European Journal of Cardiovascular Medicine

Coronary heart disease (CHD) is the leading cause of morbidity and mortality worldwide, accounting for an estimated 17.9 million deaths annually and representing nearly 32% of all global deaths [1]. Traditionally considered a disease of the elderly, premature coronary heart disease—defined as the onset of CHD before the age of 55 years in men and 65 years in women—has become an emerging concern due to its increasing incidence in younger populations, particularly in South Asia [2]. Premature CHD not only contributes to early mortality but also leads to years of lost productivity, emotional distress, and long-term economic burden on families and healthcare systems.

The pathophysiology of premature CHD shares similarities with that of classical CHD but is often influenced by a stronger burden of modifiable risk factors, including dyslipidemia, smoking, sedentary lifestyle, hypertension, diabetes mellitus, and positive family history [3]. In contrast to older patients, younger individuals often present with fewer comorbidities but tend to exhibit more aggressive risk factor clustering and higher prevalence of single-vessel disease, as shown by angiographic studies [4]. Premature atherosclerosis in such individuals is believed to result from both genetic susceptibility and early-life exposure to risk enhancers such as poor dietary habits, urbanization, and psychosocial stress [5].

India is witnessing a disproportionate rise in the burden of premature CHD, with epidemiological studies estimating that up to 25% of all myocardial infarctions occur in individuals under 40 years of age [6]. According to the INTERHEART South Asia study, Indian patients experience CHD almost a decade earlier than their Western counterparts [7]. This early onset is often associated with under-recognition of risk factors, suboptimal screening in primary care, and late presentation with acute coronary syndromes. In the Gujarat region, recent hospital-based studies have highlighted that nearly one-third of CHD patients undergoing coronary angiography were below 50 years of age, with smoking and dyslipidemia emerging as dominant contributors [8].

Despite the growing significance of premature CHD, there remains a paucity of detailed Indian studies that examine the clinical and angiographic profiles of young patients. Existing data primarily focus on older age groups, leaving a critical knowledge gap in understanding the distinct characteristics, vessel involvement patterns, and risk factor profiles of younger patients. A better understanding of these differences is essential to improve early detection, preventive cardiology strategies, and tailored management in the younger age group [9].

The present study aims to comprehensively evaluate the clinical and angiographic profile of patients presenting with premature coronary heart disease. The primary objectives include assessing the prevalence of conventional cardiovascular risk factors such as smoking, hypertension, diabetes, and dyslipidemia in young patients with myocardial infarction, as well as analyzing their demographic characteristics. In addition, the study seeks to determine the prevalence of hyperhomocysteinemia and elevated hemoglobin levels, which are emerging as important non-traditional risk factors in this subgroup.The secondary objectives include evaluating the clinical modes of presentation, characterizing the angiographic patterns of coronary lesions, and determining the prevalence of left ventricular (LV) dysfunction among these patients.

The expected outcomes of this study are to generate valuable clinical and angiographic data that can help in the early identification of at-risk individuals, support the implementation of targeted preventive strategies, and facilitate age-specific therapeutic approaches. The findings may also contribute to developing regionally relevant guidelines for managing premature coronary artery disease in the Indian population.

This study was designed as a prospective observational study conducted in the Intensive Coronary Care Unit (ICCU) of PSG Hospitals, a tertiary care teaching hospital affiliated with PSG Institute of Medical Sciences and Research (PSG IMS&R), located in Coimbatore, Tamil Nadu. The study was carried out over a period of one year, from 1st October 2010 to 30th September 2011, and included young adult patients aged 40 years or less who were admitted with a diagnosis of acute myocardial infarction (AMI). This age cut-off was chosen in accordance with prior similar studies on premature coronary artery disease (CAD), which generally define “young” patients as those aged 40 to 45 years or younger.

All consecutive patients presenting with acute coronary syndromes (ACS), including both ST-elevation myocardial infarction (STEMI) and non-ST elevation myocardial infarction (NSTEMI), during the study period were evaluated and considered for inclusion. Diagnosis was made based on typical chest pain, ECG changes, and/or positive cardiac biomarkers (Troponin T) as per standard clinical definitions. Informed consent was obtained from all patients after a thorough explanation of the purpose and scope of the study, and the study protocol was approved by the Institutional Human Ethics Committee prior to initiation.

