Journal Reading Myocardial infarction in young people Cardiol J 2009; 16, 4: 307–311 Cardiol J 2008; 15: 21–25 Presented by R 王郁菁 at ER conference room

Introduction The borderline differentiating younger from older patients is the age of 40. The borderline differentiating younger from older patients is the age of 40. MI in patients below the age of 40 constitute about 10% of all cases. MI in patients below the age of 40 constitute about 10% of all cases. The majority of sufferers are men The majority of sufferers are men Increasing prevalence among women Increasing prevalence among women 1 in 4 patients with MI <45 years are women 1 in 4 patients with MI <45 years are women Cardiol J 2009; 16,4:

Causes Main cause: coronary atherosclerosis Main cause: coronary atherosclerosis About 80% of cases About 80% of cases Usually one vessel disease Usually one vessel disease Significant lesions in coronary arteries may be present as early as age Significant lesions in coronary arteries may be present as early as age >40, the first symptoms of exercise- induced ischemia are not uncommon >40, the first symptoms of exercise- induced ischemia are not uncommon Environmental influence on genotype may promote the development of coronary artery disease in young age Environmental influence on genotype may promote the development of coronary artery disease in young age Cardiol J 2009; 16,4:

Atherosclerosis Smoking Smoking Religa et al Religa et al 100 women with first MI: 45% were smoker 100 women with first MI: 45% were smoker <45 y/o: 95% were smoker <45 y/o: 95% were smoker Impairs endothelium derived vasodilation mechanisms and vasospasm in coronary arteries Impairs endothelium derived vasodilation mechanisms and vasospasm in coronary arteries Dyslipidemia: Dyslipidemia: 29% 29% Premature coronary artery disease is most common in patients with familial hypercholesterolemia, less often in familial mixed dyslipidemia Premature coronary artery disease is most common in patients with familial hypercholesterolemia, less often in familial mixed dyslipidemia High TG, high total cholesterol (LDL), low HDL High TG, high total cholesterol (LDL), low HDL Cardiol J 2009; 16,4:

Atherosclerosis Premature ischemic heart disease in first- degree relatives Premature ischemic heart disease in first- degree relatives an independent risk factor an independent risk factor Apolipoprotein E (Allel E4): an important risk factor for atherosclerosis and IHD Apolipoprotein E (Allel E4): an important risk factor for atherosclerosis and IHD Arterial hypertension: 5% Arterial hypertension: 5% Obesity Obesity Doubles the risk of MI in men Doubles the risk of MI in men Increases the risk in women by 2.5 times Increases the risk in women by 2.5 times Excessive accumulation of TG impairs the function of cardiomyocytes, liver and pancreas Excessive accumulation of TG impairs the function of cardiomyocytes, liver and pancreas Cardiol J 2009; 16,4:

Causes without coronary artery stenosis Coronary artery embolism Coronary artery embolism Thrombosis Thrombosis Anomaly Anomaly Vessel inflammation or spasm Vessel inflammation or spasm Cardiol J 2009; 16,4:

Coagulation disorders 5% of all cases 5% of all cases Imbalance between coagulation and fibrinolysis  increase risk of thrombus forming Imbalance between coagulation and fibrinolysis  increase risk of thrombus forming Cardiol J 2009; 16,4:

Anomaly Rare cases Rare cases Myocardial bridge Myocardial bridge Coronary arteries tunnels through the myocardium Coronary arteries tunnels through the myocardium 15-85% is found during autopsies 15-85% is found during autopsies % is found from angiography % is found from angiography Cardiol J 2009; 16,4:

Drug abuse Cocaine Cocaine Amphetamine Amphetamine Increasing numbers of MI Increasing numbers of MI MI after cocaine abuse was first reported in MI after cocaine abuse was first reported in Cardiol J 2009; 16,4:

Cocaine or Amphetamine abuse Causes heart rate and systolic blood pressure increase with artery spasm Causes heart rate and systolic blood pressure increase with artery spasm Reduced coronary flow  imbalance between oxygen consumption and supply Reduced coronary flow  imbalance between oxygen consumption and supply Increase in thrombocytes aggregation Increase in thrombocytes aggregation Blocking of sodium channels and the presynaptic part of neuron Blocking of sodium channels and the presynaptic part of neuron Excessive release of neurotransmitters like norepinephrine and dopamine Excessive release of neurotransmitters like norepinephrine and dopamine Transient impairment of blood flow Transient impairment of blood flow Cardiol J 2009; 16,4:

Direct toxin lesion of myocardium, resulting in focal necrosis Direct toxin lesion of myocardium, resulting in focal necrosis Marijuana smoker Marijuana smoker Overdosing on medicines: Rifampicine Overdosing on medicines: Rifampicine Toxic influence on endothelium may be the cause of drug-induced acute coronary syndromes Toxic influence on endothelium may be the cause of drug-induced acute coronary syndromes Cardiol J 2009; 16,4:

Uric acid Another study: Another study: patients were less than 35 years old and were diagnosed as AMI 80 patients were less than 35 years old and were diagnosed as AMI Cardiol J 2008; 15: 21-25

Hyperuricemia: >7.0mg/dl Hyperuricemia: >7.0mg/dl An independent factor of mortality An independent factor of mortality Underlying mechanisms remain unclear Underlying mechanisms remain unclear Hypothesis Hypothesis Promotes vascular smooth muscle proliferation and upregulates the expression of platelet- derived growth factor and monocyte chemoattractant protein-1 Promotes vascular smooth muscle proliferation and upregulates the expression of platelet- derived growth factor and monocyte chemoattractant protein-1 May induce endothelial dysfunction by decreasing the production of nitric oxide in the vascular endothelial cells May induce endothelial dysfunction by decreasing the production of nitric oxide in the vascular endothelial cells Cardiol J 2008; 15: 21-25

Prognosis If patients have DM, that may have multi- vessel lesion If patients have DM, that may have multi- vessel lesion Young patients usually have no concomitant disorders Young patients usually have no concomitant disorders After MI in young patients After MI in young patients Higher LVEF Higher LVEF Lower levels of pro-BNP than older groups Lower levels of pro-BNP than older groups Favorable clinical course Favorable clinical course Increased risk of recurrent coronary events concerns only 5% Increased risk of recurrent coronary events concerns only 5% Problem of sudden death risk remains Problem of sudden death risk remains Cardiol J 2009; 16,4:

Thanks for your attention!!