Acute Coronary Syndrome In Young Patients Research Articles

Elevated Lp(a) and thrombophilic mutations : the experience of a general hospital

Abstract Funding Acknowledgements None. Background Thrombophilia and elevated Lp(a) levels have been studied as risk factors predisposing to cardiovascular events. There is no evidence suggesting that the common mutations causing thrombophilia or elevated Lp(a) alone could be regarded as independent risk factors for acute coronary syndromes. Purpose To compare the frequency of the simultaneous presence of thrombophilic mutations along with elevated Lp(a) levels in young patients presenting with acute coronary syndrome (ACS) compared with those without ACS. Methods We retrospectively analyzed the data from all the young patients (males<40yo, females <45yo) who were referred for thrombophilia testing to our hospital for a period of 10 years and divided them in two groups : those who presented with ACS (ACS group) and those who were referred for thrombophilia testing for other reason (non ACS group). Lp(a) level >30mg/dl was considered as elevated. We compared the frequency of elevated Lp(a) levels in patients carrying the same mutation in the two groups. P<0.01 was considered statistically significant. Results Of the 127 patients recorded in the ACS group, 25 were factor V Leiden homozygotes, 11 factor V Leiden heterozygotes, 17 PAI 4G/5G homozygotes, 8 PAI 4G/5G heterozygotes, 36 G20210A homozygotes and 12 G20210A heterozygotes. In the non ACS group, we analyzed data from 312 patients.Of them, 12 were factor V Leiden homozygotes, 29 factor V Leiden heterozygotes, 31 PAI 4G/4G homozygotes, 17 PAI 4G/5G heterozygotes, 66 G20210A homozygotes and 57 G20210A heterozygotes. Elevated Lp(a) levels were found as follows : (ACS vs non-ACS group) factor V Leiden homozygotes 14/25(56%) vs 1/12(8.33%) (p<0.01), factor V Leiden heterozygotes 7/11(8.66%) vs 2/29(6.89%), p<0.01), PAI 4G/4G homozygotes 1/17(5.88%) vs 0/31, PAI 4G/5G heterozygotes 0/8 vs 0/31), G20210A homozygotes 0/36 vs 1/66(1.51%), G20210A heterozygotes 1/12(9.44%) vs 0/57). Conclusions Lp(a) was elevated more frequently in patients carrying factor V Leiden mutation (either homozygotes or heterozygotes) who presented with ACS when compared with patients without ACS. Although it is not established, further studies are needed in order to identify any possible correlation of the combination of this mutation along with elevated Lp(a) levels with the occurrence of ACS in young patients.

Acute coronary syndrome in young (≤45 Years) patients: a multicenter observational study

Introduction: Acute Coronary Syndrome (ACS) in young individuals (≤45 y) is increasingly recognized as a significant health concern, yet research in this demographic remains limited, particularly within the Palestinian context. This study aims to bridge this gap by comprehensively investigating the clinical characteristics, age-specific profiles, gender disparities, treatment modalities, and angiographic patterns of ACS in young patients compared to their older counterparts. Materials and Methods: A multicenter observational study was conducted, enrolling 468 participants aged 18-55 diagnosed with ACS and admitted to three prominent Palestinian hospitals. Data were collected from medical records, and statistical analysis was performed to assess demographic characteristics, clinical presentations, risk factors, treatment strategies, and outcomes. Results: The majority of participants were male (87%), with a higher proportion in the older age group (>45 y). Clinical presentations varied, with Non-ST Segment Elevation Myocardial Infarction (NSTEMI) being the most common diagnosis (48%). Risk factors such as smoking, hypertension, and diabetes were prevalent, with notable gender and age-specific differences. Percutaneous Coronary Intervention (PCI) was the predominant treatment strategy (83%), with consistent medication use across age groups. Conclusion: ACS in young patients poses a significant public health challenge in Palestine, necessitating tailored preventive strategies and comprehensive management approaches. Understanding the unique demographic and clinical characteristics of young ACS patients is crucial for informing targeted interventions and policies aimed at reducing the burden of cardiovascular disease in this population. These findings contribute valuable insights to the existing literature and underscore the importance of further research in this area to improve outcomes and mitigate the impact of ACS in young individuals globally.

