COMPARISON OF RISK FACTORS IN YOUNG ADULTS WITH OLDER ADULT PATIENTS WITH RECENT MYOCARDIAL INFARCTION AT DR RUTH PFAU CIVIL HOSPITAL KARACHI

COMPARISON OF RISK FACTORS IN YOUNG
ADULTS WITH OLDER ADULT PATIENTS WITH
RECENT MYOCARDIAL INFARCTION AT DR
RUTH PFAU CIVIL HOSPITAL KARACHI
A RESEARCH THESIS
Submitted to the Board of Advanced Studies and Research
Dow University of Health Sciences Karachi
By
Dr Sajad Ahmed Badvi
MBBS, DIPLOMA IN CARDIOLOGY (DIPCARD), DOCTOR OF
MEDICINE IN CARDIOLOGY (MD) {DUHS}

Table of Contents
Abstract ....................................................................................................I
Background...............................................................................................I
Objective...................................................................................................I
Methods....................................................................................................I
Results ...................................................................................................I-II
Conclusion................................................................................................II
Chapter 1 ...................................................................................................
1. Introduction......................................................................................1
1.1 Background......................................................................................4
1.2 Objective of Study.............................................................................6
1.3 Hypothesis.......................................................................................6
1.4 Operational Definitions ......................................................................6
Chapter 2 ...................................................................................................
2. Review of Literature ...........................................................................9
2.1 Definition of M.I and Types of M.I ...................................................9-10
2.2 Pathophysiology of M.I ....................................................................12
2.3 Causes of M.I .................................................................................15
2.4 Diagnosis of M.I .............................................................................28
2.5 Management of M.I ........................................................................29
2.6 Epidemiology of M.I ........................................................................30
Chapter 3 ...................................................................................................
3. Materials and Methods.....................................................................34
3.1 Research Design and Settings............................................................34
3.2 Study Duration ...............................................................................34
3.3 Inclusion Criteria ............................................................................34
3.4 Exclusion Criteria ............................................................................34
3.5 Sampling Techniques ......................................................................34
3.6 Sample Size Estimation ....................................................................34
3.7 Data Collection...............................................................................35
3.8 Data Analysis..................................................................................35

Chapter 4 ...................................................................................................
4. Results...........................................................................................36
Chapter 5 ..................................................................................................
5. Discussion ......................................................................................46
5.1 Limitations.....................................................................................49
5.2 Recommendations ..........................................................................49
5.3 Conclusion.....................................................................................50
References .............................................................................................51

LIST OF TABLES:
Table 1: Comparison of age between groups Page:40
Bar Graph 1: Comparison of gender between groups Page:4o
Table 2: Comparison of smoking between groups Page:41
Table 3: Comparison of diabetes between groups Page:41
Table 4: Comparison of hypertension between groups Page:41
Table 5: Comparison of family history of IHD between groups Page:42
Table 6: Comparison of sedentary lifestyle between groups Page:42
Table 7: Comparison of obesity between groups Page:42
Table 8: Comparison of dyslipidemia between groups Page:43
Table 9: Comparison of substance abuse between groups Page:43
Table 10: Comparison of blood urea between groups Page:44
Table 11: Comparison of serum creatinine between groups Page:44
Table 12: Comparison of lipid profile between groups Page:45
FIGURE
 Figure: Blood supply of heart Page:27

LIST OF ABBREVIATIONS
ACS = Acute Coronary Syndrome
AHA = American Heart Association
ACEI = Angiotensin Converting Enzyme Inhibitors
AMI = Acute Myocardial Infarction
ATP = Adenosine Triphosphate
ADP = Adenosine Diphosphate
BMI = Body Mass Index
CABG = Coronary Artery Bypass Grafting
CAD = Coronary Artery Disease
CHD = Coronary Heart Disease
CBC = Complete Blood Count
CKD = Chronic Kidney Disease
DM = Diabetes Mellitus
ECG = Electrocardiography
ESC = European Society of Cardiology
FH = Family History
FBS = Fasting Blood Sugar
HBP = High Blood Pressure
HDL = High Density Lipoprotein
IHD = Ischemic Heart Disease
LBBB = Left Bundle Branch Block
LDL = Low Density Lipoprotein
PCI = Percutaneous Coronary Intervention
RBS = Random Blood Sugar
SD = Standard Deviation
WHO = World Health Organization

i
ABSTRACT
BACKGROUND: Myocardial infarction occurs when a rise or fall recorded in
troponin and one of the values must be 99th
percentile of upper reference limit along
with ischemia evidence. There is a common factor in young patients having a family
history of coronary artery disease. More young patients were smokers, and drug
abusers. However, a history of previous MI or angina was found less in younger age
patients. Similarly, major risk factors of coronary artery disease like diabetes and
obesity were also found less in young age group, compared to the older age group.
OBJECTIVE: To compare the risk factors in young adults with older adults’ patients
suffering from recent myocardial infarction admitted in the cardiology unit of civil
hospital Karachi.
METHODOLOGY: The patients admitted in the cardiology department having age
<35 years or equal to 35 years were placed in one group and patients age >35 years
were placed in another group. The questionnaire has questions regarding socio-
demographic aspects with ST-elevation and risk factors like gender, family history of
myocardial infarction, hypertension, diabetes, smoking, substance abuse, and lifestyle.
These factors with ECG and lab tests were compared to determine statistical
significance in two groups. The collected data were analyzed through SPSS v25.0. To
find the statistical significance between the two groups Chi-square test is used. The
significance was done labelled as p<0.05. All these results were presented in tables and
graphs.
My study showed that young adult group(69.8% were males v/s 3o.2% females) older
adult group(76.2% were males v/s 23.3% were females), smoking was common in
young patients (63.5% in young v/s 31.7% in older group) similarly family history of
IHD was common in young patients (57.1% in young v/s 12.7% in older group),

ii
similarly substance abuse intake without smoking were (26.9% in young v/s 39.6% in
the older group) and substance abuse used with smoking 57.1% were young v/s 19.0%
were older), diabetes mellitus was less common in young patients (12.7% in young v/s
82.5% in older group), similarly hypertension was less common in young
patients(15.9% in young v/s 98.5% in older group), sedentary lifestyle was more
common in older patients (11.1% in young v/s71.4% in older group), again obesity was
more common seen in older patients (15.9% in young v/s 55.6% in older group),
similarly dyslipidemia was also common in older group (31.7% in young v/s 82.5% in
older groups).
CONCLUSION: Smoking, Substance abuse and Family History of IHD were the more
common risk factors among young age group patients of M.I. While conventional risk
factors are common in older age group .Hence more effort is required to protect young
population. Hence, we recommend at the national level to stop smoking, have physical
activities, chose healthy and better life style to promote good health in society and
advise policy makers to spread awareness through electronic, print media and arrange
seminars in societies to avoid substance abuse materials.
KEYWORDS: Coronary Atherosclerosis, Risk factors, Young v/s Old adults,
Myocardial Infarction.

1
Chapter: 1
INTRODUCTION
Myocardial Infarction (MI) occurs when rise and fall are recorded in troponin(1)
and one of the values
above 99th
percentile of upper reference limit along with evidence of ischemia. The main symptoms of
MI are chest pain(2)
, shortness of breath, feeling of discomfort with heart burning, cold sweat, and
nausea.
The pain mostly travels from chest to arm, shoulder, jaws, neck, and back. M.I. is an old age disease
however it can also develop in young age grown-ups. However, it has different risk factors and
complications as compared to old age patients. M.I. occurs due to plaque rupture which reduces the
supply of blood to the heart. (3)
In a study (4)
conducted in the USA, it was determined that the prevalence of M.I. in the younger age
group (<45 years) was 6 to 10 percent. In a study(5)
of India, it was observed that in South Asians, the
occurrence of MI in the young population is high as compared to other regions. According to the study,
the incidence of coronary arterial disease was determined as 12 to 16 percent.
According to a study,(6) conducted in Pakistan, AMI in<40 years of age accounts for approximately
19%. It is more common in men who were smokers. However, in 10% of cases, the cause was not
related to atherosclerosis.
Another study(92)
Abdul Samad et al. performed in Pakistan shows that the rising profile of patients with
AMI is that the bulk is male, comparatively younger were <45 years, have smoked 52%, hypertension
55% and diabetes 36% and IHD 44% were major risk factors. higher management of risk factors and
the awareness of preventive ways are needed.
Study(18)
Faisal et al. Smoking 76.66%, hypertension 6.6%, diabetes 3.3% and dyslipidemia 43.3% are
common modifiable risk factors in our young adults<35 years. Three or additional risk factors in a
personal incline to CAD at comparatively in younger age.

