A retrospective analysis of 765 hospitalized heart failure patients in Sierra Leone revealed a median age of just 53 years, with 61.3% presenting with reduced ejection fraction (HFrEF). Dilated cardiomyopathy (37%) and hypertensive heart disease (31.2%) dominated causes, while ischemic heart disease accounted for only 6.3% of cases—dramatically lower than Western populations where coronary disease is the primary driver. Over 60% were recurrent cases, and half presented with the most severe NYHA Class IV symptoms, suggesting late-stage diagnosis. This West African cohort contrasts sharply with developed nations where heart failure typically affects older adults and stems primarily from coronary artery disease. The findings illuminate critical gaps in cardiovascular prevention and early detection systems in resource-limited settings. However, this remains a preprint awaiting peer review, and the single-center design from a private hospital may not represent the broader Sierra Leone population. The data nonetheless highlights how heart failure etiology varies dramatically by region and economic development, with implications for targeted prevention strategies focusing on hypertension control and cardiomyopathy screening in younger African adults.