Acute myocardial infarction in young patients – severe failures in the system of acute and secondary care

Czech version

Authors: G. Dostálová ¹; prof. MUDr. Jan Bělohlávek, Ph.D. ¹; L. Vítek ²; L. Muchová ²; M. Škvařilová ^3,4; D. Karetová ¹; K. Jirátová ¹; J. Kvasnička ²; D. Vondráková ⁵; O. Toman ⁶; A. Linhart ¹
Authors‘ workplace: II. interní klinika – klinika kardiologie a angiologie 1. lékařské fakulty UK a VFN Praha, přednosta prof. MUDr. Aleš Linhart, DrSc., FESC ¹; Ústav lékařské biochemie a laboratorní diagnostiky 1. lékařské fakulty UK a VFN Praha, přednosta prof. MUDr. Tomáš Zima, DrSc., MBA ²; I. interní kardiologická klinika Lékařské fakulty UP a FN Olomouc, přednosta doc. MUDr. Miloš Táborský, CSc., FESC, MBA ³; Kardiologické oddělení Karlovarské Krajské nemocnice, Karlovy Vary, přednosta prim. MUDr. Michal Paďour ⁴; Kardiologické oddělení Nemocnice Na Homolce Praha, přednosta prim. doc. MUDr. Petr Neužil, CSc., FESC ⁵; Interní kardiologická klinika Lékařské fakulty MU a FN Brno, pracoviště Bohunice, přednosta prof. MUDr. Jindřich Špinar, CSc., FESC ⁶
Published in: Vnitř Lék 2012; 58(10): 721-729
Category: Original Contributions

Overview

Introduction:
The incidence of cardiovascular (CV) diseases and acute myocardial infarction (AMI) in Czech Republic is declining. In spite of this in a proportion of patients AMI occurs in young age. The aim of our project was to assess the character of risk factors, precipitating diseases and the quality of care in young AMI survivors.

Methods:
We included 132 patients (97 men and 35 women) in whom AIM with ST elevations occurred before age of 45 years in men and age of 50 years in women. Several results were compared to a control group composed of 84 healthy volunteers of comparable age. We assessed the course of the disease, extent of coronary involvement, subsequent therapy and control of risk factors after 3 years from the index event.

Results:
Smoking represented the main risk factor – 85% patents were active smokers at the time of AMI and 9% were former smokers, 64% patients had a positive family history of CV disease. We found a higher prevalence of dyslipidemia history in men. In spite of high rate of statin use, laboratory examination during follow-up revealed higher triglyceride values and low levels of HDL-cholesterol in both genders. All together 23% of patients had a history of provoking underlying disease or precipitating factors (inflammatory diseases, malignancies, combined thrombophilias, drug abuse). In total 95% of patients underwent coronary angiography during the acute phase of AMI, the median time from pain onset to intervention was 9 hours. Most patients had single vessel disease, 14% had even coronary angiogram without clinically significant stenosis. The subsequent care was satisfactory concerning the rate of drug prescriptions. However, target lipid values were not reached in 78% patients and blood pressure targets in 37%.

Conclusions:
In patients who suffered AMI in young age, risk factors are dominated by smoking and positive family history of CV diseases. One fifth of patients suffer from other underlying disease (inflammatory disease, malignancies, combined thrombophilia) or have another precipitating factor (febrile disease, drug abuse). The acute care seems unsatisfactory due to late arrival of most patients to catheterization laboratories (underestimation of the disease, incorrect initial diagnosis). Subsequent therapy is well composed but lacks in intensity.

Key words:
acute myocardial infarction – atherosclerosis – risk factors – secondary prevention

Sources

1. Cifkova R, Skodova Z, Bruthans J et al. Longitudinal trends in major cardiovascular risk factors in the Czech population between 1985 and 2007/8. Czech MONICA and Czech post-MONICA. Atherosclerosis 2010; 211: 676–681.

2. Schmermund A, Schwartz RS, Adamzik M et al. Coronary atherosclerosis in unheralded sudden coronary death under age 50: histopathologic comparison with ‚healthy‘ subjects dying out of hospital. Atherosclerosis 2001; 155: 499–508.

3. Imazio M, Bobbio M, Bergerone S et al. Clinical and epidemiological characteristics of juvenile myocardial infarction in Italy: the GISSI experience. G Ital Cardiol 1998; 28: 505–512.

4. Vrtovec B, Keber I, Gadzijev A et al. Carotid intima-media thickness of young coronary patients. Coron Artery Dis 1999; 10: 407–411.

5. Coppola G, Corrado E, Piraino D et al. Carotid intimal-media thickness and endothelial function in young patients with history of myocardial infarction. Int Angiol 2009; 28: 120–126.

6. Erzen B, Sabovic M, Sebestjen M et al. Endothelial dysfunction, intima-media thickness, ankle-brachial pressure index, and pulse pressure in young post-myocardial infarction patients with various expressions of classical risk factors. Heart Vessels 2007; 22: 215–222.

