|Year : 2022 | Volume
| Issue : 3 | Page : 121-127
Analytical study of angiographic profile of acute coronary syndrome and its risk factors among young individuals (≤45 years)
Thulaseedharan Sarojadevi Ashida1, Senthilvelan Thenmozhi2, Subramanian Girija2, Jayaraman Balachander1
1 Department of Cardiology, Sri Manakula Vinayagar Medical College and Hospital, Puducherry, India
2 Department of General Medicine, Sri Manakula Vinayagar Medical College and Hospital, Puducherry, India
|Date of Submission||31-Jul-2022|
|Date of Decision||15-Sep-2022|
|Date of Acceptance||19-Sep-2022|
|Date of Web Publication||14-Dec-2022|
Department of General Medicine, Sri Manakula Vinayagar Medical College and Hospital, Puducherry - 605 107
Source of Support: None, Conflict of Interest: None
Background: Acute coronary syndrome (ACS) in young (≤45 years) patients has devastating social and economic consequences. We present the clinical presentation, coronary angiogram (CAG) findings with particular reference to angiographic severity, treatment, and short-term follow-up.
Methods: This was an ambidirectional cohort study (n = 224) conducted in the department of cardiology of a tertiary care teaching hospital in South India, catering mainly to a predominantly rural population. Patients were identified from “The CATH-lab Registry” and the data were analyzed.
Results: The mean (±standard deviation) age was 39.02 ± 5.6 years, with a male predominance (79.9%). Dyslipidemia (57.6%), smoking (25.9%), and diabetes mellitus (29.9%) emerged as major risk factors. Almost equal proportion of patients presented with ST-segment elevation myocardial infarction (STEMI; 53.12%) and non-ST elevation ACS (46.88%); 30.8% of patients had left ventricular (LV) dysfunction. CAG showed involvement of left anterior descending artery in the majority (66.38%) of patients with single-vessel disease in the STEMI group. Left main coronary artery involvement was seen in 8.9% of patients. Majority (89.7%) of young ACS patients had low syntax score. Risk factors were similar among patients with obstructive and nonobstructive CAD. Almost half (47.7%) of the patients needed revascularization, with 16.9% undergoing coronary artery bypass graft surgery. Only two patients had recurrent ACS, at a mean follow-up of 12 months.
Conclusions: The most important risk factors for young ACS were dyslipidemia, smoking, and diabetes mellitus. LV function was preserved in majority of young ACS patients and short-term prognosis (1 year) was favorable.
Keywords: Angiographic score, coronary angiogram, coronary artery disease, percutaneous coronary intervention, SYNTAX score
|How to cite this article:|
Ashida TS, Thenmozhi S, Girija S, Balachander J. Analytical study of angiographic profile of acute coronary syndrome and its risk factors among young individuals (≤45 years). Heart India 2022;10:121-7
|How to cite this URL:|
Ashida TS, Thenmozhi S, Girija S, Balachander J. Analytical study of angiographic profile of acute coronary syndrome and its risk factors among young individuals (≤45 years). Heart India [serial online] 2022 [cited 2023 Feb 3];10:121-7. Available from: https://www.heartindia.net/text.asp?2022/10/3/121/363538
| Introduction|| |
Coronary artery disease (CAD) has reached epidemic proportions in low- and middle-income countries such as India, affecting the rural population. Indian population is more prone to develop early CAD due to rapid changes in lifestyle and existing conventional risk factors. Analysis of regional differences in cardiovascular (CV) mortality in India shows that age-adjusted CV mortality is higher in the Southern and Eastern Indian states, while it is least in Central Indian states.
Acute coronary syndrome (ACS) affecting young individuals who are bread winners has devastating social and economic consequences, with loss of potential years of life. We assessed the clinical presentation, risk factors, coronary angiographic findings, treatment, and short-term follow-up of young (age ≤45 years) ACS patients.
| Methods|| |
This was an ambidirectional cohort study conducted in the department of cardiology of a 1000-bedded tertiary care teaching hospital in South India, offering curative and preventive services to a predominantly rural population. Young (age ≤45 years) patients with ACS undergoing coronary angiogram (CAG) between the period February 2014 and February 2020, with a minimum follow-up of 1 year, were identified from “The CATH-lab Registry” for ACS (ST-segment elevation myocardial infarction [STEMI] and non-ST elevation ACS [NSTEACS]). The study was approved by the institutional ethics committee. Symptoms at presentation, risk factors (diabetes mellitus, hypertension, dyslipidemia, and smoking), family history of CAD, electrocardiogram findings, cardiac biomarkers, echocardiogram, initial-first contact management, and follow-up details were recorded.
