|Year : 2011 | Volume
| Issue : 1 | Page : 7-11
Coronary artery disease in patients aged 35 or less - A different beast?
T Christus1, AM Shukkur1, I Rashdan2, T Koshy1, M Alanbaei2, M Zubaid2, N Hayat2, A Alsayegh1
1 Department of Cardiology, Chest Diseases Hospital, Ministry of Health, Kuwait
2 Faculty of Medicine, Kuwait University, Kuwait
|Date of Web Publication||25-May-2011|
Interventional Cardiologist, Chest Diseases Hospital, P.O.BOX - 4082, Safat, 13041
Source of Support: None, Conflict of Interest: None
| Abstract|| |
Aim: To assess the extent and severity of coronary artery disease (CAD) in 200 consecutive patients aged 35 years or less undergoing diagnostic coronary angiography.
Patients and Methods: Findings in these 200 patients (≤ 35 years of age) were analyzed to find the extent and severity of CAD. The mean age was 31.69 (±3.76) years. Majority were males (94%) and from the Arab ethnicity (70.5%).
Result: Smoking (71%) and history of premature CAD (27%) were the most frequent risk factors (RF). History of previous ST elevation myocardial infarction (MI) was present in 68%. Anterior wall MI was the most frequent location (63.3%). The majority (54.3%) had moderate or large size MI. Ejection fraction (EF) less than 50% was noted in 30.3%. Left main or triple vessel CAD was seen in 15%. One- and two-vessel CAD was seen in 32.5% and 19% patients, respectively. Coronary angiogram was completely normal in 23.5%. The majority (54.5%) were treated conservatively and the rest (45.5%) needed percutaneous coronary intervention (PCI) or coronary artery bypass graft (CABG). The mean number of stents used was 1.3 ± 0.67 and the mean length of stents used was 20.3 ± 12.6 mm.
Conclusion: The extent and severity of CAD was very significant in this subgroup of very young (≤35 years) Asian patients. Smoking was the main risk factor and half of the patients needed either PCI or CABG.
Keywords: Coronary artery disease; premature coronary artery disease, young patients, ethinicity
|How to cite this article:|
Christus T, Shukkur A M, Rashdan I, Koshy T, Alanbaei M, Zubaid M, Hayat N, Alsayegh A. Coronary artery disease in patients aged 35 or less - A different beast?. Heart Views 2011;12:7-11
|How to cite this URL:|
Christus T, Shukkur A M, Rashdan I, Koshy T, Alanbaei M, Zubaid M, Hayat N, Alsayegh A. Coronary artery disease in patients aged 35 or less - A different beast?. Heart Views [serial online] 2011 [cited 2020 Apr 4];12:7-11. Available from: http://www.heartviews.org/text.asp?2011/12/1/7/81550
| Introduction|| |
Manifest coronary artery disease (CAD) in a young person can have devastating consequences to the patient and to the family. , Many studies take age <40 years when choosing to study young patients with CAD. ,, Patient subgroups <35 years are at times referred as very young.  Studies in young patients focus on the clinical presentation, severity of the disease, presence of risk factors, and prognosis. ,,,
It is estimated that about 10% of individuals presenting with documented CAD are <45 years of age.  This estimate could vary considerably depending on the population at study. For example, it is known that patients from the Indian subcontinent present relatively early and may have more extensive CAD compared to their counterpart from other ethnic groups. ,,,, We also know that traditional risk factors of CAD seen in the elderly age group do not apply to younger age group. ,,,
Angiographic data regarding the extent and severity of CAD in the very young patients with manifest CAD is very limited. The limited data seem to suggest higher prevalence of single vessel CAD and less of triple vessel CAD in the young. A study from the UK found more complex stenosis morphology in the younger patients compared to the older.  On the other hand one angiographic study from North India found less diffuse disease in the younger patients. 
It is also known that the long-term prognosis and functional status of young patients who have acute myocardial infarction (MI) is not benign.  Though percutaneous coronary intervention has been done successfully in young patients with very promising short-term results; , in the long term there was need for repeat revascularization in a significant proportion of patients.  Encouraging results have been reported in young patients undergoing CABG. ,,, Lytle et al. from the Cleveland Clinic have reported excellent 5-year survival in 107 patients ≤35 years undergoing CABG. Similar encouraging results were reported by Fitzgibbon et al. in 138 men ≤39 years old.
