Clinical Profile of Acute Coronary Syndrome among Young Adults

Clinical Profile of Acute Coronary Syndrome among Young Adults
IJCCR
Clinical Profile of Acute Coronary Syndrome among Young
Adults
*Vinod Kumar Balakrishnan1, Aashish Chopra2, Muralidharan T.R.3, Thanikachalam S4
1,2,3,4
Sri Ramachandra University, College in Chennai, India
Acute Coronary Syndrome accounts for 30% of hospital admissions with cardiovascular
diseases. The risk of this syndrome is increasing among the younger adults, and a deep insight
into the clinical profile among these patients will help in devising a preventive strategy, in order
to alleviate the morbidity and mortality due to the syndrome. A cross sectional study was done
among 125 subjects admitted to our tertiary care hospital with Acute Coronary Syndrome. Their
risk factors were assessed and a 12 Lead electrocardiogram and 2D Echocardiogram were taken.
Cardio III panel which consists of Troponin I, CK MB, BNP by COBAS meter machine was also
measured. STEMI was present in 73.6% of the patients, while unstable angina was present in 16%.
About 90% of STEMI patients were males and 62% of them were hypertensives. LV Ejection
Fraction <30% was found in 9% of STEMI patients. This study elucidates the need for a preventive
strategy for primordial prevention of cardiovascular events among young adults. The study
envisaged the male, urban preponderance towards these events.
Key words: Acute Coronary Syndrome, Left Ventricle Dysfunction, Ejection Fraction, Reperfusion, STEMI
INTRODUCTION
Worldwide, cardiovascular disease (CVD) is estimated to
be the leading cause of death and loss of Disability
Adjusted Life Years (DALY). The Global Burden of
Diseases (GBD) study reported the estimated mortality
from CVD in India at 1.6 million in the year 2000. It has
been predicted that by the year 2020 there will be an
increase by almost 75% in the global CVD burden (Murray
CJL,1997). The situation in India is more alarming.
Between 1990 and 2020, these diseases are expected to
increase by 120% for women and 137% for men in
developing countries. Furthermore, South Asians have a
high prevalence of risk factors, and have ischemic heart
disease at an earlier age than do people in developed
countries (Reddy KS, 1993).
Epidemiological studies from various parts of India have
reported the rising trends and a high burden in the levels
of conventional risk factors such as diabetes, hypertension
and metabolic syndrome which are largely determined by
urbanization as evident from the urban-rural difference in
the risk factors observed in India (Mohan V, 2007; Gupta
R. 2004; Prabakaran D, 2007). Further, the long-term case
fatality following acute coronary syndrome is considerably
higher among Indians as compared to other populations
(Prabakaran D, 2005). In addition, a reversal of socio-
economic gradients for CVD risk factors has emerged in
the Indian population (Reddy KS, 2007; Ajay S, 2008).
Several registries in India like CREATE Registry and
KERALA Registry emphasis on the impact of the disease
in the young and low socioeconomic group and also
highlight on reducing symptom-to-door time, door-to-
needle time, and inappropriate use of thrombolysis and
increasing use of recommended drugs.
*Corresponding author: Vinod Kumar Balakrishnan, Sri
Ramachandra University, College in Chennai, India. E-
mail: pamilastalin2004@gmail.com
International Journal of Cardiology and Cardiovascular Research
Vol. 4(1), pp. 052-059, May, 2018. © www.premierpublishers.org, ISSN: 3102-9869
Research Article

Balakrishnan et al. 053
Acute coronary syndromes (ACS) account for about 30%
of hospital admissions of patients diagnosed with
cardiovascular diseases. The syndrome encompasses a
spectrum of events with different clinical severity based on
a partial or complete occlusion of the coronary artery. This
is predominantly due to thrombosis on a disrupted plaque
in the vessel wall. The plaque, caused by an inflammatory
process, stimulates the haemostatic CVD when the
protective endothelial cells of the vessel wall are gone
(Libby, 2001). Diagnosis of ACS is based on a group of
signs and symptoms of cardiac ischemia, an
electrocardiogram showing ST segment elevation or
depression or abnormalities of the T wave and a typical
increase and decrease in biochemical markers of cardiac
necrosis. Final diagnosis was classified as ACS- unstable
angina or myocardial infarction (STEMI or NSTEMI) is
based on the level of cardiac markers as measured in
blood (Antman, 2000; Eagle KA, 2004; Morrow DA, 2000).
