A Rising Threat of Very Young Age Myocardial Infarction

Dear Editor,

I am writing to highlight the increasing threat of myocardial infarction (MI) among individuals 40 years of age and younger. This condition often presents with atypical signs and symptoms and is frequently not properly assessed or managed. It was also observed that among Indians, premature coronary artery disease is 5%–10% more common than among other ethnicities.[1] Therefore, it is crucial to raise awareness about preventing MI in this younger population.

Beyond traditional risk factors, recent evidence suggests that COVID-19 infection can directly and indirectly increase the risk of MI in young individuals, primarily through inflammation and the hypercoagulable state.[2] While rare, myocarditis has also been reported after mRNA COVID-19 vaccination, most often in males under 30, generally with a mild and self-limiting course.[3] Importantly, the risk of severe cardiac complications is significantly greater after SARS-CoV-2 infection than after vaccination, and vaccination remains strongly recommended for young adults to lower overall risk.[4]

It has been observed that there is a notable rise in cardiovascular events among very young individuals, which is linked to common atherogenic risk factors like hypertension, diabetes mellitus, smoking, obesity, hyperlipidemia and family history with frequency of 80%–85%.[1] Moreover, some risk factors are also uniquely contributing to the rising incidence of MI in this age group, including substance abuse (amphetamines, cocaine, marijuana, etc.), strenuous physical activity, allergic and hypersensitivity reactions, psychological stress, infections (such as SARS COV 2, HIV, Helicobacter pylori, Chlamydia, etc.), thrombophilia, cardiomyopathy, spontaneous coronary artery dissection and immune diseases like autonomic neurocardiogenic syndrome (frequency 15%–20%).[1,5] There are also few articles, where COVID-19 is said to accelerate the occurrence of MI among younger population.[6]

SUBSTANCE ABUSE AND HEART PROBLEMS

Substance abuse, particularly involving substances like cocaine, heroin, and various forms of amphetamines, has become alarmingly common among young adults. This misuse can trigger a spectrum of heart-related issues, ranging from elevated heart rates to heart attacks.[7]

These findings reinforce current recommendations for substance abuse screening and counselling among young adults to prevent future adverse events. Early intervention for mental health and substance use disorders via primary care screening is also recommended as part of comprehensive cardiovascular risk reduction.

Given the wide spectrum of contributing factors, a comprehensive prevention strategy is essential. The following prevention strategies are recommended:

• Promote regular, moderate-intensity physical activity such as brisk walking, swimming, or cycling for at least 150 min per week, with gradual progression to avoid acute cardiac stress.[8]

• Conduct targeted awareness campaigns using mass media and digital health platforms to educate on modifiable risk factors and recognition of atypical MI symptoms in the young.[9]

• Implement school-based and workplace-based health programs for early screening of hypertension, diabetes, hyperlipidemia, and substance abuse, which have proven successful in risk reduction.[10]

• Integrate behavioral counseling for smoking and substance cessation, weight management, stress reduction, and healthy dietary habits into routine practice for youth and young adults where possible, with referrals to specialists as appropriate.[11]

• Ensure healthcare providers screen for cardiovascular and mental health comorbidities, emphasizing the favorable risk–benefit profile in preventing severe disease.[4]

PHYSICAL ACTIVITY AND MYOCARDIAL INFARCTION

Among all preventive measures, physical activity deserves special consideration as a protective factor against heart disease, but sudden, intense exertion, especially in previously inactive individuals, can precipitate MI.[12] Clinicians should encourage a gradual increase in activity and educate at-risk youth on warning signals that merit medical evaluation. Regular physical activity is widely recommended to prevent MI, whereas engaging in excessively strenuous activity can paradoxically increase the risk of MI. Physical activity plays a crucial role in preventing many non-communicable diseases (NCDs) and improving mental health, making it an essential part of a healthy lifestyle.[13] However, the intensity and type of exercise must be carefully managed to avoid adverse outcomes.

Vigorous exercise may acutely increase the risk of MI and sudden cardiac death due to the factors such as increased stress in myocardium, coronary artery spasm, and plaque disruption, particularly in those with pre-existing atherosclerosis. The risk is highest in habitually inactive individuals, who suddenly engage in intense physical exertion.[8]

To avoid the risk of MI, individuals should aim for regular, moderate-intensity physical activity, with gradual increase in intensity. Sudden, strenuous exertion, especially in previously inactive people, can paradoxically precipitate MI. Other Contributing Conditions Leading to MI:

• Allergic and Hypersensitivity Reactions: Severe reactions can cause coronary artery spasms and increase the risk of MI.[14]

• Psychological Stress: Chronic stress leads to elevated levels of stress hormones, promoting atherosclerosis and thrombosis.[14]

• Infections: Pathogens like, HIV, Helicobacter pylori, and Chlamydia can trigger inflammatory responses that affect cardiovascular health. The SARS-CoV-2 virus induces a hypercoagulable state and inflammatory response, potentially leading to plaque rupture and thrombosis.[1]

• Thrombophilia: Blood clotting disorders increase the risk of thrombosis, leading to heart attacks.[15]

• Cardiomyopathy: Structural heart diseases can predispose individuals to ischemic events.[15]

• Spontaneous Coronary Artery Dissection: This rare condition can cause heart attacks, especially in young women.[15]

CONCLUSION

The rising incidence of MI among very young individuals is an alarming trend that necessitates immediate attention. The interplay of traditional cardiovascular risk factors, such as hypertension, diabetes, and smoking, with non-traditional factors like substance abuse, strenuous physical activity, and infectious agents, significantly contributes to the early onset of MI in this population. Collectively, these observations underscore a pressing need for action like targeted prevention strategies, including early screening, lifestyle modifications, and comprehensive counseling, to mitigate these risks. Increasing awareness and understanding of the unique factors contributing to MI in younger individuals is crucial to improve outcomes and reducing the burden of this life-threatening condition.

Conflicts of interest

There are no conflicts of interest.

Funding Statement

Nil.