- Email: [email protected]
Premature myocardial infarction: Clinical profile and angiographic findings
International Journal of Cardiology 126 (2008) 127 – 129 www.elsevier.com/locate/ijcard
Letter to the Editor
Premature myocardial infarction: Clinical profile and angiographic findings Javier Pineda a,⁎, Francisco Marín a , Vanessa Roldán b , José Valencia a , Pascual Marco c , Francisco Sogorb a b
a Department of Cardiology, Hospital General Alicante, Spain Department of Haematology, Hospital Morales Meseguer Murcia, Spain c Department of Haematology, Hospital General Alicante, Spain
Received 21 November 2006; received in revised form 31 January 2007; accepted 17 February 2007 Available online 25 April 2007
Abstract Cardiovascular disease is a major global cause of mortality, and its fundamental underlying substrate is atherosclerosis. Young and old patients have different risk factor profiles, clinical presentations, angiographic findings and prognosis. We performed a retrospective case– control study in a cohort (cases) of premature coronary disease (≤ 45 years, n = 200) compared with consecutive (controls) older patients (> 45 years, n = 200). The proportion of premature coronary disease in our geographic area was 9%. The average age of the case group was 41 and 64 years in controls ( p b 0.001). The male sex, though majority in both groups, was significantly more prevalent in the young group (92.5%) than in the older group (76.0%, p b 0.001). The presence of smoking habit, hyperlipidemia and family history was significantly higher in the case group as well, with smoking habit being the most prevalent risk factor. In contrast, hypertension and diabetes were more frequent in controls. The number of affected vessels in cases was significantly less than the control group (1.4 ± 0.8 vs. 1.7 ± 0.9; p = 0.013). Premature coronary disease affects predominantly the male sex and shows high prevalence of cardiovascular risk factors, mainly tobacco, hyperlipidemia, and family history of ischemic heart disease. In addition, it is characterised by a less extensive coronary atherosclerosis, mainly with the higher presence of single-vessel disease in contrast to older patients, as well as lower initial mortality. © 2007 Elsevier Ireland Ltd. All rights reserved. Keywords: Myocardial infarction; Cardiovascular risk factors; Prognosis; Coronary angiography
Cardiovascular disease is a major global cause of mortality in the developed countries, its fundamental underlying substrate is atherosclerosis [1]. These lesions begin in childhood like fatty streaks and take some decades in progressing to fibrosus plaques, that could complicate by ulceration or rupture with thrombosis superimposed. This is the main pathogenic mechanism of the acute coronary syndrome [2,3]. Epidemiological studies have shown that “major” cardiovascular risk factors are age, male sex, hyperlipidemia, hypertension, smoking habit, diabetes, overweight, sedentary and family history [4–6]. Young and old ⁎ Corresponding author. Department of Cardiology. C/Pintor Baeza s/n. Alicante 03010, Spain. Tel.: +34 965938561; fax: +34 965938269. E-mail address: [email protected] (J. Pineda). 0167-5273/$ - see front matter © 2007 Elsevier Ireland Ltd. All rights reserved. doi:10.1016/j.ijcard.2007.02.038
patients have different risk factor profiles, clinical presentations, and prognosis [7]. In addition, patients with premature coronary disease tend to present less diffuse atherosclerotic lesions [7–10]. Only in recent years has it been recognised the interest of coronary disease at young age that could provide essential information about cardiovascular pathogenesis [8]. We performed a retrospective case–control study in a unique teaching centre since 1999 to 2005. Our objectives were to determine the prevalence, clinic characteristics, the presence of cardiovascular risk factors (sex, current smoker, hyperlipidemia, family history, hypertension and diabetes), as well as coronary angiographic findings, in a cohort (cases) of premature coronary disease (≤45 years, n = 200) compared with consecutive (controls) older patients (N45 years, n = 200), all of them Caucasians. We determined the infarct
128
J. Pineda et al. / International Journal of Cardiology 126 (2008) 127–129
