September 29th 2022 – World Heart Day Heart Attack In Young
Heart attacks, cardiac arrest, and other cardiovascular diseases have long been a major public health concern, but it is only recently that an increase in cardiovascular problems among the younger population has been diagnosed and reported. However, in India, premature obstructive CAD has arisen as a major concern for patients, clinicians, legislators, and policymakers. Young people with coronary artery disease (CAD) are defined as having CAD before the age of 45. With changing lifestyles, the primary cause of developing CAD at a young age is the appearance of typical risk factors in the early phases of development. It is well accepted that the CAD epidemic in India is caused by a higher prevalence of known risk factors such as diabetes, hypertension, obesity, family history, abnormal lipid profile, and others. Young Indians still have a poor understanding of heart disease. However, due to recent news of high-profile artists such as actors and singers dying of heart attacks, there is a slow but steady increase in awareness of heart attacks among the young.
Problems specific to ‘Young Women’
For a long time, the significance of CAD in young women was underestimated. Even in the absence of risk factors, the symptoms of CAD in women have low specificity, and there are some sex-related variations in the illness. Furthermore, because women are thought to have a very low risk of developing CAD at a young age, obstructive CAD in young women is typically neglected. Due to resting ST-T segment variations, lower ECG voltages, and perhaps hormonal variables, the treadmill test has very low sensitivity in women. Because of the increasing prevalence of atypical symptoms, the limited efficiency of non-invasive diagnostic testing, and the frequent discovery of normal/non-obstructive CAD on angiography, identifying predictors of obstructive CAD in younger females prior to intrusive testing is critical.
Additionally, when young women are compared to similarly aged males, gender differences in post-acute coronary syndrome mortality risk are more significant. Moreover, women are considerably more prone to develop unfavorable side effects, such as bleeding problems, following reperfusion therapy.
I was part of a small study done retrospectively at a tertiary care center on this topic, which was published in the reputed journal of ‘Indian Heart Journal’mentioned at the end of the article. Out of a total of 3656 patients who underwent PCI, 367 patients were found to be less than 45 years of age. Some of the findings are as follows.
· Though men make up the majority of patients in this age group, CAD in females under the age of 45 is not uncommon.
· Approximately 9–11% of all CAD cases are caused by obstructive CAD in young people, which is a distinct entity with a distinctive risk factor profile, clinical appearance, angiographic profile, and therapeutic outcome.
· Traditional risk factors including hypertension, diabetes, abdominal obesity, smoking, and alcohol intake are on the rise in younger women and are on par with men.
· STEMI is a typical presentation of CAD, and single-vessel disease is a more common form of angiographic pattern in the young, and the most common culprit vessel beingLAD.
· Younger patients are treated with PCI as the primary modality, and they perform better with few complications.
In terms of risk factors, genetics, sociocultural processes, biological factors, and pathophysiology, men and women present differently for obstructive CAD. Women with suspected ischemia are frequently ignored, according to a number of indisputable pieces of evidence. Young women have about 50% higher mortality risk than young men, most likely as a result of less intensive early diagnostic and therapeutic care for women. In spite of the fact that hormone protection may help women delay atherosclerosis, our research shows that at a young age, the multiple risk factors entirely outweigh the advantage.
Similar to our findings, Iragavarapu et alstudies in south India found that the average age of CAD in young individuals was 36.11 years and that males outnumbered females. According to earlier research, women experience CAD 10 years later than men. According to recent Indian population studies, traditional risk factors like hypertension, diabetes, and dyslipidemia, which were earlier more common in men, are now increasing in young Indian women. The INTERHEART study also found that young Indian women were more likely than men to have diabetes and hypertension as immediate risk factors. The prevalence of obstructive CAD in young women aged 45 is 3.1 %to 4.4 %. The presence of risk factors in young females is one of the strongest predictors of CAD since females with risk factors had a higher prevalence of obstructive CAD (89.4%) than females without risk factors (10.6%).
According to computed tomography of the heart, women’s coronary arteries are smaller than men’s. Han et al. discovered that whereas women had more microvascular dysfunction, males had more atheroma and epicardial endothelial dysfunction in their research of men and women with early CAD. In an autopsy study conducted by Vaideeswar et al., 88.4 percent of young patients had obstructive CAD caused by atherosclerosis, with females accounting for 15.5 percent of the patient population. Naturally, the LAD was the most impacted, and fibrous plaques began to form. Regardless of plaque morphology, thrombosis caused by plaque erosion was the most common cause, involving both sexes and occurring in 36.9 percent of patients.
The acute coronary syndrome was the most common presentation in multiple studies involving young participants, similar to the CREATE registry, which documented STEMI in 61% of patients. Iragavarapu et al. discovered that single-vessel disease was the most common kind of vascular illness among 120 young South Indian patients who presented with the acute coronary syndrome at a tertiary care hospital (10.4 percent). In our analysis, we discovered about 5.5 percent of participants had triple vessel disease.
Obesity, dyslipidemia, hypertension, and diabetes are all preventable conditions that can be managed and treated. The fact that ‘women are less likely to smoke is something that is thing of the past. In younger age groups, there is a larger window of opportunity for early CAD prevention. Post-menopausal women were found to have a higher prevalence of risk factors than pre-menopausal women. Pre-menopausal women stand to benefit the most from taking precautions against these risk factors. Targeted regulation of hypertension, obesity, cholesterol levels, and glycemia is required to reduce disease burden, with a focus on educating the young about mitigating these risk factors. As a result, it appears that young Indians have an additional ten years to implement preventive measures and effectively combat the CAD threat. This can be accomplished by increasing young people’s awareness of modifiable risk factors. Because “prevention is better than treatment,” awareness campaigns and programs can be developed, and specialized doctors can deliver seminars and webinars to educate the public about the importance of preventing obstructive CAD at a young age.
Take home message
· Although coronary artery disease is less common in young adults, it still presents a significant challenge for both the patient and the attending specialist.
· More attention should be paid to routine screening and counseling the young on the regulation of these modifiable risk factors in order to reduce the incidence of CAD and the mortality associated with it.