|Year : 2021 | Volume
| Issue : 3 | Page : 225-229
Clinical and angiographic profile of acute coronary syndrome patients (<40 years) and short-term prognosis: A cross-sectional study
Nivargi Varun1, Jadhav Ajitkumar2
1 Consultant, Interventional Cardiologist, Joshi Hospital, Pune, Maharashtra, India
2 Department of Cardiology, Dr. DY Patil Medical College Hospital and Research Centre, Pune, Maharashtra, India
|Date of Submission||07-Sep-2021|
|Date of Decision||15-Nov-2021|
|Date of Acceptance||20-Nov-2021|
|Date of Web Publication||14-Dec-2021|
Dr. DY Patil Medical College Hospital and Research Centre, Pune, Maharashtra
Source of Support: None, Conflict of Interest: None
Background: The rapidly changing economic stature and lifestyle choices of young individuals have affected healthcare in India. An increased prevalence of acute coronary syndrome (ACS) in young individuals has been observed. Aims and Objectives: The present cross-sectional, observational study was designed to record the clinical and angiographic profiles of young individuals (<40 years) with ACS. Materials and Methods: This cross-sectional, observational study was also designed to analyze the associations of lifestyle risk factors such as obesity, smoking, and alcohol on the occurrence of ACS and short-term (1 month) prognosis (rehospitalization and mortality). The inclusion criteria were age between 18 and 40 years with angina pectoris or equivalent at presentation and later diagnosed ACS per the consensus paper from the European Society of Cardiology/American College of Cardiology/American Heart Association/World Heart Federation joint task force. Patients with a previous history of ACS/coronary revascularization, atypical chest pain, valvular heart disease, hypertrophic cardiomyopathy, and/or congenital heart disease were excluded. Results: Out of the 403 patients that were screened, 162 young patients (18–40 years, mean ± standard deviation: 31.5 ± 4.64) were enrolled from a single tertiary cardiac care center located at Pune, Maharashtra, from May 2014 to May 2016. Most of the patient population were males (n [%]:151 [93.2]) of which 50% had positive addiction status for alcohol and smoking, family history of coronary artery disease (CAD) and a quarter of the patients had comorbidities of diabetes mellitus, hypertension, and/or abnormal lipid profile. The majority of the young ACS patients had ST-elevated myocardial infarction (STEMI: 87%), wherein anterior wall myocardial infarction was the most common electrocardiogram presentation, and primary angioplasty in myocardial infarction (PAMI) was the preferred modality of treatment in most of the young patients (61.7% vs. 38.3% thrombolysis). Conclusion: The prevalent angiographic profile of this study participants included obstructive CAD, single vessel disease, left ventricular ejection fraction (LVEF) <45, Angina Class IV, New York Heart Association (NYHA) class I, and Killip class I. Low LVEF, NYHA class IV, and Killip class IV showed association with short-term outcomes (mortality). The present study adds to the pool of information related to the western Indian population. However, a larger cohort study with a long-term follow is warranted to analyze the detailed ACS progression status in young individuals.
Keywords: 40 years, acute coronary syndrome, angina, angiographic profile, Killip, prognosis
|How to cite this article:|
Varun N, Ajitkumar J. Clinical and angiographic profile of acute coronary syndrome patients (<40 years) and short-term prognosis: A cross-sectional study. J Pract Cardiovasc Sci 2021;7:225-9
|How to cite this URL:|
Varun N, Ajitkumar J. Clinical and angiographic profile of acute coronary syndrome patients (<40 years) and short-term prognosis: A cross-sectional study. J Pract Cardiovasc Sci [serial online] 2021 [cited 2022 Jan 17];7:225-9. Available from: https://www.j-pcs.org/text.asp?2021/7/3/225/332493
| Introduction|| |
Atherosclerosis is no longer considered a disease of the developed world. Coronary artery disease (CAD) is growing more common worldwide, affecting people from all socioeconomic backgrounds. Cardiovascular mortality will certainly surpass that of every other disease group, including infection, cancer, and trauma, by 2025 on a global scale., Because CAD is so common in middle-aged and elderly patients, detailed studies are warranted related to the clinical presentation, therapy, angiographic profile, and outcome specifically in young patients (under 40 years old) with the acute coronary syndrome (ACS). According to the World Health Organization, Indians have a greater prevalence of risk factors such as diabetes mellitus and hypertension than western countries as well as early onset of CAD. This early onset of CAD among young Indians may be attributed to recent economic improvement, lifestyle changes, and an increase in the prevalence of smoking. Therefore, this observational study was designed for a detailed evaluation of risk factors, clinical and angiographic profiles of young patients with ACS. In addition, a short-term prognosis (30 days) was also recorded.
| Materials and Methods|| |
This cross-sectional, observational study was carried out at a single tertiary cardiac care center located at Pune, Maharashtra, from May 2014 to May 2016. The participants who were willing to provide consent for this research were enrolled in the study based on the inclusion criteria of age between 18 and 40 years with angina pectoris or equivalent at presentation and later diagnosed ACS under the consensus paper from the European Society of Cardiology/American College of Cardiology/American Heart Association/World Heart Federation joint task force.
