Acute Myocardial Infarction in Young Individuals

Acute myocardial infarction in twin pregnancy after assisted reproduction: A case report

BACKGROUND

Acute myocardial infarction (AMI) during pregnancy is rare, especially in twin pregnancy, and it can endanger the lives of the mother and children. Except for conventional cardiovascular risk factors, pregnancy and assisted reproduction can increase the risk of AMI during pregnancy. AMI develops secondary to different etiologies, such as coronary spasm and spontaneous coronary artery dissection.

CASE SUMMARY

A 33-year-old woman, with twin pregnancy in the 31^st week of gestation, presented to the hospital with intermittent chest tightness for 12 wk, aggravation for 1 wk, and chest pain for 4 h. Combined with the electrocardiogram and hypersensitive troponin results, she was diagnosed with acute ST-elevation myocardial infarction. Although the patient had no related medical history, she presented several risk factors, such as age greater than 30 years, assisted reproduction, and hyperlipidemia. After diagnosis, the patient received antiplatelet and anticoagulant treatment. Cesarean section and coronary angiography performed 7 d later showed stenosis and thrombus shadow of the right coronary artery. After receiving medication, the patient was in good condition.

CONCLUSION

This case suggests that, with the widespread use of assisted reproductive technology, more attention should be paid to perinatal healthcare, especially when chest pain occurs, to facilitate early diagnosis and intervention of AMI, and the etiology of AMI in pregnancy needs to be differentiated, especially between coronary spasm and spontaneous coronary artery dissection.

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The role of a comprehensive two-step diagnostic evaluation to unravel the pathophysiology of MINOCA: A review

The role of cardiac magnetic resonance (CMR) in identifying mechanisms for myocardial infarction with non-obstructed coronary arteries (MINOCA) is well established. Recent reports have highlighted the potentially key role of invasive management in this diagnostic process. Intravascular ultrasound (IVUS) and optical coherence tomography (OCT) allow precise evaluation of coronary anatomy, and assessment of coronary physiology in the catheter laboratory provides information on the hemodynamic significance of sub-critical atherosclerosis and on coronary microvascular dysfunction (CMD). We reviewed the evidence for the contribution of invasive diagnostic techniques in identifying provisional causes for MINOCA. Overall, among 82 studies including 8457 patients were selected. In the acute phase, 16 studies with IVUS or OCT (1207 patients) disclosed that plaque disruption and spontaneous coronary artery dissection had a pooled prevalence of 38% (95% confidence intervals (CI): 29% to 51%) and 16% (95% CI: 9% to 27%), respectively. In 18 studies, coronary function testing (1449 patients) showed a pooled prevalence of spontaneous and/or provoked epicardial coronary spasm of ~28% (95% CI:17% to 41%). In 3 studies (456 patients), the pooled prevalence of CMD was ~32% (95% CI: 20% to 49%). In the subacute phase, 42 CMR studies (5821 patients) showed that a pooled prevalence of myocarditis, takotsubo syndrome and cardiomyopathy of 26% (95% CI: 12% to 40%), 11% (95% CI: 5% to 25%), and 7% (95% CI: 1% to 19%), respectively. In 12 studies on thrombophilia screening (n = 834), the pooled prevalence of thrombotic disorder was ~11% (95% CI: 7%% to 25%). In conclusion, the pathophysiology of MINOCA can be established in the majority of cases using both invasive and non-invasive tools to provide direction for appropriate management.

ST-Elevation Myocardial Infarction in a 23-Year-Old Female: The Mystery of Thrombus Formation

Acute ST-elevation myocardial infarction (STEMI) is rarely seen in young adults, however, when encountered, the underlying cause is either a genetic condition leading to early-onset coronary artery disease (CAD), an acquired pro-thrombotic condition, or an idiopathic condition like spontaneous coronary artery dissection (SCAD). Our case describes a healthy 23-year-old female who presented with sudden onset severe angina and was found to have a laminated thrombus in the left anterior descending coronary artery (LAD), with no evidence of intraluminal dissection or plaque rupture. Although the underlying etiology of thrombus formation remains unknown, coronavirus disease 2019 (COVID-19) related thrombotic event is the prime suspect. In addition, another culprit that cannot be excluded is phentermine-induced coronary vasospasm, a commercially available medication for weight loss. This report addresses current literature on acute coronary syndromes in young adults and reviews the potential etiologies for coronary artery thrombosis, which led to a near-fatal acute coronary syndrome in our patient.

Epidemiological and clinical profile, management and outcomes of young patients (≤40 years) with acute coronary syndrome: A single tertiary care center study

OBJECTIVE

To study the epidemiological and clinical profile, angiographic patterns, reasons for the delay in presentation, management, and outcomes of the acute coronary syndrome (ACS) in young patients (≤40yrs) presenting to a tertiary care hospital in North India.

