Artery Disease In Young Adults Research Articles

Coronary Artery Disease in Young Adults: Who Needs Surgical Revascularization? A Retrospective Cohort Study.

Coronary artery disease (CAD) is a major cause of death and disability in developed countries. Despite the fact that prevalence accrues with age, an increasing number of young patients suffering from CAD is being observed worldwide. The aim of this study is to describe the population of young adults suffering from CAD and requiring coronary artery bypass grafting (CABG), and to assess early outcomes after the procedure. A retrospective cohort study analyzed 190 consecutive patients aged ≤50 years old that underwent CABG between 2010 and 2014. Baseline characteristics and operative data were presented in the study. Postoperative complications, such as major adverse cardiac and cardiovascular events (MACCE), prolonged mechanical ventilation (>72 hours), bleeding requiring reexploration, sternal dehiscence, and others were assessed. A population comprising mostly overweight or obese males with a mean age of 46 ± 4.1 years was analyzed. Patients suffered mostly from three-vessel disease (81%), hypertension (74.7%), and had previous history of myocardial infarction (MI) (60%). The majority of patients had normal left ventricle ejection fraction (LVEF) (83.1%). 22.6% of cases were emergent procedures. Perioperative mortality was low (1%) and overall MACCE rate stood at 2.6%. Emergent surgery was associated with a higher incidence of postoperative complications (P = .007). The number of diseased vessels, LVEF, and CCS/NYHA class-on-admission was not associated with a higher incidence of postoperative complications (P > .05 for all). CAD in young patients remains an issue described insufficiently in the literature. Among our study cohort of younger patients undergoing CABG, the majority of the patients had multivessel disease and were slightly symptomatic with normal LVEF. Although the postoperative complication rate was low, the percentage of emergent surgeries was alarmingly high in this population. Consistent with the literature, we highlight the importance of CAD screening in the young population to detect subclinical disease, which might be treated therapeutically or operated electively.

Coronary artery disease in young adults: Angiographic study - A single-center experience

Background and Objectives: Premature coronary artery disease (PCAD) seems to increase, particularly in developing countries. There are fewer data regarding myocardial infarction in young adults, with varying risk factors and patterns of coronary involvement. This study was done to present the coronary angiographic characteristics of CAD in young patients aged Materials and Methods: In this cross-sectional record-based study, patients aged Results: A total of 4526 cases underwent coronary angiogram between January 2008 and December 2014; 154 (3.40%) were Conclusions: Incidence of critical CAD in young adults is quite high. Young patients with CAD are mainly males, and SVD is more common. Emphasis should be given on diagnosis and management of risk factors in this vulnerable group.

Relationship between left ventricular mass and coronary artery disease in young adults: a single-center study using cardiac computed tomography.

We evaluated the relationship between coronary artery disease (CAD) and left ventricular mass (LVM) as measured by cardiac computed tomography (CT) in young adults ≤40years of age. We retrospectively enrolled 490 consecutive individuals (383 males; mean age, 35.2±4.4years) who underwent cardiac CT. CAD was defined by the presence of any plaque detected by coronary CT angiography. Left ventricular (LV) function, including LVM, was automatically measured by a dedicated workstation. LVM and LVM index (LVMi) in patients with CT-detected CAD were compared to those of patients without CT-detected CAD. Logistic regression analysis was used to evaluate the relationship between cardiovascular risk factors and CAD. Fifty-five individuals had CT-detected CAD (11.2%, 53 males). LVM measured by cardiac CT was 126.9±30.0g for males and 93.6±20.9g for females. LVM was higher (117.8±30.8 vs. 133.6±33.1g, P<0.001) in patients with CT-detected CAD compared with patients without CT-detected CAD. Obesity, hypertension, smoking, hypercholesterolemia, LVM and LVMi were predictors of CT-detected CAD. Body mass index (r=0.237, P<0.001) and systolic blood pressure (r=0.281, P<0.001) were positively correlated with LVM. In the multivariate analysis, LVM [odds ratio (OR)=1.016] and LVMi (OR=1.026) remained independent predictors of CAD. LVM and LVMi in patients with CT-detected CAD were higher than that of patients without CT-detected CAD. LVM and LVMi measured by cardiac CT were independent predictors of CAD.

