|Year : 2020 | Volume
| Issue : 1 | Page : 22-29
Predicting preventive strategies of acute myocardial infarction in young patients in Egypt: An observational analytical study in the form of cross-sectional study
Islam Elsayed Shehata1, Basel Hatem2, Mohamed Wafaei Aboul Enein1, Ahmed Saeid Eldamanhory1
1 Department of Cardiology, Faculty of Medicine, Zagazig University, Zagazig, Egypt
2 Department of Cardiology, National Heart Institute, Cairo, Egypt
|Date of Submission||30-Nov-2019|
|Date of Acceptance||27-Jan-2020|
|Date of Web Publication||20-Apr-2020|
Dr. Islam Elsayed Shehata
Department of Cardiology, Faculty of Medicine, Zagazig University, Zagazig 44519
Source of Support: None, Conflict of Interest: None
Background: In the developing countries, coronary artery disease commonly occurred in younger people and is the main cause of mortality worldwide. Aim: This study aims to identify risk factors and characteristics of acute myocardial infarction (AMI) in young patients. To clarify the risk factors for AMI in young patients and the prevention for it, is very important problem worldwide. Patients and Methods: 650 ST-elevation myocardial infarction (STEMI) patients were included in our study. History taking, clinical examination, electrocardiography, echocardiography, and cardiac enzymes and coronary angiography were done to all patients; demographic data and risk factors including mental stress measured by the Standard Stress Scale, left ventricular (LV) dimensions, LV systolic and diastolic function, and angiographic characteristics were measured. We excluded patients with familial dyslipidemia and Type I diabetes. We classified the patients into two groups according to age: Group I – young – 142 patients <45 years and Group II – old – 508 patients >45 years. Statistical Analysis: Variables were expressed as the mean ± standard deviation. Percentage was used for categorical variables. t-test was used for comparison. Then, the significant univariate predictors were assessed by multivariate linear regression analysis to find the independent predictors for unfavorable outcome. Data analyses were performed with SPSS (version 21.0, Chicago Inc., Chicago, Illinois, USA). Results: Young patients were 142 (21.8%); males were majority between both groups. Smoking (56.3%), addiction (17.6%), mental stress (79.6%), and family history (4.2%) were significantly associated with young age group. Spontaneous coronary dissection (SCAD) (6.3%) and coronary spasm (10.5%) are relatively common cause of young AMI patients. SCAD and spasm has its specific risk factors such as young female and smoking, respectively. Anterior STEMI occurred in 59.1% of young patients and was the most common followed by Inferior STEMI in 31%. 14.8% of young patients presented late after 12 h of onset of symptoms. The multivariate logistic regression for independent predictors of unfavorable outcome showed that hypertension, Type II diabetes mellitus, Killip class, and multiple-vessel disease were significant predictors of unfavorable outcome. Conclusion: The prevalence of STEMI in young patients is increasing due to sedentary and stressful lifestyle and bad habits as smoking and addiction. Young patients have unique risk factor profile. STEMI in young occurred most often in males. Smoking is the most common risk factor. Anterior STEMI is the most common followed by inferior STEMI.
Keywords: Habit, outcome, ST elevation myocardial infarction, young
|How to cite this article:|
Shehata IE, Hatem B, Aboul Enein MW, Eldamanhory AS. Predicting preventive strategies of acute myocardial infarction in young patients in Egypt: An observational analytical study in the form of cross-sectional study. J Indian coll cardiol 2020;10:22-9
|How to cite this URL:|
Shehata IE, Hatem B, Aboul Enein MW, Eldamanhory AS. Predicting preventive strategies of acute myocardial infarction in young patients in Egypt: An observational analytical study in the form of cross-sectional study. J Indian coll cardiol [serial online] 2020 [cited 2020 Dec 6];10:22-9. Available from: https://www.joicc.org/text.asp?2020/10/1/22/282976
| Introduction|| |
Coronary artery disease (CAD) is the main cause of mortality worldwide for men and women. Acute myocardial infarction (AMI) is one of the most common and serious presentations of CAD. AMI mainly occurs in patients older than 45; however, young can suffer myocardial infarction (MI). In the developing countries, CAD affects younger people at greater rates. The term “young” differs from 40 to 55 years of age, 45 years has been suggested as a cut-off for “young” with respect to MI by many authors. Young people who develop MI have peculiar genetic and laboratory characteristics. The pattern of care and prognosis of young with ST elevation myocardial infarction (STEMI) is not well defined. Coronary angiography in young patients with AMI has shown a high incidence of nonobstructive narrowing or single-vessel disease. Coronary angiography remains the clinical gold standard for the diagnosis of CAD.
