SHA24/057003

ST ELEVATION MYOCARDIAL INFARCTION IN YOUNG ADULTS: PREVALENCE, DEMOGRAPHICS, RISK FACTOR PROFILE AND EARLY OUTCOME AFTER PRIMARY PCI

Dr.Mehboob Ali Dar MD,DM,MRCP,FACC,CCDS,CEPS,FHRS

Consultant Interventional Cardiology &Electrophysiology

Prince Sultan Cardiac Centre Qassim, Saudi Arabia

ABSTRACT ST ELEVATION MYOCARDIAL INFARCTION IN YOUNG ADULTS: PREVALENCE, DEMOGRAPHICS, RISK FACTOR PROFILE AND EARLY OUTCOME AFTER PRIMARY PCI Mehboob Ali Dar, Akif Ali Mufti. Yasir Beshir, Akram Desoky, Hassan Khalaf, Owayid Al Shammary, Tariq I Soomro, Mohammad Sayed, Yasir Birema, Rahim Gul,Mohammad Imran, Zabah Zubair,Arshad Sodhar, Mushtaq ahmad, Fazil Ahmad

Prince Sultan Cardiac Centre, Buraidah, Al Qassim, Saudi Arabia.

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Objectives:We sought to investigate prevalence, clinical profile,in-hospital and short term clinical outcomes of Primary Percutaneous Intervention in young adults presenting with Acute MI. Methods:Total of 133patients ≤40 years of age were enrolled in retrospective data analysis.Prevalence ,risk factor profile and demographics were analyzed. Procedural success,in-hospital and short-term (1month) outcomes were assessed as primary end points. Secondary end-points were recurrent MI and new revascularization.

Results:Mean age was 36±14years (range19-40);97% males and 3% females.59(62 %) patients presented with anterior wall MI,36 (38%) with inferolateral wall MI;5% had infarction in other territories.51% patients were Saudis and 49% were non Saudis.Risk factor profile revealed-Smoking(76%), Diabetes Mellitus(22%), Hypertension (20%), Dyslipidemia(12%),Family History(12%).3 patients had cardiogenic shock at presentation.All underwent PPCI, with door to balloon time of 83± 05minutes(74-220min).Majority had SVD(47%).2VD and 3VD was seen in 33% &18% respectively.(Infarct related artery:LAD54%,RCA23%,LCX12% and Left Main Disease2%).DES was deployed in 89% .Successful recanalisation of IRA was achieved in 95% with 87% achieving TIMI III flow. No reflow occurred in 2%.Procedure related coronary artery dissection occurred in 1 patient.6% developed Ventricular Tachycardia,2patients developed complete heart block.In- hospital mortality was 3%.1 patient had acute stent thrombosis and 4 patients presented with subacute and late stent thrombosis on follow up. All patients were alive at one-month follow up.

Conclusions:Our data reveal that younger patients, predominantly males comprise a significant proportion of patients of STEMI.Smoking appears to be a prominent risk factor.Such patients have a favorable outcome after Primary PCI.High incidence of stent thrombosis in our cohort of patients needs further assessment.

INTRODUCTION • Acute myocardial infarction is a major cause of morbidity and mortality worldwide.

• The burden of AMI can be substantial if the individual is relatively young • A particular challenge remains for the clinician in the management of the young patient with coronary disease who might anticipate a life expectancy measured in decades rather than years • Incidence ranged between 2% and 10%.

• Young patients are more likely to be male, have a history of smoking and hyperlipidaemia but less likely to have other co morbidities and demonstrate less extensive coronary artery disease on coronary angiograms • There is limited data available on CAD in young adults(<40yrs) from Saudi Arabia and to the best of our knowledge our study is the first of its kind reporting on outcomes after Primary Percutaneous Revascularisation in a patient population of mixed ethnic backgrounds.

â&#x20AC;˘Population of Saudi Arabia : 30 millions â&#x20AC;˘About 31% of the population is made up of foreign nationals of multiple ethnic backgrounds.

