Behavioral and metabolic factors characterize a distinct premature atherosclerosis phenotype in Chinese patientsSmoking and Metabolic Factors Linked to Heart Attacks in China

Background and aimsPremature myocardial infarction (PMI) imposes a significant and growing public health burden in China, particularly affecting the nation's young and productive workforce. Despite accumulating localized evidence, a systematic, strategic assessment of the risk factor landscape and its alignment with global research standards is lacking. This study aims to map the evidence for PMI risk factors in China, diagnose systemic research gaps from an international comparative perspective, and propose actionable strategies for future research and prevention.MethodsWe conducted a systematic review of Chinese and English databases (from inception to September 2025), identifying 317 eligible observational studies on PMI in China. To move beyond descriptive synthesis, we developed and applied a novel “Strength-Importance Matrix” scoring system. This tool quantitatively evaluates each risk factor based on two dimensions: (1) Evidence Strength (a weighted composite of study design, sample size, methodological rigor, and result consistency) and (2) Public Health/Clinical Importance (a weighted composite of guideline recommendation strength, estimated population attributable risk, and intervention feasibility).ResultsChinese PMI patients exhibit a distinctive premature atherosclerosis phenotype dominated by behavioral and metabolic factors. Smoking (prevalence >71% in patients