CAG was performed using standard percutaneous technique. A computerized quantitative coronary analytical system for lesion quantification was used to quantify the degree of stenosis. Significant CAD was defined as ≥70% stenosis of luminal diameter in at least one of the major coronary arteries or ≥50% stenosis of left main coronary artery (LMCA).,, CAG findings were categorized as single-vessel disease (SVD), double-vessel disease, or triple-vessel disease based on the major epicardial vessel involvement or LMCA disease. Severity of CAD was quantified as low, intermediate, and high scores, using SYNTAX system.
Data were tabulated using Microsoft Excel 2007 and were analyzed using SPSS (Statistical Package for the Social Sciences, v20, IBM Corp. Armonk, New York, USA). Quantitative data were expressed as mean and standard deviation (SD). Student's t-test was used for comparison of normally distributed values and Mann–Whitney U-test was used for those variables with nonparametric distribution. Qualitative data were expressed as proportions and Chi-square test was used. Spearman's correlation coefficient test was used to detect the association between nonparametric quantitative variables. Pearson's correlation coefficient was used to evaluate the relation of different clinical, echocardiographic, and angiographic variables and their relation angiographic scoring. Logistic regression analysis was used to assess the predictors of risk factors for ACS in young patients. A value of P < 0.05 (test of significance at 5% level) was considered statistically significant.
| Results|| |
A total of 224 patients were analyzed. The baseline clinical characteristics of the patients are given in [Table 1]. Based on the registry (total number of CAG during study period), the prevalence of young ACS on CAG was 10.08% (224/2222). The mean (± SD) age was 39.02 ± 5.6 (majority: 25–40) years, with male preponderance (79.9%). The youngest was a 19-year-old boy presented with acute inferior wall MI and he was diagnosed to have protein C and protein S deficiency. Majority (96.9%) of the patients presented with angina. The common risk factors identified were dyslipidemia (57.6%), diabetes mellitus (29.9%), family history of premature CAD (16.5%), smoking (25.9%), and ethanol use (9.8%). Left ventricular (LV) dysfunction was noted in 30.8% patients at presentation. The distribution of LV dysfunction grade and type of ACS is depicted in [Table 1].
|Table 1: Demographics and risk factors of young acute coronary syndrome based on SYNTAX score|
Click here to view
CAG showed involvement of left anterior descending (LAD) artery in 85.7% (n = 192) and LMCA involvement in 8.9% of patients. On comparing the CAG profile between patients who presented with STEMI and NSTEACS, SVD was common in the STEMI group (66.38%; 79/119). Among patients diagnosed with NSTEACS (n = 105), 52 patients (49.5%) had normal epicardial coronaries on CAG. Majority of the young ACS patients had a low syntax score (89.7%). No significant differences were observed in the syntax scores between the STEMI and NSTEACS groups and across various risk factors [Table 1] and [Figure 1]. Out of 224 patients, 57 (25.5%) had normal coronaries and 34 (59.6%) of them were men.
Based on percentage of stenosis (<70% vs. ≥70%) on CAG, patients were divided into two groups. Male gender was statistically significantly (P = 0.015) associated with CAD [Table 2]. Less than 3 risk factors as contributing factor were observed in 87.5% (98/112) of patients with <70% stenosis and 78.57% (88/112) with >70% stenosis. More than 3 risk factors as contributing factors were seen in 12.5% (14/112) <60% stenosis and 21.4% (24/112) with >70% stenosis, respectively [Table 2] (P > 0.05). Diabetes mellitus (P = 0.001) and family history of CAD (P = 0.006) were contributing factors for early-onset ACS [Table 3].