Clinical and angiographic characteristics of coronary artery disease in young adults: a single centre study.

Coronary artery disease (CAD) in young adults under 40 years of age is a growing medical, social, psychological and economical problem, related to the prevalence of civilization-related diseases and unhealthy lifestyle. The problem of CAD in young people has not been characterised as well as in older individuals, as the available data mostly come from case reports and small series, often related to genetic aspects and familial occurrence of the disease. To assess clinical and angiographic characteristics of young adults with CAD and to evaluate in-hospital and long-term mortality in this patient group. The study combined a retrospective and a prospective approach. A total of 239 patients aged 40 years or younger who underwent coronary angiography (CAG) in the Swietokrzyskie Centre of Cardiology in Kielce in 2001-2008 were included in this study. Demographic characteristics, risk factor profile, laboratory test results, electrocardiographic and echocardiographic findings, CAG findings, and in-hospital mortality were assessed retrospectively in the selected groups. During the second stage of the study, clinical and mortality data were obtained prospectively in 130 patients (54.4% of the study group) during up to 5 years of follow-up. The mean patient age was 35.1 ± 4.4 years. Men made up 86.2% of the study sample, and the proportion of rural area residents was 54.8%. Among young patients with acute coronary syndromes (ACS), the most common presentation (52.8%) was ST segment elevation myocardial infarction (STEMI). Angiographically normal coronary arteries were found in 37.2% of CAD patients and in 16.9% of patients with the diagnosis of ACS. The mean degree of coronary artery lumen stenosis was 75.4% in the group with significant atherosclerotic coronary lesions (50-90%) and 95.9% in the group demonstrating a critical coronary obstruction (≥ 90%). Single-vessel disease was identified in 61.9% of patients with a positive result of CAG (stenosis > 50%, CORO(+) group). The most common location of significant atherosclerotic coronary lesions was the left anterior descending artery (61.6%) followed by the right coronary artery (27.4%). The most prevalent conventional cardiovascular risk factors were lipid abnormalities, cigarette smoking and an increased body mass index ≥ 25 kg/m2, followed by a family history of CAD and hypertension. The proportion of patients with abnormal lipid profile, cigarette smoking and overweight or obesity was particularly high in the CORO(+) group (85.6%, 83.9%, and 64.4%, respectively). In-hospital mortality rate was low, at 0.7% among ACS patients. Long-term mortality during up to 5 years of follow-up was not so favourable, at 7.75% in ACS patients and 8.5% in the CORO(+) group. The population of young patients with CAD is predominantly male, rural, and characterised by a low socio-economic status. The aetiology of CAD in this patient group differs significantly from that in older patients and it is often associated with an unhealthy lifestyle related to rapid civilization changes. The rates of CAD risk factors in young adults are high and the most important risk factors are dyslipidaemia, smoking, and overweight/obesity. Single vessel disease and STEMI presentation were predominant in young patients. Short-term prognosis in young ACS patients is excellent, but long-term prognosis is significantly worse. Further studies on CAD in young adults are warranted, particularly in larger patient populations.

Prevalence and predictors of coronary artery disease in adults with Kawasaki disease.