This study aims to identify risk factors and characteristics of AMI in young patients. To clarify the risk factors for AMI in young patients and the prevention for it, is very important problem worldwide.
| Patients and Methods|| |
This observational analytical study in the form of cross-sectional study conducted on 650 patients including 142 young age patients (<45 years of age) who presented with “AMI” in Zagazig University Hospitals (ZUH) and National Heart Institute between June 2018 and June 2019. The protocol was approved by our ZUH institutional review board, and written consent was taken from the study participants. The patients were divided according to age into 2 groups: Group 1: Included young patients aged <45 years (142 patients), and Group 2: Included old patients aged more than 45 years (508 patients).
All consecutive patients diagnosed with STEMI defined by the European Society of Cardiology (ESC)/American College of Cardiology Foundation were included in the study.
Exclusion criteria include the following: (1) electrocardiography (ECG) suggesting bundle branch block or left ventricular (LV) hypertrophy, (2) electrolyte abnormality, (3) certain conditions influencing ST-segment on ECG (e.g., suspected myocarditis, pericarditis, hypothermia, receiving Amiodarone treatment), (4) patients with inadequate data, (5) familial hypercholesterolemia, and (6) Type I diabetes (because these diseases are independent risk factors of AMI in young patients).
All patients were subjected to thorough history taking focused on age, sex, sedentary lifestyle and obesity. Nonexercise life style has 2 categories: Sedentary behavior, which is defined as sitting, lying down, and expending very little energy, and light-intensity activity as standing, self-care activities, and slow walking, which require low energy expenditure. Overweight is defined as body mass index (BMI) ≥25 kg/m2 and obesity is defined as BMI ≥30 kg/m2. Assessment of other risk factors such as Smoking, addiction to any substance, mental stress and depression. Stress is measured by the standard stress scale., Hypertension (HTN) (defined as systolic blood pressure (SBP) ≥140 and/or diastolic ≥90 mmHg and/or on anti-hypertensive treatment)., Diabetes mellitus (DM) (defined as patients having fasting plasma glucose ≥126 mg/dl and/or postprandial plasma glucose ≥200 mg/dl or a past history of DM and/or taking medication for diabetes). Dyslipidemia (defined as serum cholesterol of ≥200 mg/dl, triglyceride >150 mg/dl, low-density lipoprotein >130 mg/dl, high density lipoprotein-cholesterol (HDL-C) <50 mg/dl for female and <40 mg/dl for male, a total cholesterol/HDL-C value of ≥4.5, known cases of dyslipidemia and/or those on medication for dyslipidemia), positive family history, time of presentation from onset of symptoms, complaining of symptoms before, previous cardiovascular events including coronary, cerebrovascular and peripheral artery disease. Cardiological clinical examination includes blood pressure, heart rate (HR), heart sounds, and murmurs. Routine investigations include (1) ECG: A 12-lead surface ECG was done for each patient on admission and after 1 h with reviewing of STEMI diagnosis according to ESC guidelines[Figure 1], (2) echocardiography: analysis according to recommendations of the American Society of Echocardiography for the presence of resting regional wall motion abnormalities, LV ventricular dimensions, ejection fraction, and valvular lesions, (3) laboratory tests include cardiac enzymes (Creatine kinase [CK], CK-MB, Quantitative Troponin), complete blood count, kidney function test (creatinine and urea), liver function test (aspartate transaminase and alanine transaminase), blood glucose level, and lipid profile, (4) review the reperfusion strategy (thrombolysis or percutaneous coronary intervention), and (5) coronary angiography was done to all patients to detect the angiographic characteristics of the coronary arteries [Figure 2].
|Figure 1: Inferior wall myocardial infarction indicated by ST elevation in Leads II, III, and arteriovenous fistula with reciprocal ST depression in Leads I, aVL|
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|Figure 2: Coronary angiography: Distal right coronary artery total occlusion (Lt. Panel), Successful primary percutaneous coronary angiography (PPCI) to right coronary artery was done with TIMI III flow (Middle and Rt. Panels)|
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Variables were expressed as the mean ± standard deviation. Percentage was used for categorical variables. t-test was used for comparison. Then, the significant univariate predictors were assessed by multivariate linear regression analysis to find the independent predictors for unfavorable outcome. Data analyses were performed with SPSS (version 21.0, Chicago Inc., Chicago, Illinois, USA).
| Results|| |
Demographic data are shown in [Table 1]; of our patients, 142 (21.8%) were young (<45 years) patients. Males were majority between both groups (85.9% in young and 78.3% in old patients), with no significant difference between groups; also, there was no significant difference between groups regarding BMI (26.55 ± 3.09 in young and 26.5 ± 3.62 in old).
Risk factors and medical history are displayed in [Table 2]; DM, HTN, and sedentary life style (16.2% in young vs. 35.2% in old, 13.4% vs. 36.2%, and 28.2% vs. 40.6%, respectively) were significantly associated with >45 years group, while smoking, addiction, mental stress, and family history (56.3% in young vs. 42.7% in old, 17.6% vs. 1.2%, 79.6% vs. 46.5%, and 4.2% vs. 0.4%, respectively) were significantly associated with <45 years group.
