Successfully reported this slideshow.
We use your LinkedIn profile and activity data to personalize ads and to show you more relevant ads. You can change your ad preferences anytime.

New Perspectives Of Coronary Heart Disease In Young Adults

82 views

Published on

Ischaemic Heart Disease
I am young, I do not have to worry about heart disease
Definition of "Young", premature CAD/MI

Published in: Health & Medicine
  • Profollica�'s all-natural formula helped 90% of men reduce hair loss in a clinical trial.  https://tinyurl.com/y49r9d8j
       Reply 
    Are you sure you want to  Yes  No
    Your message goes here
  • Be the first to like this

New Perspectives Of Coronary Heart Disease In Young Adults

  1. 1. NEW PERSPECTIVES OF CORONARY HEART DISEASE IN YOUNG ADULTS DR STANLEY CHIA MBCHB(HON) MD FRCP FACC FESC FSCAI FAMS CARDIOLOGIST INTEVENTIONAL CARDIOLOGIST ASIAN HEART & VASCULAR CENTRE
  2. 2. ISCHAEMIC HEART DISEASE IN YOUNG ADULTS • Cardiovascular disease is the leading cause of death in the world ❖ 2nd commonest cause of death and hospitalization in Singapore ❖ 80% of CVD due to coronary artery disease • Large body of data and research on CAD, but... little data on premature CAD or “young” MI
  3. 3. Socioeconomic burden Heart Attack Patient’s psychology CORONARY DISEASE/MYOCARDIAL INFARCTION IS MORE THAN LIFE AND DEATH Ability to work Impact on family Long-term morbidity
  4. 4. 34 YEAR OLD MAN • Breathless on exertion for several months • Diabetes mellitus x10 years • Recently diagnosed hypertension, hyperlipidaemia • Non-smoker • Found to be in renal failure and heart failure – Left ventricular ejection fraction 35%, moderately impaired
  5. 5. Severe left circumflex artery stenosis Severe left anterior descending artery stenosis Severe Double Vessel Disease
  6. 6. 25 YEAR OLD MAN • Recent severe chest tightness • Smoked 20 cigarettes/day • Overweight • Found to have elevated cholesterol levels • Electrocardiogram showed evolved inferior MI • Cardiac Biomarkers were positive for MI
  7. 7. Severe left circumflex artery stenosis Severe left anterior descending artery stenosis Occluded right coronary artery Severe Triple Vessel Disease
  8. 8. “I’M YOUNG, I DON’T NEED TO WORRY ABOUT HEART DISEASE" Heart disease is more common among older people …
  9. 9. DEFINITION OF “YOUNG”, PREMATURE CAD/MI • Definition of premature CAD varies in literature from <35 to <55 years old • Spectrum of terminology of young CAD:
  10. 10. EPIDEMIOLOGY OF “YOUNG” CORONARY ARTERY DISEASE • 10 year incidence: (Framingham Study) • MI < 55 years: 51/1000 in men, 7.4/1000 in women • CAD: men 30-34 yrs: 12.9/1000, women 35-44 yrs: 5.2/100 • Young patients account for 2-6% of all acute coronary events • Gender: Median age of presentation in women is higher than men. In Singapore, men have 4x greater risk then women for age <65 • Ethnicity: South Asian “young” CAD prevalence ~5-10% (other ethnic groups ~1-2%). Earlier onset: ~53 yr. Europeans ~63 yr.
  11. 11. RISK FACTORS • The global INTERHEART study identified 9 risk factors that account for >90% of MI • Traditional CV risk factors apply to all ages • Majority of “young” patients have at least one identifying CV risk factor • Higher prevalence of smoking, family history, male gender, hyperlipidaemia • Lower rates of prior CHD history, DM, Hypt Yusuf, et al. Lancet 2004
  12. 12. HEART ATTACK RISK FACTORS Yusuf, et al. Lancet 2004 Lipids Smoking Diabetes Alcohol Lack of Exercise Lack of Fruits and Vegetables Hypertension Abdominal obesity Psychosocial
  13. 13. SMOKING • Probably most common and important modifiable risk factor among “young” adults • Stronger association of smoking with MI in young pts (odds ratio 3.33 vs 2.44, Yusuf et al. 2004) • Smoking rates among “young” MI ~51%-89% • “Young” patients smoked more per day, but fewer pack years prior to MI