Patients with a history of ACS/coronary revascularization, atypical chest pain, valvular heart disease, hypertrophic cardiomyopathy, and/or congenital heart disease were excluded from the study. Pregnant and lactating women were also excluded from the study.
The primary endpoint of this study was to evaluate the clinical and angiographic profile of young ACS patients. The secondary endpoint was to record the short-term mortality and factors affecting the same.
The study parameters recorded at presentation/during hospitalization/postdischarge included:
- Demographic parameters: age, gender, addiction (smoking and/or drinking) status, comorbidities, presenting symptoms
- Biochemical parameters: lipid profile, homocysteine, and high-sensitivity C-reactive protein (hs-CRP) levels
- Investigations: 12-lead electrocardiogram (ECG) findings, cardiac enzymes, type of ACS, coronary evaluation (Angiography), pre and postprocedure left ventricular ejection fraction (LVEF), thrombolysis in myocardial Infarction (TIMI) flow and outcomes
- Treatment and medications received
- In-hospital outcome and short-term prognosis after 1 month.
The Independent Ethics Committee approved the protocol. The study was conducted per the ethical principles in the Declaration of Helsinki, consistent Good Clinical Practices, and applicable regulatory requirements. All patients or their legally acceptable representatives provided written informed consent to participate in the study.
Qualitative variables are expressed as frequency and percentage (%) while quantitative variables are reported as descriptive statistics (mean/standard deviation [SD]). Chi-square test/Fisher's exact test was used to find the association between outcome with associated diseases, risk factors, laboratory parameters, treatment given, type of ACS, number, and name of vessel involved. Paired t-test was performed to find the significance of ejection fraction on admission and at discharge. Two independent sample t-test was used to find the significance between TIMI flow concerning the outcome. P < 0.05 is considered significant. Data analysis was performed using the Statistical Package for the Social Sciences version 20.
| Results|| |
Out of the 403 participants that were screened during study tenure, 162 young patients with ACS were enrolled according to the study criteria.
The youngest patient in our study was 18 years old, while maximum patients belonged to the age group of 31–35 years (n [%] = 72 [44.4%]). Approximately 42% of our patients reported having a body mass index of more than 25 kg/m2 [Table 1].
The study patients showed abnormal lipid profile namely elevated levels of total cholesterol (n % = 20.4%, >220 mg/dl), low density lipoprotein cholesterol (LDL-C) (n % = 43.2%, >130 mg/dl), and triglycerides (n % = 19.8%, >180 mg/dl). The high-density lipoprotein cholesterol (HDL-C) levels were low, <35% in 66.7% patients with ACS [Table 2]. Majority of the young patients with ACS had hs-CRP levels more than 0.7 mg/dl (90.7%). High serum homocysteine levels >15 micromol/l was found in 34% patients.
The angiographic profile of the patients is depicted in [Table 3]. Anterior wall myocardial infarction (AWMI) was the most common ECG presentation and was found to be associated with short-term prognosis outcome, i.e., mortality. The majority of the young ACS patients had ST- elevated myocardial infarction (STEMI: 87%), and cardiogenic shock was common in these patients. Intra-aortic balloon pump (IABP) insertion for cardiogenic shock was associated with a poor outcome. Primary angioplasty in myocardial infarction (PAMI) was the preferred modality of treatment in most of the young patients (61.7% vs. 38.3% thrombolysis). The number of patients with single-, double- and triple vessel disease was 82.1%, 14.2%, and 3.1%, respectively. Left anterior descending (LAD) artery was the most frequently involved coronary in young ACS patients (79.6% vs. right coronary artery: 26.5 vs. left circumflex artery: 13.6%). None of the patients had left main CAD.
The LVEF levels postprocedure increased significantly in all the patients (mean ± SD, preprocedure: 42.2 ± 4.4 vs. postprocedure: 51.4 ± 4.5, P < 0.001).
Short-term mortality outcomes
At the end of 1-month follow-up, three deaths and four re-admissions were reported. The study risk factors did not show a strong association with 1-month mortality. Higher New York Heart Association (NYHA) and Killip class (Class IV) were associated with greater mortality while angiographic TIMI 3 score was associated with a better survival outcome. Few complications related to the ACS event were reported. Overall, the short-term prognosis (1 month) was good with very few mortalities and readmissions.
| Discussion|| |
In the present study, most of the young population with ACS presented with chest pain (angina class IV) and belonged to NYHA class I and Killip class I. An earlier study reported young individuals seldom present with the symptoms of stable angina. In concordance to existing literature, in the current study, most of the time, the presenting symptom was ACS and if untreated it resulted in MI, more specifically STEMI.