Patients aged 40 years or less diagnosed as having ACS
had an unhealthy lifestyle. Cocaine use was frequent and
the prevalence of smoking, obesity, low HDL-cholesterol
and diabetes was higher. Although mortality during their
first hospital stay was low, the readmission rate was high
and readmission was associated with smoking and
decreased LVEF (Choudhury L, 1999).
The interaction between a genetic propensity to form
vulnerable plaque combined with acute stress and/or an
active infectious/inflammatory process needs further
study. If we can better identify and characterize the
mechanism of disease in this population, our
understanding of CVD in more typical cases will be vastly
improved.
OBJECTIVE
To study the clinical profile of Acute Coronary Syndrome
among young adults.
METHODOLOGY
Study Design
This study was carried out as a cross sectional study
Study Population
All patients who were admitted in our tertiary care hospital
with the diagnosis of Acute Coronary Syndrome were the
study population.
Study Period
August 2013 – January 2016
Sample Size and Sampling
Based on intensive literature review, it was observed that
ACS accounts for 30% of hospital admissions. At 95%
level of significance and 8% absolute precision, the final
sample size was calculated as 126 and was rounded off to
125. The study participants were selected by consecutive
sampling.
Inclusion criteria
•
• Age <40 years
• Suspected ACS with ST and Non ST Elevated MI
• Unstable angina with electrocardiographic changes
Exclusion criteria
•
• History of any other cardiac illness,
• Chronic inflammatory conditions like Systemic lupus
erythematosus, Rheumatoid arthritis or Multiple sclerosis.
• Pregnancy
Ethical committee approval & Informed consent
Approval was obtained from the Institutional Ethics
Committee and informed consent was obtained from the
participants prior to data collection.
Data Collection
The data on age, sex, socio economic data, medical
history, baseline clinical characteristics, time to reach
hospital, time to needle time, time to balloon time, and
other forms of treatment during the stay of hospital was
obtained. Outcome at the time of discharge were
meticulously collected. Geographical area from which
patients came for treatment - urban, semi urban or rural
area, the type of transport utilized to reach the hospital and
how they met hospital cost for the treatment were also
recorded. A 12 Lead electrocardiogram was taken with
General Electrical machine in our hospital; 2D
Echocardiogram was taken with GE VIVID E 9. Cardio III
panel which consists of Troponin I, CK-MB, and BNP by
COBAS meter machine was also measured.
Statistical Analysis
Data was entered and analyzed using SPSS version 16.
RESULTS
A definitive diagnosis of either STEMI or NSTEMI or
Unstable angina (UA) was made. Out of 1184 patients who
was admitted with ACS in our centre, 125 patients (10.5%)
comes under young adult’s category. Among them,
92(73.6%) patients were STEMI, 13(10.4%) patients were
NSTEMI and 20(16%) patients were unstable angina. Sex-
wise incidence in this study showed that males were more
commonly affected. In view of obesity as the risk factor for
CVD, based on the BMI, 19.5% of the young patients had
a BMI higher than 30, whereas 47.5% were found to be
overweight. (Table 1)

Int. J. Cardiol. Cardiovasc. Res. 054
Table 1: Demographic parameters of the study
participants
S/No Characteristics Frequency
(N=125)
Percentage
(%)
1 ACS Distribution
STEMI 92 73.6
NSTEMI 13 10.4
Unstable Angina 20 16
2 Sex
Male 104 83.2
Female 21 16.8
3 Age (in years)
18 – 25 8 6.4
26 – 30 17 13.6
31 – 35 36 28.8
36 – 40 64 51.2
4 Body Mass Index
Underweight 0 0
Normal 41 33
Overweight 60 47.5
Obesity 24 19.5
In the present study, most common symptom was angina
contributing to 97.50%(115cases) followed by dyspnea in
16.10% (19 cases), palpitations and nausea/vomiting in
6.80% (8 cases). (Figure1). It was observed that 90.2% of
the participants with STEMI were males. Moreover, 68.5%
of STEMI belonged to urban areas. The prevalence of
newly detected Hyperlipidemia was 58(46.4%) found to be
higher followed by Diabetes. Overall, STEMI group had
high prevalence of risk factors and amongst them Smoking
was found to be high followed by Hyperlipidemia. (Table
2).