2
Study, (7)
concluded that clinical findings and major risk factors of acute MI are quite different in young
age patients as in old age patients. In the US, the main cause of mortality in either sex was M.I.
Similarly, myocardial infarction was the major reason for hospitalization worldwide.
The most common risk factor which contributed to the narrowing of coronary arteries was high
cholesterol in older age. (8)
Another study determined that elevated homocysteine and alcohol are major
risk factors for developing AMI among young patients whereas in old age patient’s hypertension is the
main risk factor. (9)
Another Study concluded that the risk profile of CAD is different in old age group as compared to
young age patients and mortality is much higher in the old age group compared to young age group. (10)
Mortality in long term is fivefold less in young age people suffering from M.I, compared to old age
people. (11)
According to a study, it was determined that predictors of non-invasive therapy were the
same for all ages but different in AMI cases. (12)
However, in young age CAD patients, the potential
remains more for improvement in the cardiovascular risk profile. (13)
In a study,(14)
in young age patients of M.I, the risk factors, such as the family history of CAD, smoking,
and dyslipidemia were found to be much higher (28.6%, 64.5%, and 49.7% respectively) compared to
old age patients (19.8%, 59.4%, and 38.8% respectively). However, M.I. history and angina history
were found less in young age patients of M.I. (17.4% and 9.2%) as compared to old age patients (26.7%
and 26,1%).
It was determined in a study that dyslipidemia, hypertension, and diabetes were the predominant risk
factors in old age patients of MI. Similar to it, in different studies, (15)
smoking (58.7% -76.7%) was the
most common risk factor in young age patients as compared to old age group patients with MI (31.7%-
59.4%). (16)
In another study, (17)
SRIKANTH YANDRRAPALLI and CHRISTOPHER NABORS 2019 by Journal
of American College of Cardiology the relative risk factors in the young age population were
determined that smoking, hypertension, and dyslipidemia were more prevalent. One study,(18)
reported

3
that dyslipidemia was high in younger population (49.7% v/s 38.85), whereas other studies (19)
reported
it higher in old age patients (43.3% v/s 49.5% and 20.0% v/s 29.0%).
The risk factors such as DM and obesity were found less in the young age group. Other studies (20)
also
shown diabetes (3.3- 5% in young v/s 30-38.6% in older) and obesity (6.6% in young vs. 21.4% in
older) as fewer risk factors in the young age population.
According to a study, (21)
the risk factors of MI have significant gender differences in short and long-
term clinical outcomes of young patients. Therefore, preventive strategies should be taken to reduce the
risk factor in young adults.
The aim of my study was to find out risk factors that are causing M.I.in young population so through
preventive measures reduce chances of IHD and protecting the patients from huge expensive heart
disease treatment. Since last more than five years no research occurred on such topic.
Further aim of my study was to determine the effects of substance abuse drugs on heart how these
substances causes IHD .because nowadays the tendency of our young population to take drugs has
increased especially they use alcohol,Gutka/ Betelnut more frequently.
Most of the cases registered in my study were also found to be addictive of smoking, alcohol,
gutka/betelnut.

4
BACKGROUND
The main reason behind myocardial infarction (MI) is an imbalance of oxygen supply and
demand which is caused by the formation of plaque rupture in an epicardial coronary artery, as
a result, acute reduction of blood supply in the myocardium occurs.
The findings of an acute MI are presented below in the electrocardiographic (ECG).
ECG shows Acute Inferior Wall Myocardial Infarction
Taken from: https://emedicine.medscape.com/article/155919-overview
In acute coronary syndrome, MI is considered a part of the spectrum (ACS). The spectrum of
ACS(22)
consists of ST-segment elevation M.I, non-ST-segment elevation M.I and unstable
angina that is collectively known as an acute coronary syndrome. Patients with non-ST-
segment elevation M.I might have T-wave or ST-segment changes that occur on the surface
(ECG),
Persistent and continuing transmural myocardial injury shows ST-segment elevation MI seen
on the ECG(23)
. Many patients who develop Q-waves have already dead myocardial area or
myocardium at risk of death unless immediate reperfusion therapy has been given.

5
In the presence of cardiac enzymes, the patients are diagnosed to have NSTEMI with the
absence of raised cardiac enzymes indicates UNSTABLE ANGINA.(24)
Both these conditions
produce ST and T wave morphological changes on surface ECG.
Due to MI systolic and diastolic impairment can occur and this leads to long-term
complications. (25,26)
Primary treatment of acute MI includes coronary thrombolysis and
percutaneous revascularization. (27)
Benefit of the open infarct-related artery with percutaneous
route is more pronounced when the door to balloon time is kept within 90 minutes after first
medical contact in same way benefit with fibrinolytic is achieved when the door to injection
time within 30 minutes after first medical contact. Ventricular functions, collateral blood flow,
prevention of ventricular remodeling improves by the opening of an infarct-related artery. (28)

6
OBJECTIVE
To compare the risk factors in young adults with older adult patients suffering from recent
myocardial infarction admitted in the cardiology unit of civil hospital Karachi.
Null Hypothesis:
There is no difference in risk factors of young adults and older adults’ patients suffering from
recent myocardial infarction.
Alternate Hypothesis:
The risk factors of young adults are different from the risk factors of older adults’ patients
suffering from recent myocardial infarction
OPERATIONAL DEFINITIONS
Myocardial Infarction
Myocardial Infarction (MI) occurs when a rise or fall in cardiac troponin levels recorded with
one value must be above the 99th
percentile of upper reference level along with ischemia
evidence.
ST-Elevation MI:
It is defined as 1mm ST-segment elevation in two or more adjoining leads often with reciprocal
ST depression in contra lateral leads. Except in leads V2, V3 where criteria for men is 2.5mm
of ST elevation<40 years and 2mmST elevation >40 years and in female 1.5mm ST-segment
elevation on ECG is considered diagnostic.(4,13)

7
NST Elevation MI:
It is distinguished from unstable angina by the presence of elevated serum levels of cardiac
biomarkers, serial measurements in patients presenting with ACS should be performed. In
patients of NST elevation, MI and unstable angina both produce ST and T wave changes on
ECGs.
Hyperlipidemia:
It is a condition in which total cholesterol is >200 mg/dl, LDLC >100mg/dl, and HDL goes to
<40mg/dl or they are on statin therapy.(19,59)
Young adult age:
<35 years of age or equal to 35 years.(18)
Old adult age:
>35 years of age
Diabetes Mellitus:
All the patients having HbA1c more than 6.5% or fasting blood sugar more than 126 mg/dl and
random blood sugar more than 200 mg/dl or they are on anti-diabetic therapy will be counted
as diabetics.(29)
Hypertension:
In patients with blood pressure >130/80mmHg or patients taking antihypertensive therapy for
control of blood pressure.(30)

8
Smoker:
Patients taking minimum five cigarettes per day for at least one-year duration is called a
smoker.(48)
• Current < 1 month
• Recent 1month to 1 year
• Ex-smoker More than 1 year
• Non-smoker
Obesity:
If BMI is exceeded to 30 Kg/m2.
.(61)
Normal 18.5 to 24.9 Kg/m2
.
Overweight 25 to 27.8 Kg/m2
.
Obese > 30Kg/m2
Sedentary Lifestyle
The patient achieved a METS score <1.5 Oxygen cost ml/kg /min. watching the T.V, playing
video games, sitting in the office between 6.7 to 8 hours /day.(93)

9
Chapter: 2
REVIEW OF LITERATURE
DEFINITIONS
The fourth universal definition of myocardial infarction(31)
Heart attack's second name is myocardial infarction (MI) which is defined pathologically when
myocardial cells are dead due to ischemia. Clinically myocardial infarction is a condition
apparent in most cases from major symptoms such as chest pain. It is supported by
electrocardiographic changes, elevated cardiac biomarkers that indicate myocardial necrosis.
Detection of an increase or decrease in cardiac markers while using troponin may be associated
with the following findings. By autopsy or angiographic the identification of thrombus
intracoronary.
• Ischemia symptoms
• New wave (ST-T) or LBBB significant.
• In ECG formation of Q waves (pathologic)
• Evidence by imaging with regional wall motion abnormality.