Table 1 Characteristics of premature coronary disease patients (cases) and older (controls) Risk factors
Infarct ≤ 45 years (cases)
Infarct N 45 years (controls)
p
Age Male sex Smoking habit • Current smokers • Smokers • Ex-smokers Hyperlipidemia Family history Hypertension Diabetes No. of vessels
41 (37–44) 92.5%
64 (56–72) 76.0%
b0.001 b0.001
86.1% 8.4% 5.5% 73.5% 41.5% 28.5% 11.5% 1.4 ± 0.8
46.5% 42.0% 11.5% 59.5% 20.9% 49.5% 24.5% 1.7 ± 0.9
b0.001 b0.001 b0.001 0.001 0.001 0.013
localisation in both groups, and the extent of coronary disease severity by angiography (defined as at least 70% of reduction of lumen coronary area) [9]. Finally, cardiovascular mortality in the premature coronary group was analysed, with 36 months follow-up (Table 1). The proportion of premature coronary disease in our geographic area was 9%. The average age of the case group was 41 (interquartil range 37–44) and 64 (56–72) years in controls (p b 0.001). The male sex, though majority in both groups, was significantly more prevalent in the young group (92.5%) than in the older group (76.0%, p b 0.001). The presence of smoking habit, hyperlipidemia and family history was significantly higher in the case group as well, with smoking habit being the most prevalent risk factor. In contrast, hypertension and diabetes were more frequents in controls. Average risk factors (including smoke, hyperlipimedia, hypertension and diabetes) were 2.1 ± 0.8 in cases and 1.8 ± 0.8 in controls (p = 0.027). Regarding infarct localisation, no significant differences were found. The number of affected vessels in cases was significantly less than the control group (1.4 ± 0.8 vs. 1.7 ± 0.9; p = 0.013). The prevalence of multivessel disease was greater in this last group ( p = 0.022). Cardiovascular mortality incidence in a cohort of young patients after 36 months of follow-up was 1.4% (0.47% deaths/year). The prevalence of premature coronary disease in this report was 9.0%, as compared with 2–11% of all hospitalized myocardial infarcts described in the literature [7,9,11–13]. In most recent series, an increase of this incidence [8,11,14], due to earlier exposure to some risk factors, such as smoking habit, hyperlipidemia, stress, and the current use in clinical practice of more sensitive and specific necrosis myocardium biomarkers, like troponins, has been recognised. As confirmed in our study, the premature coronary disease is typically masculine [7–9,11,12]. The most prevalent risk factor in young patients was smoking habit, as in other series [8–12,15,16], and significantly higher than in the control group. Some studies have suggested greater blood thrombogenicity in youngs [7,11,12], with tobacco being one of the major factors associated with occlusive coronary thrombosis on atherome plaques that initially were not particularly
thrombogenic. This demonstrates the importance of the thrombotic phenomenon in this population group with atheromatosis scarcely developed [17]. Cases also showed significantly higher proportion of hyperlipidemia, a risk condition for development of premature coronary disease [7,8,10–14,18,19]. Similarly, family history is a very important risk factor for atherosclerosis in youngs [8–12,19]. However, in agreement with our results, both hypertension and diabetes are less prevalent risk factors in premature infarcts when compared with the elderly [7,8,10–13,15,18,19]. These conditions are more likely to appear in the ageing process. Regarding the extent of coronary atherosclerosis, cases showed a less evolved disease. As described in the literature, this group is characterised by a less extensive coronary disease, mainly as mono-vase form [8–10]. In the comparative series described, young patients have a more favourable outcome compared with older patients, due to better response to fibrinolytic treatment, less presence of some associated atherogenic and comorbid factors, such as hypertension and diabetes, a lower rate of cardiovascular complications and less extensive atherogenic disease [7,9,11,12,15,16,19]. Cardiovascular mortality incidence in our young group was 1.4%, similar to the GISSI-2 registry (1.2%) [19]. However, in a series with a longer follow-up period, mortality