Hidden Cardiovascular Risk: Early Menopause Triggering Acute Coronary Syndrome (ACS) in Young Patients

Sex Disparities in Myocardial Infarction: Biology or Bias?

Correlation of lipoprotein (a) levels and plaque morphology in very young acute coronary syndrome patients using optical coherence tomography

Background: Levels of lipoprotein (Lp) (a) are a useful marker for risk stratification of cardiovascular diseases. This genetic biomarker is suggestive of patient predisposition to an acute coronary event. Its correlation with the plaque morphology is yet to be explored with optical coherence tomography (OCT). Aim: To study the correlation of Lp(a) levels and plaque morphology in very young (<35 years) patients presenting with acute coronary syndrome(ACS). Methods: A prospective, single-centre, observational study was conducted at a tertiary-care centre. Very young patients with acute coronary syndrome and fit for OCT guided invasive coronary angiography were included. Lp(a) levels were compared between healthy controls and these very young ACS patients. Correlation of Lp(a) levels and plaque characteristics in very young ACS patients was done using OCT imaging. Results: A total of 80 subjects were enrolled in the study. Out of these 40 were very young ACS and 40 were age matched healthy controls. Mean levels of Lp(a) were 28.10±13.96 nmol/l and 61.20±55.88 nmol/l in healthy controls and very young patients with ACS respectively (p=0.022). In very young patients, plaque rupture and erosion were the mechanism of acute coronary syndrome in 67.5% and 32.5% patients, respectively. Among very young ACS patients, those with Lp(a) levels <75 nmol/l had a mean thin cap fibroatheroma thickness of 96.89±65.52 μm and those with Lp(a) levels ≥75 nmol/l had a mean thin cap fibroatheroma thickness of 67.85±53.80 μm (p=0.158). Conclusion: It was revealed that patients with higher Lp(a) levels had lesser thickness of fibrous cap on OCT imaging compared with lower levels of Lp(a). Lp(a) levels were independently associated with ACS in very young (<35 years) patients, with plaque rupture being the commonest mechanism. Hence, we conclude that higher Lp(a) levels predispose to ACS at a very young age associated with lowering of fibrous cap thickness.

Symptoms, a key element in the patient's decision to seek care, are critical to appropriate triage, and influence decisions to pursue further evaluation and initiation of treatment. Although many studies have described symptoms associated with acute coronary syndromes (ACS), few, if any, have examined symptom predictors of ACS and whether they differ by patients' age. To explore symptom predictors of ACS in younger (< 70 years) and older (> or = 70 years) patients. To test the hypothesis that typical symptoms are predictive of ACS in younger patients, but are less predictive in older patients. Secondary analysis of observational data gathered on 531 patients presenting to the emergency department of a regional cardiac referral center in New England with symptoms suggestive of ACS. Bivariate analyses revealed no symptoms significantly (p < .01) associated with ACS in older patients. In younger patients presence of chest symptoms and the total number of typical symptoms reported were significantly (p < .01) associated with ACS. After adjustment for age and gender, typical symptoms that were positive predictors of ACS in younger patients included chest symptoms (OR 2.37, 95% CI 1.32-4.27, p = .004) and arm pain (OR 1.78, 95% CI 1.03-3.09, p = .040). Additionally, the total number of typical symptoms reported (OR 1.68, 95% CI 1.31-2.15, p < .001) was a positive predictor of ACS in younger patients. The atypical symptom of fatigue (OR 2.52, 95% CI 1.10-5.81, p = .029) was a significant positive predictor of ACS, whereas dizziness/faintness (OR .50, 95% CI .26-.91, p = .024) was a significant negative predictor of ACS in younger patients. Logistic regression analysis using the entire sample revealed an interaction between age and number of typical symptoms indicating that younger patients had a 36% greater odds for ACS for each additional typical symptom present compared with older patients (OR 1.36, 95% CI 1.02-1.83, p = .038 for interaction between age and number of typical symptoms reported). The model with the interaction between age and chest symptoms revealed a borderline association (p = .10 for the interaction between age and chest symptoms), with younger patients being more likely than older patients to report chest symptoms. Typical symptoms are predictive of ACS in younger patients and less predictive in older patients.