10
Types of MI
According to the joint WHF/ESC/AHA task force, MI has the following 5 types.
• Type 1 includes atherosclerotic plaque rupture. Dissection, erosion fissuring in the
coronary artery leads to decrease myocardial blood flow that nearly is myocyte necrosis
resulting. The patient may have CAD. (32)
• Type 2 leads to ischemic imbalance, at this stage cell demand more oxygen, but has
less supply. (33)
• Type 3 leads to patient death when biomarkers values are unavailable. Sudden before
blood sample to biomarker has taken when unexpected cardiac death can happen.
d) Type 4a MI is associated with PCI (34)
e) Type 4b MI is associated with stent thrombosis
f) Type 5 MI is associated with CABG

11
ACUTE CORONARY SYNDROME
The expression "intense coronary disorder" (ACS) alludes to a range of conditions that occur
because of intense myocardial ischemia or potentially localized necrosis because of a sudden
decrease in blood supply to the myocardium. (35)
STEMI
The major segregating highlight of STEMI is the nearness of indications of myocardial
ischemia/damage alongside tenacious ECG ST-Segment height not necessarily elevation of
cardiovascular biomarkers. (36)
RECENT M.I
Ongoing
myocardial localized necrosis characterized that had happened two days to five weeks after
M.I. (37)

12
PATHOPHYSIOLOGY
Cellular effects of myocardial infarction (MI)
A normal heart needs a blood supply to work properly and delivers blood to the entire body.
Oxygen is also needed to work properly. Hearts need oxygen supply properly and also need
supplements for their functioning by coronary dissemination. Ischemia is a condition when
blood supply to the myocardium is inadequate.
If this event persists then it damages heart cells and becomes it's fiery and biochemically, in
the long run, heart muscles cells become irreversibly damaged.
The progression of this disorder first indicates necrosis of coagulation and then a healing phase
of myocardial scar formation called myocardial fibrosis. That is a serious health concern.
These all things slowly build changes to contractile capacity and shape of the myocardium,
especially in the left ventricle. That all reduced heart contractile capacity. Later over time
heart's left ventricle becomes widens and changes to a round shape in a process called
redesigning of the left ventricle. With time serious health problems occur with this condition
of the heart.
Ventricular redesigning is a regulated process so specific treatment strategy particularly ACE
inhibitors or ARB should be used in AMI management to reduce the occurrence and
seriousness of ventricular redesigning. (38)
Myocardial stunning and hibernation are both triggered by the loss of fundamental metabolites,
for example, adenosine, necessary for adenosine triphosphate (ATP)-dependent contraction,
which is needed for normal myocardial contractility (39)

13
Plaque
Atherosclerotic plaques which cause M. I. Plaques occur in multiple stages in a dynamic
process. The process can be seen immediately after birth, initially, intima thickening occur
which comprise of vascular smooth muscle with very few or no inflammatory cells,
subsequently, a fibrous cap atheroma with a lipid-rich necrotic core surrounded by fibrous
tissue develops and finally a thin cap atheroma develop, which is with a large necrotic core
mainly isolated from blood vessels known as vulnerable plaque that are penetrated by
inflammatory cells and are susceptible to rupture due to lack of smooth muscle cells (40,41)
The course of acute coronary thrombosis leading to ACS involves a pathogenic mechanism of
plaque rupture and less frequent plaque erosion. When complete obstruction of the coronary
artery occurs by thrombus it causes ST-Segment elevation M.I and when partial obstruction
occurs it causes either NSTEMI or unstable angina.
The Brasilia Heart Study Group shows that the antiatherogenic capacity of (HDL) to transport
blood vessels lipids can be altered by modification of high-thickening lipoprotein (HDL) in the
MI. Specialists observed simultaneous lipid substitution to HDL and the limit HDL to efflux
cell cholesterol. (42)
Settled case-control study examining plasma metabolic markers relationships with the risk of
MI, ischemic and intra-cerebral bleeding showed that lipoproteins and lipids were in a
favorable relationship with MI and ischemic stroke but were not with intracerebral hemorrhage.
(43)

14
Non-modifiable risk factors for atherosclerosis include the following:
•
Sex
•
Age
•
Family history of CHD
•
baldness Male-pattern
Modifiable Risk Factors (44)
•
Dyslipidemia
•
Diabetes mellitus
•
Obesity (abdominal obesity)
•
Smoking
•
Psychosocial stress
•
Type A personality
•
Elevated homocysteine levels
•
lack of exercise
•
Presence of peripheral vascular disease

15
COMMON RISK FACTORS OF MYOCARDIAL INFARCTION
There are various risk factors of AMI. Among them, some are modifiable (treatable)
and others are non-modifiable (cannot be changed). The major risk factors of AMI are
described below.
Age
Old age increases mortality in acute myocardial infarction. (45)
The mechanism by
which elevated age contributes to increased mortality is unknown. About 80% of heart
disease deaths occur in people aged 65 or older. (46)
Gender
Men have more lifetime heart attacks than females. (47)
Women's heart problems occur
primarily after menopause. And now, both men and women face heart disease as the
leading cause of death.
Smoking
Smoking is an important risk factor for myocardial infarction. Smoking causes early
atherosclerosis and sudden cardiac death. Smoking primarily affects unhealthy patients
with early STEMI. (48)
Cigarette smoking by atherogenesis raises the risk of AMI.
Smoking raises serum LDL cholesterol, triglyceride and decreases serum HDL-
cholesterol levels. The cigarette smoke does not do radical damage to LDL so that the
arterial wall can absorb oxidized LDL-cholesterol
Smoking induces traditional artery inflammation atherosclerosis, with higher serum
levels of C-reactive protein in smokers than in non-smokers. (49)
Smoking stimulates
the sympathetic nervous system (SNS), increases heart rate and systolic blood pressure
through the content of nicotine. This rise in levels and pressure causes myocardial
oxygen demand to rise. Increasing SNS activity also contributes to coronary arterial

16
vasoconstriction that decreases myocardial oxygen supply and increases myocardial
oxygen demand this effect contributes to causing ischemia. (50)
Diabetes Mellitus
Diabetes mellitus is an important risk factor for cardiovascular disease (CVD). The
cardiovascular mortality and morbidity in people with type 2 diabetes mellitus are
higher. (51)
Diabetes patients have a greater risk of atherosclerotic vascular disease in
both the heart and other vascularized regions. Atheromatous plaques in diabetic patients
are more vulnerable to rupture. (52)
Diabetes raises the risk of myocardial infarction as it raises the rate of atherosclerotic
progression and influences the lipid profile and plaque formation. Diabetes reduces the
synthesis of nitric oxide resulting in increased platelet aggregation and activation of
thrombosis. Platelet function is also irregular in Diabetes, which raises the risk of
thrombosis at the site of the plaque break, resulting in up-regulation of factor VII,
thrombin, tissue factor, PAI-1 clotting for diabetes individuals,(53)
myocardial infarction
is often fatal in contrast to Non-diabetic patients.
Hypertension
All systolic and diastolic hypertension increase the risk of myocardial infarction. This
is a significant risk factor in coronary blood vessels causing atherosclerosis
contributing to cause myocardial infarction. (54)
In old age, hypertension is much
greater in the heart and responsible for at least 70 percent of heart disease.
Hypertension accelerates atheroma symptoms, increases shear stress on plaques,
adversely affects coronary circulation, and degrades endothelial function and.
Hypertension management with strict compliance with proper medication and dietary
changes greatly decreases the risk of myocardial infarction. (55)