Accelerated coronary atherosclerosis in patients with Kawasaki disease, in conjunction with coronary artery aneurysm and stenosis that characterise this disease, are potential risk factors for developing coronary artery disease in young adults. We aimed to determine the prevalence and predictors of coronary artery disease in adult patients with Kawasaki disease. All patients aged 18-55 years of age diagnosed with Kawasaki disease were sampled from Nationwide Inpatient Sample database using International Classification of Diseases 9th revision (ICD 9 code 446.1) from 2009 to 2010. Demographics, prevalence of coronary artery disease, and other traditional risk factors in adult patients with Kawasaki disease were analysed using ICD 9 codes. The prevalence of Kawasaki disease among adults was 0.0005% (n=215) of all in-hospital admissions in United States. The mean age was 27.3 years with women (27.6 years) older than men (27.1 years). Traditional risk factors were hypertension (21%), hyperlipidaemia (15.6%), diabetes (11.5%), tobacco use (8.8%), and obesity (8.8%), with no significant difference between men and women. Coronary artery disease (32.4%), however, was more prevalent in men (44.7%) than in women (12.1%; p=0.03). In multivariate regression analysis, after adjusting for demographics and traditional risk factors, hypertension (OR=13.2, p=0.03) was an independent risk factor of coronary artery disease. There was increased preponderance of coronary artery disease in men with Kawasaki disease. On multivariate analysis, hypertension was found to be the only independent predictor of coronary artery disease in this population after adjusting for other risk factors.

Prognosis and disease progression in patients under 50 years old undergoing PCI: The CRAGS (Coronary aRtery diseAse in younG adultS) study

ObjectiveYoung patients undergoing percutaneous coronary intervention (PCI) are generally considered at low procedural risk, but the potentially aggressive nature of coronary artery disease and long expectancy of life expose them to a high risk of recurrent coronary events. The extent and determinants of disease progression in this patient subset remain largely unknown. The aim of the present study was to evaluate general risk factors for late outcomes among patients ≤50 years old who underwent PCI. MethodsCoronary aRtery diseAse in younG adults (CRAGS) is a multicenter European retrospective registry that enrolled 1617 patients (age ≤50 years) who underwent PCI over the years 2002–2012. The median follow-up was 3.0 years. ResultsThe majority of patients were smokers who were nevertheless prescribed adequate secondary prevention medication, including statins, aspirin, beta blockers and/or ACE inhibitors/AT blockers. At 5 years, survival was 97.8%, while freedom from major adverse cardiac and cerebrovascular events was 74.1%, from repeat revascularization 77.8% and from myocardial infarction 89.9%. Altogether 13.5% of patients exhibited disease progression that indicated a need for repeat revascularization. Other indications for repeat revascularization were restenosis (7.1%) and stent thrombosis (2.1%) at the 5-year follow-up. Independent post-PCI predictors of disease progression were multivessel disease, diabetes and hypertension. ConclusionPCI is associated with excellent survival in patients ≤50 years old. Nevertheless, despite guideline-adherent medication, every eighth patient underwent repeat revascularization due to disease progression diagnosed at the median follow-up of three years, underscoring the need for more effective secondary prevention than currently available.

Abstract MP72: Apolipoprotein B and Apolipoprotein B, LDL-C Discordance in Young Adults Are Associated With Coronary Artery Calcification at 25 Year Follow-Up: The Coronary Artery Disease in Young Adults (CARDIA) Study