Population of Buraidah 614,093 + 450,000 (adjacent cities and towns)

Indian: 1.3 million, Pakistani: 900,000, Egyptian: 900,000, Yemeni: 800,000, Bangladeshi: 500,000, Filipino: 500,000, Jordanian/Palestinian: 260,000, Indonesian: 250,000, Sri Lankan: 350,000, Sudanese: 250,000, Syrian: 100,000 and Turkish: 100,000

PRIMARY PCI SERVICES IN QASSIM

QASSIM PRIMARY ANGIOPLASTY SERVICES (QAPAS) REGISTRY •24 x7 Service •2 Cath Labs •3-4 Interventional Cardiology Consultants •10 Specialists-Hotline •3 Shifts for Nurses and Technicians •Common Bleep •ER of KFSH •Peripheral hospital transfers in BCH- 3Km Sul Habib-4km KSH Unaiza-20 km BGH-30 km Others

MATERIALS AND METHODS • Study population •

Between January 1426-1433,133 consecutive patients aged ≤ 40 years old were diagnosed to have STEMI at our institution, a tertiary referral centre in Buraidah, Al Qassim.

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Clinical data was collected retrospectively from our cath lab database and medical records on demographic characteristics, presenting signs and symptoms, blood investigation, angiographic findings and inhospital clinical outcomes.

REVIEW OF LITERATURE

Prevalence of Coronary Heart Disease by Age and Sex in the U.S. from 1999-2004

REF: Rosamond W, et al. Circulation 2007;115:e69-171.

Prevalence of unrecognized myocardial infarction as a function of age

REF: Sigurdsson E, et al. The Reykjavik Study. Ann Intern Med 1995;122:96-102

Clinical profile of young patients with acute myocardial infarction in Saudi Arabia.

Al-Khadra AH.Int Journal of Cardiology. 2003 Sep;91(1):9-13.

King Fahd Hospital of the University, King Faisal University, Dammam, Saudi Arabia.

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A retrospective study was conducted over a 3-year period from January 1999 to December 2001.

Sixty-five consecutive cases of acute MI in young patients were admitted to KFHU and were reviewed.

The mean age was 40 years (range 29-45), 96.9% were males, 66.2% were from the Indian subcontinent, 23.1% were Saudi nationals and 10.8% were of other nationality.

The major risk factor was tobacco use (76.9%), followed by low HDL (52.8%), high LDL (33.8%), diabetes (30.8%), hypertension (18.5%), family history of IHD (15.4%) and hypertriglyceridemia (7.7%).

The most common anatomical location of the MI was the anterior wall and 92.3% of the cases were MIs with ST segment elevation.

The hospital course was complicated by the development of CHF (4.6%), cardiogenic shock (4.6%), angina post-MI (3.1%), and reinfarction (3.1%).

Finally, the hospital mortality rate was 9.2%.

Clinical presentation and short-term outcome of acute coronary syndrome in native young Saudi population Journal of the Saudi Heart Association Volume 24, Issue 3 , July 2012

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Retrospectively analysis of patients with ACS between 2006 and May 2009, 924 patients were diagnosed to have ACS. Among them 107 patients (11.6%) met the definition of young [66 (61.7%) male <45years, and 41 (38.3%) female <55years]. Study population was compared to a control group of 50 elderly patients consecutively enrolled in a contemporary period.

ST-segment elevation myocardial infarction (STEMI) in 41 (38.3%) (representing 4.4% of the whole ACS population) and 11 (22%) patients of the study population and control group respectively Male:Female; 66%/34% No deaths.

Diabetes was the major risk factor

Myocardial Infarction in Young Adults: Angiographic Characterization, Risk Factors and Prognosis (Coronary Artery Surgery Study Registry) •

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FRANKLIN H. ZIMMERMAN,et al (JACC 1995;26:654-61

Angiographic characteristics,coronary risk factors and prognosis in young men and women with a history of myocardial infarction compared with that in older patients(CASS) There were 294 men _<35 years old and 210 women _<45 years old.

