Abstract
Background:
Cardiovascular diseases (CVD) and its complications are on an increasing trend in the younger age group. In this study, we aimed to identify the different risk factor profile and coronary angiographic characteristics of young adults presenting with coronary artery disease.
Methods:
We conducted this retrospective observational study at Tata Main Hospital, Jamshedpur, Jharkhand, for 5 years between April 2015 and March 2020. Inclusion criteria being patients admitted for acute coronary syndrome or chronic stable angina, aged ≤40 years, who underwent coronary angiography. Those below 40 years of age who underwent angiography in non-CAD (coronary artery disease) setting were excluded.
Results:
Among the 117 cases included in this study, 81.1% were males and 18.8% were females. Majority of cases, i.e., 52.2% were in the age group of 36–40 years. Risk factor evaluation showed hypertension as the major risk factor, present in 30.76% of patients, followed by diabetes mellitus in 21.36%, Dyslipidaemia was noted in 7.6%. History of smoking was present in 8.54%, history of smokeless tobacco use was in 7.69%, family history of CAD was noted in 9.4% of patients. Among 117 cases, SVD (single-vessel disease) was most prevalent, seen in 55.5% cases. 21.3% had normal or recanalized coronaries. Among SVD, LAD (Left anterior descending artery) was the most commonly involved vessel (80%).
Conclusions:
Young patients with CAD are mainly males, and SVD in the form of LAD is more commonly involved. In this vulnerable age group, more emphasis should be given on diagnosis and management of risk factors.
Keywords: Coronary angiography, coronary artery disease, young adults
Introduction
Cardiovascular diseases (CVD) are responsible for approximately 12 million deaths in the Indian subcontinent every year.[1] As per The Global Status Report on Noncommunicable Diseases, CVD has caused 2.5 million deaths in India in 2008. According to the World Health Organization statistics of 2014, CVD contributed to 26% of total mortality.[2]
There are several studies suggesting that Asians in general and Indians are at an increased risk of myocardial infarction at a younger age (≤40 years).[3] Heart diseases among Indians are rising and it presents 5–10 years earlier in comparison to other populations of the world. The mean age at the first presentation of acute myocardial infarction in Indians is 53 years.[4]
Premature CAD (PCAD) is defined as the onset of coronary artery disease (CAD) before the age of 40.[5,6] In young Indians incidence of CAD is about 12% –16%, which is higher than any other ethnic group.[3,7]
Assessment of atherosclerotic cardiovascular risk remains the foundation of primary prevention. All individuals should be encouraged to follow a heart-healthy lifestyle.[8]
Out of several risk factors like hypertension, diabetes mellitus, dyslipidemia, family history of CAD, obesity, the use of inhaled tobacco products is a strong risk factor for coronary artery disease, myocardial infarction (MI), and mortality in young adults.[9]
With this background, this study was done to assess the demographic and angiographic profile and risk factors of critical CAD in patients aged ≤40 years who were evaluated for chronic stable angina or for the acute coronary syndrome (ACS).
Materials and Methods
This was a cross-sectional, record-based study done in Tata Main Hospital, Jamshedpur, a 980-bedded tertiary care hospital in eastern India. The study population consisted of all patients aged 40 years or less, who underwent coronary angiogram between April 2015 and March 2020.
It was a record-based study in which the details of all such cases were extracted from the case records.
Inclusion criteria included all patients aged ≤40 years, who gave written informed consent, presented with ACS or stable angina, and who underwent coronary angiography (CAG) based on the ACC/ESC indications for CAG.[10,11]
Those aged above 40 years were excluded from the study. Those below 40 years of age who underwent angiography in non-CAD settings were also excluded.
Demographic details were noted. Detailed risk factors evaluation was done through case record and questionnaire.
Diagnostic CAG was performed by interventional cardiologists through radial or femoral route. A detailed analysis of angiographic images was done by the operator.
Patients were grouped into single-vessel disease (SVD), double vessel disease (DVD), and triple vessel disease (TVD) according to the number of major epicardial coronary arteries involved.[12] Stenosis of the coronary vessels was considered mild when the luminal diameter was reduced by <50%, moderate (50%–70%), and significant (>70%) of the original diameter.
Results
This was a retrospective observational study. We studied the coronary angiographic findings of 127 cases. Of them, 10 cases were excluded based on exclusion criteria, sample size being 117 of young CAD patients. Among the 117 cases included in the study, 95 (81.1%) were males and 22 (18.8%) were females [Table 1].
