European Journal of Cardiovascular Medicine

Acute myocardial infarction (AMI) comprises both ST–segment elevated myocardial infarction (STEMI) and non-ST-segment elevated myocardial infarction (NSTEMI) and is a leading cause of morbidity and mortality worldwide, especially in developing countries. [1] Globally, coronary artery disease remains the number one cause of mortality, responsible for 7 million of 53 million deaths reported in 2010. By 2025, cardiovascular mortality is likely to cross all comorbidities, including infection, cancer, and trauma. [2]

Cardiovascular disease is posing a major public health hazard and clinical problem in South Asia. Low and middle-income countries like ours contribute significantly to the global burden of CVD, accounting for 78% of all deaths and 86.3% of all disability. [3] As the prevalence of coronary artery disease is common in middle and older age patients, few studies have focused on the clinical presentation, risk factors, treatment & outcome of first acute myocardial infarction (MI) in very young patients (≤ 30 years). Autopsy studies have shown that the incidence of atherosclerosis increases with modifiable cardiovascular risk factors in asymptomatic young individuals. The very young patients (≤ 30 years) with first acute myocardial infarction are of particular interest considering the disability & mortality. The cut-off age of 30 has been used in most studies to define very young patients with acute myocardial infarction. [4] Most notable features of CAD in the South Asian population are 2-4 fold higher prevalence, incidence, hospitalization, and mortality; and 5-10 fold higher rates of MI and death before the age of 40 years. [5] Bangladeshis are very prone to developing premature CAD, like other South Asians. [6] It constitutes an important problem for the patient and the treating physicians because of the devastating effect of this disease on the more active lifestyle of this subgroup. In addition, these very young patients have different clinical characteristics, risk factor profiles, and prognosis from older patients. [7] Other contributing factors like obesity, lack of exercise, dyslipidemia, substance abuse, C-reactive protein, hyperuricemia, hyperhomocysteinemia, low serum vitamin-D level, and oral contraceptive pill use in very young women have been implicated in the pathogenesis of AMI. [8,9]

However, acute myocardial infarction has been recognized in the very young age groups more frequently in recent years.[10] But it has been poorly described in this group of people. It is estimated that less than 2% of all acute MI patients are aged ≤ 30 years.[4] The prevalence of AMI has progressively increased in Bangladesh, particularly among the very young (≤ 30 years) urban population in recent years. The conventional risk factors for older people did not fully explain the myocardial infarction of very young people in the community. Men have markedly higher rates of AMI than women. The rate of acute myocardial infarction in women has begun to rise sharply after menopause and has become the same of men. The main risk factors for older patients with AMI are diabetes, hypertension, smoking & obesity. [11] Although there are many studies of AMI, few studies have focused on the first acute myocardial infarction in the very young age group of ≤ 30 years. Besides, there is hardly available data in our country regarding very young individuals with first acute myocardial infarction.

In this study, we aimed to find out the difference in clinical characteristics between very young (≤ 30 years) and older (≥ 50 years) AMI patients with first acute MI.

This cross-sectional observational study was conducted Department of Cardiology of Dhaka Medical College & Hospital, Sir Salimullah Medical College & Mitford Hospital, National Institute of Cardiovascular Diseases (NICVD), Bangladesh Specialized Hospital (BSH), Dhaka, Bangladesh. This study was carried out from July 2022 to December 2023. In this study, we included a total of 160 patients with first acute myocardial infarction based on pre-defined enrollment criteria. Among the study subjects, 80 patients were included in the very young (≤ 30 years) group (Group I) and another 80 patients were included in the older (≥ 50 years) group (Group II).

These are the following criteria to be eligible for enrollment as our study participants: a) Patients aged ≤ 30 and ≥ 50 years; b) Patients with first acute myocardial infarction (STEMI and NSTEMI); c) Patients who were willing to participate were included in the study And a) Patients aged between 31 to 49 years; b) Patients with previous history of MI or revascularization (PCI, CABG); c) Patients with congenital or valvular heart disease; d) Known case of CKD/ Heart failure/ Malignancy/ Gout/ Inflammatory diseases (RA, SLE, OA), e) Patients with pregnancy and chronic alcoholism were excluded from our study.

Data Collection Procedure:

Patients/attendants were briefed about the study, and consent was taken. Detailed history and thorough physical examination were done, and risk factors were noted. Information about age, sex, history of smoking/ smokeless tobacco, substance abuse, dyslipidemias, diabetes mellitus, hypertension and family history of premature coronary artery disease (CAD), CKD, heart failure, malignancy, gout, inflammatory diseases (RA, SLE, OA) and previous history of MI / PCI / CABG was obtained through self-report. Patients were classified as obese with a BMI ≥25 kg/m². Data was collected by interview, clinical examination, and relevant investigations. After analysis of all clinical characteristics and risk factors, the information was recorded properly in the preformed data collection sheet. After compiling data from all patients, statistical analysis was done.

