A surge in prevalence and factors affecting early onset acute coronary syndrome

Acute coronary syndrome (ACS) with early onset of age (especially in <30 years) is an infrequent (up to 0.05 to 0.4%) but serious entity, with modest available data. A rise in incidence has been witnessed, especially in South Asia. The aim was to ascertain the proportion of very young patients (≤35 years) among all adult patients with ACS and important factors associated with it. Patients presenting with ACS during September 2020 to January 2021 were incorporated in this cross-sectional single-center study and were analyzed by age: Group I (20–35 years), Group II (36–45 years), and Group III (＞45 years). Demographic characteristics, angiographic findings, co-morbidities and treatment strategies were recorded. 1314 patients with ACS in the study period were examined. Patients in Group I accounted for 6.2% (81) of the study cohort. Of these, 2.1% (28) were aged 20 to 30 years and 4.03% (53) were aged 30 to 35 years. Analysis of age groups by ACS risk factors revealed that male gender, overweight, smoking, using smokeless tobacco (especially gutka), were significantly higher in Group I. Other conventional risk factors were more prevalent in Group III. In Group 1, anterior wall myocardial infarction, single vessel coronary artery disease (SVCAD) and re-canalized vessels were significantly more frequent. Significantly higher proportion of patients were treated with conservative management alone in Group I. In our crossectional study we report an inclining shift in the frequency of early onset ACS than previously observed. In this recent cohort, ACS in the youngest adult patients was significantly associated with being overweight, smoking, and smokeless tobacco use, especially gutka. Moreover, these patients’ higher rates of SVCAD and re-canalized vessels due to hypercoagulable milieu, could be better responsive to aggressive pharmacologic treatment noted in these young patients.

ACS; Premature CAD; Frequency; Risk factors; Young adult

[1] Santos-Gallego CG, Picatoste B, Badimón JJ. Pathophysiology of acute coronary syndrome. Current Atherosclerosis Reports. 2014; 16: 401.

[2] Roger VL, Go AS, Lloyd-Jones DM, Benjamin EJ, Berry JD, Borden WB, et al. Heart Disease and Stroke Statistics—2012 Update: A Report From the American Heart Association. Circulation. 2012; 125: e2–e220.

[3] Liu Y, Han T, Gao M, Wang J, Liu F, Zhou S, et al. Clinical characteristics and prognosis of acute myocardial infarction in young smokers and non-smokers (≤45 years): a systematic review and meta-analysis. Oncotarget. 2017; 8: 81195–81203.

[4] Wang X, Gao M, Zhou S, Wang J, Liu F, Tian F, et al. Trend in young coronary artery disease in China from 2010 to 2014: a retrospective study of young patients ≤45. BMC Cardiovascular Disorders. 2017; 17: 18.

[5] Chhabra ST, Kaur T, Masson S, Soni RK, Bansal N, Takkar B, et al. Early onset ACS: an age based clinico-epidemiologic and angiographic comparison. Atherosclerosis. 2018; 279: 45–51.

[6] Stoykova J, Dimitrova V, Tasheva I, Dosev L, Zlatareva-Gronkova N, Petrov I. Acute coronary syndrome and thrombophilia in young patients: clinical data, experience. European Heart Journal. 2020; 41: ehaa946–1553.

[7] Cheema FM, Cheema HM, Akram Z. Identification of risk factors of acute coronary syndrome in young patients between 18–40 years of age at a teaching hospital. Pakistan Journal of Medical Sciences. 2020; 36: 821–824.

[8] Lv S, Liu W, Zhou Y, Liu Y, Shi D, Zhao Y, et al. Hyperuricemia and smoking in young adults suspected of coronary artery disease ≤35 years of age: a hospital-based observational study. BMC Cardiovascular Disorders. 2018; 18: 178.

[9] Ference BA, Graham I, Tokgozoglu L, Catapano AL. Impact of Lipids on Cardiovascular Health: JACC Health Promotion Series. Journal of the American College of Cardiology. 2018; 72: 1141–1156.

