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Original Article

Clinical & angiographic profile of young patients(<40 years) with acute coronary syndrome

Abhishek Wadkar a,*, Anuj Sathe a, Deepak Bohara b, Hetan Shah c,Ajay Mahajan d, Pratap Nathani e

aCardiology Registrar, Department of Cardiology, Lokmanya Tilak Municipal General Hospital, Sion, Mumbai,

Maharashtra 400022, Indiab Senior Registrar, Department of Cardiology, Lokmanya Tilak Municipal General Hospital, Sion, Mumbai,

Maharashtra 400022, IndiacAssociate Professor, Department of Cardiology, Lokmanya Tilak Municipal General Hospital, Sion, Mumbai,

Maharashtra 400022, IndiadProfessor and Unit Incharge, Department of Cardiology, Lokmanya Tilak Municipal General Hospital, Sion,

Mumbai, Maharashtra 400022, Indiae Professor and Head, Department of Cardiology, Lokmanya Tilak Municipal General Hospital, Sion, Mumbai,

Maharashtra 400022, India

a r t i c l e i n f o

Article history:

Received 27 May 2013

Accepted 17 February 2014

Available online xxx

Keywords:

Thrombolysis

Myocardial infarction

Recanalised vessel

Smoking

Culprit vessel

* Corresponding author. Tel.: þ91 9820556837E-mail address: [email protected]

Please cite this article in press as: Wadkcoronary syndrome, Journal of Indian Co

http://dx.doi.org/10.1016/j.jicc.2014.02.0091561-8811/Copyright ª 2014, Indian College

a b s t r a c t

Background: We are aware of increasing prevalence of coronary artery disease in young

patients and its potential implications on morbidity and mortality.

Aim: This study was done with the aim of evaluation of clinical and angiographic char-

acteristics in young Indian patients (<40 years) with ACS.

Method: The methodology used was single centre cross-sectional study with retrospective

analysis. 400 young patients (<40 years) with ACS were included in study. All patients

underwent CAG within 72 h of admission. Risk factors, clinical features and angiographic

profile were studied.

Result: Males were predominant, anterior wall myocardial infarction was most common

presentation. Recanalised infarct related artery, ST resolution >50% at 90 min, low TIMI

frame count (less than 28), were seen in patients receiving early thrombolysis. Smoking was

themost commonand only risk factor in 34%patients. 43%patients had single vessel disease

andonly 5.5%patientshad triple vessel disease. Evidence ofheart failurewas seen in 14.5%of

patients at presentation. Family history of premature CADwas seen in 6% patients. Younger

age, early presentation, thrombolysis within 12 hwere associated with favourable outcome.

Conclusion: The study concluded that significant number of young patients had recanalised

vessel after thrombolysis. Significant number of patients can be managed with pharma-

cotherapy. Prevention of smoking, tobacco addiction, screening for hypertension, diabetes

and dyslipidemia is vital and should begin from early period of life.

Copyright ª 2014, Indian College of Cardiology. All rights reserved.

(mobile).(A. Wadkar).

ar A, et al., Clinical & angiographic profile of young patients (<40 years) with acutellege of Cardiology (2014), http://dx.doi.org/10.1016/j.jicc.2014.02.009

of Cardiology. All rights reserved.

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http://dx.doi.org/10.1016/j.jicc.2014.02.009



j o u rn a l o f i n d i a n c o l l e g e o f c a r d i o l o g y x x x ( 2 0 1 4 ) 1e62

1. Introduction
pulses, blood pressure in both upper arms and one lower limb,
Atherothrombosis can no longer be considered a disease of

the developed world. CAD is becoming increasingly prevalent

worldwide across all socio-economic strata. By 2025, cardio-

vascular mortality on a worldwide scale will likely surpass

that of every major disease group including infection, cancer

and trauma.1,2 Due to the high prevalence of CAD in middle

age and elderly patients, comparatively few studies have

focused on the clinical presentation, treatment, angiographic

profile and outcome of ACS in young patients (<40 yrs).3e7 The

young patients with ACS is of particular interest considering

the years of potential life lost. Indians have a higher preva-

lence of Diabetes Mellitus and Hypertension compared to

western population. CAD also has an earlier onset in Indians.