  14. 14. FAMILY HISTORY • Prevalence of FH 2-4 fold higher vs older patients • 41-71% of “young” MI patients have family history of heart disease (1st deg relative <55-60 years) • Strong predictor of future acute coronary event GENDER BIAS • Vast majority in men ~79-95% • Up to 90% of patients presenting with MI were men • One potential reason that young women may experience delays in prompt care
  15. 15. HYPERLIPIDAEMIA • Traditional risk for CHD in all age group • Association less robust than other risk factors • Familial-combined hyperlipidaemia reported to have relatively high prevalence up to 38% • Young MI exhibit higher endogenous cholesterol synthesis and higher non-HDL cholesterol • ApoB/ApoA1 ratio strongly associated with MI, especially in the “young” (odds ratio 4.35)
  16. 16. OTHER TRADITIONAL RISKS • Diabetes mellitus Lower rates than older • Hypertension patients with MI • Diabetes mellitus: Increased risk for MI (odds ratio 8) • Hypertension: Higher rate of untreated patients • Higher BMI / Central obesity ➢ As prevalence of obesity increasing – potential future epidemic!
  17. 17. OTHER RARE CAUSES • Cocaine use • Spontaneous coronary artery dissection (more common in women, peripartum, idiopathic, atherosclerotic) • Kawasaki disease • Factor V Leiden • Low levels of oestrogen • Oral contraceptive pill • Hyperhomocysteinaemia Kawasaki disease
  18. 18. RARE RISK FACTORS – GENETIC POLYMORPHISMS • Cholesterol ester transfer protein (CETP) gene – significant association with progression of atherosclerosis • ApoE4 allele – homozygous individuals at risk of hyperlipoproteinaemia • MTHFR gene – homocysteinaemia • Hepatic lipase – HDL metabolism • Familial hypercholesterolaemia – mutations in LDL receptor ApoB, PCSK9, ApoE gene
  19. 19. PATHOPHYSIOLOGY OF “YOUNG CAD” • 80% accounted by Conventional coronary atherosclerotic disease • 4% due to congenital coronary anatomy • 5% due to embolic phenomenon • 5% associated with coagulopathy • 6% due to spasm, inflammatory disease, radiation, trauma, substance abuse
  20. 20. CLINICAL PRESENTATION OF “YOUNG MI” • Presentation: Two-thirds NSTEMI, One-third STEMI • Prodrome: Most have no previous angina, MI or CHF • Only ~25% men had chest pain in prior 1 mth. Rate even lower among women. Compared to 2/3 in older adults • Extent of disease: Usually less extensive, usually single vessel disease. Less than 10% Triple vessel disease • Spontaneous coronary dissection – rare disease – but not as infrequent in young women.
  21. 21. Spontaneous Coronary DissectionCoronary Atherosclerosis Coronary Artery Spasm
  22. 22. Severe left circumflex artery stenosis Post Left main-LAD-LCx stenting Left main dissection Post aspiration
  23. 23. MANAGEMENT • Guidelines-recommended therapies apply -- Not age-dependent • Risk factor modification is of utmost importance • Smoking cessation – 1/3 relative risk reduction for mortality as well as for recurrent events • Young patients generally do well with revascularization (Coronary stenting, bypass surgery as appropriate)
  24. 24. RISK REDUCTION WITH STATINS IN PRIMARY AND SECONDARY PREVENTION
  25. 25. LEVEL OF RISK PRIMARY TARGET SECONDARY TARGET VERY HIGH LDL-C <70 MG/DL (1.8 MMOL/L) OR ≥50% ↓ IF BASELINE 70−135 MG/DL (1.8−3.5 MMOL/L) NON-HDL-C <100 MG/DL (2.6 MMOL/L) OR APOB <80 MG/DL HIGH LDL-C <100 MG/DL (2.6 MMOL/L) OR ≥50% ↓ IF BASELINE 100−200 MG/DL (1.8−3.5 MMOL/L) NON-HDL-C <130 MG/DL (3.4 MMOL/L) OR APOB <100 MG/DL MODERATE LDL-C <115 MG/DL (3.0 MMOL/L) NON-HDL-C <145 MG/DL (3.8 MMOL/L) LOW LDL-C <115 MG/DL (3.0 MMOL/L) NON-HDL-C <145 MG/DL (3.8 MMOL/L) LIPID TARGETS
  26. 26. LDL-C: low-density lipoprotein cholesterol; LDLR: low-density lipoprotein receptors; PCSK9: proprotein convertase subtilisin- like/kexin type 9; SREBP: sterol regulatory element binding protein ROLE OF PCSK9