The inclusion criteria for the study were: age ≤40 years, typical ischemic chest pain, ST elevation on ECG consistent with STEMI, or positive Troponin T indicating NSTEMI, and availability for complete clinical evaluation including coronary angiography. Patients were excluded if they were above 40 years of age, had non-cardiac chest pain, refused admission, or did not undergo coronary angiography for any reason.

Upon enrollment, each patient's demographic profile including age, sex, income status, and marital status was recorded. A detailed medical history was obtained regarding known hypertension, diabetes mellitus, dyslipidemia, smoking habits, alcohol consumption, and family history of premature CAD. Clinical evaluation was complemented by laboratory testing at admission, which included complete blood count, fasting lipid profile, glycated hemoglobin (HbA1c), fasting serum homocysteine, and hemoglobin levels.

Hypertension was defined as documented high blood pressure in previous medical records, current use of antihypertensive medications, or persistent blood pressure ≥140/90 mmHg during admission. Diabetes mellitus was defined based on fasting blood glucose ≥127 mg/dL, HbA1c >6.5%, or prior diagnosis of diabetes. Dyslipidemia was assessed using fasting lipid profiles.

All patients underwent a 2D transthoracic echocardiogram with color Doppler for detailed assessment of left ventricular (LV) systolic and diastolic function. Additional echocardiographic parameters such as mitral regurgitation, ventricular septal rupture, pericardial effusion, and free wall rupture were also evaluated to rule out mechanical complications.

Treatment modalities were administered based on the clinical presentation, availability of resources, and patient or family consent. Patients received either thrombolytic therapy, primary percutaneous coronary intervention (PCI), or conservative medical management. All patients were treated according to standard evidence-based protocols, which included dual antiplatelet therapy, atorvastatin, low molecular weight heparin, and other supportive measures as needed.

All patients underwent coronary angiography, either emergently at the time of primary PCI or electively after medical stabilization. Angiographic evaluation focused on identifying the presence and type of coronary artery lesions, thrombus formation, myocardial bridging, coronary ectasia, and congenital anomalies. The findings were carefully documented and correlated with clinical presentation and risk factor profile.

The collected data were compiled in Microsoft Excel and analyzed using appropriate statistical methods to evaluate the prevalence of risk factors, angiographic patterns, and clinical outcomes in young patients with premature coronary artery disease.

A total of 69 young patients aged ≤40 years, admitted with acute myocardial infarction, were included in this study. The majority (91.3%) were between 31 and 40 years, while only 8.7% were younger than 30 years. There was a strong male predominance (86.95%), with a male-to-female ratio of nearly 7:1. Most patients (91.3%) were married. In terms of residence, 37.7% hailed from urban corporations, 31.9% from municipalities, and 30.4% from rural villages. When categorized by income, 46.4% were from low-income groups (<₹72,000/year), while 34.8% and 10.1% belonged to moderate and high-income categories, respectively.

Among conventional cardiovascular risk factors, smoking was the most common, seen in 53.6% of patients, followed by dyslipidemia (29%), diabetes mellitus (24.6%), and hypertension (21.7%). Alcohol consumption was reported in 30.4%, and positive family history of CAD in 11.6%. Obesity, as defined by BMI, was noted in 7.2%. Notably, prediabetes (HbA1c 5.5–6.4%) was prevalent in nearly half of the patients (49.3%), whereas 28.9% had normal HbA1c and 21.7% had HbA1c levels suggestive of diabetes (>6.5%). Lipid profile abnormalities were significant, with LDL >100 mg/dL in 78.3%, HDL <40 mg/dL in 76.8%, and TGL >150 mg/dL in 50.7%.

Other findings included hyperhomocysteinemia in 18.8%, high hemoglobin (>17 g/dL) in 7.25%, and vasculitis-like symptoms in 2 female patients (2.9%). The predominant mode of presentation was STEMI (72.5%), with the remaining 27.5% presenting with NSTEMI. Echocardiographic evaluation revealed normal LV function in 78.25%, mild dysfunction in 18.95%, and moderate dysfunction in 2.9%; no patients had severe dysfunction.

Regarding complications, recurrent MI occurred in 3 patients (4.3%), and ventricular arrhythmias were observed in 2 patients (2.9%). There were no cases of atrial fibrillation, mechanical complications, cerebrovascular events, or in-hospital mortality.

