Clinical presentation, risk factors, and coronary angiographic profile of very young adults (≤30 years) presenting with first acute myocardial infarction at a tertiary care center in Rajasthan, India

Piyush Joshi; Archit Dahiya; Manas Thakur; Ramanand Prasad Sinha; Harsh Wardhan

doi:10.4103/heartindia.heartindia_4_22

ORIGINAL ARTICLE

Year : 2022 | Volume : 10 | Issue : 1 | Page : 21-25

Clinical presentation, risk factors, and coronary angiographic profile of very young adults (≤30 years) presenting with first acute myocardial infarction at a tertiary care center in Rajasthan, India

Piyush Joshi, Archit Dahiya, Manas Thakur, Ramanand Prasad Sinha, Harsh Wardhan
Department of Cardiology, MGMCH, Jaipur, Rajasthan, India

Date of Submission	24-Jan-2022
Date of Decision	10-Feb-2022
Date of Acceptance	16-Feb-2022
Date of Web Publication	13-Apr-2022

Correspondence Address:
Dr. Archit Dahiya
74-R Model Town, Rohtak - 124 001, Haryana
India

Source of Support: None, Conflict of Interest: None

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DOI: 10.4103/heartindia.heartindia_4_22

Abstract

Introduction: Acute coronary syndrome (ACS) in very young adults with age ≤30 years is rare. In India, the prevalence of acute myocardial infarction (AMI) in this population is <2%. ACS leads to significant effects on patient's psychology, morbidity, and increased financial burden when it occurs at this young age. Young patients with ACS on coronary angiography (CAG) show a relatively increased incidence of single-vessel disease and nonobstructive stenosis.
Materials and Methods: This retrospective observational study was conducted at the Department of Cardiology, Mahatma Gandhi Medical College and Hospital, Jaipur, Rajasthan. The medical records of very young adults (≤30 years of age) with first AMI between September 2019 to August 2021 were collected and analyzed.
Results: Twenty-two very young adult patients aged ≤30 years were admitted with first AMI. Most of the patients were within the age group of 25–30 years. Mean patient age was 27.63 ± 2.03 years and 21 patients (95.4%) were men. Regarding the risk factors for coronary artery disease (CAD), smoking was the most common (54.5%) in young patients. Dyslipidemia and family history of premature CAD were present in 8 (36.3%) and 6 (27.2%) of patients. The most common symptom in patients was chest pain (90.9%). Obstructive CAD (vessel lumen stenosis ≥ 70%) was found in 18 (81.8%) patients.
Conclusion: Very young adults presented with less extensive CAD as compared to elderly likely due to less atherosclerosis of the coronary arteries in them. The major modifiable risk factors in very young Indian population are smoking and dyslipidemia. Primary prevention by educating the public about the effects of smoking, unhealthy dietary habits, and sedentary lifestyle in early years of life may help to prevent the development of cardiac problems later in life.

Keywords: Acute coronary syndrome, coronary artery disease, smoking, young adults

How to cite this article:
Joshi P, Dahiya A, Thakur M, Sinha RP, Wardhan H. Clinical presentation, risk factors, and coronary angiographic profile of very young adults (≤30 years) presenting with first acute myocardial infarction at a tertiary care center in Rajasthan, India. Heart India 2022;10:21-5

How to cite this URL:
Joshi P, Dahiya A, Thakur M, Sinha RP, Wardhan H. Clinical presentation, risk factors, and coronary angiographic profile of very young adults (≤30 years) presenting with first acute myocardial infarction at a tertiary care center in Rajasthan, India. Heart India [serial online] 2022 [cited 2023 Jun 2];10:21-5. Available from: https://www.heartindia.net/text.asp?2022/10/1/21/343068

Introduction

Cardiovascular disease is one of the most common causes of mortality in India and worldwide.^[1],[2] Indians are more susceptible to develop coronary artery disease (CAD) as compared to western population with symptoms occurring 10 years earlier.^[3] Acute coronary syndrome (ACS) is one of the most common presentations of CAD and it includes unstable angina ST-segment elevation myocardial infarction (STEMI), and non- STEMI (NSTEMI).^[4]

ACS in very young adults with age ≤30 years is rare. In India, the prevalence of acute myocardial infarction (AMI) in this population is <2%.^[5] A similar study reported that 0.4% of patients presented with ACS in ≤30 years age group.^[6] ACS leads to significant effects on patient's psychology, morbidity, and increased financial burden when it occurs at this young age.^[7] The risk as well as the clinical factor profile and the arterial involvement pattern differs between young and elderly CAD patients.^[8],[9] Metabolic, genetic, and conventional causes may result in CAD occurring at a younger age in India.^[10]

Atherosclerosis occurring in younger age is an emerging problem and is due to civilization which is changing rapidly due to unhealthy diets, stressful work conditions, and sedentary lifestyles. Additional risk factors for CAD include smoking, substance abuse, hypertriglyceridemia, low high-density lipoprotein cholesterol, high lipoprotein-a levels, coronary vasospasm, medium vessel vasculitis, hypercoagulable states, and metabolic syndrome.