Recent economic progress, changes in lifestyle and increased

incidence of smoking are contributing to the earlier onset of

CAD in Indians.8 We therefore evaluated Acute Coronary

Syndrome; its prodromal symptoms, clinical presentation,

risk factors, angiographic profile, treatment outcome, short

term morbidity and mortality in young Indian patients

admitted to a tertiary care centre in Western India.

2. Materials and methods

A retrospective cross-sectional single centre study was con-

ducted over three years. Patients aged 40 years or less

admitted to the cardiology department of Lokmanya Tilak

Municipal General Hospital (LTMGH) between 1st September

2009 to 30th September 2012 with acute coronary syndrome

(ACS) undergoing coronary angiography were enrolled in the

study. ACS includes ST-segment elevation myocardial

infarction (STEMI), non-ST-elevation myocardial infarction

(NSTEMI) and unstable angina (UA). The study population

comprised all young patients (40 years or less) admitted with

ACS during the said period undergoing coronary angiography.

Exclusion criteria were: 1. Age greater than 40 years. 2. His-

tory of prior ACS/coronary revascularization. 3. Patients who

expired before diagnostic angiogram. The study initially

identified 436 consecutive patients who met the inclusion

criteria. On further evaluation 36 caseswere excluded because

of inadequate documentation. The remaining 400 cases were

reviewed.

Table 1 e Demographic variables and baselinecharacteristics.

Total number of cases 400

Mean age 35.4 � 3.2

Male 372 (93%)

Female 28 (7%)

Family history of premature CAD 24 (6%)

Tobacco use (current smoker and/or

tobacco chewing)

261 (65.25%)

Obesity (BMI > 30) 138 (34.5%)

Hypertension 78 (19.5%)

Diabetes Mellitus (FBS>126) 56 (14%)

Dyslipidemia (TC > 200 mg/dl, LDL-C > 130 mg/dl) 34 (8.5%)

Killips class III/IV 58 (14.5%)

Presentation within 6 h of pain 251 (62.75%)

3. Data collection

Patient with STEMI who presented within 12 h of symptoms

onset having ongoing chest pain were thrombolysed with

1.5MUStreptokinaseafter contraindicationwere ruled-out. The

standard questionnaire comprised information regarding each

patient which included age, sex, weight, BMI, previousmedical

history such as history of CAD, HTN, DM, dyslipidemia, family

history of premature CAD, history of addictions such as smok-

ing, tobacco chewing, alcoholism and cocaine abuse. Clinical

parameters included were; chest pain, dyspnoea, killips class,

historyof syncope,presyncopeandneed forCPR. Parameters on

admission such as pulse rate, symmetry of pulses, peripheral

Please cite this article in press as: Wadkar A, et al., Clinical & acoronary syndrome, Journal of Indian College of Cardiology (201

respiratory rate, rales, gallop rhythm, murmur were recorded.

ECG features such as rhythm, heart rate, ST-segment deviation,

QRSwidth, bundle branch block, AV block, T wave changes and

QTc interval were recorded. Patients were followed up till

discharge from hospital for the present event or death during

hospitalization. Coronary angiogram was done within 96 h of

admission for all patients.

4. Definitions

Definition of STEMI required 1 mm or more ST-segment

elevation in two or more contiguous leads or new onset left

bundle branch block on initial ECG and elevated cardiac bio-

markers (either CK-MB at least twice the upper limit of the

normal range or troponin I or T above cut-off).

NSTEMI was diagnosed in the presence of symptoms or

ECG changes compatible with ACS, or both and elevated car-

diac markers but criteria for STEMI were not fulfilled.

Diagnosis of UA required symptoms or ECG changes

compatible with NSTEMI or both and normal cardiac markers.

Family history of premature CAD: in first degree relative onset

younger than age of 55 years for males or younger than

65 years for females.

5. Results

Demographic variables and cardiac risk factors are listed in

Table 1.

Of the 400 patients 372 (93%) were males and 28 (7%) were

females. There were 74 patients in the age group 20e30 years,

138 patients in the age group 31e35years.