[10] Park J, Kim DH, Lee H, Hwang I, Yoon YE, Park HE, et al. Mildly Abnormal Lipid Levels, but not High Lipid Variability, are Associated with Increased Risk of Myocardial Infarction and Stroke in “Statin-Naive” Young Population a Nationwide Cohort Study. Circulation Research. 2020; 126: 824–835.

[11] Twig G, Yaniv G, Levine H, Leiba A, Goldberger N, Derazne E, et al. Body-Mass Index in 2.3 Million Adolescents and Cardiovascular Death in Adulthood. New England Journal of Medicine. 2016; 374: 2430–2440.

[12] Batra MK, Rizvi NH, Sial JA, Saghir T, Karim M. Angiographic Characteristics and in Hospital Outcome of Young Patients, Age Up to 40 Versus More Than 40 Years Undergoing Primary Percutaneous Coronary Intervention. Journal of Pakistan Medical Association. 2019; 69: 1308–1312.

[13] Puricel S, Lehner C, Oberhänsli M, Rutz T, Togni M, Stadelmann M, et al. Acute coronary syndrome in patients younger than 30 years–aetiologies, baseline characteristics and long-term clinical outcome. Swiss Medical Weekly. 2013; 143: w13816.

[14] Gotsman I, Lotan C, Mosseri M. Clinical manifestations and outcome of acute myocardial infarction in very young patients. Israel Medical Association Journal. 2003; 5: 633–636.

[15] Agrawal V, Lohiya BV, Sihag BK, Prajapati R. Clinical Profile with Angiographic Correlation in Naïve Acute Coronary Syndrome. Journal of Clinical and Diagnostic Research. 2016; 10: OC10–OC14.

[16] WHO. Global Database on Body Mass Index. Available at: https://www.euro.who.int/en/health-topics/disease-prevention/nutrition/a-healthy-lifestyle/body-mass-index-bmi (Accessed: 22 January 2021).

[17] Tsai WC, Wu KY, Lin GM, Chen SJ, Lin WS, Yang SP, et al. Clinical characteristics of patients less than forty years old with coronary artery disease in Taiwan: a cross-sectional study. Acta Cardiologica Sinica. 2017; 33: 233.

[18] Choudhury L, Marsh JD. Myocardial infarction in young patients. American Journal of Medicine. 1999; 107: 254–261.

[19] Biery DW, Berman AN, Singh A, Divakaran S, DeFilippis EM, Collins BL, et al. Association of Smoking Cessation and Survival among Young Adults with Myocardial Infarction in the Partners YOUNG-MI Registry. JAMA Network Open. 2020; 3: e209649.

[20] El-Menyar A, Zubaid M, Shehab A, Bulbanat B, Albustani N, Alenezi F, et al. Prevalence and impact of cardiovascular risk factors among patients presenting with acute coronary syndrome in the middle East. Clinical Cardiology. 2011; 34: 51–58.

[21] Franklin SS. The importance of diastolic blood pressure in predicting cardiovascular risk. Journal of the American Society of Hypertension. 2007; 1: 82–93.

[22] Soeiro ADM, Fernandes FL, Soeiro MCFDA, Serrano CV, Oliveira MTD. Clinical characteristics and long-term progression of young patients with acute coronary syndrome in Brazil. Einstein. 2015; 13: 370–375.

[23] Iragavarapu T, Radhakrishna T, Babu K, Sanghamitra R. Acute coronary syndrome in young—a tertiary care centre experience with reference to coronary angiogram. Journal of the Practice of Cardiovascular Sciences. 2019; 5: 18.

[24] Maroszyńska-Dmoch EM, Wożakowska-Kapłon B. Clinical and angio-graphic characteristics of coronary artery disease in young adults: a single centre study. Kardiologia Polska. 2015; 74: 314–321.

[25] Niccoli G, Scalone G, Crea F. Acute myocardial infarction with no obstructive coronary atherosclerosis: mechanisms and management. European Heart Journal. 2015; 36: 475–481.