Lipoprotein-associated phospholipase A2 (Lp-PLA2) is considered to be a risk factor for acute coronary syndrome (ACS), but this remains controversial. This study investigated the role of Lp-PLA2 in young Chinese patients with ACS. 228 young patients (aged ≤55 years) with ACS and 237 age-matched controls were included. Lp-PLA2 and oxidized low-density lipoprotein (ox-LDL) levels were measured by sandwich enzyme-linked immunosorbent assay. Lp-PLA2 levels were significantly correlated with smoking, total cholesterol (TC), low-density lipoprotein cholesterol (LDL-C) and ox-LDL levels (all P < 0.05). Multivariate logistic regression analysis showed that male sex (OR = 3.25, 95%CI = 1.26–8.38), smoking (OR = 3.50, 95%CI = 1.75–7.0), triglyceride (OR = 1.76, 95%CI = 1.08–2.87), high sensitivity C-reactive protein (hs-CRP) (OR = 2.11, 95%CI = 1.14–3.90) and ox-LDL (OR = 2.98, 95%CI = 1.72–5.1) were independently associated with ACS risk in young patients. Lp-PLA2 was associated with risk of ACS in young patients when adjusted for traditional risk factors, including age, sex, diabetes, hypertension, smoking, TC, LDL-C, triglyceride and hs-CRP (OR = 1.98, 95%CI = 1.10–3.56). When further adjusted for ox-LDL levels, the association between Lp-PLA2 and ACS became insignificant (OR = 1.69, 95%CI = 0.90–3.17). Lp-PLA2 was a marker of oxidative stress and inflammation, rather than an independent risk factor for ACS in young Chinese patients.

BACKGROUND AND OBJECTIVESUnderstanding the nature and pattern of young coronary artery disease (CAD) is important due to the tremendous impact on these patients’ socio-economic and physical aspect. Data on young CAD in the southeast Asian region is rather patchy and limited. Hence we utilized our National Cardiovascular Disease Database (NCVD)—Percutaneous Coronary Intervention (PCI) Registry to analyze young patients who underwent PCI in the year 2007 to 2009.DESIGN AND SETTINGSThis is a retrospective study of all patients who had undergone coronary angioplasty from 2007 to 2009 in 11 hospitals across Malaysia.METHODSData were obtained from the NCVD—PCI Registry, 2007 to 2009. Patients were categorized into 2 groups—young and old, where young was defined as less than 45 years for men and less than 55 years for women and old was defined as more than or equals to 45 years for men and more than or equals to 55 years for women. Patients’ baseline characteristics, risk factor profile, extent of coronary disease and outcome on discharge, and 30-day and 1-year follow-up were compared between the 2 groups.RESULTSWe analyzed 10 268 patients, and the prevalence of young CAD was 16% (1595 patients). There was a significantly low prevalence of Chinese patients compared to other major ethnic groups. Active smoking (30.2% vs 17.7%) and obesity (20.9% vs 17.3%) were the 2 risk factors more associated with young CAD. There is a preponderance toward single vessel disease in the young CAD group, and they had a favorable clinical outcome in terms of all-cause mortality at discharge (RR 0.49 [CI 0.26–0.94]) and 1-year follow-up (RR 0.47 [CI 0.19–1.15]).CONCLUSIONWe observed distinctive features of young CAD that would serve as a framework in the primary and secondary prevention of the early onset CAD.

It is estimated half of acute coronary syndrome (ACS) patients have one or more associated comorbid conditions. Aims were to: 1) examine the prevalence of comorbid conditions in patients presenting to the emergency department with symptoms suggestive of ACS; 2) determine if comorbid conditions influence ACS symptoms; and 3) determine if comorbid conditions predict the likelihood of receiving an ACS diagnosis. A total of 1064 patients admitted to five emergency departments were enrolled in this prospective study. Symptoms were measured on presentation to the emergency department. The Charlson Comorbidity Index (CCI) was used to evaluate group differences in comorbidity burden across demographic traits, risk factors, clinical presentation, and diagnosis. The most prominent comorbid conditions were prior myocardial infarction, diabetes without target organ damage, and chronic lung disease. In younger ACS patients, higher CCI predicted less chest pain, chest discomfort, unusual fatigue and a lower number of symptoms. In older ACS patients, higher CCI predicted more chest discomfort, upper back pain, abrupt symptom onset, and greater symptom distress. For younger non-ACS patients, higher CCI predicted less chest pain and symptom distress. Higher CCI was associated with a greater likelihood of receiving an ACS diagnosis for younger but not older patients with suspected ACS. Younger patients with ACS and higher number of comorbidities report less chest pain, putting them at higher risk for delayed diagnosis and treatment since chest pain is a hallmark symptom for ACS.

