Thrombophilic state in young patients with acute myocardial infarction

Characteristics and outcomes of myocardial infarction among patients with bleeding or hypercoagulable disorders: A nationwide analysis

OBJECTIVE

To examine the characteristics and outcomes of acute myocardial infarction (AMI) in patients with bleeding and/or hypercoagulable disorders.

BACKGROUND

Studies examining the outcomes of AMI in bleeding/hypercoagulable disorders are scarce.

METHODS

The Nationwide Readmissions Database was utilized to identify hospitalizations with AMI from 2016 to 2020. The study cohort was divided into 4 groups: (1) MI without bleeding or hypercoagulable disorders, (2) MI with bleeding disorders, (3) MI with hypercoagulable disorders and (4) MI with mixed disorders. The main outcome was all-cause in-hospital mortality.

RESULTS

A total of 4,206,005 weighted hospitalizations with AMI were identified during the study period, of which 382,118 (9.1 %) had underlying bleeding or hypercoagulable disorders. The utilization of invasive strategies for the management of MI was highest in patients without bleeding or hypercoagulable disorders (62.6 %) and lowest in patients with mixed disorders (39.3 %). In-hospital mortality was higher among patients with bleeding (adjusted odds ratio [OR] 1.22; 95 % confidence interval [CI] 1.21, 1.24) and mixed disorders (aOR 3.38; 95 % CI 3.27, 3.49) compared with patients without bleeding or hypercoagulable disorders. Among patients with any bleeding or hypercoagulable disorder, those who underwent invasive strategy had lower adjusted odds of in-hospital mortality (aOR 0.28; 95 % CI 0.27, 0.30), ischemic stroke (aOR 0.60; 95 % CI 0.56, 0.64), bleeding (aOR 0.63; 95 % CI 0.61, 0.65), blood transfusion (aOR 0.95; 95 % CI 0.91, 0.99) and 30-day urgent readmissions (aOR 0.70; 95 % CI 0.68, 0.72).

CONCLUSIONS

The inpatient management and outcomes of AMI in patients with bleeding/hypercoagulable disorders differ from patients without those disorders. Revascularization in the setting of AMI was associated with lower in-hospital mortality, which suggests that patients with bleeding/hypercoagulable disorders can be evaluated for standard approaches to managing AMI; however, confounding by indication may be a concern.

The Etiology of the Thrombotic Phenomena Involved in the Process of Coronary Artery Disease-What Is the Role of Thrombophilic Genes in the Development of This Pathology?

Cardiovascular diseases, among which includes coronary artery disease, represent one of the most important causes of mortality and morbidity worldwide. Research aimed at determining the risk factors involved recognizes a group of "traditional" risk factors, but also more recent studies identified over 100 "novel" ones which may have a role in the disease. Among the latter is the thrombophilia profile of a patient, a pathology well-established for its involvement in venous thromboembolism, but with less studied implications in arterial thrombosis. This paper reviews the literature, explaining the pathophysiology of the thrombophilia causes associated most with coronary thrombosis events. Results of several studies on the subject, including a meta-analysis with over 60,000 subjects, determined the significant involvement of factor V Leiden, prothrombin G20210A mutation, plasminogen activator inhibitor-1 and antiphospholipid syndrome in the development of coronary artery disease. The mechanisms involved are currently at different stages of research, with some already established and used as therapeutic targets.

Mechanisms of Coronary Ischemia in Women

PURPOSE OF REVIEW

Obstructive coronary artery disease is a major cause of ischemia in both men and women; however, women are more likely to present with ischemia in the setting of no obstructive coronary arteries (INOCA) and myocardial infarction with no obstructive coronary arteries (MINOCA), conditions that are associated with adverse cardiovascular prognosis despite absence of coronary stenosis. In this review, we focus on mechanisms of coronary ischemia that should be considered in the differential diagnosis when routine anatomic clinical investigation leads to the finding of non-obstructive coronary artery disease on coronary angiography in the setting of acute myocardial infarction.

