Tabriz University of Medical Sciences

Original Article

Risk factors, Clinical manifestations and Outcome of Acute Myocardial Infarction in Young Patients
AzinAlizadehasl MD1*, Farnaz Sepasi MS1, Mehrnoosh Toufan MD1
1. Dept. of Cardiology, Cardiovascular Research Center, Tabriz University of Medical Sciences, Tabriz, Iran.

(Received 9 Dec 2009; Accepted 21 Feb 2010)

Abstract
Background: Acute myocardical infarction (AMI) in young patients has different characteristics from that in older. The purpose of the present study was to assess the risk factors, presenting symptoms, features of coronary angiographic (CAG) and echocardiographic findings, complications and in-hospital mortality of young patients with AMI in a referred teaching heart center compared with those of older patients. Methods: A descriptive-analytic study was conducted involving 100 young (35 years and below) and 100 older (over 35years) patients with clinical diagnosis of AMI. The differences in the risk factors, clinical characteristics and CAG and echocardiographic findings were analyzed between the two groups between January 2000 and September 2009. Results: Compared with the older patients, the risk factor of positive family history was more frequently found among the young patients. Hypertension and diabetes mellitus were more prevalent risk factors in non-young patients. Smoking and Dyslipidemia (DLP) were prevalent risk factors in the both. In the young patients low-density lipoprotein cholesterol (LDLC), the levels of erythrocyte sedimentation rate (ESR), and white blood cell (WBC) count were significantly higher, while lower high-density lipoprotein cholesterol (HDL-C) and higher BUN were found in the elderly patients. Echocardiographic findings showed lower LVEF in older patients. Angiography identified higher incidence of no-vessel or one-vessel disease in the young patients (43.8% vs 30.1%). Young patients with AMI had lower morbidity rate than older patients with the same mortality. Conclusion: Positive family history is the major risk factor rather than smoking and dislipedemia for AMI among individuals below the age of thirty five, who often have milder coronary artery stenosis than elderly patients. Alcoholism as a social habit is more highlightedly prevalent in the young adult MI. Young patients seem to have lower morbidity, with the same mortality. J Cardiovasc Thorac Res 2010; Vol.2 (1): 29-34

Keywords: Acute Myocardial Infarction (AMI) Young Adults Risk Factors Clinical Manifestations Outcome

*Corresponding Author: Azin Alizadehasl MD, Department of Cardiology, Madani Heart Hospital, Tabriz University of Medical Sciences, Tabriz, Iran. Tel: +98 411 - 3363880 Fax: +98 411 - 3344021 E-mail:alizadeasl@yahoo.com

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Introduction
Young adults are a relatively small portion of those having acute myocardial infarction (AMI). Previous studies have estimated that young patients of less than 40 years old make up between 2% and 6% of all AMI 1-3. AMI in young patients has different characteristics from that in older. In the presence or absence of atherosclerosis, young adults can experience a myocardial infarction. Notably, young patients are at increased risk to be misdiagnosed since they do not frequently have traditional coronary risk factors 4. Coronary angiography (CAG) performed in young patients with acute myocardial infarction has identified a relatively high incidence of normal coronary arteries, nonobstructive stenosis or single-vessel disease 1,8,5. Risk factor analysis in young AMI patients has revealed a high prevalence of current smoking, hyperlipidemia and family history 6,7. There are few data regarding acute coronary syndrome (ACS) in young adults. We sought to evaluate the risk factors, clinical manifestations, laboratory findings, features of coronary angiographic (CAG) and echocardiographic findings, complications and inhospital outcomes of young patients with AMI in Madani heart center of Tabriz University compared with those of older patients.