Among STEMI patients, 44% underwent thrombolysis, 26% underwent primary PCI, and 30% were managed conservatively. Coronary angiography findings showed single-vessel disease in 62.3%, double-vessel and triple-vessel disease each in 10.1%, and recanalized vessels in 17.4%. A thrombus was visualized in 37.7% of cases. LAD involvement was most common (47.8%), followed by RCA (8.7%) and LCX (5.8%).

Urban patients had higher rates of diabetes (29.2%), LDL elevation (79.2%), and primary PCI (33.3%), while rural patients had higher rates of smoking (85.7%), hypertension (28.6%), and more conservative management. Across income groups, prediabetes prevalence remained high regardless of socioeconomic status. High-income patients underwent primary PCI more frequently (50%) compared to lower-income groups.

Gender-based analysis revealed that hypertension and smoking were more common among males, while diabetes and vasculitis were more common among females. Although males underwent PCI more frequently, there was no significant sex difference in LV dysfunction, arrhythmias, or lipid abnormalities—except for a higher incidence of low HDL among males (80% vs 55.6%).

Table 1: Demographic Profile of Study Participants (n = 69)

Table 2: Clinical Risk Factors and Biochemical Parameters (n = 69)

Table 3: Clinical Presentation, LV Function, Treatment, and Angiographic Findings (n = 69)

Table 4: Multiple Logistic Regression Analysis for Predictors of LV Dysfunction (EF < 50%)

LDL >100 mg/dL, Diabetes, Hyperhomocysteinemia, and STEMI presentation were statistically significant independent predictors of LV dysfunction in young MI patients. While, Smoking showed a positive trend but did not reach statistical significance.

Figure 1: Adjusted Odds Ratios for Predictors of LV Dysfunction

The bar graph displaying the Adjusted Odds Ratios (AOR) for key predictors of LV dysfunction (EF < 50%) in young MI patients. Each bar includes a data label for clarity, showing that STEMI presentation and LDL >100 mg/dL were the strongest independent predictors.

Figure 2: Logistic Regression Plot: Predicted Vs. Observed LV Dysfunction

The logistic regression plot showing the relationship between the predicted probabilities of LV dysfunction (from the regression model) and the observed outcomes (0 = no dysfunction, 1 = dysfunction). This graph visually validates how well the model predicts the presence of LV dysfunction in young MI patients.

This prospective observational study aimed to assess the clinical and angiographic characteristics of young patients (≤40 years) presenting with myocardial infarction. The analysis of 69 patients revealed a predominant male population, high burden of modifiable risk factors, and a distinct angiographic pattern marked by single-vessel disease, particularly involving the LAD.

The male predominance (86.95%) observed in this study is consistent with the findings of Bansal et al., who also reported a higher prevalence of premature coronary artery disease (CAD) in males under 40 years, attributing this to higher rates of tobacco use, occupational stress, and underdiagnosis in females [10]. Similarly, the INTERHEART study emphasized that traditional risk factors like smoking and dyslipidemia are more pronounced in South Asian men, contributing to earlier CAD onset [11].

Smoking, present in 53.6% of participants, emerged as the most common risk factor in this study. This aligns with research by Sinha et al., who found that smoking was a significant contributor to early myocardial infarction, especially in rural populations with poor health awareness [12]. Additionally, the current study highlighted a high prevalence of prediabetes (49.3%), echoing findings from Kumar et al., who noted that impaired glucose tolerance often precedes the clinical onset of CAD in younger individuals and may be underrecognized due to lack of routine screening in low-income settings [13].

The lipid profile findings in this cohort—LDL >100 mg/dL in 78.3%, HDL <40 mg/dL in 76.8%, and elevated triglycerides in 50.7%—were consistent with those reported by Sharma et al. in a study from North India, where dyslipidemia was observed in more than 70% of premature CAD patients and contributed significantly to atherogenesis [14]. This reaffirms the need for early lipid screening and intervention in high-risk youth.

The angiographic findings in this study demonstrated that single-vessel disease (62.3%) was most common, particularly with LAD involvement (47.8%). This pattern is supported by the work of Panwar et al., who found LAD dominance among young MI patients in their angiographic series [15]. Interestingly, the presence of thrombus (37.7%) and recanalized vessels (17.4%) in this study may reflect underlying plaque instability or spontaneous thrombolysis, a feature also noted in other Indian angiographic registries of young adults [16].