Clinical status at presentation is shown in [Table 3] and [Table 4]; there was no significant difference between groups regarding HR, but SBP and “diastolic blood pressure” were significantly higher among >45 years group. Regarding elapsed time from onset of symptoms, there was no statistically significant difference between groups.
GRACE risk score was significantly higher among >45 years group (85.1 ± 25.1 in young vs. 112.2 ± 29.7 in old) [Figure 3].
Site of MI is displayed in [Figure 4] our study showed that anterior STEMI was the most common. There was no significant difference between groups.
Laboratory investigations are shown in [Table 5]; there was no significant difference between both groups. Echocardiographic findings are shown in [Table 6]; mean ejection fraction was 50.23 ± 8.85 in young and 49.34 ± 8.8 in old; diastolic dysfunction and LV hypertrophy were significantly associated with old group. Ventricular septal rupture (VSR) occurred in only 3 patients in old and did not occur in young group.
Angiographic characteristics are shown in [Table 7]; there was no significant difference or association except that old group is significantly associated with multiple-vessel disease. Left anterior descending (LAD) (44.3%) was involved more than right coronary artery (RCA) (22.5%) and left circumflex LCX (17.6%) in young patients in our study; left main artery was affected in about 4.2% of young and about 13.6% of old patients.
|Table 7: Coronary angiographic characteristics distribution between groups|
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Reperfusion strategy is shown in [Figure 5]; there was no significant difference between groups.
Complications are shown in [Table 8]; 1.4% of young and 4.1% of old patients died. Arrhythmia occurred in 2.1% of young and 2% of old, cardiac arrest in 2.1% of young and 1.6% of old, pulmonary edema in 1.4% of young and 1.6% of old, and shock occurred in 3.5% of young and 5.2% of old. Only 3 patients had VSR, and all were older than 45 years.
Regarding medications used in Coronary Care Unit (CCU), all patients in CCU received aspirin, clopidogrel, statin, beta-blocker, angiotensin-converting enzyme inhibitor (ACEI) from the 1st day except patients who were classified as Killip classification II to IV who did not receive beta-blocker and patients with Killip class IV who did not receive ACEI. Other used drugs are shown in [Table 9]; with no significant difference between groups except that glycoprotein IIbIIIa (GPIIbIIIa) inhibitors are significantly associated with the <45 years group. Spontaneous coronary dissection (SCAD) (6.3%) and coronary spasm (10.5%) are relatively significantly higher at young AMI patients. SCAD and spasm has its specific risk factors such as young female and smoking, respectively.
|Table 9: Medications used in patients in coronary care units and distribution in groups|
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The multivariate logistic regression for independent predictors of unfavorable outcome such as major adverse cardiac events including heart failure, arrhythmia, septal perforation, SCAD, and death [Table 10] showed that HTN, Type II DM, Killip class, and multiple-vessel disease were significant predictors of unfavorable outcome.
|Table 10: Multivariate logistic regression for independent predictors of unfavorable outcome|
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| Discussion|| |
Risk factors and characteristics
Data in previous studies indicate that 3%–10% of AMI are young patients >45 years;, but, in our study, young patients represent 21.8% and the youngest was 14 years of age. This increase in the prevalence of MI in young patients can be partly attributed to the increase in the prevalence of risk factors in young. In our study, males were more affected with STEMI (85.9%) in young; this higher prevalence in males may be due to high smoking prevalence in males or due to estrogen protective effect in females. Our results were in consistency with old studies.,, However, it is noted that 14.1% of our young patients were females which is a higher percentage than that in other studies which was between 5% and 10%.
Smoking in young is a major risk factor as it will accelerate atherosclerosis pathological process depending on duration and dose of smoking. Smoking was significantly increased in young (56.3%), and this is in consistency with other studies that reported smoking to be around 46%–61% in young patients with STEMI., Also, addiction was significantly increased in young, and the percentage is increased than that in old studies. Old studies showed that addiction represented about 7% in young patients with STEMI; but, in ours, 17.6% of young compared with only 1.2% of old were addict. Cannabis and tramadol addiction were the most evident, but no one admitted cocaine addiction. The number of drug addict could be higher than that in studies as it depends on patient self-report, and there is a possibility of illicit drug use underreport due to social stigma.
Family history of CAD was found in 4.2% in young, and this was statistically significant association compared to only 0.4% of old patients had family history of CAD. This is consistent with previous studies which showed that positive family history in young patients is a significant risk factor for CAD.