METHODS

We included a total of 182 patients aged ≤40 years and presenting with ACS to the cardiology critical care unit of our department from January 2018 to July 2019.

RESULTS

The mean age of the study population was 35.5 ± 4.7years. 96.2% were males. Risk factors prevalent were smoking (56%), hypertension (29.7%), family history of premature coronary artery disease (18.2%), and diabetes (15.9%). The median time to first medical contact and revascularization was 300 (10-43200) minutes and 2880 (75-68400) minutes, respectively. ST-elevation ACS (STE-ACS) accounted for 82% and Non-ST-elevation ACS (NSTE-ACS) accounted for 18% of cases. Thrombolysis was done in 51.7% of the cases. Coronary angiography was done in 91.7% and percutaneous coronary intervention (PCI) in 52.2% (95/182) of the total cases. Coronary artery bypass surgery (CABG) was done in 2 patients (1.1%). Among those who underwent coronary angiography, single-vessel disease (SVD) was seen in 53% of the cases. There were no deaths in hospital, and only one patient died during the 30 days follow up.

CONCLUSIONS

STE-ACS was the most common presentation of ACS in the young population. Smoking was the most common risk factor. The majority of the patients had single-vessel disease, and there was a significant delay in first medical contact and revascularization.

BCL-6 promotes the methylation of miR-34a by recruiting EZH2 and upregulating CTRP9 to protect ischemic myocardial injury

Acute myocardial infarction (AMI) and the following heart failure are public health problems faced all over the globe. The current study set out to investigate the role of B-cell lymphoma 6 (BCL-6) in cardiac protection after AMI. Initially, AMI mouse models and H9c2 cell oxygen-glucose deprivation (OGD) models were established. The cell models were transfected with the vectors containing oe-BCL-6, oe-EZH2, sh-EZH2, miR-34a mimic, and miR-34a inhibitor. RT-qPCR and Western blot analysis were applied to detect the expression patterns of microRNA-34a (miR-34a), BCL-6, enhancer of zeste homolog 2 (EZH2), and C1q tumor necrosis factor-related protein 9 (CTRP9) in the treated cell models. ChIP-qPCR and co-immunoprecipitation assay were performed to detect EZH2 enrichment and H3K27me3 levels in the miR-34a promoter region and the interaction between BCL-2 and EZH2, respectively. EdU staining, TUNEL staining, and flow cytometry were performed to detect cell proliferation and apoptosis, while ELISA was conducted to detect the oxidative stress levels. It was found that miR-34a was highly expressed in heart tissues of AMI models, while BCL-6 and EZH2 were poorly expressed. BCL-2 overexpression increased the recruitment of EZH2, upregulated H3K27me3 level in the miR-34a promoter region, and inhibited the miR-34a expression. Ctrp9, the downstream negative-regulatory molecule of miR-34a, was upregulated. Besides, miR-34a/CTRP9 expression changes were found to affect cardiomyocyte apoptosis, oxidation stress, and proliferation, and prevent myocardial injury in AMI mice. Our findings indicate that BCL-6 increases the level of H3K27me3 in the promoter region of miR-34a via EZH2 recruitment and CTRP9 upregulation, which inhibits the apoptosis of myocardial cells.

Acute coronary syndrome in a young woman with a giant coronary aneurysm and mitral valve prolapse: a case report and literature review

Acute coronary syndrome in the young population is infrequently seen and has a different etiology from that in the elderly population. Giant coronary artery aneurysms are rare and usually asymptomatic, but they can cause acute clinical symptoms such as chest pain or chest tightness. We herein describe a young woman with a history of mitral valve prolapse who developed sudden-onset chest pain. She had mild elevations of her creatine kinase and cardiac troponin levels; however, no ST segment alteration was found on an electrocardiogram, and no abnormal regional wall movement was noted on echocardiography. Cardiac magnetic resonance imaging with late gadolinium enhancement revealed a "mass" at the right coronary artery and linear subendocardial enhancement at the posterior wall. Coronary angiography later confirmed a giant coronary aneurysm with a substantial thrombus. The combined presence of the coronary artery aneurysm and mitral valve prolapse in this patient was likely a sequela of Kawasaki disease.

Nitrite and myocardial ischaemia reperfusion injury. Where are we now?