Table 1.
Distribution of cases according to sex
| Sex | n (117) | % |
|---|---|---|
| Male | 95 | 81.19 |
| Female | 22 | 18.81 |
Maximum number of cases i.e., 67 (52.2%) were in the age group of 36-40 years, while 37 (31.6%) were between 31-35 years, 8 (6.8%) were between 26-30 years of age group and 5 (4.2%) were between 19 to 25 age group [Table 2].
Table 2.
Distribution of cases according to age
| Age (in yrs.) | n (117) | % |
|---|---|---|
| 19-25 | 5 | 4.27 |
| 26-30 | 8 | 6.83 |
| 31-35 | 37 | 31.62 |
| 36-40 | 67 | 57.26 |
Out of 117 cases, ST-segment elevated myocardial infarction was seen in 67 (57.2%), Non-ST segment elevated myocardial infarction in 10 (8.5%) and Unstable angina in 13 (11.1%) cases. 27 (23%) patients underwent angiography for chronic stable angina [Table 3].
Table 3.
Distribution of cases according to presentation
| CAD | n (117) | % | |
|---|---|---|---|
| AWMI | 52 | 44.44 | |
| IWMI | 13 | 11.11 | |
| LWMI | 2 | 1.70 | |
| NSTEMI | 10 | 8.54 | |
| UNSTABLE ANGINA | 13 | 11.11 | |
| CH. STABLE ANGINA | 27 | 23.07 |
Risk factor evaluation showed Hypertension as the major risk factor present in 36 (30.76%) of patients, followed by Diabetes mellitus in 25 (21.36%), Dyslipidaemia was noted in 9 (7.6%). History of smoking was present in 10 (8.54%), history of smokeless tobacco use was in 9 (7.69%), two patients were obese, Family history of CAD was noted in 11 patients. One patient had hyperhomocysteinemia. In 25 patients, none of the conventional risk factors could be elicited [Table 4].
Table 4.
Distribution of cases according to risk factor association
| RISK FACTORS | n (117) | % |
|---|---|---|
| Hypertension | 36 | 30.76 |
| Diabetes | 25 | 21.36 |
| Family history of CAD | 11 | 9.40 |
| Smoking | 10 | 8.54 |
| Smokeless tobacco | 9 | 7.69 |
| Dyslipidemia | 9 | 7.69 |
| Obesity | 2 | 1.70 |
| Hyperhomocysteinemia | 1 | 0.85 |
| Without risk | 14 | 11.96 |
Among 117 cases, SVD was most prevalent, seen in 65 (55.5%) cases, followed by DVD in 14 (11.9%) and TVD in 4 (3.41%) cases. 9 (7.6%) had mild to moderate CAD. 25 (21.3%) had normal/recanalized coronaries [Table 5].
Table 5.
Distribution of cases according to number of artery involved
| CAD | n (117) | % |
|---|---|---|
| SVD | 65 | 55.55 |
| DVD | 14 | 11.96 |
| TVD | 4 | 3.41 |
| NORMAL/ RECANALISED CORONARIES | 25 | 21.36 |
| MILD- MODERATE CAD | 9 | 7.69 |
Among the single vessel disease cases (n = 65), location of stenosis was seen in LAD (Left anterior descending) in 52 (80%), LCX (Left circumflex) in 7 (10.8%), RCA (Right coronary artery) in 6 (9.2%). Among the double vessel disease cases (n = 14) involvement of LAD + LCX was seen in 6 (42.5%), LAD + RCA in 2 (15%) and LCX + RCA in 6 (42.5%) cases. Triple vessel disease was seen in 4 cases [Table 6].
Table 6.
Distribution of cases according to Coronary artery territory
| CAD | Territory | |
|---|---|---|
| LAD | 52 (80%) | |
| SVD (n 65) | LCX | 7 (10.8%) |
| RCA | 6 (9.2%) | |
| DVD (n 14) | LAD + LCX | 6 (42.5%) |
| LAD + RCA | 2 (15%) | |
| LCX + RCA | 6 (42.5%) | |
| TVD (n 4) | LAD + LCX + RCA | 4 |
Discussion
The present study determines the demographic characteristics and angiographic extent of coronary artery lesions in young adults. This retrospective observational study was carried out on young patients of age 40 year or less. We studied the coronary angiographic findings of 127 cases. Of them 10 cases were excluded based on exclusion criteria, sample size being 117 young CAD patients.
