Clinical and Pharmacological Analysis of the Acute Coronary Syndrome Patients Under 45 Years of Age: A Prospective Cohort Study
Abstract
Background/Aim: Acute coronary syndrome (ACS) in young people is a problem of growing concern. There is an increasing need to evaluate this disease and predict its sequelae for better prevention and management. Aim of this study was to analyse clinical and pharmacological aspects of ACS hospitalised patients for a better evaluation and prediction.
Methods: The study included questionnaire based data taken from 225 patients (207 males, 18 females) admitted to Ibn Al-Nafees tertiary cardiac centre. Socio-economic, clinical and pharmacological data were obtained from all patients with follow up from time of admission to discharge.
Results: Male to female ratio was 11.5:1, anterior infarction was the predominant site (54.6 %), mortality rate was 1.3 %. Ejection fraction (LVEF) was below 45 % in 66.7 % of the patients, majority (70.7 %) with ischaemic hypokinesia. Smoking was the most common risk factor (77.3 %). Heart failure (HF) was the most common complication (57.3 %). There were significant relationship between HF occurrence and number of risk factors, LVEF, anterior site of ACS and number of echo findings. There were non-significant increase in relative risk of HF with each risk factor, positive troponin and pre-admission pain duration. Prediction tests showed an ascending positive slope of HF risk with number of risk factors, duration of admission and age.
Conclusion: There was a high rate of HF occurrence in this study which is mostly attributed to major wall damage due to blockage of the main coronary artery. Analysis demonstrated a good survival rate but high rate of HF occurrence urges for more consideration of guideline-directed management.
References
Byrne RA, Rossello X, Coughlan JJ, Barbato E, Berry C, Chieffo A, et al; ESC Scientific Document Group. 2023 ESC Guidelines for the management of acute coronary syndromes. Eur Heart J. 2023 Oct 12;44(38):3720-826. doi: 10.1093/eurheartj/ehad191.
Thygesen K, Alpert JS, Jaffe AS, Simoons ML, Chaitman BR, White HD, et al; Writing Group on the Joint ESC/ACCF/AHA/WHF Task Force for the Universal Definition of Myocardial Infarction; ESC Committee for Practice Guidelines (CPG). Third universal definition of myocardial infarction. Eur Heart J. 2012 Oct;33(20):2551-67. doi: 10.1093/eurheartj/ehs184.
Tan YC, Sinclair H, Ghoorah K, Teoh X, Mehran R, Kunadian V. Gender differences in outcomes in patients with acute coronary syndrome in the current era: A review. Eur Heart J Acute Cardiovasc Care. 2016 Nov;5(7):51-60. doi: 10.1177/2048872615610886.
Naji AA, Abbas AA, Hashem RB. Evaluation of serum RANKL level in acute coronary syndrome. Al-Kindy Coll Med J. 2014;10(2):45-8.
Freedman JE, Loscalzo J. Platelet-monocyte aggregates: bridging thrombosis and inflammation. Circulation. 2002 May 7;105(18):2130-2. doi: 10.1161/01.cir.0000017140.26466.f5.
Gilutz H, Shindel S, Shoham-Vardi I. Adherence to NSTEMI guidelines in the emergency department: regression to reality. Crit Pathw Cardiol. 2019 Mar;18(1):40-6. doi: 10.1097/HPC.0000000000000165.
Singh A, Museedi AS, Grossman SA. Acute coronary syndrome. 2023 Jul 10. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2024 Jan–. PMID: 29083796. Available at: https://pubmed.ncbi.nlm.nih.gov/29083796/.
Karthikeyan T, Raja M, Radha D, Gaur T A, Geetha J, Sakthivadivel V. Risk factors and inflammatory markers in acute coronary syndrome-ST elevation myocardial infarction (STEMI). Horm Mol Biol Clin Investig. 2023 Mar 20;44(2):115-20. doi: 10.1515/hmbci-2021-0106.
Dauriz M, Morici N, Gonzini L, Lucci D, Di Chiara A, Boccanelli A, et al. Fifteen-year trends of cardiogenic shock and mortality in patients with diabetes and acute coronary syndromes. Am J Med. 2020 Mar;133(3):331-9.e2. doi: 10.1016/j.amjmed.2019.07.044.