Breaking the silence: uncovering the underdiagnosis of SCAD in young women with acute coronary syndromes

Abstract Background Spontaneous Coronary Artery Dissection(SCAD) is a recognized cause of Acute Coronary Syndrome (ACS), particularly in young women. Despite increasing awareness, underdiagnosis of SCAD remains common. Given the distinct differences in management and potential outcomes, a prompt and accurate diagnosis of SCAD is crucial for appropriate treatment and follow-up. Purpose To assess the prevalence and implications of SCAD underdiagnosis in young women with ACS and to identify potential indicators of SCAD. Methods We included consecutive women aged ≤55 years with an ACS referred for coronary angiography (CAG) to a tertiary center from 2012 to 2021. All index CAG’s and when available intracoronary imaging recordings were retrospectively reviewed to identify angiographic signs of SCAD according to the Yip-Saw criteria. Known cardiovascular risk factors, predisposing conditions for SCAD, and major adverse cardiovascular events (hospital visits, recurrent ACS, target vessel revascularization, stroke) were collected during hospitalization and follow-up. SCAD patients were compared to ACS patients without SCAD (atherosclerotic coronary artery disease, coronary spasm, no abnormalities). Subsequentially, the initially recognized SCAD patients were compared to the reclassified SCAD patients. Results 293 patients (mean age 48±5 years) were included, 217 (74%) presenting as STEMI and 64 (22%) as NSTEMI. Based on retrospective analysis of the (intra)coronary images SCAD was the underlying cause of the ACS in 17% of all patients (n=50/293) while only recognized at initial diagnosis in 26% (n=13/50) of these cases. SCAD type 2a was most frequently missed (30%). Compared to ACS patients without SCAD, SCAD patients were younger (47±6 vs. 49±5 years, p<0.05), had lower rates of smoking (28% vs. 60%, p<0.05) and less often a history of dyslipidemia (10% vs. 24%, p<0.05) and diabetes (2% vs. 16%, p<0.05). Furthermore, the coronary tortuosity score was higher (4.7±2.0 vs. 3.0 ±1.5, p<0.05). Invasively treated SCAD patients often received ≥3 coronary stents when compared to ACS patients without SCAD (28% vs. 15%, p=0.02) mostly due to hematoma extension. Follow-up showed ACS based on atherosclerosis occurred less often in SCAD patients compared to non-SCAD patients (resp. 9% vs. 14%, p<0.05), and recurrent SCAD was only recorded in reclassified SCAD patients (5% vs. 0%, p<0.05). On multi-variate analysis, the coronary tortuosity score (1.58 [1.3-1.88]) was associated with SCAD. Conclusion This study reveals that underdiagnosis of SCAD is common in young women with ACS leading to incorrect treatment with specific medication and excessive coronary stenting. Healthcare providers should be cautious for SCAD in young ACS patients with few cardiovascular risk factors and high coronary tortuosity scores. This study emphasizes the need for greater awareness and improved diagnostic methods for SCAD in young women with ACS.

20-year trends in the prevalence of modifiable cardiovascular risk factors in young acute coronary syndrome patients hospitalised in Switzerland.

Modifiable cardiovascular risk factors (RFs) play a key role in the development of coronary artery disease. We evaluated 20-year trends in RF prevalence among young adults hospitalised with acute coronary syndromes (ACS) in Switzerland. Data were analysed from the Acute Myocardial Infarction in Switzerland (AMIS) Plus registry from 2000 to 2019. Young patients were defined as those aged <50 years. Among 58'028 ACS admissions, 7'073 (14.1%) were young (median 45.6 years, IQR 42.0-48.0), of which 91.6% had at least one modifiable RF, and 59.0% had at least two RFs. Smoking was the most prevalent RF (71.4%), followed by dyslipidaemia (57.3%), hypertension (35.9%), obesity (21.7%) and diabetes (10.1%). Compared with older patients, young patients were more likely to be obese (21.7% vs 17.4%, p < 0.001) and active smokers (71.4% vs 33.9%, p < 0.001). Among young patients, between 2000 and 2019 there was a significant increase in the prevalence of hypertension from 29.0% to 51.3% and obesity from 21.2% to 27.1% (both ptrend < 0.001), but a significant decrease in active smoking from 72.5% to 62.5% (ptrend = 0.02). There were no significant changes in the prevalence of diabetes (ptrend = 0.32) or dyslipidaemia (ptrend = 0.067). Young ACS patients in Switzerland exhibit a high prevalence of RFs, and are more likely than older patients to be obese and smokers. Between 2000 and 2019, RF prevalence either increased or remained stable, except for smoking which decreased but still affected ∼2/3 of young patients in 2019. Public health initiatives targeting RFs in young adults in Switzerland are warranted.