Figure 1: Clinical symptoms of ACS
Table 2: Risk factors of ACS
S/No Characteristics STEMI
(N=92)
n(%)
NSTEMI
(N=13)
n(%)
Unstable
angina
(N=20)
n(%)
1 Gender
Male 83 (90.2) 9 (69.2) 12 (60)
Female 9 (9.8) 4(31.8) 8 (40)
2 Socioeconomic
Area
Urban 63 (68.5) 11 (84.6) 14 (70)
Semi-urban 20 (21.7) 0 (0) 2 (10)
Rural 9 (9.8) 2 (15.4) 4 (20)
3 Smoking
Present 82(89.1) 1(7.7) 1(5)
Absent 10(10.9) 12(92.3) 19(95)
4 Hypertension
Present 57(61.9) 1(7.7) 5(25)
Absent 35(38.1) 12(92.3) 15(75)
5 Diabetes
Mellitus
Present 63(68.5) 1(7.7) 5(25)
Absent 29(31.5) 12(92.3) 15(75)
6 Familial Hypercholesterolemia
Present 66(71.7) 2(15.3) 2(10)
Absent 26(28.3) 11(84.7) 18(90)
7 Dyslipidemia
Present 66 (71.7) 2 (15.3) 3(15)
Absent 26(28.3) 11(84.7) 17(85)
Among patients with ACS, 27 had evolved presentation
and 98 had acute presentation which comprises of both
NSTEMI and STEMI. It is not statistically significant.
LVEF Distribution, KILIP Score, MI Pattern with ACS
Majority of patients presented with Acute Coronary
Syndrome had preserved LV systolic function 69.6% (87)
and 15.2% (19) had mild LV systolic dysfunction followed
by moderate and severe LV systolic dysfunction of 8% and
7.2% respectively. All patients admitted with ACS – STEMI
(n=92) were analyzed and Anterior wall myocardial
infarction was found to be most common (59%), followed
by inferoposterior wall myocardial infarction (15.30%).
One case had involvement of myocardial infarction
involving anterior and inferior region. (Table 3)

Table 2A
Table 3: LVEF Distribution, KILIP Score, MI Pattern
with ACS
S/No Characteristics Frequency
(N=125)
Percentage
(%)
1 LVEF Distribution
Normal 87 69.6
Mild 19 15.2
Moderate 10 8
Severe 9 7.2
2 KILIP SCORE
1 104 83.2
2 5 4
3 6 4.8
4 10 8
3 MI Pattern
AWMI 54 59
ALMI 6 6.5
IWMI 9 9.7
IPWMI 14 15.3
IPRWMI 5 5.9
LWMI 1 1.2
RVMI 1 1.2
ILMI 2 2.4
True PWMI 1 1.2
AWMI-anterior wall myocardial infarction, ALMI-
anterior and lateral wall myocardial infarction, IWMI-
inferior wall myocardial infarction, IPWMI- inferior and
posterior wall myocardial infarction, IPRWMI-inferior,
posterior and right ventricular myocardial infarction,
LWMI-lateral wall myocardial infarction, RVMI-right
ventricular myocardial infarction, ILMI-inferior and
lateral wall myocardial infarction, True PWMI-True
posterior wall myocardial infarction.
In this study, 87 (70%) patients with Acute coronary
syndrome had preserved LV systolic function with greater
than 55%. A 19(15%) cases were between (40 –54)% and
(30 – 40) % were 10 (85) cases. 8(6.5%) patients were less
than 30 %. In this study, 104 patients with Acute coronary
syndrome had preserved KILLIP scores with 1 (Table 4).