Guedeney P, Collet JP. Diagnosis and management of acute coronary syndrome: what is new and why? Insight From the 2020 European Society of Cardiology Guidelines. J Clin Med. 2020 Oct 28;9(11):3474. doi: 10.3390/jcm9113474.
Poudel N, Alurkar VM, Jha GS, Kafle R, Sapkota S, Lamsal L. Profile of acute coronary syndrome in young people: a hospital based observational study in western Nepal. BJHS. 2018;3(1):361-5. doi: 10.3126/bjhs.v3i1.19759.
Choudhury L, Marsh JD. Myocardial infarction in young patients. Am J Med. 1999;107(3):254–61. doi: 10.1016/S0002-9343(99)00218-1.
Avezum A, Makdisse M, Spencer F, Gore JM, Fox K, Montalescot G, et al. Impact of age on management and outcome of acute coronary syndrome: observations from the Global Registry of Acute Coronary Events (GRACE). Am Heart J. 2005 Jan;149(1):67-73. doi: 10.1016/j.ahj.2004.06.003.
Dakhil Z. 67 young patients with non-ST elevation acute coronary syndromes: baseline characteristics, in-hospital management and outcomes. Heart. 2021;107:A55-A56. doi: 10.1136/heartjnl-2021-BCS.67.
Chouhan L, Hajar HA, Pompisiello JC. Comparison of thrombolytic therapy for acute myocardial infarction in patients aged <35 and >55 years. Am J Cardiol. 1993;71:157–9. doi: 10.1016/0002-9149(93)90731-q.
Mohammad AM, Abdulhaleem BH, Habeeb QS. First 24 h’ outcomes of acute coronary syndrome in Iraq. Med J Babylon. 2020;17:154-8. doi: 10.4103/MJBL.MJBL_15_20.
Jalal Khaznadar AA, Salh RW. Impact of age on risk factors and clinical manifestations of acute coronary syndrome: observations from the coronary care unit of Sulaimani, Iraq. Hosp Pract Res. 2020;5(1):28-34. doi: 10.34172/hpr.2020.06.
Che-Muzaini CM, Norsa'adah B. Complications of acute coronary syndrome in young patients. Iran J Public Health. 2017 Jan;46(1):139-40. PMID: 28451542.
Swaroop G. Post-myocardial infarction heart failure: a review on management of drug therapies. Cureus. 2022 Jun 8;14(6):e25745. doi: 10.7759/cureus.25745.
Mendelsohn ME, Karas RH. The protective effects of estrogen on the cardiovascular system. N Engl J Med. 1999 Jun 10;340(23):1801-11. doi: 10.1056/NEJM199906103402306.
Wong CW, Kwok CS, Narain A, Gulati M, Mihalidou AS, Wu P, et al. Marital status and risk of cardiovascular diseases: a systematic review and meta-analysis. Heart. 2018 Dec;104(23):1937-48. doi: 10.1136/heartjnl-2018-313005.
Wang W, Zhao D, Sun JY, Wang WH, Cheng J, Liu J, et al. [Risk factors comparison in Chinese patients developing acute coronary syndrome, ischemic or hemorrhagic stroke: a multi-provincial cohort study]. Zhonghua Xin Xue Guan Bing Za Zhi. 2006 Dec;34(12):1133-7. Chinese. PMID: 17274911.
Zupancic ML. Acute psychological stress as a precipitant of acute coronary syndromes in patients with undiagnosed ischemic heart disease: a case report and literature review. Prim Care Companion J Clin Psychiatry. 2009;11(1):21-4. doi: 10.4088/pcc.08r00623.
Desta DM, Nedi T, Hailu A, Atey TM, Tsadik AG, Asgedom SW, et ak. Treatment outcome of acute coronary syndrome patients admitted to Ayder Comprehensive Specialized Hospital, Mekelle, Ethiopia; A retrospective cross-sectional study. PLoS One. 2020 Feb 13;15(2):e0228953. doi: 10.1371/journal.pone.0228953.
Mohanan PP, Mathew R, Harikrishnan S, Krishnan MN, Zachariah G, Joseph J, et al. Presentation, management and outcomes of 25 748 acute coronary syndrome admissions in Kerala, India: results from the Kerala ACS Registry. Eur Heart J. 2013 Jan;34(2):121-9. doi: 10.1093/eurheartj/ehs219.