Treatment was based on angiographic score [Table 3]. Out of 224 patients, 30.8% (n = 69) patients underwent percutaneous coronary intervention (PCI), 16.9% (n = 38) patients underwent coronary artery bypass graft (CABG), while the other patients were initiated on medical management (52.2%; n = 117). The mean follow-up period was 12.63 (maximum: 68) months and 2 (0.9%) patients were admitted for recurrent ACS due to noncompliance to medications. None of the patients had in-hospital or 2-week mortality. Around 164 (73.2%) patients had no significant major adverse cardiovascular events (MACEs) at 1 year of follow-up.
| Discussion|| |
The incidence of CAD has been reported to be 12%–16% among young Indian patients, with more than half of deaths occurring in patients below the age of 50 years. The age limit for young ACS varies from 35 to 55 years. Onset of CAD before 40 years of age is considered as premature CAD. Indians, in particular, are at an increased risk of myocardial infarction (MI) at young age (<40 years) due to industrialization, urbanization and lifestyle related changes called as epidemiological transition.,, Indian data suggest that CV mortality is more in southern states, while stroke is more common in eastern states of India. Hypertension, diabetes mellitus, dyslipidemia, smoking, obesity, sedentary lifestyle, reduced intake of fruits and vegetables, and psychosocial stress have been identified as risk factors. Elevated lipids are attributable to risk for MI. CV disease has attained epidemic proportions in urban population, but unfortunately, the prevalence is rapidly increasing in rural population. The World Health Organization had predicted disability-adjusted life years due to CVD to double in India between 2000 and 2020.,, This should pave way for primary prevention, early screening, detection and treatment should start from age of 20 years and should be initiated at the community level., Promoting a healthy lifestyle can overcome the burden of acute MI in young population. Primary prevention of modifiable risk factors such as smoking, dyslipidemia, and obesity should be aggressively promoted from a young age. Dyslipidemia, diabetes mellitus, and family history of CAD are the most important and significant contributors of ACS in young patients.
This is, to our knowledge, the only study to assess the significance of relationship between conventional risk factors of ACS and angiographically assessed syntax score of ACS. Diabetes mellitus evolved as a contributing factor to young ACS. Clinical profile data on young ACS is sparse from this geographic region of the country. Although our data reflect local rural population, the age distribution was similar to data from elsewhere. Dyspnea was not a major presenting symptom in our study population. Younger patients more likely present with chest pain and less likely to have heart failure. Despite 200 risk factors existing for CAD, majority are treatable and preventable. Dyslipidemia emerged as the major risk factor in the young ACS patients. Epidemiological data from angiographically proven cases of premature CAD (≤40 years) in native Indians suggest hyperlipidemia to be the most prevalent risk factor and 16.5% of our patients had a family history of premature CAD., A positive family history of premature CAD is a very strong and independent predictor of future acute coronary events.
Clustering of traditional CV disease risk factors can increase the risk of clinical CV disease. Our study identified that the sole contributor for onset of young ACS in patients with high SYNTAX score was diabetes mellitus and family history of CAD, operating individually or together. Dyslipidemia often precedes other risk factors and may be a useful target for monitoring and early intervention. There was no statistical correlation between clustering of risk factors and obstructive coronary artery disease in our study.
Acute coronary syndrome type in young patients
Chest pain was the most common presenting symptom. Like SWISS study, in our study, male gender accounts significantly among young patients presented with ACS symptoms. Proportion of STEMI and NSTEACS was almost similar in our study. This was in sharp contrast to Indian data where a higher proportion of young ACS patients were reported to have STEMI at presentation.,
CAG findings in young acute coronary syndrome
We identified significant CAD on CAG in almost 74.5% of young ACS patients, especially those presenting with STEMI (66.38% had SVD) rather than NSTEACS (50% had normal coronaries) [Table 4]. Rest of the patients had an equal proportion of single- and multivessel involvement by CAG. Single-vessel disease was reported to be significantly more common in the STEMI group, while triple-vessel disease was significantly more common in the NSTEMI/UA group based on another study on young ACS from a similar geographic location.
|Table 4: Distribution of vessel involvement in ST elevation myocardial infarction and non-ST elevation acute coronary syndrome|
Click here to view
SYNTAX score was shown to be an independent predictor of the incidence of MACE events in 1 year. Based on SYNTAX group, the risk of MACE events was 8 times increased in high syntax score group. In our study, 89.7% of patients had a low syntax score. There were no significant differences in the syntax scores between the STEMI and NSTE-ACS groups and across various risk factors.