17
Family history
The family history of myocardial infarction (MI) is an independent risk factor of MI.
Many genetic variations are associated with an increased risk of MI. (56)
The
strongest genetic effect on the risk of myocardial infarction is that of a variant found on
chromosome 9p21. Only a few of the myocardial infarction genes are associated with
classic risk factors. The history of AMI due to acute myocardial infarction in a first
degree raises the risk for men by around two times and almost three times the risk for
women. If a father has a heart attack before age 55 years and a mother before 65 years,
good family history may become very important to prevent a premature myocardial
infarction in the next generation.
Sedentary Lifestyle
In a sedentary lifestyle, people with multiple cardiac risk factors are more likely to
develop AMI. Sedentary lifestyle persons have double the risk for CAD death as that
of active people. (57)
Up to 20%-30% reduced risk of coronary heart disease through
physical activity like Brisk walking, climbing, and cycling activities provide safety
from CVD. The AHA recommends that 30 minutes or more of moderate-intensity
activity on most days of the week improves glucose tolerance, insulin sensitivity,
increases fibrinolysis, HDL and improves oxygen uptake in the heart, and increases
coronary artery diameter. (58)
Dyslipidemia
Overall, Dyslipidemia, which is a significant risk factor in cardiovascular disease was
generally referred to as total cholesterol, LDL, triglycerides or rates above the 90th
percentile or HDL-C below the 10th
percentile in the general population. (59)
The level
of non-fasting triglyceride appears to be a strong and independent predictor of potential
AMI risk, especially when the levels of total cholesterol also increase. The explanation

18
for this is that reduced levels of HDL-C and increased levels of triglyceride cause
metabolic worries and potentially adverse consequences. (60)
Framingham's study established the relationship between dyslipidemia and coronary
artery disease. The main risk factors for coronary atherosclerosis are elevated total
cholesterol, LDL, and low HDL levels. Dyslipidemia correction can reduce the risk of
myocardial disease.
Obesity
Increased BMI is directly related to increased incidence of myocardial infarction. (61)
Elevated BMI increase total cholesterol and triglyceride also decrease the level of HDL-
C. Although BMI and waist to hip ratios have a linear relation between obesity and
CAD. The waist to hip ratio is a more accurate predictor of CAD. (62)
Among
Abdominal obesity increased the risk of AMI. Obesity causes hyperinsulinemia which
is associate with lipid derangement, increase plasminogen activator inhibitor and
enhanced proliferation of cells in atherosclerotic plaque enhance chances of CAD.
Obese are those with a BMI of > 30kg/m2
.
Alcohol Consumption
Alcohol consumption increased the risk of myocardial infarction among those people
who drink alcohol daily. Heavy alcohol drinking enhances cardio-vascular risk. (63)
Heavy drinking has been shown to increase low-density lipoproteins, which increase
cardiovascular morbidity and mortality. Binge drinking has been associated with an
increased risk of thrombosis.
Most researches showed that alcohol consumption could increase LDL-C, triglyceride,
heart rate, blood pressure and thus increase the risks of atherosclerosis, atrial fibrillation
resulting in damaging cardiac muscle cells and cardiovascular system and producing
fibrinolytic enzyme inhibitors. Moderate drinking is not associated with any serious

19
morbidity; however, hypertriglyceridemias, cardiomyopathies, hypertension, and M.I.
are associated more often in those who drinks alcohol three or more times a day.
COCAINE USE
Cocaine increases the incidence of CAD also cocaine raises heart rate, blood pressure,
and enhances oxygen demand in heart muscle, and reduced coronary blood flow causes
ischemia. Cocaine abuse causes coronary spasm or thrombus formation by a-adrenergic
stimulation. (64)
Chest pain caused by infarction after 3 hours of cocaine ingestion and
also depends on the route of intake ( chest pain caused by M.I. after 30 min. with
intravenous use, 90 min with smoking , more than 80% of persons who use cocaine are
also cigarette smokers, and pain caused 135 minutes after nasal inhalation). Even single
use of cocaine caused Prinzmetals Angina which is due to coronary arterial vasospasm
(65)
Gutka/ Betel Nut:
People who chewed ten edible seeds each day were 4 times the additional possible risk to
induce CAD as compared to people who do not take it. Previously, mastication betel nut
was the reason behind several risk factors for CAD. One study established that chewing
betel nut was related to central blubber (Lin et al., 2009). However, Betel nut chewing
increase blood pressure in patients with D.M. It is also seen a positive association between
edible seed mastication and metabolic syndrome. It will so be projected that chewing betel
nut could either be a freelance factor associated with CAD(66)
or be an element by
influencing renowned risk factors for hypertension or diabetes. Several mechanisms justify
that edible seed chewing, causes narrowing of coronary arteries, and causes CAD.
Arecoline, the compound found in true pepper nut, has been reported to cause induction
of cyclooxygenase expression. The compound hydroxychavicol was found to induce the
reactive oxygen species and thereby mediating cells. Further more, the extracts of betel
nut modify LDL towards artery epithelium cells. These facts facilitate that the rationale for
CAD in betel nut mastication people may be specifically attributed to atherosclerosis.

20
Betel nut chewing could be an important risk factor for the event of CAD. it was found that
betel nut chewing increased the probability of CAD by almost 6 times. Furthermore, it was
established that those chewing edible seed for ten years had an eight-fold increase in the
risk of developing CAD. This shows that future betel nut chewing considerably vital risk
issue in conjunction with cardiovascular disease and polygenic disorder for CAD.
All these substance abuse materials like smoking, alcohol, charas, cocaine, and
Gutka/betel nut causes atherosclerosis, coronary spasm, atherogenesis, thrombosis,
increases fibrinogen level, LDLC, triglycerides, decreased HDLC, and increased C-
reactive protein .substance abuse also increases heart rate and SBP which causes
myocardial oxygen supply-demand mismatch all of these effects to contribute to
causing M.I.
A study was done by Dhruv Mohtta(67)
et al showed that patients who developed
atherosclerotic cardiovascular disease are those who use more substance abuse
materials like tobacco 62.9%, alcohol 31.8%, cocaine 12.9%, and cannabis 12.5% in
his study shows that recreational substances users had increase chances of ASCVD.
MI occurs by Non-atherosclerosis reasons are as below
• auxiliary to vasculitis coronary impediment
• hypertrophy of Ventricular (e.g., hypertrophic cardiomyopathy, left ventricular
hypertrophy)
• Coronary cholesterol, vein emboli, air, or sepsis.
• Injury to coronary arteries
• Vasospasm (angina variation)
• Arteritis

21
• Use of drugs (e.g., cocaine, ephedrine, amphetamines)
• Coronary courses aneurysms
• oxygen necessity factors expansion, for example, overwhelming effort or
hyperthyroidism, fever
• Factors that decline oxygen conveyance, for example, hypoxemia of extreme pallor
• Inclusion of the coronary courses with retrograde aortic analysis,
• Respiratory diseases
Moreover, because harmful effects of carbon monoxide or extreme aspiration problems can
lead to hypoxia which causes M.I. While not rare, diseases like Marfan, Kawasaki, Takayasu
arteritis, progeria, and cystic medial necrosis may be occur in child coronary supply.
In youth and immaturity, acute M.I is caused by acute inflammation of the coronary arteries or
irregular coronary artery origin is more common in adults with coronal corridors due to deep-
rooted affidavit of the atheroma and the plaque, which causes coronary artery spasm and
thrombosis. Intrauterine M.I, sometimes associated with coronary artery stenosis, also occurs.
(68)
SIGNS AND SYMPTOMS
In the case of acute MI, there are the following symptoms.
• Crushing Substernal chest pain. Pain is typically more severe of longer duration usually
more than 20 minutes. (69)
• Chest pain radiates to the neck, shoulder, jaw, back, left, &right arm and epigastrium.

