Young Adults Surviving Myocardial Infarction

Abstract

To the Editor: The recent report by Warren et al (Chest 75:667-670, 1979) merits comment. They found, in a group of 68 patients under the age of 36 who had suffered a myocardial infarction, nine (13 percent) had normal coronary arteries on angiogram. There is no doubt that we are seeing younger patients in our coronary care units with their first myocardial infarction. Most cardiologists are subjecting these patients to coronary arteriography as part of their post discharge evaluation for the reasons cited by the authors. Their incidence of arterio-graphically normal coronary arteries seems quite high, but the series comprises a select group of patients. They all survived their infarctions and some were referred from other hospitals. It must be realized that this was not a consecutive series of all young myocardial infarction patients seen in the coronary care unit and then subjected to angiographic evaluation. The implications of the study by Warren and colleagues are significant, especially in light of recent knowledge concerning the pathophysiology of ischemic heart disease. Coronary vasospasm must be considered in all patients with angina and/or myocardial infarction, especially in the absence of significant atherosclerosis. Dual channel ambulatory monitoring (even in the absence of chest pain) may aid in its detection. In a recent study in three patients with variant angina, 1045 spontaneous episodes of ST segment elevation were observed, 89 percent of which were asymptomatic.1Robertson D Robertson RM Nies AS et al.Variant angina pectoris: Investigation of indexes of sympathetic nervous system function.Am J Cardiol. 1979; 43: 1080-1086Abstract Full Text PDF PubMed Scopus (72) Google Scholar Ergonovine testing during diagnostic coronary angiography should also be considered in such patients. Even though the sensitivity and specificity of ergonovine testing for the detection of coronary vasospasm is not defined, the test appears to be highly specific in patients with typical Prinzmetal's angina.2Curry RC Pepine CJ Sabom MB et al.Effects of ergonovine in patients with and without coronary artery disease.Circulation. 1977; 56: 803-809Crossref PubMed Scopus (153) Google Scholar It has recently been reemphasized that patients with coronary vasospasm may have one (or more) myocardial infarctions even in the absence of atherosclerosis.3Madias JE The syndrome of variant angina culminating in acute myocardial infarction.Circulation. 1979; 59: 299-306Crossref Scopus (51) Google Scholar Two clinical conditions which may mimic ischemic heart disease and/or be associated with myocardial infarction in the absence of atherosclerosis, must also be considered. The first is the mitral valve prolapse syndrome. These patients often have electrocardiographic changes suggestive of ischemic heart disease; furthermore, they can present with acute myocardial infarction and angiographically normal coronary arteries.4Chesler E Matison RE Lakier JP et al.Acute myocardial infarction with normal coronary arteries.Circulation. 1976; 54: 203-207Crossref PubMed Scopus (39) Google Scholar Coronary spasm has been suggested as the underlying mechanism and receives further support by a recent study. Buda et al5Buda AJ Levene DL Myers MG Coronary artery spasm and mitral valve prolapse.Am Heart J. 1978; : 457-462Abstract Full Text PDF PubMed Scopus (26) Google Scholar retrospectively found ten patients with angiographic spasm (eight were at the catheter tip), and nine had evidence of mitral prolapse. We have recently encountered four patients with the prolapse-click syndrome and evidence of coronary spasm (Mautner RK, Phillips JH; unpublished observations). Hypertrophic obstructive cardiomyopathy (HOCM) is a second condition in which patients may present with angina and electrocardiographic evidence of infarction. Furthermore, Maron et al6Maron BJ Epstein SE Roberts WC Hypertrophic cardiomyopathy and transmural myocardial infarction without significant atherosclerosis of the extramural coronary arteries.Am J Cardiol. 1979; 43: 1086-1162Abstract Full Text PDF PubMed Scopus (309) Google Scholar recently reported seven patients with HOCM who, at necropsy, had evidence of transmural myocardial infarction with no significant atherosclerosis of the extramural coronary arteries. This study and our recent report of three patients with HOCM and associated coronary vasospasm7Mautner RK Thomas I Dhurandhar R et al.Hypertrophic obstructive cardiomyopathy and coronary artery spasm.Chest (in press). 1979; Google Scholar suggests a causal relationship. In conclusion, coronary artery spasm should be considered and its documentation sought in patients with ischemic syndromes and no demonstrable atherosclerosis. The total contribution of spasm in the clinical area has not yet fully unfolded; however, there is no doubt that its impact is significant.