RECENT FINDINGS

There are multiple mechanisms that contribute to MINOCA, including atherosclerotic plaque disruption, coronary artery spasm, coronary microvascular dysfunction (CMD), coronary embolism and/or thrombosis, and spontaneous coronary artery dissection. Non-coronary causes such as myocarditis or supply-demand mismatch should also be considered on the differential when there is an unexplained troponin elevation. Use of advanced imaging and diagnostic techniques to determine the underlying etiology of MINOCA is feasible and helpful, as this has the potential to guide management and secondary prevention. Failure to identify the underlying cause(s) may result in inappropriate treatment and inaccurate counseling to patients. MINOCA predominates in young women and is associated with a guarded prognosis. The diagnosis of MINOCA should prompt further investigation to determine the underlying cause of troponin elevation. Patients with INOCA and MINOCA are heterogeneous, and response to treatments can be variable. Large randomized controlled trials to determine longer-term optimal medical therapy for management of these conditions are under investigation.

Risk factors profile of young and older patients with myocardial infarction

Myocardial infarction (MI) among young adults (<45 years) represents a considerable proportion of the total heart attack incidents. The underlying pathophysiologic characteristics, atherosclerotic plaque features, and risk factors profile differ between young and older patients with MI. This review article discusses the main differences between the younger and elderly MI patients as well as the different pathogenic mechanisms underlying the development of MI in the younger. Young patients with MI often have eccentric atherosclerotic plaques with inflammatory features but fewer lesions, and are more likely to be smokers, obese, and have poor lifestyle, such as inactivity and alcohol intake. Compared to older MI patients, younger are more likely to be men, have familial-combined hyperlipidaemia and increased levels of lipoprotein-a. In addition, MI in younger patients may be related to use of cannabis, cocaine use, and androgenic anabolic steroids. Genomic differences especially in the pathways of coagulation and lipid metabolism have also been identified between young and older patients with MI. Better understanding of the risk factors and the anatomic and pathophysiologic processes in young adults can improve MI prevention and treatment strategies in this patient group. Awareness could help identify young subjects at increased risk and guide primary prevention strategies. Additional studies focusing on gene pathways related to lipid metabolism, inflammation, and coagulation are needed.

Myocardial Infarction with Non-Obstructive Coronary Arteries: Contemporary Diagnostic and Management Approaches

Myocardial infarction with non-obstructive coronary arteries (MINOCA) is diagnosed in the absence of anatomically significant stenoses (<50% of lumen diameter) on coronary angiography and characterized by heterogeneity of etiologic factors. Recently, the mechanisms of MINOCA as well as the performance of diagnostic algorithms and therapeutic strategies have been extensively studied. The purpose of this review is to reflect the current concepts regarding the etiology and pathogenesis of MINOCA, diagnostic work-up methods and individualized treatment approaches. The article covers contemporary epidemiologic data, demographic and clinical patients’ characteristics and principal causes of MINOCA. We discuss aspects of disease definition and classification of related conditions involving troponin increase in the presence of normal coronary arteries. The importance of management strategy personalization for individual patients is stressed alongside stratification of risks of recurrent cardiovascular events. This review reflects key points from international consensus statements published by leading experts and suggests promising directions for future research.

Particularities of Acute Myocardial Infarction in Young Adults

Coronary heart disease occurs more often in patients over the age of 45. However, recent data shows a growing incidence of coronary events in younger patients also. Young patients with acute myocardial infarction (AMI) represent a relatively small proportion of subjects suffering from an acute ischemic event. However, they represent a subset that is distinguished from elderly patients by a different profile of risk factors, often atypical clinical presentation, and different prognosis. The prevalence of risk factors such as smoking, dyslipidemia, and a family history of coronary events is higher in this group of patients compared to the general population with AMI. Because of an important negative impact on the patients’ psychology, impaired working abilities, and a high socioeconomical burden, myocardial infarction in young patients represents an important cardiovascular pathology. This manuscript aims to present the particularities of AMI occuring at a young age, in comparison with the rest of the population with AMI.

Acute coronary syndrome in young patients: clinical features and risk factors

Aim. To study the clinical features and risk factors (RF) associated with the development of acute coronary syndrome (ACS) in young patients.