Coronary anatomy, baseline characteristics and prognosis were compared in younger and older patients.

Results. Young men and women” more often had angiographically normal coronary arteries,” nonobstructive disease <70% stenosis and single-vessel disease than older patients (p <0.0001). Current smoking was more frequent in young patients (p < 0.0001). Hypertension and diabetes were more frequent in both older men and women, whereas a positive family history of premature coronary disease was significantly more prevalent only in young men. The survival rate at 7 years was improved for young men compared with that in older men (84% vs. 75%, p = 0.0094) and for young women compared with that in older women (90% vs. 77%, p = 0.0004).

Young patients with a myocardial infarction have a favorable prognosis compared with that in older patients.

Acute myocardial infarction: Clinical features and outcomes in young adults in Singapore Chun Pong Wong,et al

World J Cardiol 2012 June 26; 4(6): 206-210

• Investigated the clinical features and in-hospital outcomes of young adults with acute myocardial infarction(AMI) in Singapore.

• 333 consecutive patients aged ≤ 45 years old • Male predominance (94%).

• The most common risk factor was smoking (74%) followed by hypertension (28.5%) and hyperlipidemia (20.0%). 37% of patients were obese.

• The majority of patients had single vessel disease (46%) • Overall in-hospital mortality was low with 4 deaths (1.2%).

• For ethnic subgroup analysis, Indians had a 3-fold risk of developing premature AMI when compared to other ethnic groups.

SMOKING AND SUBSTANCE ABUSE • Cigarette smoking has been the single factor most strongly associated with CAD in the young adult. Kannel et al. found in patients included in the Framingham Heart Study, the relative risk for CAD was about three times higher in smokers age 35 to 44, compared to nonsmokers.

• Cocaine, especially taken in combination with tobacco or as concentrated cocaine hydrochloride base (“crack”), is especially likely to produce spasm, plaque rupture, and thrombosis by a similar mechanism but with greater intensity.

• Coronary vasospasm may occur in angiographically normal coronary arteries even in the absence of stimulants or sympathomimetic agents.

Acute Coronary Syndrome and Khat Herbal Amphetamine Use Circulation. 2011;124:2681-2689

An Observational Report

• The aim of this study was to evaluate the clinical characteristics and outcome of khat chewers presenting with acute coronary syndrome.

• 7399 consecutive patients with acute coronary syndrome were enrolled in the Second Gulf Registry of Acute Coronary Events (Gulf RACE-2).

• Nineteen percent of patients were khat chewers; majority from Yemen,95%with only 1.8% from Saudi Arabia • Khat chewers were more likely to present with ST-segment– elevation myocardial infarction • Overall, khat chewers had higher risk of death, recurrent myocardial ischemia, cardiogenic shock, ventricular arrhythmia, and stroke compared with non–khat chewers.

• Khat chewing was found to be an independent risk factor of death and for recurrent ischemia, heart failure, and stroke.

In-hospital, 1-month, and 1-year mortality rates according to khat chewing.

Ali W M et al. Circulation 2011;124:2681-2689

Copyright Š American Heart Association

In-hospital mortality rates according to khat chewing and acute coronary syndrome type.

Ali W M et al. Circulation 2011;124:2681-2689

Copyright Š American Heart Association

In-hospital mortality in khat-chewing and nonâ&#x20AC;&#x201C;khat-chewing patients with acute coronary syndrome stratified by age groups.