Methods
100 young (35 years and below) and 100 elderly (over 35 years) patients with a diagnosis of AMI admitted to Madani Heart Center of Tabriz University of medical sciences between January 2000 and Septamber 2009 were included in this study. A diagnosis of AMI was based on three criteria consistent with AMI: chest pain, electrocardiographic changes, and typical timerelated pattern of elevated cardiac enzymes (CKMB). Only patients with these criteria were included in the study. All patients were evaluated for risk factors, clinical manifestations, laboratory findings, echocardiographic and angiographic findings, outcome and in-hospital mortality. We retrospectively compared the risk factors, clinical manifestations, laboratory findings, features of

coronary angiographic (CAG) and echocardiographic findings, complications and inhospital outcomes and mortality of young patients with AMI in the young group and the non-young group. The patients demographic information, cardiovascular history and risk factors (ie, smoking, alcoholism, obesity, dyslipidemia, hypertension, diabetes mellitus, and family history) were recorded. Dyslipidemia was defined as total cholesterol greater than or equal to 220 mg/dl or triglyceride greater than or equal to 250 mg/dl; hypertension was defined as systemic blood pressure 140/90 mmHg or a history of previous treatment; diabetes mellitus was defined as fasting blood sugar 126 mg/dl or the use of specific treatment. A family history of coronary artery disease in siblings, parents, parents siblings or grandparents (males younger than 55 and females younger than 65 years of age) was registered. Clinical manifestations included: chest pain, nausea, vomiting, sweating, dyspnea and loss of consciousness, symptoms by which the patient presented. EKG changes, laboratory findings and ischemic biomarkers were all compared within the two groups. Echocardiography and Coronary Arterio Graphy (CAG) were performed using the standard technique for all the patients. Significant coronary artery stenosis was defined as at least a 75% reduction in the internal diameter of the right, left anterior descending or left circumflex coronary arteries and their major branches, or a 50% reduction in the internal diameter of the left main trunk. Based on CAG results, there were recommendations including: medical follow-up, PerCutaneus Intervention (PCI) and Coronary Artery Bypass Graft (CABG). In addition, we evaluated the in-hospital outcome of these patients, which included symptom-free discharge from hospital, post MI arrhythmia, post MI angina, cardiogenic shock and in-hospital mortality. Statistical analysis: Data are expressed as meanSD and frequencies are defined as percentages (%). The young and nonyoung groups were compared using the chi-square test and unpaired Students t-test according to standard statistical methods using SPSS for windows statistical software v.16 (SPSS Inc.

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Chicago,IL, USA) . In all analyses, significance was accepted at p<0.05.

Results
The mean age of patients was 31 4.5 years for young group and 547.5 yrs for non-young group (p< 0.001). The clinical characteristics and risk factors in the young and the non-young patients with AMI are summarized in Table 1.
Table 1- Clinical Characteristics of the Study Patients Young group Non-young group p value n=100 n=100 Age (mean yearsSD) Men Smoking Dyslipidemia Alcoholism Hypertension Diabetes mellitus Family history 314.5 91 66 20 18 14 5 36 547.5 81 55 29 2 41 30 13 <0.001 <0.05 0.148 0.188 <0.001 <0.001 <0.001 <0.001

Ninety one percent of young and 81% of non-young group were male. There was a significantly higher prevalence of positive family history among the young patients. In contrast, hypertension and diabetes mellitus were risk factors that were more frequent among the non-young patients. Our observation also supports the prevalent alcohol consumption in young adult coronary heart disease. Smoking and Dyslipidemia (DLP) were also prevalent risk factors in the both groups. No difference was observed in obesity, drug history including: opiate, oral contraception and steroid usage, chemotherapy and radiotherapy history, presenting symptoms among the study groups. Mean values of Creatine Phosphokinase (CPK), Creatine Kinase-MB (CK-MB), Lactate DeHydrogenase (LDH), cardiac Troponin I (cTnI), Hemoglobin (Hb), Triglyceride (TG) were statistically insignificant between young and nonyoung groups. Low-Density Lipoprotein Cholesterol (LDL-C), the levels of Erythrocyte Sedimentation Rate (ESR) and White Blood Cell (WBC) count were significantly higher in the young patients(P< 0.05), specially monocytes.