reaches 16% [9] or even 30% [15]. These findings justify the need of an intense and aggressive strategy of primary and second prevention of premature cardiovascular disease [20,21]. In conclusion, premature coronary disease is a more frequent entity than described in initial series. It affects predominantly the male sex and shows high prevalence of cardiovascular risk factors, mainly tobacco, hyperlipidemia, and family history of ischemic heart disease. In addition, it is characterised by a less extensive coronary atherosclerosis, mainly with higher presence of single-vessel disease in contrast to older patients, as well as lower initial mortality. References [1] Fuster V. Mechanism of arterial thrombosis: foundation for therapy. Am Heart J 1998;135:S361–6. [2] Fuster V, Badimon L, Badimon J, et al. The pathogenesis of coronary artery disease and the acute coronary syndromes (part I). N Engl J Med 1992;326:242–50. [3] Davies M. The pathophysiology of acute coronary syndromes. Heart 2000;83:361–6. [4] Castelli WP. Epidemiology of coronary heart disease: the Framingham Study. Am J Med 1984;76:4–12. [5] Neaton JD, Wentworth D. For the Multiple Risk Factor Intervention Trial Research Group: serum cholesterol, blood pressure, cigarette smoking, and death from coronary heart disease. Overall findings and differences by age for 316,099 white men. Arch Intern Med 1992;152: 56–64. [6] WHO: Reducing risks, promoting hearty life. The World Health Report; 2002. [7] Choudhury L, Marsh J. Myocardial infarction in young patients. Am J Med 1999;107:254–61. [8] Kanitz M, Giovannucci S, Jones J, et al. Myocardial infarction in young adults: risk factors and clinical features. J Emerg Med 1996;14: 139–45.
J. Pineda et al. / International Journal of Cardiology 126 (2008) 127–129 [9] Zimmerman F, Cameron A, Fisher L. Myocardial infarction in young adults: angiographic characterization, risk factors and prognosis (Coronary Surgery Study Registry). J Am Coll Cardiol 1995;26: 654–61. [10] Chen L, Chester M, Kaski J. Clinical factors and angiographic features associated with premature coronary artery disease. Chest 1995;108: 364–9. [11] Doughty M, Mehta R, Bruckman D, et al. Acute myocardial infarction in the young. The University of Michigan experience. Am Heart J 2002;143:56–62. [12] Barbash GI, White HD, Modan M, et al. Acute myocardial infarction in the young-the role of smoking. Investigators of the International Tissue Plasminogen Activator/Streptokinase Mortality Trial. Eur Heart J 1995;16:313–6. [13] Fournier JA, Cabezon S, Cayuela A, et al. Long-term prognosis of patients having acute myocardial infarction when ≤40 years of age. Am J Cardiol 2004;94:989–92. [14] Chan MY, Woo KS, Chia BL, et al. Antecedent risk factors and their control in young patients with a first myocardial infarction. Singapore Med J 2006;47:27–30. [15] Cole JH, Miller JI, Sperling LS. Long-term follow-up of coronary artery disease presenting in young adults. J Am Coll Cardiol 2003;41:521–8.
129
[16] Mukherjee D, Hsu A, Moliterno DJ, et al. Risk factors for premature coronary artery disease and determinants of adverse outcomes after revascularization in patients ≤40 years old. Am J Cardiol 2003;92: 1465–7. [17] Virmani R, Kolodgie F, Burke A, et al. Lessons from sudden coronary death. A comprehensive morphological classification scheme for atherosclerotic lesions. Arterioscler Thromb Vasc Biol 2000;20: 1262–75. [18] Genest J, McNamara J, Salem D, et al. Prevalence of risk factors in men with premature coronary artery disease. Am J Cardiol 1991;67: 1185–9. [19] Moccetti T, Malacrida R, Pasotti E, et al. Epidemiologic variables and outcome of 1972 young patients with acute myocardial infarction. Data from the GISSI-2 database. The GISSI investigators. Arch Intern Med 1997;157:865–9. [20] Wood D, De Baker G, Faergeman O, et al. Together with members of the Task Force Prevention of Coronary Heart Disease in Clinical Practice. Recommendations of the Second Joint Task Force of the European Societies on Coronary Prevention. Eur Heart J 1998;19: 1434–503. [21] Lloyd-Jones DM, Leip EP, Larson MG, et al. Prediction of lifetime risk for cardiovascular disease by risk factor burden at 50 years of age. Circulation 2006;113:791–8.