In the present study, the population primarily consisted of males. Although the sample size was small and thereby it might not be representative of the entire population, this finding is in line with previously reported studies.,,, Therefore, factors like reporting bias between genders and the protective effect of estrogens in females should also be considered. In addition, it can be postulated that the high prevalence of risk factors such as smoking (46.9%) and/or alcohol addiction in males as compared with the female might have led to a higher risk of atherosclerosis and thereafter ACS. One of the studies reported male preponderance with 82% prevalence of smoking of which 78% were between the age range of 18 and 34 years.
Half of the current study population had a positive family history of CAD. This finding is consistent with previous reports that state a higher frequency of positive family history is found in young CAD patients as compared with middle-aged or elderly patients.,,,
The INTERHEART study even reported parental CAD as a strong predictor of MI in offspring. In addition, highlights the role of genetic factors, environment, type 2 diabetes mellitus, hypertension, and obesity toward increased cardiovascular risk.,
Diabetes mellitus and hypertension are well-established risk factors of ACS, and a quarter of the current study population had a history of diabetes and hypertension. Many studies report the prevalence of hypertension ranging from 10% to 44% but that of diabetes to be <10%.,,,, In contrast to the present study, a study from Central India reports a lower frequency of hypertension (12.2%) and diabetes mellitus (2.4%).
Interestingly, a study from central India reports one-third of the patients to be obese like that of a study from north India., However, the current study had only a 2% obese population but a 46% of overweight young ACS patients. The atherogenic lipid profile like elevated levels of LDL-C and triglycerides and low levels of HDL-C observed in the present study are in concordance with previously reported data, which are known to be major risk contributors to ACS in young individuals.,,, Clustering of the risk factors, namely smoking obesity, dyslipidemia, diabetes/hypertension, and positive family history are predominant in the current young patients with CAD.
The study participants had a mean LVEF of 42 which in young ACS patients is considered as moderate LV dysfunction (LVEF range: 37%–55%). However, whether the adaptive enlargement is due to atherosclerotic plaque formation or due to other reasons cannot be made clear as IVUS was not employed in the present study. These ACS patients had a predominant rate of AWMI majorly corresponding to LAD region as reported earlier. A majority of the patients had the single-vessel disease (82.1%) with STEMI (87%). This pattern is congruent with studies reported in various regions in India as well as the CASS study.,, However, a central India study reported multivessel involvement as a predominant angiographic profile in the young CAD population.
The ACS patients in this study preferred PAMI (61.7%) as a treatment modality. Higher NYHA and Killip class were associated with short-term mortality outcomes. The single, tertiary study center was equipped with latest equipment and recent practices in the management of ACS and related complications were employed. In this study, complications related to MI management such as cardiogenic shock, IABP complications, ventricular septal rupture, and ventricular aneurysms have been extensively studied. Interestingly, the current study had a mix population of urban and rural population as opposed to most studies that have either of the population reported at a time with comparable outcomes. Furthermore, we performed a subgroup analysis of 67 very young patients, i.e., below 30 years of age (and their angiographic profile was not statistically different from those below 40 in our study population. In addition, these study results are comparable to recent studies investigating very young ACS patients. Therefore, our study would be the first one to postulate no growing prevalence of ACS in very young patients. However, a larger cohort study with a long-term follow might be useful to analyze the ACS status in young individuals.
The angiographic and clinical profiles have been extensively studied in the past decade. This study not only contributes to the pool of information but also describes advances in coronary imaging and physiology, management of PCI complications with the latest interventional strategies such as IABP and treatment of cardiogenic shock.
| Conclusion|| |
Male gender, smoking and/or alcohol addiction, dyslipidemia, family history of heart disease, and prevalent risk factors, namely diabetes mellitus and hypertension are the clinical profile identified in the young study patients with ACS. AWMI with STEMI and LAD as culprit arteries were the prevalent angiographic profile in young ACS patients observed in this study.
Ethical approval and patient consent
Poona Medical Research Foundation's Institutional Ethics Committee approval dated 9 May 2014. The study was conducted under the ethical principles in the Declaration of Helsinki, consistent Good Clinical Practices, and applicable regulatory requirements. All patients or their legally acceptable representatives provided written informed consent to participate in the study.
Authors thank Ms. Poonam Pawar for writing and editorial support.
Ethical clearance was taken from Institutional Ethics Committee which was constituted as per ICH- GCP, Schedule Y and ICMR guidelines.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Table 1], [Table 2], [Table 3]