Material and methods. The study included 474 patients with ACS. Depending on age, patients were divided into 2 groups. The first group consisted of 299 patients of young age (25-44 years), the comparison group consisted of 175 patients of mean and old age (45-74 years). Clinical and anamnestic data, parameters of general clinical and biochemical tests, electrocardiography, echocardiography and coronary angiography were determined in all patients, and polymorphisms in FII G20210-A, FV G1691-A, MTHFR C677-T genes were determined in 116 patients. The control group consisted of 53 healthy volunteers.

Results. ACS in patients <45 years old is most common in men. The number of women with ACS increases as elder patient is. The incidence of myocardial infarction (MI) and unstable angina, ST-elevated MI and non ST-segment elevation MI, Q-wave and non-Q-wave MI had no differences between patients of the younger and older age groups. In younger patients, anterior localization of myocardial infarction was more common, in mean and old patients — posterior. Complications of MI in young patients were less common than in the comparison group. In patients of mean and old ages, acute coronary event was preceded by a clinic of angina, in young patients most often it was the debut of coronary artery disease. It was revealed that single-vessel coronary lesion is more characteristic for young patients, for the elderly patients — two-vessel and multi-vessel. Pathology of the anterior descending coronary artery prevailed in both groups of patients. Most patients in both groups underwent myocardial revascularization. MI as a result of coronary artery thrombosis happened more often in young patients. The most significant RF associated with the ACS development were: increased total cholesterol and low density lipoproteins, decreased high density lipoproteins, increased body mass index, smoking, polymorphism of MTHFR-homozygote, hereditary tainted with smoking, aggravation in combination with F5-homozygote, hereditary tainted in combination with MTHFR-homozygote, hereditary tainted in combination with smoking and MTHFR homozygote.

Conclusion. We identified clinical features and RF, mostly associated with the development of ACS in patients <45 years of age. The results can serve as additional indicators showed the risk of ACS development.

Hypertension Is an Independent Predictor of Multivessel Coronary Artery Disease in Young Adults with Acute Coronary Syndrome

Background

Risk factors of multivessel coronary artery disease (CAD) among young acute coronary syndrome (ACS) patients remain elusive now.

Methods

This retrospective study analyzed data from 187 consecutive young (age ≤45 years) ACS patients (75 STEMI, 30 NSTEMI, and 72 unstable angina) hospitalized in our hospital from January 2012 to December 2016. Thirty-six young male patients with normal coronary angiography (CAG) findings (no-CAD), who underwent CAG due to suspected chest pain in this period, served as control group. There were 83 patients with single-vessel disease (SVD) and 104 patients with multiple-vessel disease (MVD) among ACS patients. Patients were followed up for a mean of 267±124 days by clinical visit or telephone calls.

Results

All included patients were male. Prevalence of hypertension (57.2% vs. 30.6%, p=0.002) and smoking (70.6% vs. 52.8%, p=0.049) was significantly higher in ACS patients than in no-CAD patients. Prevalence of hypertension (72.1% vs. 38.6%, p<0.001) and body mass index (BMI) were significantly higher in MVD group than in SVD group. Multivariable analysis revealed that hypertension was an independent risk factor for MVD after adjustment for age, gender, BMI, smoking, family history of premature CAD, hyperlipidemia, left ventricular ejection fraction, and brain natriuretic peptide (odds ratio=3.71, 95% confidence interval=1.84-7.46, p<0.001). Rate of major adverse cardiovascular events (MACE) during follow-up (20.2% vs. 4.8%) was significantly higher in MVD group compared with SVD group.

Conclusions

Hypertension is an independent predictor of MVD and MVD is associated with increased MACE rate compared to SVD in young ACS patients during the short-term follow-up.

Acute coronary disease, prognosis and prevalence of risk factors in young adults

Acute coronary disease is a rare entity in young people and is mostly related to atherosclerotic disease. However, other causes such as myocardial bridges, coronary artery dissection and antiphospholipid syndrome may be present. The prognosis of the disease in this group of patients is favorable; although women may have a higher morbidity because diagnosis and treatment can be delayed. The goal of this review is to update the knowledge about risk factors and prognosis of young patients with an acute coronary event compared to the older population.