Almost half (47.7%) of our patients needed revascularization (PCI: 30.8%; CABG: 16.9%). Young patients tolerated protocol-based extensive treatment and the outcomes were good. Although myocardial revascularization in young patients is associated with a low procedural risk, temporary work disability after revascularization is relatively common., According to the CRAGS study, though patients <50 years had excellent survival after revascularization, the rate of permanent working disability was high., This is of concern in the Indian context as young patients who are in the prime of their life, ignore their symptoms, and there is a significant delay between first contact and revascularization. Aggressive use of statins as preventive strategy may reduce CAD burden.
Young patients with ACS have been shown to have better long-term outcomes compared to older ACS. At a median follow-up of 3 years, young ACS patients had a lower prevalence of extensive CAD. Survival free from composite endpoint was better in young than in older adult patients. LV ejection fraction was preserved in almost 70% of patients. These factors may predict a better long-term outcome in our study population, provided these young patients follow appropriate risk reduction strategies. Longer follow-up is required to detect any adverse long-term outcome and its correlation with coronary angiography findings at presentation.
Limitations and future directions
This study included only patients with complete demographics due to retrospective nature of patient recruitment. Since the female proportion was 20% and analyzed only those patients reaching the hospital, this prevalence and patient profile may not be generalized to general population and other regions. We could not assess the impact of ACS and revascularization on economic implications. Body mass index could not be assessed.
A longer follow-up study is needed, with specific evaluation of the impact of revascularization and its social and economic consequences in the Indian context. Public health interventions specifically targeting younger patients for risk factor screening, primordial, and primary prevention with emphasis on lifestyle modifications are the need of the hour in our country.
| Conclusions|| |
The main risk factors for young ACS were dyslipidemia, smoking, and type-2 diabetes mellitus. STEMI and NSTEACS had almost equal proportions with preserved LV function in the majority of patients with young ACS. SVD with LAD involvement was the most common lesion and majority of the patients had a low syntax score and 47.7% of patients with young ACS needed revascularization. Short-term prognosis (1 year) is favorable in young patients with ACS.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
Ethics committee approval number: SMVMCH-ECO/AL/34/2020 Approved on 08.06.2020.
TSA: Conceptualization, design, data collection, data supervision, statistical analysis, preparation of manuscript, critical review of final manuscript ST: Conceptualization, design, data collection, data supervision, statistical analysis, preparation of manuscript, critical review of final manuscript SG: Design, data supervision, preparation of manuscript, critical review of final manuscript JB: Conceptualization, Design, data supervision, preparation of manuscript, critical review of final manuscript.
| References|| |
Institute of Medicine (US) Committee on Preventing the Global Epidemic of Cardiovascular Disease: Meeting the Challenges in Developing Countries. In: Fuster V, Kelly BB, editors. Promoting Cardiovascular Health in the Developing World: A Critical Challenge to Achieve Global Health. Washington (DC): National Academies Press (US); 2010.
Prajapati J, Joshi H, Sahoo S, Virpariya K, Parmar M, Shah K. Age-related differences of novel atherosclerotic risk factors and angiographic profile among Gujarati acute coronary syndrome patients. J Clin Diagn Res 2015;9:C05-9.
Gupta R, Guptha S, Sharma KK, Gupta A, Deedwania P. Regional variations in cardiovascular risk factors in India: India heart watch. World J Cardiol 2012;4:112-20.
Iragavarapu T, Radhakrishna T, Babu KJ, Sanghamitra R. Acute coronary syndrome in young – A tertiary care centre experience with reference to coronary angiogram. Pract Cardiovasc Sci 2019;5:18-25. Available from: https://www.j-pcs.org/text.asp?2019/5/1/18/257607
. [Last accessed on 2021 Aug 29, Last updated on 2021 Aug 16].
