Association Between Triglyceride/High-Density Lipoprotein Ratio and Premature Coronary Artery Disease in Young Saudi Population: A Case–Control Study

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.