Young patients with ACS on coronary angiography (CAG) show a relatively increased incidence of single-vessel disease and nonobstructive stenosis.^[11] Data are lacking regarding the clinical presentation, risk factors, and angiographic profile of very young adults (≤30 years of age) with ACS in Rajasthan, India. Hence, the objective of this study is to identify the clinical presentation, risk factors, echocardiographic, and coronary angiographic profile in very young adults presenting with first AMI at a tertiary care center in Rajasthan, India.

Materials and Methods

This retrospective observational study was conducted at the Department of Cardiology, Mahatma Gandhi Medical College and Hospital, Jaipur, Rajasthan. The medical records of very young adults (≤30 years of age) with first AMI between September 2019 to August 2021 were collected and entered in MS Excel sheet. Data were further analyzed with IBM SPSS Modeler 16.0. The study was approved by the institutional ethical committee via letter MGMC&H/IEC/JPR/2021 (dated September 27, 2021).

Inclusion criteria

Very young adults ≤30 years of age presented with first AMI
Final diagnosis of AMI was defined as per the fourth universal definition of myocardial infarction^[12]
Diagnosis of STEMI and NSTEMI was defined according to the American Heart Association/the American College of Cardiology Foundation guidelines.^[13],[14]

Exclusion criteria

Patients with stable angina
Patients with prior history of ACS, percutaneous coronary intervention (PCI), or coronary artery bypass graft (CABG) surgery
Patients with prior cardiomyopathies, pericardial disease, or valvular heart disease
Patients of known allergy to contrast
Age younger than 18 years
Electrolyte abnormality
Patient with COVID-19 positive status.

Coronary angiographic profile and PCI or CABG reports of eligible patients were also recorded. The obstructive coronary artery disease was labeled when there was ≥70% lesion in the left anterior descending (LAD), left circumflex (LCX), right coronary artery (RCA), or their major branches or ≥50% luminal narrowing of the left main coronary artery.

Patients were categorized in one of the following single, double, or triple-vessel diseases. The other lesions on angiography which were not severe were labeled as nonobstructive CAD.

Results

Out of a total of 1378 coronary angiograms performed for various indications to rule out CAD during the study period, 22 very young adult patients aged ≤30 years were admitted with first AMI at the Department of Cardiology, Mahatma Gandhi Medical College and Hospital, Jaipur, Rajasthan. The demographic and risk factor profile of very young ACS patients are summarized in [Table 1]. Mean patient age was 27.63 ± 2.03 years and 21 patients (95.4%) were men.

Table 1: Demographic and risk factors profile of coronary artery disease in very young acute coronary syndrome patients (n=22)

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Regarding risk factors for CAD, smoking was the most common (54.5%) in very young patients. Dyslipidemia and family history of premature CAD were present in 8 (36.3%) and 6 (27.2%) of patients. A total of 7 (31.8%) patients were alcoholic, 5 (22.7%) patients were overweight, 3 (13.6%) patients were hypertensive, and 2 (9%) patients were diabetic.

The most common symptom in patients was chest pain (90.9%). It was followed by sweating (77.2%), shortness of breath (13.6%), palpitations (9.0%), and syncope (4.54%). Two patients presented with cardiogenic shock and another two patients had ventricular tachycardia. One patient presented with complete heart block and temporary pacemaker was inserted as lifesaving measure. STEMI (77.2%) was more common as compared to NSTEMI (22.7%). Mean left ventricular ejection fraction was 40.3 ± 8.5%. Clinical characteristics of very young ACS patients are summarized in [Table 2].

Table 2: Clinical characteristics of coronary artery disease in very young acute coronary syndrome patients (n=22)

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Five (22.7%) patients underwent thrombolysis before undergoing CAG. All of these patients were referred to our center after thrombolysis at other hospitals without PCI capabilities. Four of these postthrombolysis patients had obstructive CAD on angiography and underwent PCI with drug-eluting stent (DES). One patient had recanalized vessel and managed medically.

Obstructive CAD (vessel lumen stenosis ≥70%) was found in 18 (81.8%) patients and nonobstructive CAD in four patients (18.1%). Single-vessel disease was the most common (59%) finding. The most common culprit vessel was the LAD artery (40.9%) followed by the RCA (13.6%). Double-vessel disease was seen in 22.7% of patients and the most common combination of vessels was LAD and RCA (13.6%). No patient of triple-vessel disease or left main disease was observed. Based on the overall assessment, 18 (81.8%) patients underwent PCI with DES placement and rest of the patients were advised medical treatment (18.1%). Coronary angiographic characteristics of the patients are summarized in [Table 3].

Table 3: Coronary angiography profile and revascularization pattern of coronary artery disease in very young acute coronary syndrome patients (n=22)

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Discussion

ACS is a life-threatening condition caused by atherosclerosis leading to acute narrowing of the coronary artery and followed by rupture of an unstable plaque with thrombosis. Diabetes mellitus, hypertension, smoking, family history of CAD, and lipid abnormalities are prominent risk factors in the development of early atherosclerosis.