Table 4: Types of ACS with LVEF and KILLIP scores.
S/N Factors Type of ACS Total
N(%)STEMI
N(%)
NSTEMI
N(%)
Unstable
Angina
N(%)
1 LVEF
≥ 55% 57(62) 11(83) 20(100) 87(70)
40 -54% 18(19) 1(8) 0(0) 19(15)
30 to 40% 9(9) 1(8) 0(0) 10(8)
<30% 8(9) 0(0) 0(0) 8(6.5)
2 KILIP Scores
1 72(78.3) 12(92.3) 20(100) 104(83.2)
2 5(5.4) 0(0.0) 0(0.0) 5(4)
3 5(5.4) 1(7.7) 0(0.0) 6(4.8)
4 10(10.9) 0(0.0) 0(0.0) 10(8)
In this study, patients with ACS reported with 45(36%) had
a Medical management treatment. 5(4%) cases were
reported dead. (Table 5)
Table 5: Treatment Analysis of ACS
S/N Treatment Frequency
(N=125)
Percentage
(%)
1 Medical management 45 36
2 PCI 56 45
3 CABG 10 8
4 Advised PCI 8 6
5 Advised CABG 1 1
6 Death 5 4
REPERFUSION STRATEGY IN STEMI
In our study, out of 125 patients, the number of patients
who had STEMI was 92. primary percutaneous coronary
intervention was done in 16 patients,28 patients had
evolved presentation,48 was thrombolysed (Tenecteplase-
18, Reteplase-9,&Streptokinase-21)and 23 patients had
recanalised coronary vessel by pharmacoinvasive
strategy.
Table 6: Reperfusion strategy in STEMI
S/No Reperfusion strategy Frequency
(N=125)
Percentage
(%)
1 Total STEMI 92 73.6
2 Evolved STEMI 28 30
3 Primary PCI 16 17
4 Tenectaplase 18 38
5 Reteplase 9 19
6 Streptokinase 21 44
7 Recanalised vessel by
Pharmacoinvasive strategy
23 48
A majority of the patients (71.2%) had single vessel
disease which was seen on coronary angiography,
followed by 11.9% had triple vessel disease, 11% had
double vessel disease and 5.9% of patients had normal
coronaries. About 56% of the patients had involvement of
the left anterior descending artery, 28% had involvement
of the right coronary artery and 14% had involvement of
the left circumflex coronary artery, and 1% of case had
involvement of Left main disease which was seen on
coronary angiography. In this study 11% of patients were
in cardiogenic shock and 8% cases had malignant
arrhythmia such as VT/VF. And out of total group of cases,
eleven of them had cardiac arrest and 4 cases were
revived and are doing well. (Table 7)
Table 7: Vessel Involvement of the patients
S/No Factors Frequency
N= 125
Percentage
(%)
1 Vessel involvement
Normal 7 5.9
Single vessel 84 71.2
Double vessel 13 11
Triple vessel 14 11.9
2 Vessel
characteristics
LAD 85 56
LCX 22 14
RCA 43 28
LM 2 1
4 Complication
Cardiogenic shock 14 11
Arrhythmia 10 8
VSR 0 0
5 Cardiac Arrest
Yes 11 9
No 114 91
DISCUSSION
Coronary Artery disease is leading cause of death globally.
In 2001, coronary artery disease accounted for 7·1 million
deaths worldwide,15·7 million (80%) of which were in
under developed countries. Coronary artery disease is
expected to increase by 120% for women and 137% for
men in developing countries, compared with 30–60% in
developed countries. Furthermore, South Asians have a
high prevalence of risk factors, and have coronary artery
disease at an earlier age than in developed countries.
Acute coronary syndromes (ACS) comprises for about
thirty percent of admissions of patient diagnosed with
cardiovascular diseases and about a third of the patients
in this population have mortality due to an ACS event.
