PROFILE OF ACUTE CORONARY SYNDROME IN YOUNG PEOPLE : A HOSPITAL BASED OBSERVATIONAL STUDY IN WESTERN NEPAL Affiliation

Paudel N, Alurkar VM, Jha GS, Kafle R, Sapkota S, Lamsal L. Profile of Acute Coronary Syndrome In Young People: A Hospital Based Observational Study in Western Nepal. BJHS 2018;3(1)5 : 361-365. * Corresponding Author Dr. Navaraj Paudel Consultant Cardiologist Manipal College of Medical Sciences, Pokhara, Nepal Email: paudeldrnavarajdm@gmail.com https://orcid.org/0000-0003-4551-0808 ORA 57 1* 2 3 3 4 5 Paudel N , Alurkar VM , Jha GS , Kafle R , Sapkota S , Lamsal L


Methodology
A retrospec ve study was designed.All pa ents admi ed for acute coronary syndromes were taken and data of acute coronary syndrome involving pa ents aged less than 45 years from April 2015 through December 2017 were collected in a pre-structured proforma and analyzed.

Results
There were 712 (489 males and 223 females with M:F=2.19:1)acute coronary syndrome pa ents admi ed during the study period.Only 79 (12.9%) pa ents were pa ents <45 years of age.Commonest risk factor of acute coronary syndrome was smoking (69%) followed by dyslipidemia (46.8%), hypertension (45.5%) and diabetes (14%).Out of 79 pa ents of young acute coronary syndrome, 37 (46.8%)presented with ST elevated myocardial infarc on, 16 (20.2%)with non-ST elevated myocardial infarc on and 26 (32.9%) with unstable angina.Most common finding in coronary angiography was single vessel disease (35%) -le anterior descending artery being the commonest (53% of single vessel disease), double vessel disease (17.7%), non-cri cal coronary artery disease (16.4%), triple vessel disease (7.6%) and le main (1.2%).Myocardial bridging was seen in 1.2% and 20% had normal coronaries.Comparison of males and females in different categories of acute coronary showed that males predominate significantly in ST elevated myocardial infarc on (odds ra o: 2.99; p=0.03) but there was no significant difference between the males and females presen ng either with Non ST elevated myocardial infarc on or unstable angina.

INTRODUCTION
Acute coronary events and ischemic heart disease (IHD) are considered as one of the most common cause of death in 1 the world.Acute coronary syndrome (ACS) is a clinical spectrum of the ischemic heart disease that includes unstable angina (UA), non-ST segment eleva on myocardial infarc on (NSTEMI) and ST segment eleva on myocardial infarc on (STEMI).ACS in older popula on (>45 years in male and >55 years in female) is rela vely higher than Data were collected in a preformed proforma and analyzed in SPSS so ware version 16.The significant difference between two groups was compared using ANOVA.Odds ra o was calculated for required appropriate values and p values were considered significant at a predetermined significance level of 5%.

RESULTS
Total number of pa ents admi ed and treated for the diagnosis of ACS was 712.Out of them 489 were males and 223 were females.The male to female ra o was 2.19:1.Among these 79 (12.9%) pa ents were admi ed for STEMI, NSTEMI or UA more than 18 years and <45 years of age.On further analysis of pa ents with ACS under 45 years of age, 52 pa ents were male while 27 pa ents were female (Figure 1). Figure 2 shows pa ern of sex distribu on of pa ents with ACS in further subdivision with age.1).
Further comparison of males and females in different categories of ACS was done.This showed that males predominate significantly in STEMI but there was no significant difference between the males and females presen ng either with NSTEMI or UA (table 2).
All 79 cases of ACS underwent CAG.Most common finding in CAG was single vessel disease (SVD) (35%) -le anterior descending artery (LAD) was the commonest (53% of SVD).
Next common finding was double vessel disease (DVD) (17.7%), followed by non-cri cal coronary artery disease (CAD) (16.4%), triple vessel disease (TVD) (7.6%) and le main (1.2%).Myocardial bridging was seen in 1.2% and 20% had normal coronaries (Table 3).same clinical se ng in different frame of me too.Not only young males, young females have also been seen presen ng with rising trends of ACS in this study.The older measurements may be the ' p of the iceberg' since young asymptoma c pa ents usually do not undergo medical inves ga ons due to low suspicion unless the disease is very Smoking is the commonest risk factor in this study (69%) followed by dyslipidemia (46.8%), hypertension (45.5%) and diabetes (14%).There are literatures repor ng smoking 18 by up to 82% of young pa ents suffering from ACS. Case control studies showed that smoking is an independent risk factor for the development of ischemic heart disease in 19 young pa ents.Smoking persistence is associated with the occurrence of secondary events a er MI in young pa ents.A study showed that decreased le ventricular ejec on frac on at presenta on and the con nua on of smoking a er myocardial infarc on were most predic ve for further 20 MACEs in young pa ents.Taken together, it shows importance of stopping smoking in the primary and secondary preven on of ACS specifically in these individuals.
In this study, risk factors like dyslipidemia and hypertension were also found to be higher (46% and 45% each).We know that hypertension and dyslipidemia are considered as conven onal risk factors.Various studies shows hypertension [21][22][23] in 30-50% of individuals with ACS.
In a study done in central Nepal, hypertension was found in 58% of young ACS 10 and dyslipidemia in 24% of cases.Dyslipidemia (mainly high LDL and low HDL) along with metabolic syndrome were also seen in significant numbers in pa ent with ACS in a study by Yagi H in Japan.This study also suggested smoking as a crucial risk factor among all other risk factors in cases of In this study, all 79 cases of ACS underwent CAG.Most common finding in CAG was SVD (35%) -LAD was the commonest (53% of SVD), DVD (17.7%), non-cri cal CAD (16.4%),TVD (7.6%) and le main (1.2%).Myocardial bridging was seen in 1.2% and 20% had normal coronaries.These findings are similar to findings shown by Colkesen et 25 al.where LAD was the commonest vessel involved in young STEMI pa ents with ≤35 years of age followed by RCA, LCX, and LMCA.
In the current study, out of 79 pa ents of young ACS pa ents 37 (46.8%)presented with STEMI, 16 (20.2%)presented with NSTEMI and 26 (32.9%) presented with UA.Further comparison of males and females in different categories of ACS was done.This showed that males predominate significantly in STEMI but there was no sta s cally significant difference between the males and females presen ng either with NSTEMI or UA.Parajuli M et al also have shown that STEMI is significantly common in males 26 than females.Hua et al from China and Andrea R from Brazil have also showed that males have higher incidence of STEMI, increased rates of hospitaliza on and complica ons 27,28 associated with ACS than females.