22
• Sometimes it is due to pressure feeling that is characterized by aching, as squeezing or
constricting nature.
• Most patients have the feeling of indigestion, gas, fullness-like symptoms.
Patients that have myocardial infarction have fatigue, chest discomfort, and malaise as
symptoms. These symptoms can show in days and even in weeks. Sometimes
symptoms may occur suddenly or sometimes it happens without warning
In MI the patient’s vital signals may demonstrate as:
• The heartbeat of the patients is increased in case of high sympathoadrenal discharge.
(70)
• Sometimes due to atrial fibrillation, pulse rhythm can be irregular.
• Due to peripheral arterial vasoconstriction patient's blood pressure is initially elevated,
which can cause pain.
• When MI is in the right ventricular, cardiogenic shock can happen. (71)
• Due to pulmonary congestion or anxiety respiratory rate enhance.
• Sometimes wheezing, coughing, and the production of frothy sputum can occur.
• Sometimes patients develop respiratory distress for which they need ventilatory
support.

23
PHYSICAL EXAMINATION
While examining a patient with myocardial infarction, various clinical findings are sought out
which are described below.
Vital signs
Heart rate
Usually, heart rate is increased in AMI, Because during M. I heart muscles receive a small
amount of blood from arteries that supply blood to muscle, which are blocked. In M.I. the pulse
may be regular or irregular. Irregular pulse is seen in ventricular ectopy, atrial fibrillation,
sometimes ventricular tachycardia, flutter and accelerated idioventricular rhythm or other
supraventricular arrhythmias are seen.
Blood pressure
The blood pressure of M.I. patients is elevated initially, due to pain, anxiety, and agitation.
Also due to large infract area or impaired global cardiac contractility. As well as systolic blood
pressure may be decreased in M.I due to tachycardia which impairs stroke volume.
Respiratory rate
Due to pain, anxiety, or congestion the respiratory rate is increased. Patients with pulmonary
Oedema may have a respiratory rate of more than 40 breaths/min.
Temperature
Fever is a non-specific response to tissue necrosis. In between 24-48 hours fever usually
develops and the curve is generally parallel with the time that elevates creatine kinase level in
blood. Mostly body temperature does not exceed 102°F.

24
Neck veins
In the case of acute inferior-wall MI with RV infarct, the patients have right ventricular
immersion, the failure of the right ventricle makes the vein visible. (72)
Hepatomegaly, edema,
hypotension is caused by impaired right ventricular function.
Heart Sounds
An S3and S4 gallop sounds are audible in patients with large MI.(73)
Ruptured, mitral postero
medial, papillary muscle produce a state that is known as mitral regurgitation, produces a pan
systolic murmur. Pericardial friction rub that is produced through sliding contact of
inflammation-roughed surfaces of pericardium due to post-MI pericarditis.
Chest Auscultation
Wheezes and rales are auscultated, these conditions can occur from secondary to respiratory
venous hypertension. Extensive acute left ventricular MI is associated with this condition. (74)
Abdomen
MI Patient develops abdominal pain along with nausea, vomiting, and abdominal distension,
hepatomegaly, and positive Hepatojugular reflux are elicited in RV INFARCTION.

25
HISTORY
In the case of the initial diagnosis of MI, only some clues are obtaining from physical
examination while patients’ history is crucial in-patient presentations. The patient that has acute
MI, they usually have chest pain that led to prodromal symptoms of fatigue, malaise, chest
discomfort is symptoms of typical ST-elevation M.I. happen without warning.
In the case of acute MI typical chest pain can happen and it remains more than 20 minutes. It
also radiates to the shoulder, neck, and jaw and down to the left arm, this pain is retrosternal.
In the case of M.I. substernal pressure sensation can occur, which is also perceiving as aching,
burning, squeezing. Some patients have symptoms as epigastric condition, feeling of
indigestion, and fullness or gas. (75)
Sometimes many patients, do not recognize chest pain, and suddenly high pain threshold
happens to them. These patients have a disorder that impairs pain perception so this may result
in a defective anginal warning system. Moreover, some patients can have high threshold pain
due to mental status that is caused by medication.
MI mostly occurs in the daytime in the morning hours, as the morning increases the
sympathetic tone, this may increase the heart rate, high blood pressure, myocardial
contractility, coronary vascular tone, all these factors can explain better the whole circadian
variation. Morning is important because at that time blood viscosity is also high, and
coagulation can occur.
Rapid evaluation in case of initial state a brief history and focused physical examination is
included.
Other symptoms of myocardial infarction include the following:
Myocardial infarction symptoms are as follows:

26
• Anxiety
• Profuse sweating
• Cough
• Nausea, with or without vomiting.
• Shortness of breath
• Wheezes
• Rapid or irregular heart rate
• indigestion, Fullness
In United State, most deaths are due to heart disease. Heart diseases increase as age increase,
so it is an important, risk, albeit non-modifiable factor for cardiovascular disease in the general
population.(76)
It is also common in those patients that have chronic kidney disease.
In 1995 in the USA chronic heart disease in men and women was prevalent at the age of 65.
And the incidence in women was 90 per 1000 and in men, it was 83 per 1000. And the
cumulative prevalence was 217 per 1000 for men and 129 per 1000 women. It was proved that
the elderly had a high rate of chronic heart disease(77)
.
Patients that have chronic kidney disease have more chances to carry heart disease, mostly that
patients have the highest risk of cardiovascular disease. So many cardiovascular risk factors
are increased by declining kidney function. We can say that there is a direct relation between
CVD and CKD. In these patients, there are standard factors that only account for a small portion
that is observed in these patients.

27
Aging is an important determinant of kidney function. According to a study in the USA, more
than a third of the US has CKD in those people that have the age of 70. (78)
And this disease
increases with time. According to the postulate that older individuals that have CKD also have
the effect of CVD. In that case, some of the symptoms are diabetes, obesity, hypertension, and
other vascular diseases are present.
Blood Supply of the Heart
This Figure is taken from:
https://o.quizlet.com/xuwAGdOcf7jnc2YOQnTqPQ_b.jpg

28
DIAGNOSIS
Laboratory studies
Following lab tests in the diagnosis of MI are carried out:
• Cardiac enzymes/biomarkers: according to the cardiology society of Europe and
American Cardiology College in suspected patients of M.I. following tests are
recommended. The marker which is used to diagnose is troponin as it is sensitive and
specific. (79)
• Troponin levels rise in serum when necrosis of the myocardial occurs.
• CBC (complete blood count)
• Lipid profile
• Metabolic panel comprehensive
Electrocardiography
In initial evaluation and triage ECG is the most significant tool in those patients that have acute
coronary syndrome when MI is suspected. 80% of cases are confirmed by ECG(80)
. In M.I ECG
also identifying the site of occlusion in infarct-related arteries.
ECHOCARDIOGRAPHY
Useful for detecting wall motion abnormalities, LV function, and also see mechanical
complications of M.I.(81)
CARDIAC IMAGING (CORONARY ANGIOGRAPHY)
If patients have confirmed MI, then angiography is carried out to check the arteries of the heart.