Introduction: High ApoB has been shown to predict cardiovascular disease (CVD) in adults even in the context of low LDL-C. It is not known, however, if high ApoB and high ApoB, low LDL-C discordance in young adults are associated with coronary artery calcium (CAC) in mid-life. Methods: Data were derived from CARDIA, a multicenter study of the development and determinants of CVD risk factors in young adults recruited at ages 18 to 30. All participants with complete baseline CVD risk factor data, ApoB, and year-25 CAC score were included in this study. Baseline lipid fractions and ApoB were measured by standard assays. Year-25 CAC was assessed using two consecutive CT scans with presence of CAC defined as having a positive, non-zero Agatston score using the average of two scans. Baseline ApoB values were divided into tertiles. Four mutually exclusive concordant/discordant groups were created based on median ApoB and LDL-C. Logistic regression was performed for unadjusted and adjusted models. Results: 3496 participants were included [mean age=25±3.6, BMI=24.5±5Kg/m2, 44.4% male, and the following mean lipid values (mg/dL): total cholesterol=177.3±33.1, LDL-C=109.9±31.1, HDL-C=53±12.8, ApoB=90.7±24, median triglycerides=61(IQR 46-83)]. Compared with the lowest ApoB tertile, the middle [OR=1.55 (95% CI 1.22-1.95)] and high [OR=2.35 (95% CI 1.87-2.97)] tertiles exhibited increased odds of developing year-25 CAC in traditional risk factor-adjusted models. High ApoB, low LDL-C discordance was also associated with year-25 CAC in adjusted models [OR=1.57 (95% CI 1.12-2.20)]. Conclusions: These data suggest a dose-response association between ApoB in young adults and presence of mid-life CAC independent of baseline traditional CVD risk factors. High ApoB, low LDL-C discordance was also associated with year-25 CAC, suggesting that ApoB in young adults may help identify individuals with modest LDL-C levels who are at increased risk for subclinical atherosclerosis in mid-life.

White Blood Cell Count and the Risk for Coronary Artery Disease in Young Adults

BackgroundThe association between white blood cell (WBC) count and coronary artery disease (CAD) is unknown in young adults. Our objective was to assess the association between WBC count and its changes over time with CAD incidence in the Metabolic, Life-style and Nutrition Assessment in Young adults (MELANY) study, a cohort of Israeli army personnel.Methods and Findings29,120 apparently healthy young men (mean age; 31.2±5.5 years) with a normal baseline WBC count (3,000–12,000 cells/mm3) were followed during a mean follow up of 7.5±3.8 years for incidence of CAD. Participants were screened every 3–5 years using a stress test, and CAD was confirmed by coronary angiography. In a multivariate model adjusted for age, body mass index (BMI), LDL- and HDL-cholesterol, blood pressure, family history of CAD, physical activity, diabetes, triglycerides and smoking status, WBC levels (divided to quintiles) above 6,900 cells/mm3 (quintile 4) were associated with a 2.17-fold increase (95%CI = 1.18–3.97) in the risk for CAD as compared with men in quintile 1 (WBC≤5,400 cells/mm3). When modeled as a continuous variable, a WBC increment of 1000 cells/mm3 was associated with a 17.4% increase in CAD risk (HR 1.174; 95%CI = 1.067–1.290, p = 0.001). A decrease in the WBC level (within the normal range) during the follow-up period was associated with increased physical activity and decreased triglyceride levels as well as with reduced incidence of CAD.ConclusionsWBC count is an independent risk factor for CAD in young adults at values well within the normal range. WBC count may assist in detecting subgroups of young men at either low or high risk for progression to CAD.

Genetic Ancestry-Smoking Interactions and Lung Function in African Americans: A Cohort Study

BackgroundSmoking tobacco reduces lung function. African Americans have both lower lung function and decreased metabolism of tobacco smoke compared to European Americans. African ancestry is also associated with lower pulmonary function in African Americans. We aimed to determine whether African ancestry modifies the association between smoking and lung function and its rate of decline in African Americans.Methodology/Principal FindingsWe evaluated a prospective ongoing cohort of 1,281 African Americans participating in the Health, Aging, and Body Composition (Health ABC) Study initiated in 1997. We also examined an ongoing prospective cohort initiated in 1985 of 1,223 African Americans in the Coronary Artery Disease in Young Adults (CARDIA) Study. Pulmonary function and tobacco smoking exposure were measured at baseline and repeatedly over the follow-up period. Individual genetic ancestry proportions were estimated using ancestry informative markers selected to distinguish European and West African ancestry. African Americans with a high proportion of African ancestry had lower baseline forced expiratory volume in one second (FEV1) per pack-year of smoking (−5.7 ml FEV1/ smoking pack-year) compared with smokers with lower African ancestry (−4.6 ml in FEV1/ smoking pack-year) (interaction P value = 0.17). Longitudinal analyses revealed a suggestive interaction between smoking, and African ancestry on the rate of FEV1 decline in Health ABC and independently replicated in CARDIA.Conclusions/SignificanceAfrican American individuals with a high proportion of African ancestry are at greater risk for losing lung function while smoking.

