Author + information
- Published online February 4, 2019.
- Ali M. Agha, MD,
- Jean-Paul Bryant, BS,
- Maria Marquez, BS,
- Khurram Butt, MD,
- Nicholas Feranec, MD,
- William F. Sensakovic, PhD,
- Julie Pepe, PhD,
- Usman Siddiqui, MD,
- Thomas J. Ward, MD,
- Fiona Tissavirasingham, MD and
- Jeremy R. Burt, MD∗ ()
- ↵∗Florida Hospital Orlando, 601 East Rollins Street, Mail Stop 163, Orlando, Florida 32803
Little is known about the prevalence and risk factors for coronary artery disease (CAD) in young adults, possibly owing to the limited number of anatomic studies in this patient population. The Partners YOUNG MI Registry demonstrated that myocardial infarction rates among young adults have not decreased despite significant progress in primary prevention, highlighting the need for additional research regarding cardiovascular disease in the young (1).
We sought to determine the frequency and risk factors for premature CAD in young adults who underwent coronary computed tomography angiography (CTA) for evaluation of undiagnosed chest pain at our institution.
A group of 1,420 subjects (men < age 40 years and women < age 50) who underwent coronary CTA for evaluation of undiagnosed chest pain were evaluated for CAD. Severity of CAD was recorded according to the CAD RADS (Coronary Artery Disease Reporting and Data System) classification system, in addition to the vessel/segment affected, and plaque type (calcified vs. noncalcified).
Demographic and clinical information was also collected from retrospective chart review, including age, past medical history including diabetes (diagnosis/treatment or A1c ≥6.5), hypertension (diagnosis/treatment, or systolic blood pressure ≥140 mm Hg, or diastolic blood pressure ≥90 mm Hg), or obesity (body mass index ≥30 kg/m2), social history including current or prior history of cigarette smoking or recent cocaine use (within last week or positive toxicology screen), and laboratory values including lipid panel.
The frequency of premature CAD by coronary CTA was 14.2%; 2.7% of subjects demonstrated ≥50% stenosis. Graphically, the frequency of CAD among men increased during their mid-30s, and a similar trend was noted among women during their mid-40s (offset by approximately 10 years) (Figure 1).
The coronary artery most frequently affected by CAD was the left anterior descending artery (72.5% of subjects with CAD). Nearly 38% with CAD had multivessel disease. The proximal segment was most frequently affected in a majority of the coronary arteries. Among those with plaque, 53.6% of patients had exclusively noncalcified plaque, whereas 46.4% of patients had some calcified or mixed plaque.
There was a greater frequency of hypertension among those with CAD versus those without CAD (50.2% vs. 36.3%; p < 0.001), as well as diabetes (23.3% vs. 11.7%; p < 0.001) and obesity (59.2% vs. 51.7%; p < 0.048). However, there was not as strong of an association between obesity and CAD among the young subjects in this study compared with in older patients. There was a clear association between premature CAD and total cholesterol (p = 0.002), triglyceride levels (p = 0.002), and low-density lipoprotein levels (p = 0.011). However, a lipid panel was not available for approximately 30% of patients, and the potential for selection bias should be considered. There was no statistically significant difference between the prevalence of cigarette smoking among those with CAD versus those without CAD (38.8% vs. 35.6%; p = 0.381). There was no difference in the prevalence of recent cocaine use among those with CAD versus those without CAD (3.0% vs. 4.2%; p = 0.422).
In multivariate analysis, hypertension (odds ratio: 1.49, 95% confidence interval: 1.08 to 2.06) and diabetes (odds ratio: 1.98, 95% confidence interval: 1.34 to 2.95) were associated with CAD in young adults.
Before men reached their mid-30s and women reached their mid-40s, the frequency of CAD in this cohort was low. After these age cutoffs, there was an appreciable increase in the frequency of CAD and consequently there may be a higher yield of CCTA.
Most clinical risk factors for CAD in young adults are similar to those seen among older subjects. However, there was no association between cigarette smoking and CAD in our young cohort. This may be explained by the presumably limited number of pack years, as 1 study suggests a dose-response relationship between smoking and coronary atherosclerosis among asymptomatic patients undergoing coronary CTA (2). Although there was not an appreciable association between recent cocaine use and CAD in our study, usage rates were low (4.0%). Of note, cocaine use has been associated with worse all-cause and cardiovascular mortality among patients with a myocardial infarction at age ≤50 years (3).
Similar to the CARDIA (Coronary Artery Risk Development in Young Adults) study, our study further supports the importance of early risk factor modification for the prevention of CAD (4). The advent of CCTA has allowed us to identify both noncalcified plaques (not previously identified in the CARDIA study) in addition to calcified plaques. This is of interest, considering that a majority of plaques identified in our young patient population were noncalcified plaques, as opposed to the calcified plaques typically seen in older adults. Patients with CAD in this young cohort could see a life expectancy gain if treated aggressively with lifestyle modification and/or medical management.
Please note: This project was not completed using any grants, contracts, and other forms of financial support. The authors have reported that they have no relationships relevant to the contents of this paper to disclose.
- 2019 American College of Cardiology Foundation
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