Two-year prognosis after acute coronary syndrome in younger patients: Association with feeling depressed in the prior year, and BDI-II score and Endothelin-1

Background Ever since the concept of preventive cardiology has come into vogue, several risk identification models have come up which combine several risk factors to create a risk prediction score for occurrence of cardiovascular (CV) event. While carrying a proven validation in Western population, none of the risk prediction model has been satisfactorily evaluated in Indians especially young &amp;lt;40 years old. Objectives To compare Artificial Intelligence based novel risk score with traditional risk scores in young (less than 40 years age) patients presenting with acute coronary syndrome (ACS) and to estimate the relative efficacy of different coronary artery disease (CAD) risk scores in young Indian Patients. Design Single center, Observational, Non-interventional study. Participants Cohort of Patients more than 20 but less than 40 years old with ACS in the department of Cardiology from 1st January 2019 to 31st October 2019. Methods 314 young patients [mean age 36.14±4.17 years] presenting with acute coronary syndrome (ACS) were enrolled. The three clinically most pertinent risk assessment models [Framingham Risk score (FRS), World Health Organization risk prediction charts (WHO/ISH), and QRISK3 scores] and Artificial Intelligence based novel risk score (AICVD) were applied on day 1 of presentation, and tried to see whether one risk score versus other risk score could have predicted the event earlier had we applied it before the occurrence of ACS. Risk factors considered included those already in traditional scoring systems and new risk factors (diet, alcohol, tobacco, dyslipidemia, physical activity, family history of heart disease, history of heart disease, heart rate, respiratory rate, chronic heart symptoms and psychological stress). Results WHO/ISH provided the lowest high risk estimate with only 1 (0.9%) patient estimated to be having &amp;gt;20% 10-year risk. The FRS estimated high risk (&amp;gt;20% 10-year risk) in 3 (1%) patients. The QRISK3 estimated high risk (&amp;gt;10% 10-year risk) in 20 (6.5%) patient. In comparison, AICVD risk prediction model stood tall by identifying 73 (23.2%) patients as high risk and 62.74% patients as more than moderate risk for having CV events at 7 years (p&amp;lt;0.001). Conclusion Perhaps, this is the first study which has compared artificial intelligence based novel risk prediction model with the three most commonly applied models, in the young Indian patients. We found that a cohort of young Indian patients presenting with ACS, when studied retrospectively, was identified as “high risk” most likely by AICVD risk prediction model rather than the traditional counterparts. The WHO/ISH risk prediction charts and FRS were the poorest predictors. Performance of QRISK3 score also remained less than satisfactory. These findings suggested that AICVD risk prediction model is a promising tool to assess for CV risk in Indian population. Funding Acknowledgement Type of funding sources: None. Predictability of risk prediction models

Sirolimus-coated balloon in acute and chronic coronary syndromes: the PEACE study, a subanalysis of the EASTBOURNE registry