Increase in sudden death from coronary artery disease in young adults

Increase in sudden death from coronary artery disease in young adults

Association of Blood Group A with Coronary Artery Disease in Young Adults in Taiwan

We aimed to investigate the association between the ABO blood groups and the risk of coronary artery disease (CAD) and myocardial infartion (MI) in a young Taiwanese population. We retrospectively recruited 277 consecutive subjects (men younger than 45 years and women younger than 55 years) who underwent coronary angiography (136 with documented CAD and 129 without CAD) at our center, between 2005 and 2008. Their ABO blood groups were determined using standard agglutination techniques. Patients with CAD showed a significantly different blood group distribution (O, 30.1%; A, 39.7%; B, 26.5%; AB, 3.7%) than that shown by the controls (O, 42.6%; A, 24.0%; B, 27.1%; AB, 6.2%; p=0.032). Patients with blood group A had a greater risk of CAD and MI than those with non-A blood groups (OR=2.08, 95% CI=1.23-3.54; OR=2.21, 95% CI=1.19-4.09, respectively). After adjustment for common cardiovascular risk factors such as age, gender, hypertension, cigarette smoking, diabetes mellitus, body mass index, family history of CAD, and lipid profiles; blood group A remained significantly associated with an increased risk of CAD and MI (OR=2.61, 95% CI 1.11-6.14, p=0.028; OR=3.53, 95% CI=1.21-10.29, p=0.021, respectively). Our findings suggest that blood group A is an independent risk factor for CAD and MI in young people in Taiwan.

Increase in sudden death from coronary artery disease in young adults

Sudden cardiac death (SCD) is the most common cause of death in adults aged <65 years, making it a major public health problem. A growing incidence in coronary artery disease (CAD) in young individuals has been predicted in developed countries, which could in turn be associated with an increase in SCD in this population. The aim of the study was to assess the prevalence of CAD among autopsies of young individuals (<40 years) who had sudden death (SD). We selected all the autopsies referred to the Montreal Heart Institute and Maisonneuve-Rosemont Hospital from January 2002 to December 2006 that corresponded to individuals <40 years old who had died suddenly. For each decedent, the following data were collected: cause of death, autopsy findings, available clinical history, toxicological findings, and cardiovascular risk factors. From a total of 1,260 autopsies, 243 fulfilled the inclusion criteria. Coronary artery disease was the main cause of SCD from age 20 years, representing the 37% of deaths in the group of 21 to 30 years old, and up to 80% of deaths in the group of 31 to 40 years old. Among individuals who died of CAD, 3-vessel disease was observed in 39.7% of cases. Moreover, among the whole population <40 years old, at least 1 significant coronary lesion was observed in 39.5% of cases, irrespective to the cause of death. In the multivariable analysis, an increased BMI (hazard ratio 1.1 for each kg/m(2), 95% CI 1.01-1.1) and hypercholesterolemia (hazard ratio 2.4, 95% CI 1.7-333.3) showed to be the modifiable factors related to an increased risk of SD from CAD. In our population, CAD was the main cause of SD from age 20 years. These data bring into question whether present prevention strategies are sufficient and reinforce the need to extend prevention to younger ages.