Pinto E. Blood pressure and ageing. Postgrad Med J. 2007 Feb;83(976):109-14. doi: 10.1136/pgmj.2006.048371.
Mirza AJ, Taha AY, Khdhir BR. Risk factors for acute coronary syndrome in patients below the age of 40 years. Egypt Heart J. 2018 Dec;70(4):233-5. doi: 10.1016/j.ehj.2018.05.005.
Fox KA, Eagle KA, Gore JM, Steg PG, Anderson FA; GRACE and GRACE2 Investigators. The Global Registry of Acute Coronary Events, 1999 to 2009--GRACE. Heart. 2010 Jul;96(14):1095-101. doi: 10.1136/hrt.2009.190827.
Ahmad WAW, Zambahari R, Ismail O, Sinnadurai J, Rosman A, Piaw CS, et al. Malaysian National Cardiovascular Disease Database (NCVD)–Acute Coronary Syndrome (ACS) registry: How are we different? CVD Prev Control 2011;6(3):81– 9. doi: 10.1016/j.cvdpc.2011.04.004.
Gaudron P, Eilles C, Kugler I, Ertl G. Progressive left ventricular dysfunction and remodeling after myocardial infarction. Potential mechanisms and early predictors. Circulation. 1993 Mar;87(3):755-63. doi: 10.1161/01.cir.87.3.755.
Jenča D, Melenovský V, Stehlik J, Staněk V, Kettner J, Kautzner J, et al. Heart failure after myocardial infarction: incidence and predictors. ESC Heart Fail. 2021 Feb;8(1):222-37. doi: 10.1002/ehf2.13144.
32. Ponikowski P, Anker SD, AlHabib KF, Cowie MR, Force TL, Hu S, et al. Heart failure: preventing disease and death worldwide. ESC Heart Fail. 2014 Sep;1(1):4-25. doi: 10.1002/ehf2.12005.
Lewis EF, Velazquez EJ, Solomon SD, Hellkamp AS, McMurray JJ, Mathias J, et al. Predictors of the first heart failure hospitalization in patients who are stable survivors of myocardial infarction complicated by pulmonary congestion and/or left ventricular dysfunction: a VALIANT study. Eur Heart J. 2008 Mar;29(6):748-56. doi: 10.1093/eurheartj/ehn062.
DeLeon‐Pennell KY, Meschiari CA, Jung M, Lindsey ML. Matrix metalloproteinases in myocardial infarction and heart failure. Prog Mol Biol Transl Sci. 2017;147:75-100. doi: 10.1016/bs.pmbts.2017.02.001.
Gragnano F, Capolongo A, Terracciano F, Gargiulo G, De Sio V, Cesaro A, et al. Escalation and de-escalation of antiplatelet therapy after acute coronary syndrome or PCI: available evidence and implications for practice. J Clin Med. 2022 Oct 23;11(21):6246. doi: 10.3390/jcm11216246.
Wallentin L, Becker RC, Budaj A, Cannon CP, Emanuelsson H, Held C, et al; PLATO Investigators; Freij A, Thorsén M. Ticagrelor versus clopidogrel in patients with acute coronary syndromes. N Engl J Med. 2009 Sep 10;361(11):1045-57. doi: 10.1056/NEJMoa0904327.
Wiviott SD, Braunwald E, McCabe CH, Montalescot G, Ruzyllo W, Gottlieb S, et al; TRITON-TIMI 38 Investigators. Prasugrel versus clopidogrel in patients with acute coronary syndromes. N Engl J Med. 2007 Nov 15;357(20):2001-15. doi: 10.1056/NEJMoa0706482.
Ibanez B, James S, Agewall S, Antunes MJ, Bucciarelli-Ducci C, Bueno H, et al; ESC Scientific Document Group. 2017 ESC Guidelines for the management of acute myocardial infarction in patients presenting with ST-segment elevation: The Task Force for the management of acute myocardial infarction in patients presenting with ST-segment elevation of the European Society of Cardiology (ESC). Eur Heart J. 2018 Jan 7;39(2):119-77. doi: 10.1093/eurheartj/ehx393.
Bloom MW, Greenberg B, Jaarsma T, Januzzi JL, Lam CSP, Maggioni AP, et al. Heart failure with reduced ejection fraction. Nat Rev Dis Primers. 2017 Aug 24;3:17058. doi: 10.1038/nrdp.2017.58.
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