Never too young to have heart disease

SUDDEN death from a heart attack in the young is tragic and catastrophic, as it deprives young children of a parent and leaves parents heartbroken at the sudden loss of a beloved child.

In an autopsy study of 760 young (less than 35 years) victims of accidents, suicides or homicides by McGill published in Circulation journal in 2000, advanced cholesterol deposits causing narrowing and hardening of heart (coronary) arteries (atherosclerosis) were seen in 2 per cent of men and no women aged 15 to 19 years.

Some 19 per cent and 8 per cent of men and women aged 30 to 34 years, respectively, had at least 40 per cent narrowing of the left anterior descending artery, the main blood supply to the main heart chamber.

In the Framingham Heart Study, the incidence of a heart attack over a 10-year follow-up was 12.9/1,000 in men 30 to 34 years old and 5.2/1,000 in women 35 to 44 years old. Hence, in young men, close to 20 per cent have coronary artery disease (CAD) and about 13 out of every 1000 develop a heart attack.

Risk factors

Preventing heart disease is always the best strategy. To do this, identifying risk factors and proactively managing the risk factors will decrease the likelihood of heart disease.

If your parents had CAD before the age of 50 years, your risk is increased, but although genetic risk is inherited, we can reduce other modifiable risk factors.

Smoking is the worst health decision a young person can make. In the Framingham Heart Study, young smokers had three times higher risk of developing CAD compared to non-smokers. In female smokers, the risk is more than five times the risk of non-smoking women. It gets much worse with the use of oral contraceptives in female smokers - death from CAD increases 13-fold.

Parents should take note that a smoke-filled home is a health hazard for their children. A 2007 study on children aged 11 who had daily exposure to second-hand smoke showed that there was significant impairment in the ability of their heart arteries to increase the diameter when there was increased demand for more blood to the tissues. Hence, even passive smoking can have a detrimental impact on heart arteries.

In recent years, many youths have turned towards e-cigarettes or vaping as an alternative to traditional smoking. While it is known that traditional cigarettes contain 7,000 chemicals, many of which are toxic, much less is known about the chemicals from e-cigarettes or vaping.

There has been reported lung injury and deaths in patients with e-cigarette, or vaping, product use associated lung injury (EVALI) and the majority of these deaths involve those who modify their vaping devices or use black market modified e-liquids containing tetrahydrocannabinol (THC).

The Centers for Disease Control and Prevention (CDC) in the United States have identified vitamin E acetate, a thickening agent used in THC vaping products, as a chemical of concern among people with EVALI as it was found in lung fluid samples of EVALI patients. Current data suggests that vaping increases the risk of heart and lung disease.

The manner in which the risk factors translate into real world CAD risk is shown in the Coronary Artery Risk Development in Young Adults (Cardia) study which evaluated 5,115 young adults, aged 18 to 30, from 1986 till present. The study examined the impact of risk factors on atherosclerosis in heart arteries by screening for calcium deposits in the wall of heart arteries using computed tomography X-ray scanning.

The more calcification there was, the more extensive was the atherosclerosis of the coronary arteries. The study showed that likelihood of CAD increased as follows: 50 per cent increase in risk by smoking 10 cigarettes a day or with every 30 mg/dL rise in LDL-C; 30 per cent increase in risk by each 10 mm Hg rise in systolic blood pressure; and 20 per cent increase in risk by each 15 mg/dL rise in blood sugar levels.

Most young people assume that they will never get CAD until they are much older, and hence they are often unwilling to pull the brakes on a reckless lifestyle. You may be surprised that, unlike older CAD patients, younger CAD patients are less likely to have symptoms.

In three quarters of young CAD patients, the initial presentation of an existing severe CAD is an impending heart attack or a heart attack. About two-thirds of young CAD with a heart attack do not have chest pain prior to the infarct. Among those who have preceding chest pain, the first episodes are usually present only in the week preceding the heart attack.

What lies ahead

In a 2003 Journal of the American College of Cardiology publication by Cole, more than 800 young CAD patients diagnosed on coronary angiogram were followed up for 15 years. The mean age for severe CAD was 35 years and 36 years for women and men respectively.

After 15 years, 30 per cent of the young CAD had died. The 15-year death rate was higher for those who had a previous heart attack (45 per cent), those with underlying diabetes mellitus (65 per cent), and those with more than 50 per cent reduction in heart pump function (83 per cent).

Medication alone was associated with higher death rate compared to opening of heart arteries by balloon dilatation or open heart artery bypass graft surgery. In another study of men and women who had heart attack before aged 40, 25 per cent died in less than 15 years.

Data from the Swedish national heart registry (SwedeHeart registry) showed that almost one in five young CAD patients who underwent open heart bypass graft surgery died 15 years later.

CAD in young adults is associated with a poor long-term outlook. A previous heart attack, the presence of diabetes mellitus, chronic smoking and severely impaired heart pump function is associated with a significantly higher risk of death.

Making the right decisions

Given the grim long-term outcome of young CAD patients, prevention is still the best strategy. Take the right measures to set off on a better future.

If you have a family history of CAD and high LDL-C, seek medical advice early.

Smokers harm their family and friends and smoking cessation is the best gift of health they give to themselves and loved ones.

Get that cholesterol down. Reducing your "bad" cholesterol or LDL cholesterol to optimal levels is one of the most important strategies in preventing a future heart attack. Beyond dietary changes, cholesterol lowering medication may be required to achieve your target cholesterol levels.

If you have diabetes mellitus or high blood pressure, a combination of lifestyle measures and medication can help control these conditions. A regular moderate exercise routine can help to reduce your sugar and blood pressure.

Keep yourself well hydrated by drinking about 2 litres of liquid daily as more than 90 per cent of heart attacks are due to blood clots

If you have a healthy diet, you should avoid calcium supplements as calcium supplementation can lead to an increase in the calcium deposits in the heart arteries.

Finally take heart that the Framingham Heart Study showed that if you are not obese, do not smoke, do not have high blood pressure, do not have high LDL-C, do not have diabetes and do not have low HDL cholesterol, there is only a 5 per cent risk of getting heart disease at the age of 95 years. Hence, investing in risk factor control from young pays off.

• This article is produced on alternate Saturdays in collaboration with Royal Healthcare Heart, Stroke & Cancer Centre