Characteristics and treatment analysis of young acute coronary syndrome patients in a tertiary care hospital: A cross-sectional retrospective study.

The prevalence of acute coronary syndrome (ACS) has been rising in the younger population worldwide. To fully comprehend the effects of the condition, it is crucial to examine the evolving characteristics and treatment options. The purpose of this study is to evaluate the characteristics and treatment analysis for young ACS patients in a tertiary care setting. This cross-sectional, retrospective, single-center study included a random sample of patients who had been hospitalized for ACS over the period of a year. We collected and analyzed data on risk factors, diagnoses, angiographic patterns, and potential treatments. The study involved 198 young ACS patients in total. The majority of patients (57%) had no risk factors, and the majority of them (44%) had ST-elevation myocardial infarction (STEMI) as their diagnosis. The most common type (48%) was single-vessel disease (SVD). Statins and antiplatelet medications made up the majority of the patients' nonsurgical treatments (88% and 87%, respectively). A statistically significant difference exists between young and older ACS patients with gender (p < 0.01). However, it is not clinically relevant. Men were the majority of young ACS patients, and STEMI, SVD were more prevalent. The majority of young ACS patients had no significant risk factors. To determine the risk factors of young ACS patients, a more thorough case-control study is critically needed.

Clinical and economic impact of coronary artery bypass graft and percutaneous coronary intervention in young individuals with acute coronary syndromes and multivessel disease: A real-world comparison in a middle-income country.

In recent decades, the world watched a dramatic increase in the incidence of acute coronary syndromes (ACS) among young individuals (≤55 years-old) and a relative decrease in the elderly. The management of ACS in young patients with multivessel disease still needs to be elucidated, as these individuals maintain a long life expectancy. To compare clinical outcomes and care costs in individuals with premature ACS and multivessel disease undergoing coronary artery bypass graft surgery (CABG) or percutaneous coronary intervention (PCI). Participants included all individuals ≤55 years-old admitted with ACS to public hospitals in Brasília (Brazil) between 2013 and 2015 and who underwent cardiac catheterization with SYNTAX score ≥23 or Duke category 6. Outcomes were adjudicated with death certificates and data from medical records. The primary outcome was the occurrence of major adverse cardiovascular events (MACE), defined as death due to cardiovascular causes, recurrent hospitalizations due to cardiovascular ischemic events, and incident heart failure New York Heart Association III-IV. As secondary outcome we assessed indirect and direct costs by evaluating the cost of lost productivity (in international dollars (Int$) per year) due to illness and death, outpatient costs and costs with new hospitalizations. Multivariate and principal components (PC) adjusted analyzes were performed. Among 1,088 subjects (111 CABG and 977 PCI) followed for 6.2 years (IQR: 1.1), 304 primary events were observed. MACE was observed in 20.7% of the CABG group and 28.8% of the PCI group (p = 0.037). In multivariate analyses, PCI was associated with a hazard ratio (HR) = 1.227 (95% CI: 1.004-1.499; p = 0.0457) for MACE, and in PC-adjusted HR = 1.268 (95% CI: 1.048-1.548; p = 0.0271) compared with CABG. Despite direct costs were equivalent, the cost due to the loss of labor productivity was higher in the PCI group (Int$ 4,511 (IQR: 18,062)/year vs Int$ 3,578 (IQR: 13,198)/year; p = 0.049], compared with CABG. Among young individuals with ACS and multivessel disease, surgical strategy was associated with a lower occurrence of MACE and lower indirect costs in the long-term.

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

IntroductionLevels of lipoprotein (LP) (a) are useful marker for risk stratification of cardiovascular disease. This genetic biomarker is suggestive of patient predisposition to acute coronary event. The present study was to study correlation of LP(a) levels and plaque morphology in very young patients (<35 years) with acute coronary syndrome (ACS). MethodsA prospective, single-center, observational study consisting of very young patients with ACS and fit for optical coherence tomography (OCT) guided invasive coronary angiography was conducted at tertiary-care centre. LP(a) levels were compared between healthy controls and very young ACS patients. Correlation of LP(a) levels and plaque characteristics in very young ACS patients was done using OCT imaging. ResultsOut of enrolled 80 subjects, 40 were very young ACS and 40 were matched healthy controls. In very young patients, plaque rupture and erosion were mechanism of ACS in 67.5% and 32.5% patients, respectively. Mean levels of LP(a) were 28.10 ± 13.96 nmol/l in healthy controls and 47.19 ± 29.85 nmol/l in very young patients with ACS (p = 0.022). Among very young ACS patients, patients with LP(a) levels<75 nmol/l and ≥75 nmol/l had mean thin cap fibroatheroma thickness of 117.08 ± 52.542 μm and 95.00 ± 36.286 μm, respectively (p = 0.2355). ConclusionHigher levels of LP(a) were seen in younger patients with ACS compared with matched healthy individuals. Plaque rupture was the commonest mechanism of ACS in very young ACS patients. Patients with high LP(a) levels had lesser thickness of fibrous cap in OCT imaging compared with low levels of LP(a).

