Review
Myocardial Infarction in the “Young”: Risk Factors, Presentation, Management and Prognosis

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Myocardial infarction (MI) in the “young” is a significant problem, however there is scarcity of data on premature coronary heart disease (CHD) and MI in the “young”. This may lead to under-appreciation of important differences that exist between “young” MI patients versus an older cohort. Traditional differences described in the risk factor profile of younger MI compared to older patients include a higher prevalence of smoking, family history of premature CHD and male gender. Recently, other potentially important differences have been described. Most “young” MI patients will present with non-ST elevation MI but the proportion presenting with ST-elevation MI is increasing. Coronary angiography usually reveals less extensive disease in “young” MI patients, which has implications for management. Short-term prognosis of “young” MI patients is better than for older patients, however contemporary data raises concerns regarding longer-term outcomes, particularly in those with reduced left ventricular systolic function. Here we review the differences in rate, risk factor profile, presentation, management and prognosis between “young” and older MI patients.

Introduction

The leading cause of death in the world is coronary heart disease (CHD) [1] and while there is a large body of data available for CHD, literature focussing on premature CHD and myocardial infarction (MI) in the “young” is lacking. Consequences of MI can be devastating particularly at a “young” age due to its greater potential impact on the patient's psychology, ability to work and the socioeconomic burden. As “young” MI patients may be the main income producer of the family, the aftermath of MI can also affect multiple dependents. Clinicians may not appreciate the differences that exist between “young” and older MI patients.

In this paper we report the differences in rate, risk factor profile, presentation, management and prognosis between “young” and older MI patients.

Section snippets

Methods

A literature search was conducted via MEDLINE and GOOGLE for the years between 1980 and 2015 using the keywords “young” and “myocardial infarction”. The search was restricted to papers published in the English language and in peer-reviewed journals.

Definition and Epidemiology

There is disparity in the literature on the definition of “young” with respect to premature CHD and MI. The term “young” varies from ≤40 [2], [3], [4] to ≤55 years of age [5]. Others have suggested 45 years as a cut-off when defining “young” with respect to MI [6], [7], [8]. As there is no universally accepted age cut-off, this review will not use a single definition but rather will accept the cut-off or range used by the authors of the data being reviewed.

There is a paucity of data on MI in

Risk Factors

The extent of relative risk for future events of traditional cardiovascular risk factors are comparable in “young” and older adults [16]. The majority of patients suffering MI at a “young” age are reported to have at least one identifiable cardiovascular risk factor [6], [17], [18], [19]. Hoit et al. reported a higher prevalence of smoking, family history of premature CHD and male gender among “young” MI patients compared with their older counterparts [6]. Others have supported this finding

Clinical Presentation and Angiographic Findings

Up to two-thirds of “young” MI patients will present with non-ST elevation myocardial infarction (NSTEMI) with approximately a third presenting with STEMI [10]. It appears that, overall, the incidence of STEMI is reducing among the “young” but the proportion of “young” patients diagnosed with STEMI is increasing [10]. Most “young” MI patients do not report a history of previous angina, MI or congestive heart failure and they report this less frequently in their histories than their older

Management

The management of MI generally is not dependent on age and guideline-suggested therapies are just as applicable to younger patients as they are to their older counterparts [44], [45]. With respect to STEMI management, the benefits of primary angioplasty over thrombolysis are as applicable in “young” patients as they are in older individuals and no particular age cohort has a greater relative benefit [46]. “Young” age is an independent predictor for favourable prognosis following thrombolysis

Prognosis

In-hospital and short-term outcomes are generally favourable in “young” MI patients. In-hospital and six-month mortality has been shown to be 0.7% and 3.1%, respectively [21]. This compares favourably to their older counterparts whose in-hospital and six-month mortality were 8.3% and 12%, respectively [21]. Beyond five years post-MI, however, there is an alarming drop in survival among “young” MI patients with mortality exceeding 15% at seven years [20] and being between 25-29% at 15 years [5],

Summary

The incidence of MI in “young” patients is substantial. Smoking remains one of the most important risk factors and should be the target of any program aimed to reduce the rate of MI in the “young”. “Young” MI patients often lack warning symptoms of escalating chest pain. Coronary angiography in the “young” tends to reveal less extensive disease in comparison with their older counterparts and hence they are more often managed with percutaneous revascularisation. Short-term outcomes post-MI at a

Funding

Supported by the Western Health Research Grant 2013.

Conflict of Interest

The authors report no relationships that could be construed as a conflict of interest.

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