Heart failure in people younger than 50 years is more common in black than white americans and is closely associated with poorly treated and controlled hypertension: the cardia study

HEART FAILURE IN PEOPLE YOUNGER THAN 50 YEARS IS MORE COMMON IN BLACK THAN WHITE AMERICANS AND IS CLOSELY ASSOCIATED WITH POORLY TREATED AND CONTROLLED HYPERTENSION: THE CARDIA STUDY Heart failure (HF) is a major public health issue that leads to substantial morbidity and mortality in the United States. Age, hypertension, and coronary ischemia are all well-documented risk factors for HF in older adults, but less is known about the incidence, risk factors, and demographics associated with HF in younger people. The Coronary Artery Risk Development in Young Adults (CARDIA) study, a 20-year multicenter longitudinal study of black and white men and women designed to investigate the development of coronary artery disease in young adults, offered an opportunity to explore these relationships. Beginning in 1985–1986, persons 18 to 30 years of age were enrolled from 4 American cities: Birmingham, Alabama; Chicago, Illinois; Minneapolis, Minnesota; and Oakland, California. The cohort was well balanced with respect to self-reported race (52% black) and sex (55% women). Multiple clinical measurements, including blood pressure (BP), were obtained at baseline and after 2, 5, 7, 10, 15, and 20 years. BP was measured in standardized fashion, with hypertension defined as a BP of at least 140 ⁄90 mm Hg or use of antihypertensive medications. During both their study examinations and in yearly telephone follow-up, participants were asked about overnight hospitalizations. For each hospitalization, records were obtained and adjudicated for the presence of incident HF, defined as a hospitalization where the final diagnosis of HF was made by a treating physician and HF was treated with at least a diuretic and either digitalis or an afterload-reducing agent. Death was also reported to the study centers every 6 months, and each death was adjudicated to determine whether it was due to HF. In year 5, as part of the examination, participants underwent echocardiography. Systolic function was considered abnormal if the ejection fraction (EF) was either <40% or qualitatively described as abnormal; systolic function was considered borderline if the EF was 40% to 60%. Left ventricular hypertrophy (LVH) was defined as a left ventricular mass index at least 51 g ⁄m. Using multiple statistical tools, the CARDIA investigators compared baseline and subsequent development of risk factors in participants in whom HF did and did not develop. The CARDIA study enrolled 5115 individuals with a mean age of 25 years and a mean baseline BP around 110 ⁄70 mm Hg. The retention rate in the study was exceptionally high, with 87.5% of the original cohort completing the yearly telephone interview at year 20 and 71.8% completing the year 20 in-person examination. During the 20 years of follow-up, incident HF occurred in 27 patients (0.5%), which was more common than the incidence of myocardial infarction. Twenty-six of the 27 patients who developed incident HF were black. The cumulative incidence of HF was 1.1% in black women and 0.9% in black men, compared with 0.08% in white women and 0% in white men. From the Division of General Internal Medicine ⁄ Division of Cardiology, University of Nevada School of Medicine; Risk Reduction Center, Saint Mary’s Regional Medical Center, Reno, NV; Primary Care Service Line, Ralph H. Johnson VA Medical Center; and Division of General Internal Medicine ⁄Geriatrics, Medical University of South Carolina, Charleston, SC Address for correspondence: Michael J. Bloch, MD, Risk Reduction Center, Saint Mary’s Regional Medical Center, 645 North Arlington Street, Suite 460, Reno, NV 89503 E-mail: mbloch@aol.com

Cardiac autonomic control and the effects of age, race, and sex: The CARDIA study