Using Machine Learning Techniques to Predict MACE in Very Young Acute Coronary Syndrome Patients.

Coronary artery disease is a chronic disease with an increased expression in the elderly. However, different studies have shown an increased incidence in young subjects over the last decades. The prediction of major adverse cardiac events (MACE) in very young patients has a significant impact on medical decision-making following coronary angiography and the selection of treatment. Different approaches have been developed to identify patients at a higher risk of adverse outcomes after their coronary anatomy is known. This is a prognostic study of combined data from patients ≤40 years old undergoing coronary angiography (n = 492). We evaluated whether different machine learning (ML) approaches could predict MACE more effectively than traditional statistical methods using logistic regression (LR). Our most effective model for long-term follow-up (60 ± 27 months) was random forest (RF), obtaining an area under the curve (AUC) = 0.79 (95%CI 0.69–0.88), in contrast with LR, obtaining AUC = 0.66 (95%CI 0.53–0.78, p = 0.021). At 1-year follow-up, the RF test found AUC 0.80 (95%CI 0.71–0.89) vs. LR 0.50 (95%CI 0.33–0.66, p < 0.001). The results of our study support the hypothesis that ML methods can improve both the identification of MACE risk patients and the prediction vs. traditional statistical techniques even in a small sample size. The application of ML techniques to focus the efforts on the detection of MACE in very young patients after coronary angiography could help tailor upfront follow-up strategies in such young patients according to their risk of MACE and to be used for proper assignment of health resources.

Acute coronary syndromes in young patients: Phenotypes, causes and clinical outcomes following percutaneous coronary interventions.

BackgroundThe prevalence of acute coronary syndromes (ACS) among young individuals is increasing, but the phenotypic characteristics, causes and clinical outcomes in this group have not been well described. MethodsBetween 2009 and 2017, 8712 ACS patients underwent percutaneous coronary intervention (PCI) and were prospectively enrolled. We defined a young patient as female <50 years and male <45 years. The causes of ACS were defined by an adjudication committee. The primary endpoint was the patient-oriented composite endpoint (POCE) of all-cause mortality, myocardial infarction or any revascularization at 12 months. ResultsAmong 8712 ACS patients, 472 (5.4%) patients were young (26% female). The main cause of ACS in young patients was atherosclerosis (86.5%), followed by coronary artery embolism (9%), and spontaneous coronary artery dissection (SCAD) (4.5%). POCE occurred less frequently in young compared to old patients (8.5% vs. 16.7%, hazard ratio 0.48 (95% confidence interval 0.35–0.66), p < 0.001). The rates of the individual components of the POCE were lower in young including all-cause mortality (3.2% versus 9.5%, 0.32 (0.19–0.54), p < 0.001), myocardial infarction (1.9% versus 3.7%, 0.49 (0.25–0.95), p = 0.035) and any revascularization (5.1% versus 7.4%, 0.65 (0.43–0.97), p = 0.037). Young patients with SCAD had a higher rate of death as compared to those with atherosclerosis, mainly attributed to cardiac deaths. ConclusionsOne out of 20 ACS patients undergoing PCI was young and the principal cause was atherosclerosis. Young carry a lower risk for future events compared to older ACS patients. The underlying cause leading to ACS should be considered in appropriate risk stratification of young patients.Clinical Trial Registration:Clinicaltrials.gov. NCT02241291

Prevalence of Metabolic Syndrome Components among EarlyAge onset Acute Coronary Syndrome Patients in Bangladesh