Letter to the Editor
Premature myocardial infarction: Clinical profile and angiographic findings Javier Pineda a,⁎, Francisco Marín a , Vanessa Roldán b , José Valencia a , Pascual Marco c , Francisco Sogorb a b
a Department of Cardiology, Hospital General Alicante, Spain Department of Haematology, Hospital Morales Meseguer Murcia, Spain c Department of Haematology, Hospital General Alicante, Spain
Received 21 November 2006; received in revised form 31 January 2007; accepted 17 February 2007 Available online 25 April 2007
Abstract Cardiovascular disease is a major global cause of mortality, and its fundamental underlying substrate is atherosclerosis. Young and old patients have different risk factor profiles, clinical presentations, angiographic findings and prognosis. We performed a retrospective case– control study in a cohort (cases) of premature coronary disease (≤ 45 years, n = 200) compared with consecutive (controls) older patients (> 45 years, n = 200). The proportion of premature coronary disease in our geographic area was 9%. The average age of the case group was 41 and 64 years in controls ( p b 0.001). The male sex, though majority in both groups, was significantly more prevalent in the young group (92.5%) than in the older group (76.0%, p b 0.001). The presence of smoking habit, hyperlipidemia and family history was significantly higher in the case group as well, with smoking habit being the most prevalent risk factor. In contrast, hypertension and diabetes were more frequent in controls. The number of affected vessels in cases was significantly less than the control group (1.4 ± 0.8 vs. 1.7 ± 0.9; p = 0.013). Premature coronary disease affects predominantly the male sex and shows high prevalence of cardiovascular risk factors, mainly tobacco, hyperlipidemia, and family history of ischemic heart disease. In addition, it is characterised by a less extensive coronary atherosclerosis, mainly with the higher presence of single-vessel disease in contrast to older patients, as well as lower initial mortality. © 2007 Elsevier Ireland Ltd. All rights reserved. Keywords: Myocardial infarction; Cardiovascular risk factors; Prognosis; Coronary angiography
Cardiovascular disease is a major global cause of mortality in the developed countries, its fundamental underlying substrate is atherosclerosis [1]. These lesions begin in childhood like fatty streaks and take some decades in progressing to fibrosus plaques, that could complicate by ulceration or rupture with thrombosis superimposed. This is the main pathogenic mechanism of the acute coronary syndrome [2,3]. Epidemiological studies have shown that “major” cardiovascular risk factors are age, male sex, hyperlipidemia, hypertension, smoking habit, diabetes, overweight, sedentary and family history [4–6]. Young and old ⁎ Corresponding author. Department of Cardiology. C/Pintor Baeza s/n. Alicante 03010, Spain. Tel.: +34 965938561; fax: +34 965938269. E-mail address: [email protected] (J. Pineda). 0167-5273/$ - see front matter © 2007 Elsevier Ireland Ltd. All rights reserved. doi:10.1016/j.ijcard.2007.02.038
patients have different risk factor profiles, clinical presentations, and prognosis [7]. In addition, patients with premature coronary disease tend to present less diffuse atherosclerotic lesions [7–10]. Only in recent years has it been recognised the interest of coronary disease at young age that could provide essential information about cardiovascular pathogenesis [8]. We performed a retrospective case–control study in a unique teaching centre since 1999 to 2005. Our objectives were to determine the prevalence, clinic characteristics, the presence of cardiovascular risk factors (sex, current smoker, hyperlipidemia, family history, hypertension and diabetes), as well as coronary angiographic findings, in a cohort (cases) of premature coronary disease (≤45 years, n = 200) compared with consecutive (controls) older patients (N45 years, n = 200), all of them Caucasians. We determined the infarct
128
J. Pineda et al. / International Journal of Cardiology 126 (2008) 127–129
Table 1 Characteristics of premature coronary disease patients (cases) and older (controls) Risk factors