188 patients in the age group 36e40 years (Fig. 1).

The most common risk factor was smoking present in184

patients, 104 patients were tobacco chewers. 78 patients had

systemic HTN, 56 patients were diabetic, 34 patients had

dyslipidemia, 54 patients were regular alcohol drinkers, and

family history of premature CAD was present in only 24 pa-

tients. In 23 patients no risk factors could be found. (Table 1).

Distribution of ACS was as follows:

ngiographic profile of young patients (<40 years) with acute4), http://dx.doi.org/10.1016/j.jicc.2014.02.009



Fig. 1

j o u r n a l o f i n d i a n c o l l e g e o f c a r d i o l o g y x x x ( 2 0 1 4 ) 1e6 3

� STEMI 346 (86.5%)

� NSTEMI 24(6%) &

� UA 30(7.5%)

Of 346 patients with STEMI, AWMI was most common (250

patients), followed by IWMI (46 patients). IWMI þ RVMI was

seen in 32 patients, IWMI þ PWMI was seen in 18 patients.

Chest pain was the most frequent symptom present in 388

patients (97%). Dyspnoea was present in 180 (45%) patients.

64.5% patients presented with killips I, 21% presented with

killips II, 9% presented with killips III, 5.5% patients presented

in killips IV. Syncope was seen on 4% patients on or before

admission (Table 2).

Out of 346 patients with STEMI 280 patients received

thrombolysis (within 12 h of index pain), 3 patients underwent

primary PCI & 10 patients required rescue PCI (in view of failed

thrombolysis or delayed presentation). Thrombolysis was

successful (relief of angina and reduction in ST-segment

elevation by 50% or more at 90 min after thrombolysis) in 211

patients (all of whom presented within 6 h of onset of pain). 6

patients continued to have persistent pain/ST elevation >50%

despite thrombolysis within 6 h of pain. All of patients with no

Table 2 e Symptoms and signs of ACS.

Symptoms

Chest pain 388 (97%)

Atypical chest pain 42 (10.5%)

Typical angina pectoris 346 (86.5%)

Radiation of pain 317 (79.25%)

Dyspnoea 180 (45%)

Nausea and or vomiting 55 (13.75%)

Diaphoresis 225 (56.25%)

Palpitation, apprehension or anxiety 74 (18.5%)

Change in level of consciousness 21 (5.25%)

Syncope on presentation 16 (4%)

Signs

Tachycardia (>100/min) 263 (65.75%)

Bradycardia 27 (6.75%)

SBP > 140 &/or DBP > 90 on presentation 63 (15.75%)

Hypotension (SBP<90 mmHg) 22 (5.5%)

Tachypnoea (>24 respiration/min) 110 (27.5%)

S4 gallop 93 (23.25%)

Elevated JVP 145 (36.25%)

Rales or Wheeze 138 (34.5%)

Chest wall tenderness 30 (7.5%)

Absence of above signs 65 (16.25%)


risk factors and presentation within 6 h (15 cases) had suc-

cessful thrombolysis (Table 3).

We studied 28 females with ACS. Of these 22 had STEMI

(AWMI 16, IWMI 6), 4 had NSTEMI, 2 had UA. Smoking and or

tobacco use were seen in 16 cases, 3 patients were diabetic, 3

patients had no risk factors. CAG in STEMI females showed

stenotic lesion in 7 cases, recanalised vessel in 11 patients, 3

patients had non-significant lesionwhile 1 patient had normal

vessels.

In 80% patients with IWMI (n ¼ 86) had some form of

conduction system disturbance on presentation .The distri-

bution of conduction system abnormality in IWMI was as

follows: Most common conduction system abnormality was

first degree AV block (54%), followed by Wenckebach phe-

nomenon (23%) and Third degree AV block (18%). All 1st de-

gree AV blocks resolved within 48 h with or without

thrombolysis. 40% of second degree AV block resolved within

12 h of thrombolysis, remaining resolved within 48 h. Third

degree AV Block was more common when patient had asso-

ciated RVMI. RVMI was seen in 17 out of 21 patients with CHB.