Among the 117 cases included in the study, 95 (81.1%) were males and 22 (18.8%) were females. The mean age (SD) of candidates <40 years of age who underwent coronary angiogram was 35.8 year.
Previous studies on epidemiological data from angiographically proven cases of PCAD (≤40 years) in native Indians suggest dyslipidaemia as the most prevalent risk factor.[13,14,15] In contrast, in our study, hypertension was the most common risk factor, followed by Diabetes mellitus and family history of CAD. 12% patients did not have any risk factors. Often, there is a tendency to miss blood pressure measurement during general examination of young patients. But the above finding in our study highlights the importance of detecting and adequately treating hypertension even in younger population.
In this study, nearly third-fourth of the cases (70.92%) had significant CAD, normal/recanalized coronaries were reported in 21%.
In a study from Poland on angiographic characterization in CAD patients aged <40 years, the mean age in the study group was 35.1 ± 4.4 years and men made up 86.2% of the study group. Angiographically, normal coronary arteries were found in 16.9% of patients diagnosed as ACS. SVD in CAG was seen in 61.9% of patients with positive result of CAG (stenosis >50%). The significant atherosclerotic coronary lesions mainly affected the left anterior descending (LAD) coronary artery (61.6%), followed by right coronary artery (RCA) (27.4%).[16]
In a study from Bangladesh, 38% of patients <40 years of age had normal coronary arteries and 4% had noncritical coronary lesions.[6]
In another study from Nepal, SVD (58.3%) was the most common finding in CAG and 7.6% patients had normal or non-obstructive coronary lesions.[17]
In this study, about two-third of the cases with critical CAD had SVD (74, 66.07%), followed by DVD (25, 22.32%) and TVD (13, 11.61%). LAD was the most common vessel involved (60), followed by RCA (52), left circumflex (41), and left main.[3]
In another study from South India, majority of the patients (57.14%) had SVD, followed by normal coronaries (22.45%); 16.3% had DVD and 4% had multivessel disease.[18]
In consistence with Badran et al., Ahmed Hussein, and Christus et al.,[19,20,21] the present study also found higher rate of SVD among PCAD.
Heart diseases are occurring in Indians 5–10 years earlier than in other populations around the world.[22] According to the INTERHEART study, the median age for the first presentation of acute myocardial infarction in the South Asian (Bangladesh, India, Nepal, Pakistan, Sri Lanka) population is 53 years, whereas that in Western Europe, China, and Hong Kong is 63 years.[3]
Primary care physicians need to be aware of this fact of earlier onset of CAD in our population, so that they can be more vigilant in dealing with young patients with chest pain. Prompt diagnosis and timely referral to a cardiac centre for further management, including timely coronary interventions, can result in better outcomes such as preserved LV function, reduction in risk of arrhythmias and heart failure and overall improvement in morbidity and mortality.
It is equally important to emphasize on primary prevention and aggressive risk factors modification, including focus on healthy lifestyle, thereby reducing the incidence of CAD in young.
There are a few main limitations of this study. First, only patients who presented with symptoms and underwent angiogram were included in this study. Second, this was a single-centre study, hence the results cannot be generalized to the community. Nevertheless, this study identifies and scrutinizes a decent sample size to investigate the prevalence of PCAD and provides valuable information regarding the magnitude of the problem.
Conclusion
Incidence of critical CAD is increasing in young adults due to an unhealthy lifestyle. It leads to the loss of work days, transition from an active to sedentary working life and decreased efficiency.
Affected young patients were observed predominantly to be males. Hypertension was the most common risk factor. SVD was more common and LAD was the most commonly involved coronary artery.
In this vulnerable age group, more emphasis should be given on early diagnosis and management of modifiable risk factors. For those who do not have any risk factor further evaluation should be done to search non-conventional risk factors.
Prevention of the disease by changing lifestyle, dietary habits, and regular exercise is the best way to improve the results.
Ethics clearance
The proposal for study was presented to our institutional Ethics Committee and necessary clearances were obtained.
Financial support and sponsorship
Nil.
Special Thanks
Priyanka Ranjan for helping in collection and sorting of data.
Conflicts of interest
There are no conflicts of interest.
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