7. Barra S, Scala S, Cuomo V et al. Subclinical atherosclerosis and genetic risk markers in healthy offspring of patients with premature myocardial infarction. Minerva Cardioangiol 2011; 59: 127–134.

8. Barra S, Gaeta G, Cuomo V et al. Parental history of premature myocardial infarction is a stronger predictor of increased carotid intima-media thickness than parental history of hypertension. Nutr Metab Cardiovasc Dis 2011; 21: 391–397.

9. Cuomo S, Guarini P, Gaeta G et al. Increased carotid intima-media thickness in children-adolescents, and young adults with a parental history of premature myocardial infarction. Eur Heart J 2002; 23: 1345–1350.

10. Morgan TM, House JA, Cresci S et al. Investigation of 95 variants identified in a genomewide study for association with mortality after acute coronary syndrome. BMC Med Genet 2011; 12: 127.

11. Manolio TA, Collins FS, Cox NJ et al. Finding the missing heritability of complex diseases. Nature 2009; 461: 747–753.

12. Ridker PM, MacFadyen J, Libby P et al. Relation of baseline high-sensitivity C-reactive protein level to cardiovascular outcomes with rosuvastatin in the Justification for Use of statins in Prevention: an Intervention Trial Evaluating Rosuvastatin (JUPITER). Am J Cardiol 2010; 106: 204–209.

13. Caglar IM, Vural A, Turhan Caglar FN et al. Kounis Syndrome together with Myocardial Bridging Leading to Acute Myocardial Infarction at Young Age. Case Report Med 2011; 2011: 490310.

14. Mitani Y, Ohashi H, Sawada H et al. In vivo plaque composition and morphology in coronary artery lesions in adolescents and young adults long after Kawasaki disease: a virtual histology-intravascular ultrasound study. Circulation 2009; 119: 2829–2836.

15. Kounis NG, Mazarakis A, Tsigkas G et al. Kounis syndrome: a new twist on an old disease. Future Cardiol 2011; 7: 805–824.

16. Finkel JB, Marhefka GD. Rethinking cocaine-associated chest pain and acute coronary syndromes. Mayo Clin Proc 2011; 86: 1198–1207.

17. Rubin JB, Borden WB. Coronary heart disease in young adults. Curr Atheroscler Rep 2012; 14: 140–149.

18. Corti R, Hutter R, Badimon JJ et al. Evolving concepts in the triad of atherosclerosis, inflammation and thrombosis. J Thromb Thrombolysis 2004; 17: 35–44.

19. Maradit-Kremers H, Crowson CS, Nicola PJ et al. Increased unrecognized coronary heart disease and sudden deaths in rheumatoid arthritis: a population-based cohort study. Arthritis Rheum 2005; 52: 402–411.

20. Gaspar J, Benchimol C, Gadelha T et al. Arterial thrombosis and acute myocardial infarction with angiographically normal coronary arteries in a woman heterozygous for both factor V Leiden and prothrombin mutation. Rev Port Cardiol 2011; 30: 727–729.

21. Mugnolo A, Toniolo M, Cicoira M et al. Myocardial infarction in a young patient with a previous history of repeated thrombophlebitis: combination of factor V Leiden and prothrombin G20210A gene polymorphisms with coronary artery disease. J Cardiovasc Med (Hagerstown) 2010; 11: 125–126.

22. Kim RJ, Becker RC. Association between factor V Leiden, prothrombin G20210A, and methylenetetrahydrofolate reductase C677T mutations and events of the arterial circulatory system: a meta-analysis of published studies. Am Heart J 2003; 146: 948–957.

23. Khandanpour N, Willis G, Meyer FJ et al. Peripheral arterial disease and methylenetetrahydrofolate reductase (MTHFR) C677T mutations: A case-control study and meta-analysis. J Vasc Surg. 2009; 49: 711–718.

24. Van de Werf F, Bax J, Betriu A et al. ESC Committee for Practice Guidelines (CPG). Management of acute myocardial infarction in patients presenting with persistent ST-segment elevation: the Task Force on the Management of ST-Segment Elevation Acute Myocardial Infarction of the European Society of Cardiology. Eur Heart J 2008; 29: 2909–2945.

25. Thygesen K, Alpert JS, White HD. Joint ESC/ACCF/AHA/WHF Task Force for the Redefinition of Myocardial Infarction. Universal definition of myocardial infarction. Eur Heart J 2007; 28: 2525–2538.

26. Day C. Metabolic syndrome, or what you will: definitions and epidemiology. Diab Vasc Dis Res 2007; 4: 32–38.

27. Kotseva K, Wood D, De Backer G et al. EUROASPIRE Study Group. EUROASPIRE III: a survey on the lifestyle, risk factors and use of cardioprotective drug therapies in coronary patients from 22 European countries. Eur J Cardiovasc Prev Rehabil 2009; 16: 121–137.

