Elsevier

Mayo Clinic Proceedings

Volume 95, Issue 1, January 2020, Pages 136-156
Mayo Clinic Proceedings

Review
Acute Myocardial Infarction in Young Individuals

https://doi.org/10.1016/j.mayocp.2019.05.001Get rights and content

Abstract

Globally, cardiovascular disease remains a major cause of adverse outcomes in young individuals, unlike its decline in other age groups. This group is not well studied and has a unique risk profile with less traditional cardiovascular risk factors compared with older populations. Plaque rupture still remains the most common etiology of myocardial infarction, but unique syndromes such as plaque erosion, coronary microvascular dysfunction, spontaneous coronary artery dissection, and coronary spasm related to drug use are more prevalent in this age group. Such diversity of diagnosis and presentation, along with therapeutic implications, underscore the need to study the profile of myocardial infarction in young persons. We searched PubMed for articles published from 1980 to 218 using the terms acute myocardial infarction, young, plaque rupture, plaque erosion, spontaneous coronary artery dissection (SCAD), coronary vasospasm, variant or Prinzmetal angina, drug-induced myocardial infarction, myocarditis, coronary embolism, microvascular dysfunction, MINOCA, and myocardial infarction in pregnancy and reviewed all the published studies. With the data from this search, we aim to inform readers of the prevalence, risk factors, presentation, and management of acute myocardial infarction in young patients and elaborate on special subgroups with diagnostic and therapeutic challenges. We also outline a parsimonious method designed to simplify management of these complex patients.

Section snippets

Prevalence

Overall, prevalence estimates vary because the clinical profile of atherosclerotic and nonatherosclerotic phenotypes is poorly defined. This lack of definition is especially true for patients who present with MI with nonobstructive coronary arteries (MINOCA) because angiography-based differentiation without routine intracoronary imaging and nonuniform work-up have led to poor identification of nonplaque mechanisms.4 There are also limited data on the incidence of MI in young patients. The

MI Related to Traditional Cardiovascular Risk Factors in Patients With Atherosclerotic CAD

In a large, multinational cohort study with follow-up of 2 decades, the traditional cardiovascular risk factors were equally predictive of mortality in young men compared with older men.63 Similarly, among 7302 eligible young women without major electrocardiographic abnormalities or prevalent CAD at baseline, the long-term (31-year) risk of development of CAD and mortality was higher in women with major coronary risk factors.64 A similar risk factor profile and association with outcomes was

Clinical Presentation

Concordant with overall trends, two-thirds of all MIs in young patients present with non–ST-elevation (Table 2).80 In general, clinical presentation in young patients with MI is indistinguishable from that of older patients, and most patients present with chest pain due to plaque rupture. However, certain differences are noteworthy. First, a history of angina symptoms before MI is less common, seen in approximately one-fourth of patients.81 Second, 69% of patients younger than 45 years do not

General Principles

The current classification for MI ignores patients with minimal or no CAD, and using the Universal Definition of Myocardial Infarction,58 its etiology is still unclear in approximately 12% of women. Furthermore, patients with different etiologies and varying severity of atherosclerosis and left ventricular function are combined, leading to management dilemmas and phenotypic heterogeneity. To address the deficiencies in the current classification, using an inductive approach and grouping

MI Related to Traditional Cardiovascular Risk Factors

The treatment of young patients with MI due to plaque rupture should follow the current guidelines. This process would require guideline-directed medical management and coronary revascularization, similar to treatment for older individuals.

Recreational Drug Use and Psychosocial Factors

Recreational drug use and psychosocial factors are important and need to be considered in every young patient presenting with MI, especially patients who lack traditional cardiovascular factors and those in whom coronary vasospasm is detected during coronary

Follow-up and Prognosis

The prognosis for young patients with MI is not benign. The adverse cardiovascular events are similar in patients presenting with or without significant obstruction in coronary arteries. Mortality is higher compared with age- and sex-matched controls.

Patients with SCAD typically have recurrent MI rates of 10% to 30% at 2 to 3 years. The event rate at 5 years is between 15% and 37% and at 10 years is approximately 50%.28, 117, 133 In a report from Mayo Clinic, recurrence of SCAD was noted in 17%

Recommendations

We recommend a systematic approach to arriving at a correct diagnosis. Any young patient with confirmed MI should undergo coronary angiography to identify the atherothrombotic culprit (Table 4 and Figure 6). If risk factors (smoking, diabetes mellitus, hyperlipidemia, hypertension, peripheral arterial disease) and angiographic features (thrombus, presence of atherosclerotic disease elsewhere in the coronary vascular bed) favor atherothrombotic disease, then we recommend following the American

Conclusion

This review focuses on the prevalence, risk factors, unique syndromes, and overall profile of young patients presenting with MI. We also discuss the management of important syndromes that are more prevalent in the younger population. Lastly, we propose a unique method that will help clinicians stratify young patients with MI into different diagnostic categories. This approach will be of immense help in arriving at the right diagnosis and individualizing the treatment of MI in young patients.

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    For editorial comment, see page 29

    Potential Competing Interests: Dr Behfar is a member of the board of and has received grants (funds paid to his institution) from Rion LLC; has patents (planned, pending, or issued) from Rion LLC and Celyad; has received royalties from Celyad; and has stock/stock options in Rion LLC. The other authors report no competing interests.

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