Out of 21 patients with CHB, 12 resolved within 12 h of

thrombolysis, 5 resolved after 48 h. In 4 patient CHB resolved

only after successful angioplasty. None of patients required

pacing e temporary or permanent.

Sixty-three patients of AWMI had conduction system

disturbance on admission. The distribution of conduction

system abnormality in AWMI (n ¼ 246) was as follows: The

most common was LAHB seen in (45%) followed by RBBB

(18%), followed by bifascicular block 16% (RBBB þ LAHB). CHB

was seen in 12 cases. Five out of 12 cases with CHBwith AWMI

died within 1 h of admission despite thrombolysis (not

included in analysis), 3 patients reverted back to sinus rhythm

after successful coronary intervention. Two patients required

CABG with permanent epicardial pacemaker implantation.

Two patients underwent percutaneous coronary intervention

followed by permanent pacemaker implantation in view of

persistent CHB for >72 h after PCI. Sustained ventricular

tachycardia requiring cardioversion was seen in 37 patients

(Table 4).

Recurrent angina was noted in 47.9% of STEMI cases. Free

wall rupture was seen in 5 patients out of whom 3 had

Table 3 e Effect of Thorombolysis in STEMI.

Parameter Thrombolysed(280)

Notthrombolysed

(66)

Pvalue

Recanalized artery 90 08 0.0008

Thrombus on CAG 03 15 0.0001

ECG resolution by >50%

at 90 min

211 10 0.0001

TIMI frame count

(average)

28 42 0.004

Mechanical

complication (VSR,

MR, Free wall rupture)

4 9 0.030

Major bleeda 3 1 0.05

a Major bleeding was defined as that which required more than 2

units of red blood cells or equivalent whole blood trans-

fusion.(CREATE Registry).

ngiographic profile of young patients (<40 years) with acute), http://dx.doi.org/10.1016/j.jicc.2014.02.009



Table 4 e Mortality and morbidity for STEMI (n [ 346).

Recurrent angina 166 (47.9%)

Pump failure (high JVP, S3, shock) 128 (36.9%)

Non-sustained VT 164 (46.82%)

Sustained VT 37 (9.2%)

Primary or Secondary VF 21 (6.06%)

Conduction disturbance (Fascicular

block, AV Block)

131 (37.8%)

Atrial arrhythmias 39 (11.27%)

Post infarct pericarditis 19 (5.49%)

Stroke 3 (0.86%)

Myocardial free wall rupture 5 (1.44%)

Other Mechanical Complication

(VSR, acute ischaemic MR)

9 (2.6%)

Death 28 (8.09%)


received fibrinolysis. Ventricular septal rupture was seen in 5

patients (4 with AWMI and 1 with IWMI). All 5 died during

same admission. Acute severe MRwas seen in 4 patients all of

whom had IWMI and associated tethered PML. 3 out of these 4

patients with severe MR succumbed during same admission

(Table 3, Table 4).

On echocardiography and Doppler evaluation RWMA was

noted in 335 out of 346 patients with STEMI. 11 out of 24 pa-

tients with NSTEMI had RWMA on presentation or follow-up

scan during same admission. Only 4 out of 30 patients with

UA had RWMA on presentation or follow-up scan.

In patients with STEMI LVEF (by Simpson’s method) was

preserved only in 5% patients, 22% had LVEF in the range of

40e50%, 53% had LVEF 30e40%, 20% had LVEF < 30% (Fig. 2).

Ninety seven percent patients had some form of diastolic

dysfunction at presentation or on follow-up scan .2.5% of

patients had trivial to mild pericardial effusion.

Four Hundred patients underwent CAG; their CAG findings

are summarized in Table 5.

Table 5 e Angiographic findings.

Single vessel disease (SVD) 172 cases (43%)

SVDeLAD 134

SVDeRCA 32

SVDeLCX 6

6. Observations

� We analysed 400 young patients with ACS, STEMI in young

patients were much more common than NSTEMI/UA.

� Smoking followed by tobacco chewing was the most

common risk factor (65.25%).

� Diabetes and hypertension were present in 14% and 19.5%

respectively.