The incidence of hyperhomocysteinemia (18.8%) in the present study draws attention to non-traditional risk factors in early CAD. According to Malhotra et al., elevated homocysteine levels are associated with endothelial dysfunction and may be an independent risk enhancer in Indian youth due to genetic and nutritional factors [17].

The left ventricular function was preserved in most patients, with 21.7% having EF <50%. This is similar to the findings of Goyal et al., who reported that despite myocardial infarction, young patients tend to have better cardiac reserve compared to elderly due to lesser atherosclerotic burden and preserved microvasculature [18]. However, in our multivariate analysis, factors such as diabetes, hyperhomocysteinemia, and elevated LDL emerged as significant predictors of LV dysfunction, suggesting that even young individuals are vulnerable to myocardial damage when exposed to metabolic and inflammatory risk factors.

Management outcomes revealed that thrombolysis was more common in rural patients, while primary PCI was more frequently utilized in urban and high-income patients, reflecting disparities in access and infrastructure. This observation is consistent with Mehta et al., who highlighted that socioeconomic status significantly influences treatment modality in Indian ACS care [19].

Finally, the absence of in-hospital mortality and low complication rate in this study is encouraging and aligns with previous literature showing better short-term prognosis in younger MI patients. However, the long-term risk of recurrent events remains high without aggressive lifestyle modification and follow-up, as emphasized by Joshi et al. in their long-term cohort analysis of young Indian MI survivors [20].

Although myocardial infarction is relatively uncommon in individuals aged less than 40 years, its occurrence in this age group represents a serious clinical and public health concern due to its impact on long-term morbidity, quality of life, and productivity. This study confirms that male gender, dyslipidemia, and smoking remain the predominant risk factors for premature coronary artery disease, consistent with existing literature. A noteworthy and emerging trend observed in this study is the alarming prevalence of prediabetes (49.3%), which was uniformly high across gender, income levels, and rural-urban distribution. This finding underscores the urgent need to incorporate HbA1c screening in all young individuals with cardiovascular risk, to enable timely intervention before the onset of overt diabetes.

Smoking prevalence was notably higher among rural patients (85.7%) compared to urban counterparts, reflecting ongoing disparities in health education and behavior. While acute STEMI was the most frequent presentation (72.5%), left ventricular dysfunction was relatively less common (21.75%), likely due to preserved myocardial reserve in younger patients. Single-vessel disease was the most common angiographic pattern (62.3%), with LAD involvement seen in nearly half of the cases. Primary PCI was more frequently performed in urban, male, and higher-income groups, highlighting the impact of accessibility and resource availability on treatment decisions.

This study reinforces the importance of early risk stratification, routine metabolic screening, and aggressive lifestyle modification in the younger population. Public health strategies must emphasize tobacco cessation, dietary regulation, and physical activity promotion to curb the growing trend of premature CAD in India. Furthermore, improved awareness and equitable access to timely revascularization are essential for optimizing outcomes in this vulnerable group.

LIMITATIONS AND RECOMMENDATIONS

This study, while providing valuable insights into the clinical and angiographic profile of young patients with myocardial infarction, is limited by its single-center design and relatively small sample size of 69 patients, which may affect the generalizability of the findings. The short follow-up period, restricted to in-hospital outcomes, does not capture long-term events such as reinfarction, mortality, or revascularization needs. In addition, the absence of a control group of older patients limits direct age-based comparisons. Serum homocysteine and lipid measurements were taken only once, which may not reflect longitudinal trends. Moreover, certain psychosocial and genetic factors potentially relevant in premature CAD could not be assessed due to resource limitations.

Future studies with larger multicentric cohorts, longitudinal follow-up, and inclusion of genetic, inflammatory, and lifestyle parameters are recommended to build a comprehensive risk model for premature coronary artery disease. Public health initiatives should focus on community-based screening for dysglycemia and dyslipidemia in the younger population, especially in rural and low-income groups. Additionally, integration of preventive cardiology into primary care, early counseling for high-risk individuals, and ensuring equitable access to timely revascularization therapies like PCI should be prioritized to mitigate the rising burden of premature CAD in India.

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