If we want to understand the complexities of manifest CAD in the young, we need to study patients from different population subgroups in detail. Though there are studies on CAD in the young, overall there is a paucity of detailed studies from various geographical and ethnical subgroups. Also angiographic studies are very few and do not analyze the details of angiographic morphology.
Therefore, we analyzed the ethinicity, extent and severity of CAD in the very young in patients undergoing diagnostic coronary angiography in our hospital.
| Patients and Methods|| |
Two hundred consecutive patients aged ≤35 years undergoing diagnostic coronary angiography (CAG) were enrolled in the study. Relevant historical details were gathered and entered in a specially prepared questionnaire. Height and weight were measured and the body mass index (BMI) expressed as kg/m 2 was calculated. BMI more than 25 and ≤30 was considered overweight and >30 as obesity. Overnight fasting samples were obtained for the blood tests.
Diagnsotic CAG was performed from the right femoral artery using the standard percutaneous techniques. Selective left and right coronary angiograms were performed in multiple angulated views. In most cases left ventricle (LV) was entered and the left ventricular end diastolic pressure (LVEDP) was measured. LV angiography was done in the right anterior oblique projection. LV ejection fraction (EF), extent of myocardial wall motion abnormality (to assess the size of the MI), and the severity of mitral regurgitation (MR) if any were noted.
Detailed analysis of the angiographic images was done by two experienced interventional cardiologists. With regard to the coronary arteries attention was paid to the presence of any luminal narrowing and to the number of coronary vessels and segments involved. Morphology of the lesions and other angiographic abnormalities were also documented. Eye-balling method was used to estimate the percentage and length of the lesions. Depending on the degree and extent of regional wall motion abnormality, MI size was estimated as small, medium, or large.
Coronary artery segments studied
We evaluated the following coronary artery segments separately to assess the extent and severity of disease. Left main coronary artery, proximal, mid and distal left anterior descending (LAD) artery segments, major diagonal branches, proximal, mid and distal circumflex artery segments, major obtuse marginal branches (in addition Ramus Intermedius branch if present), proximal, mid and distal right coronary artery (RCA) segments, posterior descending artery (PDA), and posterolateral (PL) segments.
Data was entered and analyzed using SPSS version 13.
| Results|| |
Out of 6918 patients catheterized during a 36-month period, there were 200 patients ≤35 years of age. Their mean age was 31.69 (± 3.76) years with a range of 19-35 years. There were 188 males (94%) and 12 females (6%). The major proportion (68.9%) of the patients was Arabs and the rest was mostly from the Indian subcontinent.
Risk factors for CAD
Risk factor profile was fully evaluated [Table 1]. As expected, smoking was the most common risk factor seen in 71% (142/200). Obesity (BMI more than 30 kg/m 2 ) was seen in 20% and overweight (BMI more than 25 kg/m 2 ) in 39%. Family history of CAD was obtained in 27% of patients, whereas hypertension and diabetes mellitus were seen only in 19.5% and 17%, respectively. Mean serum LDL cholesterol was 3.27 mmol/L (±0.14) with 36.5% having values >3.4 mmol/L and 70% having values >2.5 mmol/L. Serum total cholesterol >4.9 mmol/L was seen in 42.7%.
|Table 1: Baseline features and coronary risk factors in patient population|
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Indications for CAG
Most of the patients (72.5%) were referred for CAG after acute coronary syndrome. History of prior MI was obtained in 68% [Table 2].
In the 136 patients with history of MI, involvement of the anterior wall was the most common and was seen in 63.3% [Table 3]. Clinical evidence of heart failure was seen in 5.6%.
Hemodynamic features and LV angiography
Mean LVEDP was 17.72 mmHg. LV end-diastolic and end-systolic volumes were mildly increased. LVEF was <50% in 30.3% patients. MR was seen in 10.5% and was mild in most the cases. The majority of patients (54.3%) were found to have moderate or large size MI (as estimated from LV angiogram) [Table 4].
Coronary angiographic features are shown in [Table 3]. Significant CAD was seen in a high percentage (65%) with the majority (32.5%) having single-vessel CAD. Most patients with significant CAD had either one or two segments involved. However a good number of patients had more segments involved, with eight segments being the most extensive. Similarly distal vessel coronary artery disease was not uncommon, being documented in 33 patients. In those with involvement of multiple segments (three to eight segments), complex lesion anatomy was seen in 12 patients. Total occlusion of significant size vessel was seen in 44 patients. Total 26.5% of patients had proximal LAD segment involved. About half of the patients needed revascularization with PCI (32%) or CABG (13.5%) [Table 5].