Aim: Metabolic Syndrome (MetS), a significant risk factor for coronary artery disease (CAD), is now highly prevalent in South Asian countries, including Bangladesh. The diseases also affect young people. A large number of young populations with acute coronary syndrome (ACS) have MetS. The aim of this study was to determine the prevalence of MetS and the combination of components in patients with early age onset ACS (age ≤50 years). Methods: This prospective study comprised 678 consecutive patients age ≤50 years hospitalized for ACS during 2012-2013. The patients were categorized according to the criteria stated in the latest joint statement for the global definition of MetS. Results: Among 678 ACS patients, 236 (34.8%) patients have filled the criteria of MetS. The mean age was 42.4 ± 0.28 years. The prevalence of MetS was higher in females than in males (48.8% vs. 30.4%, p &lt; 0.001). One component of MetS was found in 26.4%, two components in 29.8%, three or more components in 34.8% of young ACS study participants. Among the various components of MetS, low HDL and high TG were the crucial common components of MetS in young ACS patients in Bangladesh (low HDL: 51.9%, high TG: 44.8%). Conclusions: We conclude that the prevalence of MetSin patients with early age onset ACS (age ≤50 years) is high in Bangladesh. Since Low HDL and high TG are the most common components of MetSin our study, these biochemical parameters would be a clinical target for early treatment. Strategies are needed for the early detection and treatment of cardio-metabolic risk factors to prevent coronary artery disease progression and prognosis.

752 Acute coronary syndrome in young patients: long-term follow-up and quality of life assessment

Abstract Aims Early onset acute coronary syndrome (ACS) is associated with a more aggressive evolution and its consequences can be devastating to the quality of life (QOL), affecting the patient’s psychology, ability to work, and the socioeconomic burden. In the last decade, the incidence of ACS in young patients (≤45 years old) is increased but unfortunately, little is known about long-term follow-up and impact on quality of life. The aim of this study was to analyse the clinical evolutions and the QOL in this specific group of patients. Methods and results We included 91 consecutive young patients (≤45 years at the time of presentation) with ACS referred from October 2013 until March 2021 to our clinic. All enrolled patients underwent angiography. We analysed the clinical presentation, echocardiography, and therapy at the time of discharge. Furthermore, patients underwent telephone follow-up after 40 months: new hospitalizations, cardiovascular events, bleeding, and relevant changes in medical therapy were investigated. In addition, patients were also invited to participate to a survey to investigate QOL, sexual, and socioeconomic changes after ACS. QOL was explored through the EQ-5D scale using the time trade-off (TTO) and visual analogue scale (VAS) technique based on European values. Mean age was 40.6 ± 3.6 years and 17.6% were women. Most patients had obstructive coronary artery disease at angiography (90.1%) and 85.7% underwent PCI. At a median follow-up of 40 months, major adverse cardiovascular events (MACE) a composite of death, myocardial infarction, stroke and definite stent thrombosis, occurred in 12% of patients (Figure 1). Patient reported bleeding occurred in 29.8%, while bleeding requiring hospitalization in 3.6%. Univariate predictors of MACE were previous stroke, Killip class at presentation, current drug use, left ventricle ejection fraction, wall motion score index (WMSI), and haemoglobin at admission. Young patients showed reduced levels of QOL (TTO: 0.85 ± 0.17—VAD: 0.79 ± 0.17), with higher levels among individuals without obstructive coronary artery disease (Figure 2). Predictors of lower quality of life were WMSI, left anterior descending (LAD) stenting, left ventricular aneurysm and ventricular thrombus (Figure 3). After 12 months from the index event, 31.5% of patients were still on dual antiplatelet therapy, and the mean number of medications was 4.65 ± 2.3. Conclusions In conclusion, young patients have a high residual risk of ischaemic and bleeding events and impaired QOL. Optimization of medical therapy and better patient information is of upmost importance to mitigate residual risk of adverse events.

Abstract 9862: Correlation of Lipoprotein(a) 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 (&lt;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 &lt;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 (&lt;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.

Associations between hyperhomocysteinemia and the presence and severity of acute coronary syndrome in young adults\u2009\u2264\u200935\xa0years of age

