angulations. Results: A total of 898 subjects were included in the study, comprising 440 healthy controls and 458 patients with PCAD. Higher HbA1c levels were significantly associated with PCAD (adjusted OR = 13.03, 95% CI [7.32, 23.18], p < 0.001). Importantly, the TG/HDL ratio, the primary biomarker of interest, remained significantly associated with PCAD after full adjustment. Each unit increase in the TG/HDL ratio was associated with more than a threefold increase in the odds of PCAD (adjusted OR = 3.39, 95% CI [2.22, 5.16], p < 0.001), independent of age, sex, BMI, HbA1c, smoking, and total cholesterol levels. Among females, the TG/HDL ratio demonstrated an area under the curve (AUC) of 0.796, with an optimal cut-off value of 0.91, yielding 77.8% sensitivity and 71.4% specificity. Among males, the TG/HDL ratio yielded an AUC of 0.786, with a higher optimal cut-off value of 1.09 providing 73.4% sensitivity and 65.4% specificity. Conclusions: Our study indicates that the TG/HDL ratio and HbA1c are significantly associated with PCAD in young Saudi male and female populations, demonstrating good sensitivity and specificity. Females exhibited a lower cut-off value than males. Smoking and elevated cholesterol levels were also identified as prominent risk factors. However, the TG/HDL ratio did not distinguish between moderate and severe coronary stenosis, as assessed by the Gensini score.

Patients with prior acute myocardial infarction (AMI) generally show low rates of achieving secondary prevention targets. Here we evaluated adherence to guideline-recommended secondary prevention strategies after AMI in Saudi Arabia. This ambispective multicenter cohort study included consecutive patients seen for follow-up visits 6–24 months after hospitalization for AMI. A standardized questionnaire was used to evaluate control of blood pressure (<130/80 mmHg), HbA1c (<7%), LDL-C (<1.4 mmol/L), lipoprotein(a) (<50 mg/dL), body mass index (18.5–24.9 kg/m²), physical activity targets, smoking habits, guideline-directed medical therapy (GDMT), and referral to cardiac rehabilitation. Among 108 AMI patients (mean age 58.4 ± 10.9 years; 80.6% male; 76.9% Saudi nationals), 53.7% had uncontrolled blood pressure, ~40% uncontrolled glucose, and 67% above-target LDL-C levels. Most participants were overweight (40.7%) or obese (37%), and 28.7% achieved the physical activity targets. One-third of patients were not receiving all GDMT, 15.7% were current smokers, and 25% had been referred to cardiac rehabilitation. No patient met all guideline-recommended secondary prevention targets. This pilot study highlights gaps in secondary prevention among AMI survivors. Upcoming study phases will aim for national representation and help identify key clinical and demographic drivers to improve secondary prevention efforts across Saudi Arabia.