Percutaneous coronary intervention
In patients undergoing PCI, the mean number of stents used was 1.3±0.67. The mean length of stents used was 20.3±12.6 mm and the mean diameter of the stents was 3.03±0.25mm.
Coronary artery bypass graft surgery
In patients undergoing CABG the mean number of grafts was 2.57±1.29 (range 1-5). And 47.6% needed three or more grafts and in 23.8% four or five grafts were used.
| Discussion|| |
Peculiarities of CAD in the young
There is a special interest in studying CAD in the young due to the peculiarities in this subgroup. Studies have been done to evaluate CAD in the young as well as to compare it with CAD in an older age group. ,,, Younger patients have relatively lower prevalence of traditional risk factors such as diabetes mellitus, systemic hypertension, and hyperlipidemia. However, history of smoking and family history of early CAD are seen more commonly. ,
In agreement with earlier studies, we found a history of smoking to be the most important risk factor in 71% of the patients. Similarly family history of CAD was present in a high percentage of patients. A complex interplay of genetic and environmental factors in the presence of smoking is the most likely reason for the early manifestation of CAD in these patients.
Not much literature is available with respect to angiographic features in very young patients undergoing CAG, and when available they represent only a very small percentage of total population of young patients with CAD. Wolfe et al. from the USA analyzed angiographic features in 35 patients who were <35 years of age (1.5% of the total number catheterized). They were compared with 100 patients ≥55 years of age. They found a very low prevalence of triple-vessel CAD in the first group (14.3%) as compared to 43% in the second group. In the study by Glover et al.,  120 consecutive patients 35 years or younger underwent coronary angiography following a clinical MI. Significant CAD was seen in 78% and the prevalence of triple-vessel CAD was 42%.
In an earlier article published from our center, we had studied 60 patients less than 35 years of age following a first MI.  Significant CAD was present in 73.3%. However triple-vessel CAD was seen only in 5%. In 25% there was involvement of more or equal to three coronary artery segments.
Chen et al. from the United Kingdom analyzed the findings in 100 male patients with the clinical onset of disease at age ≤45 years. These were compared with the findings in 100 older male patients ≥60 years. Younger patients were found to have angiographically complex stenosis morphological features (59% vs 36%; p<0.01). At the same time, they had less extensive CAD (one vessel CAD in 54% vs 36%; p< 0.001). Triple-vessel disease was present in only 10% of the young patients.
Wei et al. from Boston compared young men and women with MI and noted atherosclerosis to be more advanced and accounting for most MIs in men and less so in women. The prevalence of normal coronaries, atherosclerotic CAD, and nonatherosclerosis causes of MI in young patients have varied in different studies. ,,,,,,
Implication of angiographic findings from the present study
LVEF <50% was seen in above a third of our patients. LV dysfunction in this young age would definitely affect the long-term prognosis. When compared to our earlier study on very young patients  and published in 1999, the percentage of triple-vessel disease has increased from 5% to 12.5% and that of single-vessel disease has decreased from 46.7% to 32.3%. In the present study involvement of ≥4 segments was seen in 20.8% patients as compared to only 11.4 % in our earlier study. Whether these differences represent a more aggressive disease in the later years is not clear.
Uniqueness of this study
We have studied very young Asians from the Arab and Indian subcontinent backgrounds. Cut-off age of ≤35 years years represents very young patients. We used the number of diseased vessels involved (one-, two-, three vessel or left main) to assess the severity of CAD. We have done more detailed analysis of the angiographic features.
Limitations of the study
We have not done a detailed analysis of the various lipoprotein subfractions. Analysis of the lipoprotein subfractions including Lp(a) would throw more light on the pathogenesis of premature CAD in our patients. We also could not do any genetic studies. As in many other studies we have used eye-balling to grade angiographic stenosis. It could be argued that a more objective quantitative analysis would yield more accurate results.
The future scope
We live in an age where there is a global rise in the prevalence of manifest CAD. This is occurring even in developing countries and is affecting a significant number of people at a younger age. There is an urgent need to study this subject at greater depth and come out with adequate preventive and therapeutic measures before it is too late.
| Acknowledgments|| |
We appreciate the technical help we received from our Cardiac Catheterization laboratory staff, both radiology technicians and nursing staff. Also we acknowledge the secretarial help from Shahid Khan and his colleagues.
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[Table 1], [Table 2], [Table 3], [Table 4], [Table 5]
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