Background Coronary artery disease (CAD), which clinically manifested as an acute coronary syndrome (ACS) is an important extrahepatic cardiovascular complication of non-alcoholic fatty liver disease (NAFLD). To date, little is known about the correlation between young patients with ACS and NAFLD. Aim to assess the correlation between NAFLD and severity of CAD in young ACS patients and determine the prevalence of NAFLD in this cohort. Methods This cross-sectional study included young (45 years and less) ACS patients. Coronary angiogram was performed to assess CAD severity, and complexity determined by SYNTAX score. CAD severity was classified into: no apparent CAD, mild CAD, single vessel disease (SVD) and multi-vessel disease (MVD). Liver ultrasound was used to diagnose and grade the NAFLD (grade 1–3). NAFLD fibrosis score (NFS) was calculated, and patients were stratified to low, indeterminate, and high probability for advanced liver fibrosis. Results Total of 85 patients with median age of 40 years (IQR 35–43) and predominated by males (84.7%). Thirty-three (38.9%) had ST elevation myocardial infarction (STEMI), 32 (37.6%) had Non-STEMI and 20 (23.5%) had unstable angina. MVD was demonstrated in 36.5%, SVD in 24.7%, mild CAD in 31.8%, and no apparent CAD in 7.1% of the patients. Median Syntax score was 16 (IQR 9.0–22.3). NAFLD was diagnosed in all, 85 (100%) patients, with 13 (15.2%), 36 (42.4%) and 36 (42.2%) patients had grade 1, 2 and 3 liver steatosis respectively. NFS detected low advanced fibrosis probability in 60 (70.6%) patients, indeterminate probability in 24 (28.2%) patients and high probability in only 1 (1.2%) patient. No significant correlation between grades of NAFLD with ACS subtypes (p=0.72), severity of CAD (p=0.882) and SYNTAX score (p=0.982). No significant association between NFS and ACS subtypes (p=0.232), severity of CAD (p=0.445) and SYNTAX score (p=0.624, r=0.07). Conclusions NAFLD is highly prevalent in young patients presented with ACS, and it should be routinely screened in our clinical practice. However, in a small cohort, we observed no significant correlation between severity of NAFLD and severity of CAD among young ACS patients.

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Acute coronary syndromes in young patients: Presentation, treatment and outcome

ABSTRACTBackground:Acute coronary syndrome (ACS) refers to a group of clinical symptoms compatible with acute myocardial ischemia and includes unstable angina, non-ST segment elevation myocardial infarction and ST-segment elevation myocardial infarction.Aims and Objectives:To study the incidence of lipid profile abnormalities in young patients (age 40 years or below) with ACS with clinical and cardiovascular risk profile.Material and Methods:The study was conducted on 223 young patients of acute coronary syndrome with age 40 years or below. 89 young patients with acute coronary syndrome having lipid abnormalities were further followed up after 1 month.Results:Majority of patients (55.15%) in the study population belonged to 35–40 years age group. Mean age of study population was 35.65 + 4.62 years with 90.13% males and 9.86% females. Main presenting symptom was precordial chest pain in 93.72% patients. Smoking was the commonest risk factor in young adults (81.7%). Other risk factors like diabetes, hypertension, family history were less common in young adults. Drug addiction was also higher in younger population (16%). Majority of young adults with acute coronary syndrome had more than 1 (47.53%) risk factor. Majority of patients were in Killip class I (86.9%) and only few patients (13.1%) had Killip class II or above. ST elevation myocardial infarction was far more common than NTEMI/USA and was found in 164 (73.5%) patients. Most common type of infarction was anterior wall myocardial infarction (62.80%). Majority of young patients had negative TMT, so it suggests that ACS in younger population has lesser complications during presentation, hospital stay and on follow-up.Conclusion:ACS in young continues to increase in Indian subcontinent. Younger patient with an ACS have different clinical characteristics and a different prognosis than older patients. The extent of CAD and degree of myocardial necrosis has influence on presentation and subsequent MACE in ACS and in this study, it appears dyslipidemia do not play any significant role in influencing extent of CAD and has little effect on outcome whether during acute stage or on immediate follow-up after ACS.

Living alone is reported as an independent risk factor for cardiovascular disease. However, little is known about the association between clinical outcomes and living alone in patients with acute coronary syndrome (ACS). The aim of this study was to determine whether living alone is an independent prognostic risk factor for long-term mortality stratified by age in patients with ACS who were treated with primary percutaneous coronary intervention (PCI). We conducted an observational cohort study of ACS patients who underwent PCI between January 1999 and May 2015 at Juntendo University Shizuoka Hospital, Japan. The primary endpoint was all-cause death. Among 2547 ACS patients, 381 (15.0%) patients were living alone at the onset of ACS. The cumulative incidence of all-cause death was comparable between living alone and living together (34.8% vs. 34.4%, log-rank P = 0.63). However, among younger population (aged <65 years), the incidence of all-cause death was significantly higher in the living alone group (log-rank P = 0.01). Multivariate Cox hazard analysis revealed a significant association between living alone and all-cause death, even after adjusting for other risk factors (hazard ratio 2.30, 95% confidence interval 1.38-3.84, P = 0.001). Although living alone was not significantly associated with long-term clinical outcomes in patients with ACS, it was a predictive risk factor among younger ACS patients. Careful attention should be paid to patients' lifestyle, especially younger patients with ACS.