Mental stress was significantly associated with young patients in our study; about 79.6% of young patients had mental stress. Previous studies also reported that mental stress and psychological problems like depression are risk factors of CAD, as it can predispose to adrenergic stimulation which augments myocardial oxygen requirement aggravating myocardial ischemia, also causes coronary vasoconstriction, especially in atherosclerotic coronary arteries; so, it affects myocardial oxygen supply, platelet, and endothelial dysfunction; also, it is associated with increased platelet activation, increased hs-CRP, and decreased heart rate variability.
However, we found that sedentary life style was significantly associated with old age, nearly 40.6% of old patients had sedentary life style compared to 28.2% of young age patients. Sedentary life style as a risk factor for morbidity and mortality of cardiovascular disease was reported in other studies.
Obesity is a major health problem in the world. Obesity is associated with increased vascular risk regardless of physical activity. Earlier studies showed that obesity represented about 20%; and, in our study, it was 16.1% of young patients and 17.4% of old patients which are very approximate.
Dyslipidemia was seen in about 47%–48% in young patients according to old studies,, but our study showed that dyslipidemia was seen in 35.9% of young patients and 35.4% of old patients.
HTN represents up to 38.1% in young patients; this is lower than that in older patients with MI, and prevalence of HTN shows recent increase from 8.86% (2001–2002) to 27.7% (2009–2010)., 13.4% of young patients in our study had HTN, but it was significantly associated with old patients in 36.2% of them. Diabetes represents about 14.7% in young patients, and its prevalence in older patients is much higher.
, 16.2% of young patients in our study had diabetes, but it was significantly associated with old patients in 35.2% of them.
Thus, smoking, addiction, mental stress, and family history are significant risk factors in young patients presented with STEMI, while DM, HTN, and sedentary life style are significant risk factors in old patients.
ST elevation myocardial infarction characteristics
Some studies indicate, as does ours, that anterior STEMI is the most common in young patients,, while others indicate that inferior STEMI is the most common or both has the same frequency. There was no significant difference with the old patients.
Elapsed time from the onset of symptoms to presentation
There was no significant difference with old patients. Some studies showed that young patients were presented with less elapsed time from onset of symptoms than in old patients. This may be due to atypical presentation in old patients and delay in recognizing symptoms. This elapsed time may be affected by individual variations as intermittent coronary artery occlusion or collateral circulation or ischemic preconditioning or ischemic myocardium metabolic status.
Our results were inconsistent with previous studies that showed mean ejection fraction 51.00 ± 13.00 in young group and 48.00 ± 15.00 in old patients. Diastolic dysfunction and LV hypertrophy were significantly associated with old group.
The percentage of patients receiving thrombolysis in young patients in our study was in consistency with that in other studies which was about 32%–59% of young patients., The >45 years group is significantly associated with CABG. These results are similar to old data which indicated that old patients are associated with CABG in increasing numbers.
Coronary angiographic characteristics
Our study showed that there was no significant difference between old and young patients regarding which artery was affected, but the >45 years group is significantly associated with multiple vessels CAD. However, young group showed increased percentage of patients (69.7%) had multivessel disease in contrast to previous studies that showed that young patients were significantly associated with single vessel disease (47%–50%)., This may be attributed to increased prevalence of risk factors and its presence early in life.
LAD (44.3%) was involved more than RCA (22.5%) and LCX (17.6%) in young in our study, and other studies reported the same results. Normal coronaries were found in 4.2% of young which is statistically significant compared with 0.8% of old patients. Old studies reported the same that normal coronaries showed prevalence in young more than old patients.
There was no significant difference between young and old patients regarding complications except in mechanical complication as VSR which were significantly associated with old patients, and SCAD and coronary spasm were more common in young AMI due to female preponderance and smoking prospectively. Our results are in consistency with and not largely different from previous studies.
Medications used in CCU
There was no significant difference between groups regarding the medications used in CCU, except that GPIIbIIIa inhibitors were significantly associated with young patients. This was reported also in other studies. This association may be explained by the choice of more aggressive strategy for anti-ischemic usage in young due to relatively low risk of bleeding and avoidance of these agents in old due to relatively high risk of bleeding.
Only standard risk factors of CAD were identified, and several novel risk factors as fibrinogen, homocysteine, markers of inflammation, and platelet glycoprotein IIIa gene (PIA2) polymorphism were not evaluated.
| Conclusion|| |
Incidence of acute “STEMI” in young patients is increasing due to sedentary and stressful lifestyle and bad habits as smoking and addiction. Young patients have unique risk factor profile. The most prevalent and important risk factors in these patients are smoking, addiction, and hyperlipidemia with less prevalence of HTN and DM. CAD s in young patients tend to be less extensive with single-vessel involvement, especially the LAD artery.
Financial support and sponsorship
The study was performed at Zagazig university hospitals with no funding sources.
Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6], [Table 7], [Table 8], [Table 9], [Table 10]