Statistical Analysis:

Quantitative data was expressed as mean and standard deviation, and qualitative data was expressed as frequency distribution and percentage. Qualitative data were compared using the Chi-square test and Fisher’s exact test. Multivariate analysis was conducted using binary logistic regression. A p-value <0.05 was considered significant. Statistical analysis was performed by using SPSS 26 (Statistical Package for Social Sciences) for Windows version 10. This study was ethically approved by the Institutional Review Committee of Chattogram Maa Shishu-O-General Hospital.

This study included 160 patients of first acute MI who were recorded in the data collection sheet. The study subjects were divided into two groups- 80 patients were included in the very young (≤ 30 years) group (Group I), and another 80 patients were included in the older (≥ 50 years) group (Group II).

Figure 1 shows that in Group I, there were 57 male and 23 female patients. In contrast, Group II had 65 male and 15 female patients. In both groups, the male gender was predominant. There was no statistically significant difference in gender distribution between the two age groups (p = 0.137).

Table 1: Comparison of presenting symptoms between the groups (N=160)

Group-I: ≤ 30 years, Group-II: ≥ 50 years, s = significant, ns = non-significant

Table 1 compares the frequency of common presenting symptoms between Group I (n = 80) and Group II (n = 80) of patients experiencing their first acute myocardial infarction. Statistically significant differences (p < 0.05) were observed in the occurrence of chest pain, sweating, shortness of breath, epigastric pain, syncope, and nausea/vomiting, with higher frequencies of atypical symptoms such as epigastric pain and nausea/vomiting in Group II. Palpitations showed no significant difference between groups (p = 0.807).

Table 2: Comparison of clinical examination findings between the groups (N=160)

Group-I: ≤ 30 years, Group-II: ≥ 50 years, s = significant, ns = non-significant

This table shows the clinical examination findings and vital signs between Group I (n = 80) and Group II (n = 80) in patients with first acute myocardial infarction. No statistically significant differences were observed in raised

jugular venous pressure (JVP), oedema, presence of S3, lung crepitations, radial pulse, or respiratory rate (p > 0.05 for all). However, Group-II patients demonstrated significantly higher median systolic and diastolic blood pressures (SBP and DBP) compared to Group-I (p = 0.004 and p = 0.029, respectively).

Table 3: Comparison of risk factors between the groups (N=160)

Group-I: ≤ 30 years, Group-II: ≥ 50 years, s = significant, ns = non-significant

Table 3 shows that Group I patients had a higher prevalence of smoking, dyslipidemia, obesity, family history of CAD, and substance abuse. Conversely, hypertension and DM were more prevalent in Group II. Statistically significant differences were observed in smoking, diabetes mellitus, hypertension, dyslipidemia, obesity, family history of coronary artery disease (CAD), and substance abuse (all p < 0.05). No significant differences were noted in smokeless tobacco use (p = 0.114).

Table 4: Comparison of complications between two age groups (N=160)

Group-I: ≤ 30 years, Group-II: ≥ 50 years, s = significant, ns = non-significant; VT=ventricular tachycardia, VF =ventricular fibrillation, BBB= bundle branch block

Table 4 presents a comparison of in-hospital complications between Group I and Group II. The findings show that cardiogenic shock and complete heart block (CHB) were significantly more prevalent in Group I compared to Group II, while VF was exclusively observed in Group I. Other complications were similarly present in both groups. A statistically significant difference was observed in the incidence of cardiogenic shock (p = 0.008), while other complications did not differ significantly between the groups.

Table 5: Multivariate logistic regression analysis in both age groups

OR= Odds ratio, CI= Confidence interval, Group-I: ≤ 30 years; Group-II: ≥ 50 years

This table presents the results of multivariate logistic regression identifying independent risk factors associated with the Groups. In Group I, smoking (OR = 12.0), dyslipidemia (OR = 8.89), obesity (OR = 21.89), family history of coronary artery disease (CAD) (OR = 17.69), substance abuse (OR = 4.34), and elevated C-reactive protein (CRP) levels (OR = 1.08 per unit increase) were significantly associated with AMI (all p < 0.001). For Group II, diabetes mellitus (OR = 12.69), hypertension (OR = 26.62), and low serum vitamin D levels (OR = 1.11 per unit decrease) were significant predictors (all p < 0.001). Odds ratios (ORs) are presented with 95% confidence intervals (CIs).

The findings of this study show that there were 57 (71.3%) male patients and 23 (28.7%) female patients in the very young group. In contrast, 65 (81.3%) male patients and 15 (18.7%) female patients were in the older group. But the statistical difference was not significant (p=0.137). Chest pain (95%) and sweating (80%) were predominant in the very young (≤30 years) group. Conversely, in the older (≥ 50 years) group, chest pain (73.8%) and SOB (45%) were predominant. Nausea/ vomiting (26%), epigastric pain (26.3%), and syncope (12.5%) were significantly higher in the older group than the very young group. Statistical analysis revealed significant differences in all of these symptoms (p < 0.05).