Infarct ≤ 45 years (cases)
Infarct N 45 years (controls)
p
Age Male sex Smoking habit • Current smokers • Smokers • Ex-smokers Hyperlipidemia Family history Hypertension Diabetes No. of vessels
41 (37–44) 92.5%
64 (56–72) 76.0%
b0.001 b0.001
86.1% 8.4% 5.5% 73.5% 41.5% 28.5% 11.5% 1.4 ± 0.8
46.5% 42.0% 11.5% 59.5% 20.9% 49.5% 24.5% 1.7 ± 0.9
b0.001 b0.001 b0.001 0.001 0.001 0.013
localisation in both groups, and the extent of coronary disease severity by angiography (defined as at least 70% of reduction of lumen coronary area) [9]. Finally, cardiovascular mortality in the premature coronary group was analysed, with 36 months follow-up (Table 1). The proportion of premature coronary disease in our geographic area was 9%. The average age of the case group was 41 (interquartil range 37–44) and 64 (56–72) years in controls (p b 0.001). The male sex, though majority in both groups, was significantly more prevalent in the young group (92.5%) than in the older group (76.0%, p b 0.001). The presence of smoking habit, hyperlipidemia and family history was significantly higher in the case group as well, with smoking habit being the most prevalent risk factor. In contrast, hypertension and diabetes were more frequents in controls. Average risk factors (including smoke, hyperlipimedia, hypertension and diabetes) were 2.1 ± 0.8 in cases and 1.8 ± 0.8 in controls (p = 0.027). Regarding infarct localisation, no significant differences were found. The number of affected vessels in cases was significantly less than the control group (1.4 ± 0.8 vs. 1.7 ± 0.9; p = 0.013). The prevalence of multivessel disease was greater in this last group ( p = 0.022). Cardiovascular mortality incidence in a cohort of young patients after 36 months of follow-up was 1.4% (0.47% deaths/year). The prevalence of premature coronary disease in this report was 9.0%, as compared with 2–11% of all hospitalized myocardial infarcts described in the literature [7,9,11–13]. In most recent series, an increase of this incidence [8,11,14], due to earlier exposure to some risk factors, such as smoking habit, hyperlipidemia, stress, and the current use in clinical practice of more sensitive and specific necrosis myocardium biomarkers, like troponins, has been recognised. As confirmed in our study, the premature coronary disease is typically masculine [7–9,11,12]. The most prevalent risk factor in young patients was smoking habit, as in other series [8–12,15,16], and significantly higher than in the control group. Some studies have suggested greater blood thrombogenicity in youngs [7,11,12], with tobacco being one of the major factors associated with occlusive coronary thrombosis on atherome plaques that initially were not particularly
thrombogenic. This demonstrates the importance of the thrombotic phenomenon in this population group with atheromatosis scarcely developed [17]. Cases also showed significantly higher proportion of hyperlipidemia, a risk condition for development of premature coronary disease [7,8,10–14,18,19]. Similarly, family history is a very important risk factor for atherosclerosis in youngs [8–12,19]. However, in agreement with our results, both hypertension and diabetes are less prevalent risk factors in premature infarcts when compared with the elderly [7,8,10–13,15,18,19]. These conditions are more likely to appear in the ageing process. Regarding the extent of coronary atherosclerosis, cases showed a less evolved disease. As described in the literature, this group is characterised by a less extensive coronary disease, mainly as mono-vase form [8–10]. In the comparative series described, young patients have a more favourable outcome compared with older patients, due to better response to fibrinolytic treatment, less presence of some associated atherogenic and comorbid factors, such as hypertension and diabetes, a lower rate of cardiovascular complications and less extensive atherogenic disease [7,9,11,12,15,16,19]. Cardiovascular mortality incidence in our young group was 1.4%, similar to the GISSI-2 registry (1.2%) [19]. However, in a series with a longer follow-up period, mortality reaches 16% [9] or even 30% [15]. These findings justify