  27. 27. CVdeath,MI,stroke HospforUAorCorRevasc CVdeath,MI,stroke • Patients with atherosclerotic disease, LDL of 70 mg/dL • Evolocumab on a background of statin therapy lowered LDL cholesterol levels by 30 mg /dL (0.78 mmol/L) • Further Reduced the risk of cardiovascular events.
  28. 28. PROGNOSIS POST-MI • Both PCI and CABG are associated with excellent Immediate and medium-term survival (at 5yrs) • Short term mortality low compared to older adults • However 5 years post-MI, drop in survival • Long term mortality exceeds 15% at 7 years, and 25-29% at 15 years • Compared to general population, mortality increased by 74-fold Barbash et al. Eur Heart J 1995 Fournier et al. Am J Cardiol 2004 Zimmermann et al. JACC 1995
  29. 29. PROGNOSIS • Predictors for Mortality: Presence of heart failure, ventricular arrhythmias, angina, re-infarction • Strongest predictor of prognosis is left ventricular ejection fraction • LVEF <45% (Odds ratio 4.4. 95% CI 1.6-124) • Obesity and smoking are also associated with adverse outcomes – mortality and future acute coronary events
  30. 30. PROGNOSIS • Gender: Mortality of is 2x higher in women than in men < 50 yrs • Diabetes and Multi-vessel CAD: PCI had lower event-free survival (revascularization, CVA, MI) at 5 years • Reduction of Health-related quality of life • Angina • Depression
  31. 31. WORKUP OF SUSPECTED YOUNG CAD • Description of symptoms – typical and atypical • Conventional Risk factors – diabetes, BP, Lipids • Family history – 1st degree relative, IHD, SCD • Social habits – Smoking, drugs, exercise • Further risk stratification 1. Electrocardiogram 2. Exercise stress test 3. Echocardiogram
  32. 32. COMMON SCREENING TESTS 1. Electrocardiogram (ECG) 2. Exercise Treadmill ECG Test 3. Stress Echocardiogram 4. Myocardial Perfusion Imaging 5. Computed Tomography Coronary Angiogram
  33. 33. 1. Electrocardiogram 2. Exercise Stress Test
  34. 34. 3. Echocardiogram 4. Myocardial Perfusion Scan
  35. 35. CT Coronary Angiogram and Calcium Scoring
  36. 36. ASSOCIATION OF CORONARY CALCIUM WITH CHD AND DEATH IN YOUNG ADULTS • Individuals aged 32-46 years (n~3000+) • Prospective community study, calcium score measured at baseline and follow up 12.5 years • Presence of any calcium was associated with 5-fold increased risk of CHD events and 3-fold increased risk of CVD events • Calcium score of >100 associated with early death (hazard ratio 3.7) • Coronary calcium associated with risk of CAD, CVD, death Carr JJ, et al. JAMA Cardiol 2017;2:391-399
  37. 37. Carr JJ, et al. JAMA Cardiol 2017;2:391-399
  38. 38. • 4146 patients with stable chest pain • Following exercise stress test, randomized to CT coronary angiogram vs standard care (stress echo, nuclear perfusion etc) • Median follow-up 5 years – Death and non-fatal MI The Scot-Heart Investigators. N Eng J Med 2018 Aug.
  39. 39. The Scot-Heart Investigators. N Eng J Med 2018 Aug. • CTCA group had a lower 5-year event rate of death and non-fatal MI vs standard care (2.3% vs 3.9%, HR 0.41- 0.84, P=0.004) • Overall rates of angiogram, revascularization similar, but more patients in CTCA group had preventive therapies (aspirin, statins) and anti-anginal therapy.
  40. 40. SO HOW DID WE MANAGE THE “BOY” WITH TRIPLE VESSEL CORONARY DISEASE?
  41. 41. Severe left anterior descending artery stenosis Occluded right coronary artery
  42. 42. Severe left circumflex artery stenosis
  43. 43. MORE IMPORTANTLY… • Risk Factor control • Smoking cessation • Diet, weight loss, cardiac rehabilitation • Chronic Anti-platelet therapy • Aggressive lipid lowering 1. Statins 2. Ezetimibe 3. PCSK9 inhibitors
  44. 44. Mount Elizabeth Novena Specialist Centre Mount Elizabeth Medical CentreGleneagles Medical Centre

×