Notably, smoking emerges as a prominent risk factor, with a significantly higher prevalence in the very young group compared to the older group (75% vs. 43.8%, p<0.001). Smokers among Nepalese patients were found in 58.6% by Pandey et al. and  80.8% by Limbu et al. of the study population. [12,13] Similarly, up to 77.4% of Bangladeshi patients [14] and ranging from 14.3% to 64.7% of the Pakistani patients were smokers.[15,16] However, some previous studies also identified the use of smokeless tobacco consumption as a risk factor, with a frequency ranging from 0.3% to 60.6% for acute MI. [17,18]

Additionally, diabetes mellitus and hypertension exhibited significantly higher frequencies in the older group compared to the very young group, underscoring their importance as traditional cardiovascular risk factors in older individuals experiencing their first AMI (p < 0.05).

Research conducted in Pakistan and Bangladesh revealed that over 50% of patients had diabetes, which is the greatest prevalence.[19,20] According to Bhardwaj et al., diabetes mellitus was present in up to 80.6% of young Indian patients with CAD. [21]

Other studies revealed that the prevalence of hypertension ranged from 8.8% to 80.0% in older patients. [19,22] Some studies found that the percentage of hypertension ranged from 27.8% to 57.5% in Nepali older patients.[23,24] Likewise, studies from Pakistan had a prevalence of hypertension ranging from 10.2% to 75.0% in older patients. [15,20] Additionally, several studies from Bangladesh indicated a prevalence range for hypertension in older patients was from 14.0% to 80.0%, [19,25] while studies from India revealed that 8.8% by Gopalakrishnan et al., and  44.7% by Jariwala et al. of young patients with CAD had hypertension. [22,26]

Dyslipidemias, obesity, and a family history of CAD had a higher frequency in the very young group compared to the older group (p < 0.05). Many other studies found that 2.5% to 97.3% of very young CAD patients had dyslipidemias.[27,28] In Bangladesh, dyslipidemia was present in 11.9%  to 97.3% of young patients. [28,29] According to an Indian study, 88.3% of Indian younger patients had dyslipidemias. [22]

Many other relevant studies found that 1.7% to 97.1% of young South Asian patients with CAD had a high BMI (~23 kg/m²). [30,31] Two studies by Ravi et al and Laudari et al found that the proportion of high BMI patients in Nepal was roughly 13.3% and 25.0%, respectively. [24,32] Studies from Pakistan and Bangladesh were found to have high BMIs, ranging from 15.6% to 97.1% in younger patients. [31,33,34] Younger patients with CAD, up to 60%, had positive family histories . [19]

The prevalence of young CAD patients with a positive family history was studied in Nepal, and it varied from 2.9% by Pandey et al. to 31.6% by Dahal et al. [35,36] In Pakistani and Bangladeshi populations, the prevalence of a positive family history of CAD was 60.0% and 57.1%, respectively. [19,20] A study by Wadkar et al. revealed the lowest prevalence of a family history of CAD in India (6.0%), whereas a study by Sinha et al. reported a frequency of 46.8%. [37,38] Conversely, chewing tobacco demonstrated a higher prevalence in the older group, although not statistically significant (p = 0.114), suggesting a less definitive association with AMI compared to other risk factors.

In our study, cardiogenic shock was significantly more prevalent in the very young group compared to the older group (16.3% vs. 3.8%, p = 0.008), while ventricular fibrillation (VF) was exclusively observed in the very young group (33.3%). However, other complications such as acute LVF, tachyarrhythmia, bradyarrhythmia, and cardiac arrest did not show statistically significant differences between the two age groups (p>0.05). According to Akanda et al., very young patients with CAD had a prevalence (0.8%) of cardiogenic shock in their studies.[29] Some other relevant studies indicated that the incidence rate of cardiogenic shock varies from 0.2% to 36.9% in the Indian population. [37,39]

In the present study, multivariate logistic regression analysis in very young patients showed smoking, dyslipidemias, obesity, family history of CAD, substance abuse, and serum CRP levels were significant independent predictors of first acute MI occurrence. On the other hand, Multivariate logistic regression analysis in older patients showed DM, hypertension, and serum vitamin-D levels were the most powerful independent predictors of first acute MI occurrence.

Limitations of the study

Our study was a single-center study. We took a small sample size due to the short study period. After evaluating those patients, we did not follow up with them for the long term and did not know other possible interference that may happen in the long term with these patients.

This study evaluated that there was a significant difference in clinical presentations and risk factor profiles between very young (≤ 30 years) and older (≥ 50 years) patients with their first acute MI. Very young patients presented with more typical symptoms, higher complication rates, and a distinct risk factor profile. Conversely, older patients exhibited a more atypical presentation with a lower complication rate. The findings of this study indicated that smoking, dyslipidemia, obesity, a family history of CAD, substance abuse, and serum CRP level were statistically significant risk factors in very young (≤ 30 years) patients experiencing their first acute myocardial infarction. Conversely, DM, hypertension, and serum vitamin D levels were statistically significant risk factors for the occurrence of first acute MI in older (≥ 50 years) patients.

Further study with a prospective and longitudinal study design, including a larger sample size, needs to be completed to validate the findings of our study and to evaluate the role of emerging risk factors for acute myocardial infarction.

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