CONCLUSION
Acute coronary syndrome in young people was higher (12.9%).Males predominate in all types but sta s cally significant predominance was seen in STEMI.Smoking was the commonest risk factor for ACS in young.Single vessel disease par cularly le anterior descending artery was the commonest finding in coronary angiography.Public awareness regarding stoppage of cigare e smoking should be focused to prevent such events especially in the young popula on.

RECOMMENDATIONS
Larger prospec ve studies including conven onal and novel risk assessment should be done to assess the actual data in the community as we have seen that the trend of young ACS has been increasing.

LIMITATION OF THE STUDY
This is a retrospec ve, single centered study so our analysis was limited by reliance on secondary source of data.Also conven onal risk factors are only considered but novel risk factors like homocystenemia, thrombophilic condi ons etc. could not be assessed due to unavailability of these tests and being retrospec ve study, we could not do much on it either.

2 younger
popula on.The prevalence of ACS among popula on less than 45 years of old (considered as young ACS) is 2 to 10% in studies conducted from different parts of 2-9 world.There are few studies in Nepal regarding ACS in 10-11 young with a prevalence of 8.8-11%.Cardiovascular risk factors, such as smoking, dyslipidemia, obesity, and family history of coronary artery disease (CAD), have been seen as more frequent among young ACS in 2-11 these studies.Not only this, there are different theories behind the exact pathophysiology of ACS as different other e ologies and novel risk factors like homocysteinemia may be implicated than older popula on.The extent of coronary involvement, the clinical presenta on, and clinical outcome 12-15 also differs from older popula on.The aim of this study was to find out the extent of this problem and also to describe its possible correlates.METHODOLOGY This is a retrospec ve study conducted at Manipal College of Medical Sciences-Teaching Hospital, Pokhara, Nepal.A er clearance from the ins tu onal ethical board, the study popula on for the present analysis was selected from the records of inpa ents with ACS who presented in the hospital between April 2015 to Dec 2017.Inclusion criteria involved were all pa ents admi ed for STEMI, NSTEMI or UA more than 18 years and <45 years of age.The term ACS refers to any group of clinical symptoms compa ble with acute myocardial ischemia and includes UA, NSTEMI and STEMI.Medical records were reviewed which included proper medical history, drug abuse, smoking, physical examina on, lipid profiles, 12-lead electrocardiogram (ECG), echocardiography.coronary angiography(CAG) and percutaneous coronary interven on (PCI) data were taken as per availability.Dyslipidemia was defined in accordance with the reports of the Na onal Cholesterol Educa on Program (Adult 16 Treatment Panels II and III).

Figure 1 :Figure 2 :
Figure 1: Sex Distribu on of ACS

17 severe
as stated by Romboldt et al.

21 ACS
as compared to stable CAD.Risk factors like diabetes is 24 associated with mul vessel disease and poor prognosis.In our study diabetes was seen in 14% of individuals which is 10 comparable to a study done in central Nepal.

Table 1 :
Demographic distribu on of different types of ACS in pts with age <45 years (n = 79) SN

Table 2 :
Comparison of males and females presen ng with STEMI, NSTEMI and UA in pts with age <45 years

Table : 3
TotalPa ents with symptoms of ACS are very common in emergency departments.There is growing incidence and prevalence of acute coronary syndrome in young adults.The major patho-physiologic mechanism is either plaque rupture or fissuring with superimposed thrombus.Today, ACS is one of the commonest causesof hospitaliza on.The prevalence of ACS among popula on less than 45 years of age (considered as young ACS) is 2 to 10% in studies 50 pa ents underwent PCI (at least culprit vessel in all the STEMI), 6 pa ents of NSTEMI and 7 pa ents of UA underwent PCI.Commonest risk factor for CAD was smoking (69%) followed by dyslipidemia (46.8%), hypertension(45.5%)and diabetes (14%).Smoking Dyslipidemia Diabetes mellitus Hypertension Strong family history Proteinuria Risk Factors of ACS Figure 3: DISCUSSION