We describe the baseline characteristics, management, and outcomes of acute coronary syndrome (ACS) in patients of age ≤ 40 in the Gulf region of the Middle East. We studied 8176 hospitalized patients (≤ 40 years) with ACS. Ten percent (805) of the recruited patients were ≤ 40 years. The mean age was 37 years and 89% were males. The prevalence of smoking and diabetes in the young patients was high (58% and 21%, respectively). The most common ACS was ST elevation myocardial infarction. Younger patients were more aggressively treated with more frequent use of glycoprotein inhibitors, thrombolytics, and primary percutaneous coronary intervention. They had less in-hospital heart failure, left ventricular dysfunction, shock, stroke, and low rate of in-hospital mortality (1%). Measures to combat the rising prevalence of diabetes and smoking are needed.