BackgroundThe prevalence of acute coronary syndrome (ACS) continues to increase among young Chinese adults. Homocysteine (HCY) has been suggested as a promoter of atherosclerosis leading to coronary artery disease (CAD). Yet, it remains uncertain whether HCY is associated with the ACS and the severity of coronary artery stenosis in young adults.MethodsYoung patients (18–35 years of age) diagnosed with ACS who underwent coronary angiography (CAG) at Anzhen Hospital between January 2013 and June 2019 were assigned to the ACS group. As confirmed by CAG during the same period, an equivalent age-matched population without CAD was assigned to the non-CAD group. A serum HCY level > 15 µmol/L was defined as hyperhomocysteinemia (HHCY). The Gensini score assessed the severity of coronary artery stenosis.ResultsA total of 1103 participants, including 828 ACS patients and 275 non-CAD subjects, were enrolled in this study. Young ACS patients had higher level of serum HCY and greater prevalence of HHCY compared with non-CAD subjects [for HCY, 16.55 (11.93–29.68) vs 12.50 (9.71–17.42), P < 0.001; for HHCY prevalence, 62.08% vs 26.18%, P < 0.001]. Multivariate logistic regression analysis with the stepwise method indicated that HHCY was an independent predictor associated with the presence of ACS, after adjusting for traditional confounders (OR, 4.561; 95% CI, 3.288–6.327; P < 0.001). Moreover, young ACS patients with HHCY had increased prevalence of ST-segment elevation myocardial infarction (STEMI) (P = 0.041), multi-vessel disease (P = 0.036), and decreased value of left ventricular ejection fraction (LVEF) (P = 0.01). Also, the HCY level was significantly correlated with Gensini Score in ACS patients (r = 0.142, P < 0.001).ConclusionHHCY is significantly associated with the presence of ACS and the severity of coronary artery stenosis in young adults ≤ 35 years of age.

Comparison of demographic profile, risk factors, and in-hospital outcome in young and old patients with acute coronary syndrome: A single-center experience.

Background:Coronary artery disease (CAD) is witnessing a demographic transition with increasing prevalence in younger individuals. Data is scarce comparing various characteristics of acute coronary syndrome (ACS) between young and old patients in an Indian setting. Hence, we evaluated the epidemiological, demographic, risk factor, and outcome profile of young and old ACS patients in Indian setting.Methods:This was a prospective observational study, which enrolled 50 consecutive ACS patients each into two groups: younger (≤45 years) and elderly (>45 years), respectively. Comparison of clinical presentation, electrocardiography, echocardiographic findings, conventional, nonconventional risk factors, and in-hospital outcomes including duration of hospital stay and major adverse cardiac events (MACE) were made between the two groups. Multivariate regression analysis of risk factors as determinants of MACE adjusting for other confounding factors was also performed.Results:Fifty patients in each group were compared. Mean age in the younger and elderly group was 36 ± 4.69 and 61.58 ± 10.69 years, respectively. Male sex, smoking, family history of CAD, hyperhomocysteinemia, and obesity were observed more in the younger population. While dyslipidemia, low physical activity, diabetes mellitus, and history of previous ACS was more in the older population. Single-vessel disease was more common in younger patients while multivessel involvement was more common in elderly patients. Older patients had longer hospital stays and more in-hospital MACE including deaths. By multivariate analysis, shock was found to be an independent predictor of MACE in both groups.Conclusion:Younger ACS patients have a different risk profile and better in-hospital outcomes compared to older patients.

Abstract 236: Triaging Young Patients With Acs in the Ed - A Case Report

Introduction: Cardiovascular Disease (CVD) is the leading cause of death in the United States. According to the Centers for Disease Control and Prevention (CDC), one person dies every 37 seconds from complications of CVD. One of the main complication of CVD is acute coronary syndrome (ACS) which includes unstable angina as well as an acute myocardial infarction (AMI). 1 More than 790,000 Americans have an AMI annually, of which 73% are first-time AMIs. 2 These events generally affect older people, with an average age of 65.6 years for men and 72 years for women. Furthermore, only 0.3% of men and women under the age of 39 will have an AMI. 3,4 As a result, it is often overlooked among this population in the acute care setting. We present the case of a young man with a delayed diagnosis of ACS despite typical presentation and EKG findings. Case presentation: A 27 year old male presented after three days of progressive substernal chest pain at rest. ECG revealed anterolateral ST elevations, but “No STEMI” was noted on the EKG and a troponin was not drawn for 4 hours. While the ED did not have a specific diagnosis in mind, they did not believe such a young person likely had ACS and originally ‘misread’ the EKG. Triage to PCI did not occur until troponin returned positive later that afternoon, more than 8 hours after initial presentation. Cardiac angiography showed a complete occlusion of the mid LAD requiring a single DES. Post-procedure ECG showed persistent anterolateral ST elevation raising concern for future complications in part due to delayed triage. Discussion: The delayed presentation and triage of this patient warrants discussion. While there is a lack of data on door to balloon time based on age for ACS patients, it appears extremely likely that this diagnosis was missed, despite EKG findings and typical chest pain, in part due to age related bias. This case raises concern that providers are hesitant to diagnosis ACS in young patients due to its low prevalence in this population and warrants further study on steps that can be taken to decrease missed ACS diagnoses and the resultant suboptimal medical outcomes that may follow.