the need of an intense and aggressive strategy of primary and second prevention of premature cardiovascular disease [20,21]. In conclusion, premature coronary disease is a more frequent entity than described in initial series. It affects predominantly the male sex and shows high prevalence of cardiovascular risk factors, mainly tobacco, hyperlipidemia, and family history of ischemic heart disease. In addition, it is characterised by a less extensive coronary atherosclerosis, mainly with higher presence of single-vessel disease in contrast to older patients, as well as lower initial mortality. References [1] Fuster V. Mechanism of arterial thrombosis: foundation for therapy. Am Heart J 1998;135:S361–6. [2] Fuster V, Badimon L, Badimon J, et al. The pathogenesis of coronary artery disease and the acute coronary syndromes (part I). N Engl J Med 1992;326:242–50. [3] Davies M. The pathophysiology of acute coronary syndromes. Heart 2000;83:361–6. [4] Castelli WP. Epidemiology of coronary heart disease: the Framingham Study. Am J Med 1984;76:4–12. [5] Neaton JD, Wentworth D. For the Multiple Risk Factor Intervention Trial Research Group: serum cholesterol, blood pressure, cigarette smoking, and death from coronary heart disease. Overall findings and differences by age for 316,099 white men. Arch Intern Med 1992;152: 56–64. [6] WHO: Reducing risks, promoting hearty life. The World Health Report; 2002. [7] Choudhury L, Marsh J. Myocardial infarction in young patients. Am J Med 1999;107:254–61. [8] Kanitz M, Giovannucci S, Jones J, et al. Myocardial infarction in young adults: risk factors and clinical features. J Emerg Med 1996;14: 139–45.
J. Pineda et al. / International Journal of Cardiology 126 (2008) 127–129 [9] Zimmerman F, Cameron A, Fisher L. Myocardial infarction in young adults: angiographic characterization, risk factors and prognosis (Coronary Surgery Study Registry). J Am Coll Cardiol 1995;26: 654–61. [10] Chen L, Chester M, Kaski J. Clinical factors and angiographic features associated with premature coronary artery disease. Chest 1995;108: 364–9. [11] Doughty M, Mehta R, Bruckman D, et al. Acute myocardial infarction in the young. The University of Michigan experience. Am Heart J 2002;143:56–62. [12] Barbash GI, White HD, Modan M, et al. Acute myocardial infarction in the young-the role of smoking. Investigators of the International Tissue Plasminogen Activator/Streptokinase Mortality Trial. Eur Heart J 1995;16:313–6. [13] Fournier JA, Cabezon S, Cayuela A, et al. Long-term prognosis of patients having acute myocardial infarction when ≤40 years of age. Am J Cardiol 2004;94:989–92. [14] Chan MY, Woo KS, Chia BL, et al. Antecedent risk factors and their control in young patients with a first myocardial infarction. Singapore Med J 2006;47:27–30. [15] Cole JH, Miller JI, Sperling LS. Long-term follow-up of coronary artery disease presenting in young adults. J Am Coll Cardiol 2003;41:521–8.
129
[16] Mukherjee D, Hsu A, Moliterno DJ, et al. Risk factors for premature coronary artery disease and determinants of adverse outcomes after revascularization in patients ≤40 years old. Am J Cardiol 2003;92: 1465–7. [17] Virmani R, Kolodgie F, Burke A, et al. Lessons from sudden coronary death. A comprehensive morphological classification scheme for atherosclerotic lesions. Arterioscler Thromb Vasc Biol 2000;20: 1262–75. [18] Genest J, McNamara J, Salem D, et al. Prevalence of risk factors in men with premature coronary artery disease. Am J Cardiol 1991;67: 1185–9. [19] Moccetti T, Malacrida R, Pasotti E, et al. Epidemiologic variables and outcome of 1972 young patients with acute myocardial infarction. Data from the GISSI-2 database. The GISSI investigators. Arch Intern Med 1997;157:865–9. [20] Wood D, De Baker G, Faergeman O, et al. Together with members of the Task Force Prevention of Coronary Heart Disease in Clinical Practice. Recommendations of the Second Joint Task Force of the European Societies on Coronary Prevention. Eur Heart J 1998;19: 1434–503. [21] Lloyd-Jones DM, Leip EP, Larson MG, et al. Prediction of lifetime risk for cardiovascular disease by risk factor burden at 50 years of age. Circulation 2006;113:791–8.