Cardiovascular Journal of Africa: Vol 28 No 6 (November/December 2017)

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CARDIOVASCULAR JOURNAL OF AFRICA • Volume 29, No 1, January/February 2018 36 AFRICA
Atherosclerotic disease is the predominant aetiology of
acute coronary syndrome in young adults
AK Pillay, DP Naidoo
Abstract
Objectives: Few studies have evaluated young adults in their
third and fourth decades with coronary artery disease (CAD).
This study evaluated the clinical and angiographic profile of
young adults ( < 35 years) with CAD.
Methods: A 10-year (2003–2012) retrospective chart review
was performed on patients less than 35 years diagnosed with
CAD at Inkosi Albert Luthuli Central Hospital, Durban.
Results: Of the 100 patients who met the study criteria, the
majority were male (90%), of Indian ethnicity (79%), and
presented with acute coronary syndrome (93%). Smoking
(82%), dyslipidaemia (79%) and dysglycaemia (75%) were
the most prevalent risk factors. Almost half of the subjects
(48%) met criteria for the metabolic syndrome. Angiographic
findings revealed multi-vessel (42%), single-vessel (36%) and
non-occlusive disease (20%); only two subjects had normal
epicardial vessels. Disease severity was influenced by dyslipi-
daemia (p = 0.002) and positive family history (p = 0.002).
Non-coronary aetiologies were identified in 19% of subjects.
Conclusions: Atherosclerotic disease associated with risk-factor
clustering was highly prevalent in young adults with CAD.
Keywords: coronary artery disease, young adults, risk factors,
metabolic syndrome
Submitted 21/1/17, accepted 13/7/17
Published online 12/12/17
Cardiovasc J Afr 2018; 29: 36–42
DOI: 10.5830/CVJA-2017-035
Coronary artery disease (CAD) is considered premature when
it appears in adults under the age of 55 years in males and 65
years in females. Premature coronary artery disease (PCAD)
is an emerging problem, frequently presenting as premature
myocardial infarction (MI) in recent years.1,2 A recent review
of young adults (< 40–45 years)3 with CAD described two
forms of the disease, one characterised by limited (single) vessel
disease with a favourable outcome, and the other by extensive
multi-vessel involvement with a more rapid progression of
atherosclerosis.
Coronary atherosclerosis, beginning as a fatty streak and
raised atheromatous plaque, has been noted to begin early in
adolescence,4 the majority of patients remaining asymptomatic
until later in life. 3 This silent process makes the estimation
of disease prevalence a particular challenge in young adults.3
Although a prevalence of four to 10% has been reported among
individuals with myocardial infarction under age 40–45 years,5,6
autopsy studies have found advanced coronary atheroma in up
to 20% of men and 8% of women between 30 and 34 years of
age.7 In a local study by Ranjith et al., 20% ( n = 491) of 2 290
patients presenting with MI, between 1996 and 2002 were under
the age of 45 years.8 This increased cardiovascular risk in youth
has been noted to be particularly high among the South African
Indian community in whom risk-factor clustering has been
described.8-10
In contrast to older subjects, major cardiovascular risk factors
such as hypertension and diabetes mellitus are less commonly
observed among young adults with PCAD.11 Subtle forms of
dysglycaemia such as insulin resistance and impaired glucose
tolerance have been found to be more common than diabetes
in this age group and add to the risk of PCAD.12 Risk-factor
clustering in the form of the metabolic syndrome has also been
reported to be common among young patients.11 Additional,
‘non-conventional’ risk factors may also be more commonly
found among younger subjects. These include psychosocial
factors such as stress12-14 and anger,15 the use of recreational drugs
such as cocaine16 and marijuana,17 connective tissue disease18,19
and HIV infection.20,21
Earlier studies have documented at least one major risk factor
in over 90% of young subjects with CAD; 22,23 more recently the
INTERHEART study24 identified major risk factors in subjects
with CAD worldwide among young subjects. A corresponding
increase in mortality rate has also been associated with an
increasing number of risk factors.25 Little is known about the
underlying aetiology and angiographic profile of young subjects
presenting with CAD. In this study we analysed the clinical and
angiographic profile of young adults ( < 35 years) presenting to
the Cardiology Unit at Inkosi Albert Luthuli Central Hospital
over a 10-year period.
Methods
A retrospective chart review was conducted on young patients ( <
35 years) with CAD referred to the Cardiology Department at
Inkosi Albert Luthuli Central Hospital (IALCH) over a 10-year
period between 2003 and 2012. All patients were referred with a
diagnosis of acute coronary syndrome (ACS) or stable angina.
The diagnosis of ACS was made according to criteria outlined
by Braunwald et al. and encompasses unstable angina, non-ST-
segment elevation (non-Q wave) MI (NSTEMI) and ST-segment
elevation (Q wave) MI (STEMI).26
The ethics committee of the Faculty of Health Sciences,
Nelson R Mandela School of Medicine, University of KwaZulu-
Natal granted approval for the study (BE324/13).
Department of Internal Medicine, University of KwaZulu-
Natal, Durban, South Africa
AK Pillay, MB BCh, FCP,
Department of Cardiology, University of KwaZulu-Natal,
Durban, South Africa
DP Naidoo, PhD,