29
MANAGEMENT
Pre-hospital care
Patients that have chest pain mostly include:
• Nitroglycerin for chest pain, given by the spray
• Non-enteric-coated chewable aspirin. Dose 325 mg stat
• Telemetry and pre-hospital ECG.
Emergency department and inpatient care
Design for medication and therapy include:
• Telemetry and ECG within 10 minutes After arrived in ER.
• Intravenous access, pulse oximetry supplemental oxygen when SaO2 Less than 94%
• Immediate giving of non-enteric-coated chewable aspirin. Dose 325 mg stat
• Oral p2y12 receptor antagonists
• Parenteral Antithrombotic Therapy.
• Recanalize infarct-related arteries within 90 minutes door to balloon time if PCI capability is
available. Primary PCI is the early goal to achieve. (82)
• Revascularize infarct-related arteries with fibrinolytic within 30 minutes door to injection time
in such patients where Primary PCI facility is not present. (83)

30
EPIDEMIOLOGY
United States statistics
In the United States, the main source of death is the coronary supply route, every year 500,000
to 700,000 deaths are occurred due to CAD. The cause of death due to M.I is approximately
one-third of all deaths in the population for those over the age of 35 years occurs annually
within the USA.
The yearly incidence death rate is about 600 cases per 100,000 individuals. The proportion of
patients diagnosed with NSTEMI has dynamically expanded as compared to ST-Elevation M.I.
Despite a decline in age-balanced deaths in the United States due to M.I. because of CAD-
related awareness is increased among peoples. since the mid-1970s, the total number of M.I-
related mortalities has not decreased.
The severity of M.I. in women is almost higher than in men. The CAD is more progress in the
dark population than white people at the age of 75 years. Among the Hispanic populace,
coronary artery disease mortality isn't as high as among dark people and white people. (84)
The
index mortality rate associated with acute M.I. is almost three times higher than that of men
compared to women.
European statistics
In European nations computer source design is the major source of death. CAD rate has
decreased by 30 percent in the European nation from the mid-1960s to the 1990s. eastern
European death expansion rate is intense. In the early 1900s, the MI death rate has decreased.
(85)

31
Cardiovascular disease in other developed countries and developing nations
A study of death statistics by the World Health Organization (WHO) found that in Japan, CAD
mortality was considerably lower, and WHO evident that about 30% mortality deceased by
mid-1990. CAD mortality is significantly lower than in the USA and Europe. because Japan
continues its strict control policies towards blood pressure and tobacco control and builds a
strategy to control BMI, Diabetes, and cholesterol level to prevent CAD deaths. (86)
(Ref.from
international Journal of Cardiology vol.291 Sep. 2019.
In China crucial rise in mortality associated with CAD is observed, which is likely due to
increased cardiovascular risk factors dyslipidemia and transcendent smoking. (87)
CAD levels
and related mortality are projected to rise significantly from an estimated 80 percent growth,
from approx.9 million in 1990 to 20 million by 2020, in other developing economics including
Asia, Latin America, the Middle East, and Sub-Saharan Africa.
It is suspected that these regional trends in the incidence of CAD and subsequent extreme MI
are potentially associated with consumption of high calories diet, reduce physical activity, and
higher smoking rates.
Notable Canadian-drove worldwide research has identified 9 efficient danger factors (smoking,
strange rates of blood lipids, obesity, diabetes, diet, physical activity, use of liquor, and
psychosocial factors) that are estimated to represent over 90%. across Africa, Asia, Australia,
Europe, Middle East, North and South America. (88)
The INTERHEART agents found that these hazard factors are the equivalent in pretty much
every geographic district and each racial/ethnic gathering around the world, and they are steady
in people. The INTERHEART preliminary demonstrated that smoking 1-5 cigarettes day by

32
day expanded the danger of an intense MI by 40%, and the hazard expanded with the measure
of tobacco smoked every day.
In the last few years, the study indicates that the approximate proportion of abdomen to hip
will supplant BMI as a sign of fitness, with the reason that all forms of tobacco – including
separate and unfiltered cigarettes, funneling and bites tobacco-are valuable and the stomach
robustness is a more important risk factor than weight gain (BMI).(89)
Patient Education
Patients with dynamic side effects of intense coronary disorder (ACS) ought to be told to call
crisis administrations, and they ought to be transported by crisis restorative administrations
faculty, not independent from anyone else, family, or companions. When suspected ACS
incidents last longer than 20 minutes, patients must be advised to reach the crisis office
immediately when closely associated syncope/ presyncope or hemodynamic shakiness is
present.
On the off chance that nitroglycerin is recommended to a patient with suspected ACS, if pain
not alleviates after taking nitroglycerin is experienced 5 minutes after the primary portion, the
patient should contact crisis administrations.
If help is experienced inside 5 minutes of the principal nitroglycerin portion, repeated dosages
can be allowed at regular intervals for a limit of 3 portions aggregate. If at that point, the
manifestations have not yet completely settled, the patient, a relative, or a parental figure should
contact crisis administrations.
Diet assumes a significant job in the improvement of coronary vessel diseases Instruct post-
myocardial dead tissue (MI) patients about the job of a low-cholesterol and low-salt eating
regimen. (90)

33
A dietitian should see and assess all patients before releasing them from the clinic. Moreover,
accentuation on exercise preparation ought to be made, because present proof exhibits that
heart diseases recovery after MI results in lower rates of repetitive cardiovascular occasions.
All patients ought to be instructed concerning the basic job of smoking in the improvement of
CAD. Smoking discontinuance classes ought to be offered to enable patients to abstain from
smoking after their MI. (91)

34
Chapter: 3
MATERIALS AND METHODS
Study Design:
Cross-Sectional Analytical Study
Sample Setting:
The study was conducted at Cardiology Department, Dr. Ruth Pfau Civil Hospital,
Karachi.From 15.3.2019 to 15.3.2020.
Sampling Technique:
Non-Probability Purposive Sampling
Sample Size:
Using open Epi 6, taking prevalence of 14% v/s 41% the highest in different studies for risk
factors, with a margin of error of 5%, the sample size will be 126 (63 in each group).
Inclusion Criteria:
• According to WHO criteria, all patients of recent MI of aged 25years and above of
either sex.
• Given consent to participate in the study.
• Exclusion criteria:
• Patients having any chronic co-morbid diseases. (PAH, CLD, Malignancy, etc)
• Patients already CABG, Most CABG Patients would be having prior MI

35
• Patients with congenital heart diseases (ASD, VSD, PDA, TOF) and valvular heart diseases
(Mitral, Tricuspid, pulmonary, and Aortic).
DATA COLLECTION PROCEDURE:
After getting approval from the scientific committee and IRB of DUHS, the study was conducted on
patients suffering from recent MI. Written consent was taken from all the participants for inclusion in
the study.
An equal number of patients i.e.,126 were taken for the study. The admitted patients <35 years of age
were placed in one group and the patients of >35 years were placed in another group.
A research proforma was developed for this study after pretest and validation were used to collect the
data from all the patients. The questionnaire had questions regarding socio-demographic aspects with
ST-elevation and risk factors like gender, family history of myocardial infarction, hypertension,
diabetics’ smoking, and lifestyle.
These factors with ECG and lab tests were compared to determine statistical significance in two groups.
(All tests and ECG are free at Civil Hospital Karachi)
DATA ANALYSIS PROCEDURE:
For data analysis, SPSS v25.0 was used. For qualitative data, frequencies along with percentages were
calculated. For quantitative data, mean with standard deviation were measured. To determine any
statistical difference, the Chi-square test was implemented in two groups. The significance was done
based on p<0.05. All these results were presented in the shape of tables and graphs. Confounding factors
and biases were controlled by strict follow-up of inclusion and exclusion criteria of the study.