In contrast, lower High-Density Lipoprotein Cholesterol (HDL-C) and Higher BUN were found in the elderly patients than in the young patients (31.88 9.25 vs 37.5311.43 and 20.0212.16 vs 16.118.67 mg/ dl, respectively; P< 0.001 and P=0.01). Anterior and Inferior MI were more frequent in both groups; forty five percent of young group and fifty five percent of non-young group with AMI indicated Ant MI while fifty two percent of young group and forty eight percent of non-young group with AMI indicated Inf MI. Our study revealed no correlation between the MI site and Right Ventricular MI (RVMI). Analysis showed significant differences between the frequency of ABO blood groups and AMI. AMI was common among A, O, B and AB blood groups, respectively in both groups. Echocardiographic data suggested lower LVEF in elderly patients compared with the younger patients(4010 vs 4510 %; P=0.011). Ninety two percent and eighty two percent of young group and non-young group respectively had no Mitral Regorgitation(MR) or mild MR, while six percent of young group and fourteen percent of nonyoung group presented moderate or severe MR (P =0.010). CAG was performed in 73 of all young patients (73%) and 80 of all non-young patients (80%). Normal Coronary Artery (NCA) or single-vessel disease were observed in 74 and 52.6% of young and non-young group, respectively. Two and three vessel diseases were observed in 16.4% vs 22.5% and 9.6% vs 25% in young and non-young groups, respectively(P values<0.05 ). Overally, angiography identified higher incidence of no-vessel or one-vessel disease in the young patients (43.8% vs 30.1%), but the incidence of onevessel disease, three-vessel diseases and two-vessel was more frequent in the elderly patients, respectively (46.2% vs 30.1%, 25% vs 9.5%, and 22.6% vs16.4%), most commonly compromising the left anterior descending (LAD) coronary artery in both groups. In both groups of study RCA and then LCX lesions after LAD lesions were most commonly compromising in angiographic data. All the CAG data are indicated in Table2.

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Table 2 -Angiographic Findings of the Study Patients

Young group, n=100 Non-young group, n=100 p value

Discussion
NS 0.001 0.021 0.004 0.005 0.07 0.0001 <0.05 NS 0.0001

CAG (%) Culprit lesions None (%) RCA (%) LAD (%) LCX (%) LMT (%) No. of diseased vessels 0 (%) 1 (%) 2 (%) 3 (%)

73 (73) 32(43.8) 22 (30.1) 32 (43.8) 12 (16.4) 1 (1.4) 32(43.8) 22(30.1) 12 (16.4) 7 (9.6)

80 (80) 5 (6.3) 39 (48.8) 61 (76.3) 29(36.3) 4 (5) 5 (6.3) 37 (46.3) 18 (22.5) 20 (25)

CAG, coronary angiography; RCA, right coronary artery; LAD, left anterior descending coronary artery; LCX, left circumflex coronary artery; LMT, left main trunk;

Based on CAG results, there were recommendations including: Medical Follow Up (MFU), PerCutaneus Intervention (PCI) and Coronary Artery Bypass Graft (CABG). Higher Medical Follows Up (MFU) among individuals below the age of thirty five was recommended while higher percutaneous coronary intervention (PCI) was performed in the elderly patients (47.9 vs 69.1%). PCI and CABG (39.7 vs 12.3%) respectively were the second and third Recommendations in young patients while CABG and MFU (18.5 vs 11.1%) respectively were the second and third Recommendations in elderly patients (P-values< 0.05). In addition, we evaluated the prognosis and in-hospital outcome of these patients, which included symptom-free discharge from hospital, post MI arrhythmia, post MI angina, cardiogenic shock and in-hospital mortality. (Table 3). In-hospital mortality occurred in 7(7%) and 8(8%) of below and over 35 years old patients, respectively.
Table 3- In-hospital outcome Young group, n=100 Post MI arrythmia Post MI angina Cardigenic shock In-hospital mortality NS= Non-Significant 3 2 2 7 Non-young group, n=100 5 4 4 8 p value NS NS NS NS