Ali W M et al. Circulation 2011;124:2681-2689

Copyright Š American Heart Association

RESULTS

DEMOGRAPHICS TOTAL NO: 133 NATIONALITY

Breakup %age of Non Saudi population

INDIANS:4.3% PAKISTANIS:3% EGYPTIANS:3% YEMENIS:2.6% BANGLADESHIS:1.6% PHILIPINOS:1.6%

Frequency

Percent

Saudi

67

50.4%

Egyptain

11

8.2%

Bangladeshi

32

24.1%

Pakistani

8

6%

<24

6

4.5%

Indian

13

9.8%

25 - 34

31

23.3%

Philipino

2

1.5%

35 - 40

96

72.2%

Total

133

100%

Total

133

100%

GENDER Male Female Total

Frequency

Percent

127 6 133

95.5% 4.5% 100%

AGE RANGE Frequency

Age range :(19-40 years)

Percent

• MODE OF ADMISSION: Frequency

Percent

E/R

51

38.2%

REFERRAL

82

61.8%

Total

133

100%

• LAB FINDING: NO OUT OF 110

Std. Heart rate, mean+_SD, bpm : 81.2+_19 Minim Maximu Deviati SBP, 124+-30Mean +_SD, mm Hg: DBP Mean.82+_16SD, mm Hg: Mean um m on TROPNIN 24 9.91 0.1 50 13.872 CKMB 101 220.21 17 950 196.43 SERUM 300 35.41 CREAT 104 91.59 46 Mean Hb 105 14.079 6.8 16.8 1.531 %

RISK FACTOR PROFILE NON SAUDI TOTAL

SAUDI

BANGLA

INDIAN PAKISTANI

EGYPTAIN PHILLIPINO

DIABETES

40 (30%) 25(37%)

6(18%)

3(23%)

3(37%)

3(27%)

0

SMOKER

91 (68.5%) 44(65%)

22(68%)

9(69%)

6(75%)

8(72%)

2(100%)

HYPERTENSION 31 (23.2%) 19(28%)

9(28%)

1

0

2

0

DYSLIPEDEMIA 15 (11.3%) 12(17%)

1

1

0

1

0

3

2

1

1

0

FAMILY Hx

16 (12%)

9(13%)

DRUG ADDICTION: 2patients(Hashish,Amphetamine)

KILLIP 1 KILLIP 2 KILLIP 3 KILLIP 4 Total

KILLIP CLASS Frequency 87 13 5 5 110

Percent 79.2% 11.8% 4.5% 4.5% 100%

5

5

CLINICAL PRESENTATION TYPE OF MI

AWMI IWMI LWMI

Frequency/133Pts 83 29 13

Percent 62.4% 21.8% 9.8%

OTHERS

08

6%

TOTAL

133

100%

PHARMACOTHERAPY PLAVIX 300mg 600mg Total

Frequency

Percent

28

25.5%

82

74.5%

110

100%

IIb/IIIa inhibitor use GIVEN NOT GIVEN Total

Frequency

Percent

81

73.6%

29

26.4%

110

100%

ASPRIN AND STATIN WERE USED IN 100% WHEREAS BETA BLOCKER AND ACE INHIBITORS WERE GIVEN TO 92% AND 87%, RESPECTIVELY. HEPARIN GIVEN TO ALL DURING INTERVENTION

IIb/IIIa use

ANGIOGRAPHIC CHARACTERESTICS FEMORAL V/S RADIAL ACCESS

Normal SV-CAD 2V-CAD 3V-CAD 3VD + Lt Main Total

ANGIO RESULT Frequency 17/133 54/133 37/133 23/133 2/133 133

3 OUT OF 54 SVD (i.e 5.5% of SVD and 2.2% of total) HAD NON CRITICAL LESION and WERE OPTED FOR MEDICAL TREATMENT WITHOUT ANY CORONARY INTERVENTION. CORONARY ARTERY VASOSPASM WAS LABELLED IN 3 OUT OF 17 PATIENTS HAVINNG TOTALLY NORMAL CORONARIES

108 :2

Percent 12.8% 40.6% 27.8% 17.3% 1.5% 100%

REVASCULARISATION Percent

Frequency

PCI

83%

11O/133

CABG NO INTERVENTION

2.25%

3/133

15%

20/133

TYPE OF STENT Frequency 100 10 110

Percent 90.9% 9.1% 100%

DES BMS Total

N0 OF Pt Min STENT LENGTH DOOR TO BALLON TIME

Max

Mean

110

12

55

28.15

90

28

240

99.21

STENT/ PATIENT RATIO 148:110 (1.3:1)