Comparison of long-term mortality between living alone patients vs. living together patients with acute coronary syndrome treated with percutaneous coronary intervention.

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.

Clinical and angiographic features of acute coronary syndrome in young adults: A Tunisian Cohort

Acute coronary syndrome (ACS) in young adults seems to be not as low as expected. It presents one of the highly debated issues in cardiology according to the increasing number of those patients. The aim of our study was to describe the clinical and angiographic profile in young patient ≤ 40 years diagnosed with ACS. We performed a retrospective study including 74 patients younger than 40 years of age with clinical and electrocardiographic evidence of ACS, hospitalized in our cardiology department from January 2016 to Mach 2019. All patients underwent a coronary angiography. We analyzed the risk factors, clinical profile, type of ACS and angiographic features of these patients. Mean age was 33 ± 7 years old [26-40] and 94% of them were males (five women versus 70 men). All men were smokers, including four man addicted on cannabis, and only two women were non-smokers. The most common risk factors were diabetes mellitus (14 patients; 19%), systemic hypertension (10 patients; 13.5%), dyslipidemia (7 patients; 9.4%), obesity (7 patients; 9.4%) and a family history of premature coronary artery disease (5 patients; 6.7%). Ten patients (13.5%) were having ST segment elevation myocardial infraction, 13 patients (17.5%) were hospitalized for a non-ST segment elevation and 51 patients (69%) have a history of an unstable angina. The most common abnormal arteriography findings were the involvement of one vessel (23 patients; 31%), followed by double-vessel disease noticed in two cases (2.7%). There was one patient of our population with three-vessel disease (1.3%). The most common vessel to be involved was the left anterior descending (12 cases; 16%). Normal coronary angiography was noticed in 37 patients (50%). ACS in young patients has a huge impact on the patient, the society and the economic burden. It presents a real challenge that the cardiologist must be aware of in order to set on the ideal therapeutic strategy including the perfect clinical management and an early prevention program to control the cardiovascular risk factors.

Major risk factors for developing acute coronary syndrome in young adults

Aim . To study the factors associated with the development of acute coronary syndrome in young adults. Methods . 299 patients with acute coronary syndrome (ACS) aged 25 to 44 years admitted to the Cardiology Department at the Regional Government Budgetary Healthcare Institution “Altai Regional Cardiology Dispensary” were enrolled in the study. The mean age of patients was 40.3±0.2 years. The control group included 53 healthy subjects without cardiovascular diseases aged 25 to 44 years (the mean age of 39.9±0.79 years). Traditional risk factors were assessed in all patients. CBC and blood biochemistry were performed in all patients to determine lipid profile and fasting glucose levels. Additionally, height and weight were measured with the subsequent calculation of the body mass index. Patients with ACS underwent electrocardiography, echocardiography, coronary angiography. Gene polymorphisms FII G20210A, FV G1691A, MThFr C677T were evaluated by polymerase chain reaction in 116 young adults present with ACS and 53 healthy volunteers. Results . Based on the comprehensive assessment of the clinical and demographic data, traditional risk factors and hemostatic and folate metabolism gene polymorphisms assessment in young adults, the most significant risk factors associated with the development of ACS in young patients included smoking, elevated low-density lipoprotein cholesterol with the presence of FV G1691A heterozygous polymorphism. The obtained findings could be effectively used in clinical practice to determine patients at high risk of cardiovascular diseases. Conclusion . Thus, screening for high risk of cardiovascular diseases among young adults should include genetic testing of FV G1691A and MTHFR C677T gene polymorphisms along with traditional risk factors to introduce additional examinations and employ novel preventive strategies.

Lipoprotein(a) screening in young and middle-aged patients presenting with acute coronary syndrome.