BackgroundStratification variables of age, race, and sex figure prominently in the assessment of cardiovascular disease risk. Similarly, cardiac autonomic regulation, measured by RR interval variability (RRV), is associated with risk. The relationship among these variables is unclear. MethodsWe examined the cross-sectional relationship between RRV and age, race, and sex in 757 subjects from the NHLBI-funded Coronary Artery Disease in Young Adults (CARDIA) Study. ResultsAge was a significant determinant of RRV, despite the narrow range (33–47): participants aged 33–39 years had had greater levels of HF power, LF power, and standard deviation (SD) of RR intervals than did those aged 40–47 years. There was no age effect for the LF/HF ratio. Compared to whites, blacks had lower levels of LF power, SD, and lower LF/HF. Blacks and whites did not differ in HF power. Finally, compared to men, women had lower levels of LF power, SD, and LF/HF but did not differ in HF power. ConclusionsData from the CARDIA study suggest that in adults in the 33–47 year age range, indices of RRV were greater in younger compared to older subjects, in men compared to women and in whites compared to blacks. These findings are broadly consistent with those of other large studies examining relationships between RRV and age, sex, and race. However, patterns of associations between RRV and these stratification variables are not entirely consistent with an underlying autonomic physiology linked to cardioprotection.

Cardiovascular disease in type 1 diabetes mellitus

The association between type 1 diabetes and coronary heart disease has become very clear since the late 1970. It has been demonstrated that there is an important increased risk in morbidity and mortality caused by coronary artery disease in young adults with type 1 diabetes compared with the non diabetic population. The underlying pathogeneses is still poorly understood. While the role of glycemic control in the development of microvascular disease complication is well established its role in CVD in patients with DM1 remains unclear with epidemiologic studies reporting conflicting data. Recent findings from the DCCT/EDIC showed that prior intensive diabetes treatment during the DCCT was associated with less atherosclerosis, largely because of reduced level of HbA1c during the DCCT. The improvement of glycemic control itself appeared to be particularly effective in younger patients with shorter duration of the disease. Other analyses suggested the glycemia may have a stronger effect on CAD in patients without than in those with albuminúria. Other major determinants of coronary artery disease are the components of metabolic syndrome and the surrogate measure of insulin resistence: eGDR. It is proposed that patients with DM1 should have aggressive medical therapy, risk factor modification and careful monitoring not only of his blood sugar but also of the other processes involved in the atherosclerotic process, mostly the ones with family history of type 2 diabetes.

Syndrome X (angina pectoris with normal coronary arteries) and myocardial infarction in patients with anti-phospholipid (Hughes) syndrome

Patients with clinical features of angina pectoris in the absence of coronary artery pathology have remained an enigma to clinicians. Previous data has suggested that almost 20% of women with symptoms suggestive of angina had abnormal stress induced ischaemia. This phenomenon is more commonly observed in women than in men. 1 Anti-phospholipid (Hughes) syndrome (APS) is an autoimmune disease of unknown aetiology characterized by arterial and/or venous thromboses, pregnancy losses and the presence of anti-phospholipid antibodies (aPL). 2 Although thrombosis and pregnancy loss are the cardinal features of APS, heterogeneous clinical features such as cardiac valve involvement, livedo reticularis and low platelets are also described. 3 There is accumulating evidence to suggest that there is an increased risk of accelerated atherosclerosis in patients with primary APS as well as APS associated with SLE. 4 Since the description of the APS (Hughes) syndrome in 1983, a number of cardiac manifestations have been described in association with APS, 5,6 including cardiac valvular abnormalities (Libman‐Sacks endocarditis). The syndrome has been implicated in coronary artery disease in young adults and coronary artery bypass graft occlusions. 7 Vaarala 8 described an increased prevalence of myocardial infarction (MI) in patients with aPL. Hamsten et al. 9 found an association between the presence of aPL and recurrent cardiovascular events in young survivors of MIs. Although typical MI with occluded coronary arteries is well described in patients with APS, there are a number of reports describing anginal chest pain and MI with normal coronary arteries in patients. In 2002, we described a patient with syndrome X and Hughes syndrome, suggesting that MI in APS may be associated with normal coronary arteries. 10 Further anecdotal

Imaging Popliteal Artery Disease in Young Adults with Claudication: Self-Assessment Module

The educational objectives of this self-assessment module on imaging popliteal artery disease in young adults with intermittent claudication are for the participant to exercise, self-assess, and improve his or her knowledge of the imaging and clinical features of popliteal artery entrapment syndrome, cystic adventitial disease,and masses associated with popliteal artery obstruction.