IRA INTERVENTION LAD LCX RCA

Frequency 72 15 28

Percent 62.5% 13% 24.5%

ANGIOGRAPHIC SUCCESS:108 OUT OF 110 ( 98%)

TIMI FLOW Frequency 1 7 100 110

TIMI 1 TIMI 2 TIMI 3 Total

Percent 0.9% 6% 91%

MANUAL THROMBUS EXTRACTION FREQUENCY

PERCENT

DONE

57

52%

NOT DONE

53

48%

PCI COMPLICATIONS FREQUENCY NONE

106

PRESENT

4

PERCENT 96.3% 3.6%

STENT THROMBOSIS • • • • •

5 PATIENTS (4.5%) 2 DEATHS (40%) 1 ACUTE 2 SAT 2LATE

STENT THROMBOSIS..CONT 1. 35/M INDIAN,IWMI,3VD, PCI-RCA(BMS),SAT WITHIN ONE WEEK,RECANALISED,DISCHARGED HOME 2. 39YRS/M,SAUDI,DM,SMOKER,AWMI,PPCI-LAD(TAXUS), SAT WITHIN 4 DAYS,RECANALISED,DISCHARGED HOME. 3. 34/M PHILIPINO,SMOKER,IWMI,PPCI-RCA(OPTIMA STENT),LATE ST,RECANALISED, DISCHARGED HOME 4. 40 YRS/M,SAUDI,AWMI, PPCI-LAD,2 STENTS(TAXUS),ACUTE ST WITHIN 4 HOURS,REPAET CATH PROX DISSECTION FLAP,DISTAL MALPPOSED STENT,ANOTHER STENT DEPLOYED,NO REFLOW, DIED IN HOSPITAL 5. 35 YRS/M, SAUDI,DIABETIC, SMOKER,AWMI,3VD,POOR LV FUNCTIONS, EF<30%,PPCI-LAD,(ENDEAVOR+TAXUS), LATE ST, REPEAT CATH, FAILURE TO RECANALISE IRA, DIED IN HOSPITAL

IN HOSPITAL OUTCOMES INTERVENTION GROUP 110/133 Frequency Percent NORMAL 16 14.5% Mildly Impaired 45-54 35 31.8% Moderately Impaired 30-44 52 47.3% Severely Impaired <30 6 5.5% Total 110 100% NON PCI GROUP 23/133 Frequency NORMAL 19 Moderately Impaired 30-44 2 Severely Impaired <30 2 Total 23

Percent 82% 9% 9% 2 6 100%

VALVULAR LESIONS Frequency NO MR 70 Trace MR 17 Mild MR 19 Moderate MR 4 Total 110

2

2

Percent 63.6% 15.5% 17.3% 3.6% 100%

COMPLICATIONS

IN HOSPITAL OUTCOME:  Intervention group:3 DEATHS( 107/110 = 97.3%)  Mortality of intervention arm: 3/110 = 2.7%  Non PCI group:I DEATH, NOT RELATED TO CABG (22/23 = 96%) (INCLUDING 3 PATIENTS OF CABG)

 1 MONTH FOLLOW UP: INTERVENTION GROUP

Loss to follow up was around 28 patients, mostly non Saudis All others were alive at 1 month

CONCLUSIONS • STEMI is not rare in young adults with a striking male predominance • Among the non Saudis Bangladeshis were the most frequent ethnic group.

• Smoking is a major risk factor in this age group followed by diabetes, hypertension and family history • Drug addiction appeared less frequent but may be underreported in our cohort of patients • Most of the patients presented with AWMI/LAD was the IRA in most patients.

• Coronary vasospasm was diagnosed in 3 patients • Majority had SVD and 83% underwent Primary PCI. • DES was the most frequently used stent, angiographic success was achieved in majority of patients.

• Stent thrombosis was seen in 5 patients and remains a matter of further investigation.

• Most of the patients had a complication free hospital stay with a very low in hospital mortality.