AMI is defined as rapid myocardial necrosis due to supply/demand mismatch. Acute myocardial infarction is a potentially dangerous syndrome caused by acute obstruction of coronary flow. Narrowing of the coronary artery lumen due to atherosclerosis and subsequent rupture of an unstable plaque with thrombosis causes acute obstruction and infarction 10. In the presence or absence of atherosclerosis, young adults can experience a myocardial infarction. Notably, young patients are at increased risk to be misdiagnosed since they do not frequently have traditional coronary risk factors. Classical risk factors for athero-sclerosis and the subsequent development of IHD are well known and include hypercholesterolemia, hypertension, smoking, diabetes mellitus, and a positive family history. This is the classical profile of older patients suffering a myocardial infarct. Younger patients who develop myocardial infarction have a completely different profile. In the presence or absence of atherosclerosis, young adults can experience a myocardial infarction. Notably, young patients are at increased risk to be misdiagnosed since they do not frequently have traditional coronary risk factors 9,11 . Few of these patients have classical risk factors and most are heavy smokers 12,13,14. In the current study compared with the elderly patients, the risk factors of smoking, dyslipidemia and positive family history were more frequently found among the young patients. Our observations also support the prevalent alcohol consumption and emphasis on alcohol cessation to prevent young adult coronary heart disease, while Hypertension and diabetes mellitus were more prevalent in non-young patients. Few studies have systematically analyzed the risk factors of this population of patients. Fornier et all 2 found that in the young patients there was a significantly higher prevalence of smoking and family history. In contrast, hypertension and diabetes mellitus were risk factors that were more frequent among the non-young group. To highlight the mechanism and impact of drug-induced MI with patent coronary arteries among young patients who have relatively few coronary risk factors in

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comparison with older patients, Menyar conducted a review of the literature. In those cases drug-induced coronary spasm was highlighted. CAD was associated with 12 illicit substances in teenagers (i.e., cocaine, marijuana, alcohol, butane, and amphetamine). It is well known that ethanol induces concentration-dependent vasospasm in coronary arteries. CAD, with its consequences in young patients, raises the crucial role of thorough historytaking in young adults because they who smoke still harbor other illicit substances and should be considered a high risk for CAD. In contrast to Menyars study our findings do not support the idea of significant opiate history in the young group, maybe unfortunately because of patients low reliance to health workers 15. According to our laboratory findings in the young patients the levels of erythrocyte sedimentation rate (ESR), lowdensity lipoprotein cholesterol (LDL-C) and white blood cell (WBC) count (leukocytosis) especially monocytosis were significantly higher, while lower high-density lipoprotein cholesterol (HDL-C) and higher BUN were found in the elderly patients. Alizadeasl et al 16 in their study of ABO blood groups relation and AMI indicated that the incidence of ischemic heart disease was higher in subjects of blood group A or its subgroups. Here in both groups of study, AMI was higher among A, then it was common among O, B and AB blood groups, respectively( A>O>B>AB). Men< 35 years and women <45 years have a higher prevalence of non obstructive (<70% stenosis) or single- vessel coronary artery disease (CAD) in contrast to their older counterparts 1,5,8. It is well established that young patients with MI have a higher frequency of angiographically normal coronary arteries than their older counterparts 17. Our study supports these findings, too. As described in our literature above, young adults are characterized by a less extensive coronary disease, mainly as no-vessel or one-vessel form, in comparison to non-young adults (43.8% vs 30.1%). Higher medical follows up among individuals below the age of thirty five was recommended while higher percutaneous coronary intervention (PCI) was performed in the elderly patients. Based on CAG data the second and the third recommendations were PCI and CABG in young

group and CABG and MFU respectively in nonyoung group. Gotsman et al and Bouraoui et al 18,19 determined that outcome and In-hospital complications are the same as in the older adults, but the prognosis seems to be better. However, the long-term prognosis for young adults with AMI is uncertain and a long term follow-up study is needed 18 . In addition, the small sample size of our report is a major limitation and a larger study should be performed to confirm our findings. According to our findings young patients with AMI had a lower morbidity rate than older patients, but had close mortality in the two groups due to lack of sufficient collateral arteries in the young group.

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