Towards the end of the Spanish paradox?

For many decades, we have known the association between cardiovascular disease and atherogenic lipid profi le (low HDL-cholesterol, high LDL-cholesterol and high Lp(a) levels). The great majority of these studies have been performed on adult subjects. However, studies of autopsies made on young soldiers killed during the Korean War revealed the presence of aortic fatty streaks. Therefore, the atherosclerosis theory suggests that the development of the atherosclerotic plaque may occur in a very early stage of life. Recent studies confi rm this assertion showing the presence of fatty streak and fi brous plaques among children and teenagers. Other studies clearly showed the association between teenagers having a high risk lipid profi le and the development of coronary artery disease in young adults. These data suggest that an early screening of teenagers at risk could reduce the incidence of future cardiovascular events. Therefore, the AVENA study is important (see article in this issue, Ruiz et al). The main objective of this study was to provide references values for the serum lipids among Spanish teenagers. This type of study is precious because they are not numerous. The AVENA study is also essential because it concerns European teenagers, which will enable us to compare various regions from the South of Europe. The results of the AVENA study are very similar to the ones observed in the meta-analysis performed in Spain fi fteen years before by Plaza et al. However, important differences are to be underlined. For the Spanish teenagers, the HDLcholesterol levels were slightly lower than the ones measured two decades before and the total cholesterol levels were slightly higher compared to the data from Greece. These data suggest that Spain is loosing its cardiovascular advantage, which was well-known as the Spanish paradox. The process of acculturation (the modifi cation of the culture of a group or an individual as a result of a contact with a different culture) is not only related to the migratory phenomena but it also is a result of the globalization. The Spanish life-style is changing as in most industrial countries. Nowadays, the consumption of fat among Spanish children and teenagers is increasing, while their vegetable and fruit intake is decreasing. They also reduce their physical activities. A raise of obesity and metabolic syndrome are the consequences expected for the next decades. These very fast life-style changes will have dramatic consequences on the incidence of cardiovascular disease. The red light is on: about ten percent of the US teenagers suffer from metabolic syndrome and two thirds present at least one metabolic abnormality. Biomarkers of increased risk of cardiovascular disease are already present in these young subjects. The AVENA study should be the fi rst step for early prevention of cardiovascular disease. We hope that the future recommendations are going to promote a change of life-style rather than prescriptions of pills or “polypills”. The success of such a strategy cannot take place without the creation of a real health promotion politic in European countries. Juan Ruiz

Prognosis of coronary artery disease in young adults

In this way, in order to determine the clinical evolution in males with coronary heart disease under 50 years of age a group of 229 male patients before 50 years of age (mean age 43F5 years), who were admitted to our Coronary Care Unit as result of an episode of coronary disease, were prospectively studied. A mean follow-up of 32F13 months was made with special attention to mortality and the cause as such, appearance of angina, myocardial infarction, heart failure and the need for coronary revascularization. The results are summarized in Table 1. Two patients died in the acute phase: one due to sigmoid adenocarcinoma with severe carcinomatosis and the other due to sudden death. During follow-up the causes of mortality were as follows: sudden death eight (73%), heart failure one (9%) and neoplasia two (18%). We conclude that medium term prognosis of young male patients with coronary disease shows a mortality of around 5% being sudden death the principal etiology. The appearance of an episode of angina is frequent in the follow-up of these patients (36%). The number of patients presenting heart failure or myocardial infarction is small. Almost 10% of these patients require coronary revascularization during a follow-up of 3 years.

Comparative value of carotid ultrasound, high sensitivity C-reactive protein, and low-density lipoprotein particle size in predicting coronary artery disease in young adults

Comparative value of carotid ultrasound, high sensitivity C-reactive protein, and low-density lipoprotein particle size in predicting coronary artery disease in young adults