Abstract Body (Do not enter title and authors here): Introduction: A growing number of patients develop atherosclerotic cardiovascular disease (ASCVD) despite the absence of standard modifiable risk factors i.e. hypertension (HTN), type 2 diabetes (T2D), dyslipidemia (DSL), and cigarette smoking (SMuRF-less). There is scarcity of studies on prevalence and clinical profiles of SMuRF-less patients in the Middle Ease (ME).

Aim: To study the prevalence and clinical features of ME patients with ASCVD who are SMuRF-less vs. those with ≥ 1 SMuRFs, presence of other risk factors and utilization of secondary preventive medications in the 2 groups, and one year survival.

Methods: Clinical details of adult patients with ASCVD who participated in 5 previous registries were analyzed according to the absence or presence of ≥ 1 SMuRFs.

Results: Of the 5002 patients included in the analysis, 676 (13.5%) were SMuRF-less and 4326 (86.5%) had ≥ 1 SMuRFs. Prevalence of the 4 SMuRFs in the whole cohort was 53.5% HTN, 47.8% T2D, 40.2% smoking, and 37.5% DSL, and the SMuRF group was 61.9%, 55.2%, 46.5%, and 43.4%, respectively. Compared with the SMuRFs group, patients in the SMuRFless group were younger (mean age 52±11.4 years vs. 56.3±11.5 years, respectively, p<0.001) and more likely to be women than men (38.6% vs. 27.9%, p<0.0001). Furthermore, SMuRF-less patients had lower mean body mass index, and less prevalence of metabolic syndrome, heart failure, and family history of ASCVD. Utilization of secondary cardiovascular prevention medications was significantly less in the SMuRF -less group than those with SMuRFs; dual antiplatelet therapy (36.4% vs. 69.5%), statins (66.3% vs. 87.4%), B blockers (57.5% vs. 70.5%), and renin-angiotensin inhibitors (35.2% vs. 55.3%, respectively, all p<0.001. Of the subgroup with one year follow up after percutaneous coronary intervention (N=2641), mortality rate was not different in the 2 groups; 1.4% vs. 1.8%, p=0.98.

Conclusions: In this first study of SMuRFs in ASCVD patients in the Middle East, SMuRF-less patients account for nearly 14% of the studied cohort. These patients were younger, had less comorbid disease, received less guidelines-recommended prevention medication, and had same one year event rate compared with patients who have SMuRFs.