36
Chapter: 4
RESULTS
This study was conducted to compare the risk factors of young adults with older adults with
recent myocardial infarctions. So, data collected and analyzed the results were as follows
The mean deviation age of young adults was 29.87 with a standard ± deviation of 5.85 and the
mean age of older adults was 58.58 with a standard deviation ± 10.13 in our study. When we
check statistical significance between these two groups the p-value showed a significant
difference as the p-value was less than the level of significance (p=<0.001).
The gender-wise distribution between groups showed differences as in young adults 44 out of
63(69.8%) were male and 19 out of 63(30.2%) were female. Similarly, in the older adults’
group, 48 out of 63(76.2%) were male and 15 out of 63(23.8%) were female (p=<0.422). These
also showed that males in both groups were more than females.
The smoking was more common in the young age group. 40 young patients were smokers out
of 63 (63.5%) as compared to the old adults group 20 patients were smokers out of 63 (31.7%).
The p-value also showed a significant difference in these two groups (p= < 0.001).
The diabetes risk factor was also more in the older adults’ group 53 out of 63 Patients (82.5%)
than young adults group in which 8 patients out of 63 (12.7%) were diabetics. P-value also
showed a significant difference in these groups (p=< 0.001).
The hypertension risk factor was more common in the older adults’ group 62 patients out of 63
(98.4%) and low in the young adults’ group 10 out of 63 (15.9%) were hypertensive. Chi-
square results also showed similar results (p=< 0.001).

37
The family history of IHD was more common in the young adults’ group 36 patients out of
63(57.1%) and less common in the older adults’ group 8 patients out of 63 (12.7%). Chi squares
results showed a significant difference in both groups (p<=0.001).
The sedentary lifestyle was more common in the older adults’ group 45 patients out of 63
(71.4%) and less in the young adults’ group 7 out of 63 (11.1%). Results showed significant
differences in both groups (p=< 0.001).
Obesity was also common in the older adults’ group 35 patients out of 63 (55.6%) than young
adult group 10 out of 63 (15.9%). The older adults’ group is a statistically significant difference
from young adults’ groups (p=< 0.001).
Dyslipidemia was also more in the older adults’ group 52 patients out of 63 were (82.5%) and
less in the young adults’ group 20 out of 63 (31.7%). Results showed a significant difference
in both groups (p=< 0.001).
Substance abuse use was more commonly seen in younger adult’s group compared to older
adults’ group. Substance abuse user younger adults were(84% v/s 58% older age group) with
or without smoking. In substance abuse material alcohol taken by the younger patients were 5
out of 63(7.93%) while 15 patients(23.80%) intake alcohol along with smoking while, in older
group 13 out of 63(20.63%) taking only alcohol, while 2 patients(3.17%) take alcohol along
with smoking, cocaine taking by the younger group were 3 out of 63(4.8%) along with smoking
charas taking more commonly by the younger group were 10 out of 63(15.9%) and the older
group were 7 out of 63(11.1%) in both groups all charas taker were smokers, only Gutka /
Betel nut chewing by young’s group were 12 out of 63(19.04%) and along with smoking were
8(12.69) and older groups who chewing were 12 out of 63 (19.04%) and 3 patients(4.76%)
uses both Gutka/Betel nut along with smoking overall P-value of 0.999 between two groups.

38
In young adults, the mean Deviation of blood urea was 28.11 mg/dl ± 11.72mg/dl Std Deviation
and in older adults, the mean Deviation of blood urea was 54.53 mg/dl ± 9.03 Std Deviation.
When we checked for statistical significance the p-value showed that there is a significant
difference between the two groups as the p-value was less than the level of significance
(p=0.001). Blood urea value is more in the older adults’ group.
The mean Deviation of serum creatinine in young adults was 1.10 ± 0.11 mg/dl Std Deviation
and in the older adults’ group, the mean Deviation of creatinine was 1.09 ± 0.10 mg/dl Std
Deviation. When checked statistical difference between these two groups, the p-value is greater
than the level of significance which showed no significant difference (p=< 0.736).
The mean Deviation of total cholesterol in young adults was 164.81 ± 21.44mg/dl Std
Deviation and in the older adults group mean Deviation was 212.68 ± 20.25 mg/dl Std
Deviation. The p-value showed a significant difference in both groups (p=< 0.001). Young
adults had normal range values while older adults had high cholesterol.
The level of TG was more in older adults’ groups and less in young adults’ groups. The mean
Deviation of young adults was 121.63 ± 45.78mg/dl Std Deviation and the mean Deviation of
older adults was 223.98±40.38 mg/dl Std Deviation. When the difference was checked
statistically the p-value showed a significant difference between these two groups. (p= <
0.001).
The value of LDL is also a significant difference in both groups as the mean Deviation of LDL
in young adults was 117.10±27.91 mg/dl Std Deviation and in older adults mean Deviation was
178.19±33.19 mg/dl Std Deviation. The value of p was also less than the level of significance
(p= < 0.001).

39
The mean and total Deviation of HDL in the young adults’ group was 55.52±12.34 with
standard deviation and the mean Deviation of HDL in older adults was 30.43 ± 8.31with
standard deviation. The value of HDL was more in the younger adults’ group than the older
group. The p-value was also less than the level of significance (p= < 0.001).
At the end of the results, it was seen that all risk factors of myocardial infarction in the older
adults’ group were more positive than young adults’ groups. Older people had more chance of
myocardial infarction as they had more risk factors.

40
Table-I: Comparison of age between groups
Variable Young Adults Older Adults p-value
Mean + SD Mean + SD
Age 29.87 + 5.85 58.58 + 10.13 < 0.001
Figure-1: Graphical presentation of gender

41
Table-II: Comparison of smoking distribution between groups
Smoking
Groups
Total p-value
Young Adults Older Adults
Yes
40 20 60
< 0.001
63.5% 31.7% 47.6%
No
23 43 66
36.5% 68.3% 52.4%
Total
63 63 126
100.0% 100.0% 100.0%
Table-III: Comparison of diabetes distribution between groups
Diabetes
Groups
Total p-value
Young
Adults
Older Adults
Yes
8 52 60
< 0.001
12.7% 82.5% 47.6%
No
55 11 66
87.3% 17.5% 52.4%
Total
63 63 126
100.0% 100.0% 100.0%
Table-IV: Comparison of hypertension distribution between groups
Hypertension
Groups
Total p-value
Young
Adults
Older
Adults
Yes
10 62 72
< 0.001
15.9% 98.4% 57.1%
No
53 1 54
84.1% 1.6% 42.9%
Total
63 63 126
100.0% 100.0% 100.0%

42
Table-V: Comparison of family history of IHD distribution between groups
Family
History of
IHD
Groups
Total p-value
Yes
36 8 44
< 0.001
57.1% 12.7% 34.9%
No
27 55 82
42.9% 87.3% 65.1%
Total
63 63 126
100.0% 100.0% 100.0%
Table-VI: Comparison of sedentary lifestyle distribution between groups
Sedentary
Lifestyle
Groups
Total p-value
Young
Adults
Older Adults
Yes
7 45 52
<0.001
11.1% 71.4% 41.3%
No
56 18 74
88.9% 28.6% 58.7%
Total
63 63 126
100.0% 100.0% 100.0%
Table-VII: Comparison of obesity distribution between groups
Obesity
Groups
Total p-value
Yes
10 35 45
< 0.001
15.9% 55.6% 35.7%
No
53 28 81
84.1% 44.4% 64.3%
Total
63 63 126
100.0% 100.0% 100.0%

43
Table-VIII: Comparison of dyslipidemia distribution between groups
Dyslipidaemia
Groups
Total p-value
Young
Adults
Older
Adults
Yes
20 52 55
< 0.001
31.7% 82.5% 43.7%
No
43 11 71
68.3% 17.5% 56.3%
Total
63 63 126
100.0% 100.0% 100.0%
Table-IX: Comparison of substance abuse distribution between groups
Substance Abuse
Groups
Total p-value
Young
Adults
Older Adults
No Substance
Abuse
10 26 36
0.999
15.87% 41.26% 28.57%
Only Alcohol 5 13 18
7.93% 20.63% 14.28%
Alcohol + Smoker
15 2 17
23.80% 3.17% 13.49%
Cocaine + Smoker
3 0 3
4.76% 0.0% 2.38%
Chars + Smoker
10 7 17
15.87% 11.11% 13.49%
Only Gutka/Betel Nut 12 12 24
19.4% 19.4% 19.4%
Gutka/Betel nut +
Smoker
8 3 11
12.69% 4.76% 8.73%
Total
63 63 126
100.0% 100.0% 100.0%
Use of Substance Abuse with smoking in Young Group is 84 % in my data
Use of substance abuse with smoking in older group is 58 % in my data