� Dyslipidemia was seen in only 8.5% of patients.

Fig. 2


� Young patients with STEMI present commonly with chest

pain and typical symptoms of angina. AWMI is the most

common presentation of STEMI in young patients.

� Signs of heart failure were seen in young patients (14.5%

with killips III/IV).

� Conduction system abnormalities were more common but

transient with IWMI than AWMI.

� Successful thrombolysis was done in 75.3% of patients all

of whom who presented within 6 h of index pain.

� Of patients with STEMI, 53% patients had LVEF between 30

and 40% while 22% had LVEF between 40 and 50%.

� Recanalised vessel was seen in 24.5%.

� CHB in AWMI have higher mortality respond poorly to

pharmacotherapy.

� LADwas themost frequent involved culprit vessel in lieu to

AWMI.

� Total mortality was 8.9% in young patients with STEMI at

30 days.

7. Discussion

In our study with mean age of 35.4 years 86.5% patient with

ACS were STEMI, as compared to European heart survey9,10

with mean age of 63 years and 42% patients with STEMI;

CREATE Registry11 with 20,468 Indian patients with mean age

of 57 years and 61% patients with STEMI; 80% incidence of

STEMI in young Americans patients with ACS12; and 67% from

the Thai ACS13 registry database. Thus most of the studies in

young population with ACS have shown that STEMI is the

most common presentation of ACS in this group of patients.

Thus it is conclusively established that Indian patients with

CAD have early onset of illness (one decade earlier than

western population) and aremore likely to presentwith STEMI

compared to western and Southeast Asian population.

At the path physiological level this might reflect increased

thrombogenicity and/or plaque rupture in moderate degree of

stenotic lesions.14 Younger patients had a lower in-hospital

mortality rate, lower incidence of congestive heart failure

Double vessel disease (DVD) 54 (13.5%)

LAD þ RCA 22

LAD þ LCX 24

LAD þ RAMUS 2

LCX þ RAMUS 4

LCX þ RCA 2

Triple vessel disease (TVD) 22 (5.5%)

Left main 2 (0.5%)

Normal 11 (2.75%)

Thrombus 18 (4.5%)

Recanalised infarct related vessel (for STEMI only)a 98 (24.5%)

Small vessel disease 23 (5.75%)

a <50% lesion with TIMI III flow in the echocardiographically and

ECG correlated target vessel.




Fig. 3 e Spontaneous coronary artery dissection.

Fig. 4 e Partially recanalised left main thrombus.

j o u r n a l o f i n d i a n c o l l e g e o f c a r d i o l o g y x x x ( 2 0 1 4 ) 1e6 5

and a shorter length of stay compared to older age group

(CREATE REGISTRY).

Risk factors for CAD in young patients are known from

previous studies.15e19 Smoking and dyslipidemia have been

reported as most important cardiovascular risk factors in

young patients. In our study smoking was seen in 46% of pa-

tients whilst 26% patients were tobacco chewers (a common

addiction in south Asian population). In CREATE Registry

40.2% patients were smokers. In our study only 14% were

diabetic and 19.5% were hypertensive; reflecting young pop-

ulation in our study. In CREATE Registry DM and HTN were

seen in 30.4% and 37.7% of patients respectively.

Family history of premature CAD was seen only in 24 pa-

tients (6%), as compared to 40.2% by Mark et al20 in young

American population with ACS. This may suggest that envi-

ronmental and lifestyle related changes are more important

risk factors in young Indian patients with ACS.

In this study, 93% patients were males. In CREATE Reg-

istry 76.4% patients with mean age 57 years were males.

Branco21 LM et al noted that young patients with myocardial

infarction are predominantly males at 94.5%. Thus young

patients with ACS are more likely to be males which may be

partially attributable to high prevalence of smoking and

tobacco use in males. Gender difference tends to decrease

with age.

In our study at 30 days death was seen in 8.9%, stroke in

0.86%, major bleeding in 1%, and Reinfarction in 1.5%. These

outcomes were comparable with patients in older age group

aswell as shown by CREATE Registry for STEMI. Outcome at 30

days in CREATE Registry for STEMI were as follows: Death

8.6%, Stroke 0.7%, Major bleeding 0.3%, Reinfarction 2.3%,

Cardiac arrest (resuscitation) 3.4%.