28. Widimsky P, Zelizko M, Jansky P et al. CZECH investigators. The incidence, treatment strategies and outcomes of acute coronary syndromes in the ‘reperfusion network’ of different hospital types in the Czech Republic: results of the CZech Evaluation of acute Coronary syndromes in Hospitalized patients (CZECH) registry. Int J Cardiol 2007; 119: 212–219.

29. Widimský P, Želízko M, Janský P et al. Registr CZECH. Jak léčíme akutní koronární syndromy v České republice? Výsledky registru CZECH. Cor Vasa – Kardio 2007; 49: 7–8.

30. Honjo K, Iso H, Inoue M et al. Adult height and the risk of cardiovascular disease among middle aged men and women in Japan. Eur J Epidemiol 2011; 26: 13–21.

31. Lawlor DA, Taylor M, Davey Smith G et al. Associations of components of adult height with coronary heart disease in postmenopausal women: the British women’s heart and health study. Heart 2004; 90: 745–749.

32. Paajanen TA, Oksala NK, Kuukasjärvi P et al. Short stature is associated with coronary heart disease: a systematic review of the literature and a meta-analysis. Eur Heart J 2010; 31: 1802–1809.

33. Batty GD, Shipley MJ, Gunnell D et al. Height, wealth, and health: an overview with new data from three longitudinal studies. Econ Hum Biol 2009; 7: 137–152.

34. Smulyan H, Marchais SJ, Pannier B et al. Influence of body height on pulsatile arterial hemodynamic data. J Am Coll Cardiol 1998; 31: 1103–1109.

35. Picchi A, Pasqualini P, D’Aiello I et al. Acute ST-elevation myocardial infarction in a 15-year-old boy with celiac disease and multifactorial thrombotic risk. Thromb Haemost 2008; 99: 1116–1118.

36. Di Tola M, Barillà F, Trappolini M et al. Antitissue transglutaminase antibodies in acute coronary syndrome: an alert signal of myocardial tissue lesion? J Intern Med 2008; 263: 43–51.

37. Forte GI, Vaccarino L, Palmeri M et al. Analysis of polymorphisms Leiden Factor V G1691A and prothrombin G20210A as risk factors for acute myocardial infarction. Biogerontology 2011; 12: 485–490.

38. Armitage JM, Bowman L, Clarke RJ et al. Study of the Effectiveness of Additional Reductions in Cholesterol and Homocysteine (SEARCH) Collaborative Group. Effects of homocysteine-lowering with folic acid plus vitamin B12 vs placebo on mortality and major morbidity in myocardial infarction survivors: a randomized trial. JAMA 2010; 303: 2486–2494.

39. Albert CM, Cook NR, Gaziano JM et al. Effect of folic acid and B vitamins on risk of cardiovascular events and total mortality among women at high risk for cardiovascular disease: a randomized trial. JAMA 2008; 299: 2027–2036.

40. Di Minno MN, Tremoli E, Coppola A et al. Homocysteine and arterial thrombosis: Challenge and opportunity. Thromb Haemost 2010; 103: 942–961.

41. Widimsky P, Stellova B, Groch L et al. PRAGUE Study Group Investigators. Prevalence of normal coronary angiography in the acute phase of suspected ST-elevation myocardial infarction: experience from the PRAGUE studies. Can J Cardiol 2006; 22: 1147–1152.

42. Monhart Z, Grünfeldová H, Janský P et al. Pilotní registr akutního infarktu myokardu – hodnocení kvality péče v non-PCI nemocnicích v průběhu 5 let. Vnitř Lék 2010; 56: 21–29.

43. Morillas P, Bertomeu V, Pabón P et al. PRIAMHO II Investigators. Characteristics and outcome of acute myocardial infarction in young patients. The PRIAMHO II study. Cardiology 2007; 107: 217–225.

44. Pařenica J, Kala P, Jarkovský J et al. Akutní srdeční selhání a časný rozvoj dysfunkce levé komory u pacientů s akutním infarktem myokardu s elevacemi ST léčených primární perkutánní koronární intervencí. Vnitř Lék 2011; 57: 43–51.

45. Krupicka J, Widimska P, Nechvatal L et al. Inter-hospital transport for primary angioplasty does not compromise left ventricular function: six-month echocardiographic follow-up of the PRAGUE 1 Study. Jpn Heart J 2003; 44: 313–322.

46. Horowitz JD, Arstall MA, Zeitz CJ et al. Is there still a role for treatment with beta-adrenoceptor antagonists in post-myocardial infarction patients with well-preserved left ventricular systolic function? Acute Card Care 2008; 10: 144–147.

47. Prugger C, Keil U, Wellmann J et al. EUROASPIRE III Study Group. Blood pressure control and knowledge of target blood pressure in coronary patients across Europe: results from the EUROASPIRE III survey. J Hypertens 2011; 29: 1641–1648.