44
Comparison of laboratory investigation between groups.
Table-X: Comparison of blood urea distribution between groups
Variable
Young Adults Old Adults
P-value
Mean + SD Mean + SD
Blood Urea(mg/dl) 28.11+ 11.72 54.53+ 9.03 <0.001
Table-XI: Comparison of serum creatinine distribution between groups
Variable
P-value
Mean + SD Mean + SD
Serum Creatinine (mg/dl) 1.10 + 0.11 1.09 + 0.10 0.736

45
Table-XII: Comparison of lipid profile distribution between group
Variable
P-value
Mean + SD Mean + SD
Cholesterol(mg/dl) 164.81 + 21.44 212.68 + 20.25 < 0.001
TG (mg/dl) 121.63 + 45.78 223.98 + 40.38 < 0.001
LDL (mg/dl) 137.10 + 27.91 198.19 + 33.19 < 0.001
HDL (mg/dl) 55.52 + 12.34 30.43 + 8.31 < 0.001

46
Chapter: 5
DISCUSSION
MI is an old age disease however it is also seen in young age adults, but the young age group
has fewer conventional risk factors. Same in my study the young adults have fewer
conventional risk factors of myocardial infarction than older adult groups. below 40 years of
age cholesterol accumulated in less amount within arteries resulting in less chances of coronary
atherosclerosis. Hypertension and diabetes are also less likely to occur at a young age(Table: III
and IV)
. However, young groups have different risk factors and complications as compared to old
age patients. That may be the reason why CAD is becoming prevalent in our part of world.
Myocardial infarction is a very serious disease for a patient and also for its family. If a patient
at a young age gets this disease then it carries significant morbidity, psychological effects, and
financial constraints for the patient and his family, and this way patient may loss their life years.
In my study, I took cut off age less than 35 years or equal to 35 in the young adults’ group of
recent M.I. from the study of Faisal et al (18).
I had take two groups one was below 35 years or
equal to 35 years called young adults’ groups and the second is above 35 years called older
adults’ groups. For both groups, 63 patients were selected. More conventional risk factors were
present in older adults’ group. I studied both the groups of patients with respect to the gender
distribution, presence of hypertension, and diabetes mellitus ,F.H. ,smoking ,substance abuse
etc
In the young adult group, 69.8% were male patients and 30.2% were female patients. In past,
there were very few studies that compare gender distributions also in these types of studies.
Similarly, in older adults’ groups, 76.2% were male and 23.8% were female. The gender
distribution is significant in our study. The male ratio was more than female in both groups.

47
Same in other studies Abdus Samad et al(92)
and Faisal et al(18)
showed male ratio was more
than the female ratio.
It was determined in my study that dyslipidemia, hypertension, and diabetes were the
predominant risk factors in old age patients of M.I. Similar to it, in different study(15)
In a studies (6,9)
in young age patients of MI, the risk factors like family history of CAD,
smoking, and substance abuse was found much higher. Same in my study the ratio of risk
factors like family history of CAD, smoking with substance abuse is higher (57.1%, 84%
respectively) compared to old age patients (12.7%, 58% respectively) which were alarming
finding.
A study (67)
done by Dhruv Mohtta et al showed that patients who developed the
atherosclerotic cardiovascular disease are those who use more substance abuse materials like
tobacco 62.9%, alcohol 31.8%, cocaine 12.9%, and cannabis 12.5% in his study this shows that
recreational substances users had increase chances of ASCVD.
Similarly in my study substance abuse materials like smoking, alcohol, cocaine, charas,
gutka/betel nut takers were more commonly seen in young adults (84%), compared to the older
adults’ group (58% respectively).
All these substance abuse materials cause atherosclerosis, coronary spasm, atherogenesis,
thrombosis, increases fibrinogen level, LDLC, triglycerides, decreases HDLC, and also
increase C-reactive protein, increases heart rate and SBP which causes myocardial oxygen
supply-demand mismatch all of these effects contribute to causing Myocardial Infarction in
young people.
It was determined in a study(14)
that smoking, CVD family history, and male gender were the
predominating risk factors in young age patients of MI, whereas hypertension, and diabetes
were the predominating risk factors in old age patients of MI.(15)

48
It was determined in a study done by Faisal(18)
et al that smoking (76.6%), family history of
CVD (33.3%), and male gender (90%) were dominating risk factors in young age patients of
M.I. same in my study it showed that smoking(63%), family history CVD(57%) and male
gender(70%) were more prevalent in young age patients of recent M.I .than older age patients.
Another big AAUS study done in Pakistan by Abdus Samad(92)
et al showed that male gender
(68.1%) hypertension (55.2%) smoking (52%) and diabetes (37.8%) were major risk factors.
My study shows that smoking with substance abuse(84%) was the main risk factor in the young
adult group and risk factors hypertension(98%), diabetes(82%), and dyslipidemia(82%) were
more prevalent in the old age group patients of recent M.I.
Similar to it, in different studies,(6,9,14,16)
smoking (58.7% -76.7%) was the most common risk
factor in young age patients as compared to old age group patients with MI (31.7%-59.4%).
Almost similarly in my study smoking was (63.5% in young v/s 31.7 in older age group
patients) another study,(17)
showed relative risks in the young age population were
hypertension, CAD family history, and dyslipidemia. One study by A. LIUQAT PMC 6284873
reported that dyslipidemia was high in the younger population (49.7% v/s 38.85), whereas other
study,(8)
reported it is higher in old age patients (43.3% v/s 49.5% and 20.0% v/s 29.0%).
My study, shows that diabetes was less common in young patients (12.7% in young v/s 82.5 %
in older group) and similarly obesity was also less common in young patients (15.9% in young
v/s 55.6 % in older group). Other studies(20)
also shown that diabetes (3.3- 5% in young v/s 30-
38.6% in older) and obesity (6.6% in young vs. 21.4% in older) as fewer risk factors in the
young age population. According to a study(21),
there was a significant gender difference for
CAD in the short and long-term clinical outcomes of young patients with MI. Therefore,
preventive strategies should be taken to reduce the gender-different risk factor in young adults.
(Ref. Epidemiol community health 2016 Nov 70(11)1057-1064).

49
My study mainly focused is to compare the risk factors of myocardial infarction in young and
older adults. The level of blood urea, serum creatinine, total cholesterol, and TG were high in
older adults’ groups than young adults’ group(8)
. But HDL was high in young adults. These
values are significantly different between these two groups.
LIMITATIONS OF STUDY
• Single-center study
• Selection bias
• Limited sample size
RECOMMENDATIONS
• Multi-center study.
• The probability Sampling Technique will be helpful for the generalization of results to
the larger population.
In the future Community should be educated about the harmful effects of smoking and
substance abuse materials’ also control other modifiable risk factors along with routine
screening which would help in preventing coronary artery disease in them, who belong to the
highly productive group in the community.

50
CONCLUSION
I concluded in this study that the risk factors like diabetes, hypertension, obesity, dyslipidemia,
and sedentary lifestyle were more prevalent in the older adults group than young adults group,
and Smoking, Family history of IHD and Substance abuse materials like alcohol, charas,
cocaine, gutka/betel nut were more common risk factors in young adults that causing M.I.
Hence, we recommend at the national level to stop smoking, do physical activities, chose
healthy and better lifestyle to promote good health in society and according to my study 84%
of young patients are using some form of substance abuse. Hence I recommend to our
policymakers to introduce and implement some expend kinds of law and enforce them properly
to protect our young population from potentially deadly IHD disease. spread awareness through
electronic, print media and arrange seminars on how to avoid substance abuse materials in
young peoples. There is also a need for screening of blood sugar, blood pressure, dyslipidemia,
and control of these atherosclerotic risk factors to reduce CVD risk in the population.

51
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