Acute coronary syndrome is spectrum of events with
different clinical severity based on extent of occlusion of
the coronary artery and is predominantly due to thrombosis
on a ruptured plaque in the vessel wall. This ruptured
plaque, caused by an inflammatory process, activates the
hemostatic cascade due to release of tissue factor
released from debris of ruptured plaque which attract
thrombus.

This study is aimed to do A Clinical profile of Acute
coronary syndrome in young adults. The subsequent
patients who were admitted through Emergency room or
cross reference which are taken up for this study in a
tertiary care setup. We enrolled125 young adults below 40
years and above 18 years during study period of 30months
with an objective to find out occurrence of various type of
acute coronary syndrome as an In Hospital registry and
also do a multivariate analysis of clinical features, risk
factors, clinical presentation and laboratory data including
bio markers, occurrence of cardiogenic shock, Acute LV
failure, sudden onset of mitral regurgitation, ventricular
septal rupture are looked and documented. Incidence of
Acute coronary syndrome below 40 years in Thai Registry
was 5.8% but in our present study it was found to be 6.5%
subjects.
Myocardial Infarction when it occurs in young individuals
especially carries a significant morbidity, psychological
effects, and economic burden to the person and the family.
In our present study majority of patients presented with
mean age of 34.6 and there is clear preponderance of male
subjects 83.2% than female subjects. In addition, ST
elevation myocardial infarction occurred in 74% of
incidence. These observations are in agreement with
CREATE registry first of its tempo in India comparing of
patients in Tamil Nadu state with Acute coronary syndrome
ensured about 60% of patients presented with STEMI a
major group of acute coronary syndrome. In contrast with
developed countries indicates same as less than 40%
patient with Acute coronary syndrome had STEMI.
Similar findings were observed in a study (Sricharan KN,
2012) on Acute Myocardial Infarction in Young Adults
wherein 70% of patients were within the age group of 35-
40 years and 90% were males. Another study (Goornavar
S M et.al., 2011) in Karnataka found that half proportion of
cases were in36-40 years age group and 94.7% were
males.
This emphasizes that patient is more likely to have disease
early in life and develop myocardial infarction in younger
age without much collaterals due to short duration of
disease at that point of age resulting in involvement of
large myocardial area and make prognosis worse.
The association of Obesity, Diabetes Mellitus, Systemic
Hypertension, Dyslipidemia and Smoking are all validated
risk factor related to coronary artery disease. In present
study people who had disease less than 40 years of age
found to have two or more risk factors. This observation
emphasizes a primordial prevention strategy at population
level by bringing down all risk factors to target level.
The present study indicated that 90% of them were
smokers. The other risk factor Diabetes Mellitus was
observed in 31% of patients. Many studies at population
level showed that there is increasing incidence of Diabetes
mellitus apart from occurrence of diabetes mellitus in
young age as low as 18 years. Further pre-diabetic status
has been considered as precursor for Acute Coronary
Syndrome and establish Coronary Artery Disease which is
considered as synonym of Diabetes Mellitus. Similar
finding was noted in Oman study for Acute coronary
syndrome which found that diabetes mellitus was noted in
28% of cases. It was quite obvious to see overweight in
form of Obesity is seen in 47% of case. Dyslipidemia was
found to be another significant risk factor comprising of
47% of patients which is precursor for atherosclerotic
coronary artery disease. Comparing to other study it was
found prevalence of systemic hypertension 26% and
dyslipidemia 20% (Tamrakar R, 2013; Kanitz MG 1993).
The association of cluster of risk factors in age group less
than 40 years made age vulnerable to acute coronary
syndrome. The clinical presentation of acute coronary
syndrome with chest pain being common and Anterior wall
MI on ECG which was found in 59% of cases whereas
single vessel disease – Left anterior descending artery on
angiography was seen in 71.2%. Similar findings were
observed in various studies. (Sricharan K.N 2012;
Goornavar SM 2011; TamrakarR, 2013).
In STEMI group total recanalization of vessel by
pharmacoinvase therapy was found to be of 48% of cases.