In our study recanalised infarct related artery and single

vessel disease (infarct related artery only) was seen in 24.5%

and 43% of patients respectively, whereas triple vessel disease

was seen in only 5.5% of patients reflecting that ACS in young

patients is a result of rupture of a single vulnerable plaque or

de novo thrombosis. Also the number of recanalised vessels

(24.5%) reflects thrombotic milieu as one of the major aeti-

ology factors in this group of patients. In a study by Mohsen

Sharif et al22 angiographically normal coronaries were seen in

1% of patients. All patients with Q wave MI were young,

smokers and were males in this study, a finding which

corroborate with our study.

Spontaneous dissection was another cause found in our

study in 2 patients (Fig. 3). Both of themhad history of physical

exertion prior to the event. Spontaneous dissection has been

reported as a cause of ACS and its association with physical

exertion has been well documented.23

Although, we cannot definitely attribute prothrombotic

state as the only etiologic factor in the small subgroup of pa-

tients with recanalised artery, the fact that almost all of these

patients did not have any conventional risk factor (except

smoking in 34% of patients) the plausible explanation remains

that perhaps, smoking induces acute or subacute endothelial

dysfunction precipitating thrombus formation. Excellent

response to thrombolysis in this group of patients is another

reassuring fact for the above explanation. Thus we will not be

wrong in inferring that thrombolysis should be as effective as

Primary PCI in this subgroup of patients.


In our study, single vessel disease was seen in 172 patients

(43%), 54 patients (13.5%) had double vessel disease, 22 pa-

tients (5.5%) had triple vessel disease, 98 patients (24.5%) had

recanalised vessel, isolated left main lesion seen in 2 patients

(Fig. 4). Only 11 patients (2.75%) had normal coronaries (Table

5). This is comparable with a study done in young patients

with ACS by M Kanitz20 et al with 202 patients; which showed

single vessel disease in 125 (61.9%), double vessel disease in 36

(17.8%), triple vessel disease in 13 (6.4%), normal in 28 (13.8%).

Young patients who receive thrombolysis have higher

incidence of recanalised artery with favourable outcome.

Significant numbers of patients without traditional risk fac-

tors respond favourably to thrombolysis and the underlying

path physiology may be different from that of older patients.

Mechanical complications of MI may be reduced by use of

thrombolytic therapy.

Number of females is significantly lower thanmales, which

may be related to lower incidence of smoking/tobacco use in

this subgroup.

The favourable outcomes in young patients could be due to

presence of typical symptoms of angina, early seeking of

medical care leading to fast supply of reperfusion therapy and

other supplementary care. Young patients are alsomore likely

ngiographic profile of young patients (<40 years) with acute), http://dx.doi.org/10.1016/j.jicc.2014.02.009




to receive guidelines recommended treatment due to fewer

contraindication to thrombolysis. Furthermore we hypothe-

size that the favourable outcome might also be related to the

lower prevalence of extensive CAD in young patients.

8. Conclusion

� Our study has significant clinical implications. Most young

patients with STEMI are eligible to primary reperfusion

therapy. Rapid detection of STEMI in young patients with

chest pain is hence vital in order not to delay admission to

coronary care unit and further reperfusion therapy, which

was shown to improve the outcome significantly in these

patients.

� AWMI was the most common MI in young patients, with

LAD being the culprit vessel.

� Recanalised coronaries were commonly seen in patients

who received thrombolysis.

� Not all patients with MI require angioplasty or bypass

surgery. Our study shows that significant number of pa-

tients can be managed by pharmacotherapy. Early recog-

nition of symptoms, prompt transport to hospital, and

early initiation of therapy improves survival.

� Young patients presenting with ACS often receive early

aggressive treatment and have favourable outcome. Pri-

mary prevention of smoking, tobacco chewing, and

screening for Diabetes Mellitus, Hypertension, Dyslipide-

mia and Obesity should begin from early period of life.

Conflicts of interest

All authors have none to declare.

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