The adjusted Global AntiphosPholipid Syndrome Score (aGAPSS) for risk stratification in young APS patients with acute myocardial infarction

BACKGROUND

Young adults with acute myocardial infarction are a critical group to examine for the purpose of risk factor stratification and modification. In this study we aimed to assess the clinical utility of the adjusted Global AntiphosPholipid Syndrome Score (aGAPSS) for the risk stratification of acute myocardial infarction in a cohort of young patients with antiphospholipid syndrome (APS).

METHODS

The analysis included 83 consecutive APS patients (≤50years old) who presented with arterial or venous thromboembolic events. Data on cardiovascular risk factors and antiphospholipid antibodies (aPL) positivity were retrospectively collected. The aGAPSS was calculated by adding the points corresponding to the risk factors, based on a linear transformation derived from the ß-regression coefficient as follows: 3 for hyperlipidaemia, 1 for arterial hypertension, 5 for aCL IgG/IgM, 4 for anti-b2 glycoprotein I IgG/IgM and 4 for LA.

RESULTS

Higher aGAPSS values were observed in patients with acute myocardial infarction when compared to the others [mean aGAPSS 11.9 (S.D. 4.15, range 4-18) Vs. mean aGAPSS 9.2 (S.D. 5.1, range 1-17); T test: p<0.05]. Significantly higher aGAPSS values were also seen in patients with acute coronary syndrome compared to patients with a history of peripheral or cerebrovascular arterial thrombotic events [mean aGAPSS 11.9 (S.D. 4.15, range 4-18) Vs. mean aGAPSS 6.7 (S.D. 5.7, range 1-17); T test: P<0.005].

CONCLUSIONS

The aGAPSS is based upon a quantitative score and could aid risk stratifying APS patients younger than 50years for the likelihood of developing coronary thrombotic events and may guide pharmacological treatment for high-risk patients.

Intravascular Images of Coronary Stenosis with Multiple Channels in a Patient with Antiphospholipid Syndrome: The Optical Coherence Tomography Findings

Intravascular images of coronary stenosis by antiphospholipid syndrome (APS) would be beneficial to understand the mechanism of this disease. A 59-year-old woman with APS/systemic lupus erythematosis (SLE) underwent emergent coronary angiography which revealed stenosis with micro channels in the proximal left anterior descending artery. According to optical coherence tomography (OCT), the central lumen was surrounded by a thick septum with a homogenous and high intensity. Multiple small channels existed near the vessel wall with diffuse intimal hyperplasia. White thrombi were floating distal to the stenosis. Intravascular images obtained by optical coherence tomography (OCT) revealed the microstructure of complex coronary stenosis, which had ambiguous findings on angiography and intravascular ultrasound (IVUS) in an acute coronary syndrome (ACS) patient with APS/SLE.

A 16-year-old with ST elevation myocardial infarction: case report and review of the literature

Chest pain in young adults presents a unique diagnostic challenge, placing young patients at an increased risk to be misdiagnosed, as this patient population typically does not demonstrate the traditional risk factors associated with cardiovascular disease. This study details the case of a 16-year-old male who presented with new-onset chest pain and ST elevation on electrocardiogram. His history was unremarkable for known cardiac risk factors, but laboratory evaluation demonstrated markedly elevated troponins and electrocardiographic findings confirmed ST-segment elevation myocardial infarction. Coronary angiography demonstrated 100% occlusion of the left anterior descending artery, which was managed with percutaneous transluminal coronary angioplasty, thrombectomy, and bare-metal stenting. The patient had an uneventful recovery. This study examines the major causes of ST elevation myocardial infarction in young adults and reviews the major differences between younger and older myocardial infarction populations with emphasis on risk factor profile, pathophysiological mechanisms, clinical presentation, angiographic findings, and prognosis. This review highlights the need for consideration of a wide differential in younger subsets of the population presenting with chest pain and ST elevation. The implementation of current adult management protocols and guidelines for ST elevation myocardial infarction should not be overlooked due to age. Given the potential for premature death and long-term disability with resulting individual and societal consequences, it is crucial to understand the importance of correct diagnostic evaluation in this clinical scenario.