Cardiogenic shock occurred in 11% of study group and
3.6% cases were recovered by revascularization therapy
through percutaneous coronary intervention but rest had
malignant arrhythmia which lead to instability of subject
and leading to prolonged cardiopulmonary resuscitation
but could not be revived which lead to mortality. In hospital
mortality in this study was 6% of cases and they were in
cardiogenic shock status, malignant arrhythmia or
pulseless electrical activity noted.
Unlike West, majority of the patients in our part of the world
are not covered with health insurance, the people who
underwent primary PCI were meagre.
CONCLUSION
Present study revealed Acute Coronary Syndrome in age
group below 40years with preponderance towards males.
People from urban area seem to be vulnerable through this
atherosclerotic tendency. There is high prevalence of
dominant risk factors which has been validated globally.
This study uncovers the reason for premature
atherosclerotic heart disease below 40 years of age in both
male and female without associated high family history is
the association with unfavorable environmental influence
which triggered various risk factor associations. Further
study emphasizes the need for primordial prevention to
evolve interventional methods by public education at
school & college level, general public awareness creation
about young age acute coronary events.

SUMMARY
Acute coronary syndromes are a major cause of concern
in the present-day world particularly when it happens in a
younger age group population. It poses a huge economic
burden to the society also with loss of life at a productive
age group. Though the technologies have emerged to
combat the situation by various newer revascularization
techniques which are becoming available more and more
in various parts of the world the main crux should be on
preventive strategies which are possible only by
dissemination of health education on all possible means by
lifestyle modification, early identification and modification
of risk factors. This study particularly exposes the
ramifications on various modalities in the presentation of
acute coronary syndromes in younger population which
paves way for further larger studies and will help health
policy makers to plan proper mean to achieve the goal of
reducing cardiovascular mortality on the whole especially
in younger population.
LIMITATIONS OF THIS STUDY
Firstly, not all the risk factors for AMI, which were reported
in the INTERHEART study, were assessed. These factors
included lack of physical activity, dietary factors,
psychosocial habits, psychiatric illness such as
depression, and alcohol consumption (Yusuf S, 2004).
However, in a more recent analysis of the INTERHEART
data, the addition of these risk factors did not show to
improve score discrimination in an external cohort
(McGorrian C, 2011). The current study did, however,
include all the risk factors used to calculate the
INTERHEART modifiable risk score, which was
subsequently proposed for the estimation of CHD risk in
multiple regions of the world. Secondly this study was
conducted in a single center.
Despite the recent decline in mortality from coronary heart
disease (CHD), this disease remains the leading killer
globally of all ages. CHD in young adults is not as well
characterized as CHD in older individuals because it
occurs less frequently, but this disease can have
devastating consequences for young patients and their
families. As in older adults, the majority of coronary events
in young adults are related to atherosclerosis, and one or
more of the traditional CHD risk factors is typically present.
Young patients, however, are more likely than older
patients to be smokers, male, obese, and to have a
positive family history. Risk factor reduction is thus of major
importance in managing young CHD patients.
Approximately 20% of CHD in young adults, however, is
related to non-atherosclerotic factors, such as coronary
abnormalities, connective tissue disorders, and
autoimmune diseases. Cocaine and other illicit drug use
have been increasingly associated with acute myocardial
infarction and accelerated atherosclerosis. The differences
in etiologies and risk profiles of younger and older CHD
patients result in differences in disease progression,
prognosis, and treatment. Limited data suggest that
prognosis may be better in the young population, although
long-term mortality studies have suggested otherwise.
Screening for CHD in the young population may help to
improve prognosis in young patients by detecting
subclinical disease, although more studies are necessary
to establish reference limits for this young population.
Additional research must also focus on treatment concerns
that are specific to young patients.
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Accepted 21 March 2018
Citation: Balakrishnan V.K., Chopra A., Muralidharan
T.R., Thanikachalam S. (2018). Clinical Profile of Acute
Coronary Syndrome among Young Adults. International
Journal of Cardiology and Cardiovascular Research, 4(1):
052-059.
Copyright: © 2018 Balakrishnan et al. This is an open-
access article distributed under the terms of the Creative
Commons Attribution License, which permits unrestricted
use, distribution, and reproduction in any medium,
provided the original author and source are cited.

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