This study helps in identifying the clinical presentation, risk factors, echocardiographic, and CAG profile in very young adults ≤30 years of age presenting with first AMI. The mean age of patients with ACS was 27.63 ± 2.03 years and 54.5% of patients were from rural background. In the present study, male predominance (95.4%) was observed, which is similar with other studies.^{[5],[15],[16]} The protective effects of estrogen in women preventing atherosclerosis and smoking being much more common in males have been responsible for male predominance.^[5]

Out of a total of 1378 coronary angiograms performed for various indications to rule out CAD during study period, 22 very young adult patients aged ≤30 years were admitted with first AMI. This prevalence of 1.59% of AMI in very young adults in our study is similar with study published by Deshmukh et al. in 2019.^[15]

In our study, risk factors for CAD were males (95.4%), smokers (54.5%), dyslipidemia (36.3%), consumption of alcohol (31.8%), family history of premature CAD (27.2%), obesity (22.7%), hypertension (13.6%), diabetes (9%), and stressful life events (9%).

Cigarette smoking was found to be the main risk factor (54.5%) for the occurrence of coronary events in very young patients. It is one of the important causes of endothelial dysfunction. The INTERHEART study also showed smoking as a more significant risk factor in younger men population as compared to women.^[17] Many other studies have also shown that smoking is a major risk factor for AMI in young patients.^{[5],[6],[16],[18]} Smoking cessation should be encouraged as primary prevention to reduce the burden of CAD in younger population as it can result in vasoconstriction, promotes atherosclerosis, and subsequently creates a thrombotic milieu in the vessel.^[5]

Dyslipidemia was present in 36.3% in this study. Various studies conducted in young patients of ACS have reported dyslipidemia ranging from 21.2% to 51.2%.^[5],[15] These studies indicate that lifestyle (sedentary) factors and lipid metabolism abnormalities may play a major role in the development of CAD in young patients. Family history of premature CAD is another major risk factor for ACS in younger patients. Family history of premature CAD was present in 27.2% of patients in our study as compared to 9.8%–46.8% in other studies.^[5],[15]

Obesity is a risk factor which is indirectly linked to ACS. 22.7% of patients were obese in our study as compared to 39.1% in study by Sinha et al.^[5] Diabetes mellitus, hypertension, and stress are important risk factors for CAD. In our study, two patients had diabetes mellitus, and three had hypertension. The diabetes mellitus prevalence was 2.4%–17.2% in other studies and the hypertension prevalence was 12.2%–20.5% in other studies.^[5],[15]

Stressful life events may lead to plaque rupture resulting in ACS. The frequency of stressful life events was low (9%) in the studied population. The prevalence of stressful life events was much higher (29.6%) in study by Sinha et al.^[5]

In this study, the most common symptoms at the time of hospitalization were chest pain (90.9%), sweating (77.2%) and is similar to study by Sinha et al.^[5] STEMI was the most common presentation (77.2%) as compared to NSTEMI (22.7%). Anterior wall myocardial infarction (59%) was the most common STEMI in this study which was similar to other studies in young patients.^[5],[15] Mean left ventricular ejection fraction in this study was found to be 40.3% ± 8.5%.

In this study, obstructive CAD was found in 81.8% of young patients. Other studies have reported a similar prevalence rate.^{[5],[18],[19]} However, some studies have reported lower rates of obstructive CAD.^{[15],[20],[21]} Nonobstructive CAD was seen in 18.1% of the patients in our study.

In this study, single-vessel disease was the most common (59%) finding and this predominance was similar to the other studies on young patients with ACS.^{[5],[15],[16],[18],[19],[20]} Low prevalence of double-vessel disease suggests that extensive coronary involvement is not a common finding in young adults presenting with ACS. In single-vessel disease group, LAD involvement was the most common infarct-related artery (40.9%), whereas RCA was involved in 13.6% and LCX in 4.5%. The findings are similar with other studies where LAD was the most common.^{[5],[15],[18],[19],[20],[21]} Another study showed that younger patients with ACS had more frequency of normal or minimal lesion coronary anatomy as compared with older patients with ACS.^[22]

Based on the overall assessment, 18 (81.8%) patients underwent PCI with DES placement and rest of the patients were advised medical treatment 4 (18.1%) in this study. Very young adults suffer from lack of awareness and poorer control of risk factors due to various socioeconomic factors in our society.

Limitations

Small number of patients in this study is its main limitation. Furthermore, there was lack of intracoronary imaging in our study. There was no follow-up of patients and as there was no control group, the statistical significance of each risk factor could not be analyzed.

Conclusion

Very young adults presented with less extensive CAD as compared to elderly likely due to less atherosclerosis of the coronary arteries in them. The major modifiable risk factors in very young Indian population are smoking and dyslipidemia. Primary prevention by educating the public about the effects of smoking, unhealthy dietary habits, and sedentary lifestyle in early years of life may help to prevent the development of cardiac problems later in life. This will result in decreasing the burden from the already thinly stretched health-care system in our country.

Ethical approval

This study was approved by Institutional Ethics Committee via letter MGMC&H/IEC/JPR/2021 (dated- 27/09/2021).

Authors' contributions

All authors contributed to the study conception, design, material preparation, data collection and analysis. All authors have read and approved the final manuscript.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

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