Alluri AR, Paruchuri B, Shaik M, Kumar GS, Kumar PS. Clinical and angiographic profile of young rural Indian population admitted with acute coronary syndrome in a tertiary care hospital. Int J Contemp Med Res 2021;8:E1-5. Available from: https://www.ijcmr.com/uploads/7 / 7/4/6/77464738/ijcmr_3445_v1.pdf
. [Last accessed on 2021 Aug 29].
Wang X, Wang Z, Li B, Yang P. Prognosis evaluation of universal acute coronary syndrome: The interplay between SYNTAX score and ApoB/ApoA1. BMC Cardiovasc Disord 2020;20:293.
Chow CK, Islam S, Bautista L, Rumboldt Z, Yusufali A, Xie C, et al
. Parental history and myocardial infarction risk across the world: The INTERHEART study. J Am Coll Cardiol 2011;57:619-27.
Schoenenberger AW, Radovanovic D, Stauffer JC, Windecker S, Urban P, Niedermaier G, et al
. Acute coronary syndromes in young patients: Presentation, treatment and outcome. Int J Cardiol 2011;148:300-4.
Das SR. Predicting and preventing myocardial infarction in the young. Diabetes Care 2020;43:1679-80.
Paynter NP, Kiefe CI, Lewis CE, Loria CM, Goff DC, Lloyd-Jones DM. Accumulation of metabolic cardiovascular risk factors in black and white young adults over 20 years. J Am Heart Assoc 2015;4:e001548.
Achari V, Thakur AK. Association of major modifiable risk factors among patients with coronary artery disease – A retrospective analysis. J Assoc Physicians India 2004;52:103-8.
Mohan V, Deepa R, Rani SS, Premalatha G, Chennai Urban Population Study (CUPS No. 5). Prevalence of coronary artery disease and its relationship to lipids in a selected population in South India: The Chennai Urban Population Study (CUPS No. 5). J Am Coll Cardiol 2001;38:682-7.
Goel PK, Bharti BB, Pandey CM, Singh U, Tewari S, Kapoor A, et al
. A tertiary care hospital-based study of conventional risk factors including lipid profile in proven coronary artery disease. Indian Heart J 2003;55:234-40.
Joshi P, Islam S, Pais P, Reddy S, Dorairaj P, Kazmi K, et al
. Risk factors for early myocardial infarction in South Asians compared with individuals in other countries. JAMA 2007;297:286-94.
Deora S, Kumar T, Ramalingam R, Nanjappa Manjunath C. Demographic and angiographic profile in premature cases of acute coronary syndrome: Analysis of 820 young patients from South India. Cardiovasc Diagn Ther 2016;6:193-8.
Jenkins CD, Stanton BA, Savageau JA, Denlinger P, Klein MD. Coronary artery bypass surgery. Physical, psychological, social, and economic outcomes six months later. JAMA 1983;250:782-8.
Gunn J, Kiviniemi T, Biancari F, Kajander O, Mäkikallio T, Eskola M, et al
. Predictors of permanent work disability among ≤50-year-old patients undergoing percutaneous coronary intervention. Scand J Work Environ Health 2015;41:460-6.
Lautamäki A, Gunn JM, Airaksinen KE, Biancari F, Kajander OA, Anttila V, et al.
Permanent work disability in patients ≤50 years old after percutaneous coronary intervention and coronary artery bypass grafting (the CRAGS study). Eur Heart J Qual Care Clin Outcomes 2017;3:101-6.
Wu WY, Berman AN, Biery DW, Blankstein R. Recent trends in acute myocardial infarction among the young. Curr Opin Cardiol 2020;35:524-30.
Revaiah PC, Vemuri KS, Vijayvergiya R, Bahl A, Gupta A, Bootla D, et al
. Epidemiological and clinical profile, management and outcomes of young patients (≤40 years) with acute coronary syndrome: A single tertiary care center study. Indian Heart J 2021;73:295-300.
Tini G, Proietti G, Casenghi M, Colopi M, Bontempi K, Autore C, et al
. Long-term outcome of acute coronary syndromes in young patients. High Blood Press Cardiovasc Prev 2017;24:77-84.
[Table 1], [Table 2], [Table 3], [Table 4]