Elevated lipoprotein(a) [Lp(a)] is an independent risk factor for coronary artery disease (CAD). However, its role in real-world practice and implications for clinical care remains limited. Under investigation herein, are the clinical characteristics associated with increased Lp(a) levels in patients presenting with acute coronary syndrome (ACS). Lp(a) was measured at admission in patients ≤ 65 years of age presenting with ACS in a single center. Logistic regression model was used to determine the independent association of clinical characteristics with elevated Lp(a). A total of 134 patients were screened for Lp(a); 83% males, mean age 52 ± 8 years. Median Lp(a) level was 46 nmol/L (interquartile range [IQR] 13-91). Elevated Lp(a) > 72 nmol/L (30 mg/dL) was documented in 32% and associated with younger age at CAD diagnosis. In a multiple logistic regression model, premature CAD (odds ratio [OR] 3.85, 95% confidence interval [CI] 1.48-10.07, p = 0.06), previous revascularization (OR 2.56, 95% CI 1.17-5.59, p = 0.019) and probable/definite familial hypercholesterolemia (FH) (OR 3.18, 95% CI 1.10-9.21, p = 0.033), were independently associated with elevated Lp(a). In contrast, Lp(a) levels were not associated with other traditional cardiovascular risk factors, previous statin treatment, C-reactive protein level or ACS type. In young and middle-aged patients presenting with ACS, premature CAD, previous revascularization and FH were independently associated with elevated Lp(a), indicating progressive CAD and higher cardiovascular risk. These results, are in accordance with guideline based recommendations for Lp(a) screening, and may be of importance in addressing residual cardiovascular risk in young ACS patients, in light of the novel emerging therapies targeting Lp(a).

SYNTHETIC CANNABINOIDS: A LESS UNDERSTOOD CAUSE OF ACUTE CORONARY SYNDROME

SESSION TITLE: Monday Abstract Posters SESSION TYPE: Original Investigation Posters PRESENTED ON: 10/21/2019 02:30 PM - 03:15 PM PURPOSE: Current research suggests there is an association between natural cannabinoid use and acute coronary syndrome (ACS). Via an extensive literature review we will describe how synthetic marijuana can cause ACS in patients lacking typical cardiac risk factors. METHODS: Cardiology, critical care, and emergency medicine journals were searched for keywords including marijuana, tetrahydrocannabinol (THC), K2/spice in addition to ACS, myocardial infarction and sudden death. Inclusion criteria were topic relevance, peer review, and recent publication. RESULTS: A Norwegian study revealed THC as the only drug present in six postmortem patients with unexplained sudden death. Another larger study identified a 4.8-fold increase in acute myocardial infarction risk within an hour of marijuana use. Multiple case reports have linked synthetic derivatives, known as K2/spice, with ACS in young patients with no known health issues including three cases of myocardial infarction in teenage boys as well as several ACS events in healthy adults. CONCLUSIONS: An active component of both natural and synthetic marijuana is THC. It blocks parasympathetic pathways via norepinephrine release and is thought to be the cause of most cardiovascular effects. One study found a 6-53% increase in heart rate and a 4-9% rise in cardiac output after smoking marijuana, while another found a 30% increase in cardiac output and a dose-dependent increased heart rate of 20-100%. Both factors can lead to oxygen demand/delivery mismatch, which marijuana exacerbates further by increasing carboxyhemoglobin. THC can also disrupt oxygen delivery via vasospasm of the coronary vessels, increased shear stress of the arterial walls, and by forming a procoagulant state due to increased tissue factor expression in monocytic cells. Cannabinoid receptor type 1 (CB1R) is one of two receptors found abundantly in the central and peripheral nervous systems. When bound by THC, CB1R triggers autonomic responses which directly affect the vascular endothelial and smooth muscles, myocardium, and circulating erythrocytes. A recent study found CB1R leads to p38 and JNK mitogen-activated protein kinase (MAPK) activation. This increases reactive oxygen species (ROS) generation and contributes to endothelial and cardiomyocyte cell dysfunction or death. Synthetic cannabinoids are mixtures of several synthetic CB1R agonists. They can be up to 170-times more potent, leading to severe cardiac outcomes. CLINICAL IMPLICATIONS: More research is needed to fully understand effects of synthetic cannabinoids on the cardiovascular system, as synthetic marijuana may be much more dangerous than natural cannabis. It is paramount for both emergency and critical care physicians to be cognizant of the possible detrimental effects of synthetic marijuana in order to prevent ACS related events in the future. DISCLOSURES: No relevant relationships by Gary Esper, source=Web Response No relevant relationships by Peter Nesbitt, source=Web Response No relevant relationships by Ravi Patel, source=Web Response No relevant relationships by Heidi Storer, source=Web Response No relevant relationships by O'Rell Williams, source=Web Response No relevant relationships by Thijs Wolf, source=Web Response