Cardiovascular disease remains the leading cause of death worldwide despite major advances in technology and treatment, with coronary heart disease (CHD) being a key contributor. Following an acute myocardial infarction (AMI), it is imperative that blood flow is rapidly restored to the ischaemic myocardium. However, this restoration is associated with an increased risk of additional complications and further cardiomyocyte death, termed myocardial ischaemia reperfusion injury (IRI). Endogenously produced nitric oxide (NO) plays an important role in protecting the myocardium from IRI. It is well established that NO mediates many of its downstream functions through the 'canonical' NO-sGC-cGMP pathway, which is vital for cardiovascular homeostasis; however, this pathway can become impaired in the face of inadequate delivery of necessary substrates, in particular L-arginine, oxygen and reducing equivalents. Recently, it has been shown that during conditions of ischaemia an alternative pathway for NO generation exists, which has become known as the 'nitrate-nitrite-NO pathway'. This pathway has been reported to improve endothelial dysfunction, protect against myocardial IRI and attenuate infarct size in various experimental models. Furthermore, emerging evidence suggests that nitrite itself provides multi-faceted protection, in an NO-independent fashion, against a myriad of pathophysiologies attributed to IRI. In this review, we explore the existing pre-clinical and clinical evidence for the role of nitrate and nitrite in cardioprotection and discuss the lessons learnt from the clinical trials for nitrite as a perconditioning agent. We also discuss the potential future for nitrite as a pre-conditioning intervention in man.

Association between age and infection in patients with acute ST-elevation myocardial infarction

Background

ST-elevation myocardial infarction (STEMI) in young patients has a unique risk profile. We aimed to detect bacteria in aspirate of infarct artery in young versus old patients.

Results

Aspirates of consecutive 140 patients who underwent a primary coronary intervention were taken for bacteriological, microscopical, and immunohistochemical (for bacterial pneumolysin) examinations. Their results were calculated in young (≤ 50 years) versus old (> 50 years) patients. Median age (interquartile range) was 45 (38–48) years in young (60 patients) and 59 (55–65) years in old (80 patients) patients, p < 0.0001. Both groups had similar baseline data except age, males, diabetes, hyperlipidemia, family history, lesion length, and ectatic vessel. Different bacteria were cultured in 11.3% of all patients involving 22.6% of young and 2.8% of old patients [hazard ratio 8.03 (95% CI 1.83–51.49), p = 0.002]. By multivariate analyses, age groups and leukocytic count were independent predictors of infection (bacteria and pneumolysin), p = 0.027 and p < 0.0001, respectively. Optimal cutoff value of leukocytic count was 12,250 cells/μl [ROC curve sensitivity 85.7%, specificity 86.4%, and AUC 0.97 (95% CI 0.95–1.0), p < 0.001]. Infection was an independent predictor of STEMI in young versus old patients, p < 0.001. Nevertheless, in-hospital events occurred insignificantly different and neither age groups nor infection was predictor of in-hospital events.

Conclusions

Young patients had significantly higher percentage of bacteria in their infarcted artery than old patients. High leukocytic count in patients below 50 predicts infection that causes acute myocardial infarction. Antibacterial trials directed toward this group are required for secondary prevention.

Three novel ATG16L1 mutations in a patient with acute myocardial infarction and coronary artery ectasia: A case report

INTRODUCTION

Acute myocardial infarction (AMI) is a specific type of coronary artery disease (CAD) caused by the rupture of coronary atherosclerotic plaques. Coronary artery ectasia (CAE) is a rare phenotype of cardiovascular disease that may promote thrombosis and inflammatory responses leading to myocardial infarction due to abnormal dilatation of blood vessels and coronary blood flow disorders. It is a complicated disease and shows interaction between genetic and environmental factors.

PATIENT CONCERNS

A 34-year-old male patient was admitted to our hospital on May 12, 2016, with complaints of chest pain for 1 hour duration.

DIAGNOSIS

Coronary angiography through the emergency medical service (EMS) system showed 100% occlusion at the first turning point of the right coronary artery (RCA), along with tumor-like expansion of the proximal segment of the RCA and the end of the left main (LM) artery. The patient was diagnosed with AMI and CAE. Three-point mutations in the ATG16L1 gene were identified by direct sequencing.

INTERVENTIONS

After admission, the patient underwent emergency green channel coronary angiography and percutaneous coronary intervention (PCI) to assess and unblock the stenosis and occlusion of the RCA lumen, but no stenting was performed because the catheter could not pass the second inflection point of the RCA. Aspirin enteric-coated tablets, clopidogrel sulfate tablets, tirofiban hydrochloride, and low molecular weight heparin calcium were given as anticoagulant and antiplatelet therapy. Atorvastatin calcium tablets were used to regulate blood lipid levels. Perindopril and spironolactone were used to inhibit the renin-angiotensin-aldosterone system (RAAS) to reverse myocardial remodeling. Acetylcholinesterase inhibitors (ACEI) and beta blockers were administered to resist ventricular remodeling and improve cardiac function and prognosis after the patient's blood pressure and heart rhythm were stabilized.

OUTCOMES

After active rescue treatment, the patient recovered and was discharged. A coronary angiogram performed 2 years later showed that the RCA blood flow was restored, and the patient had recovered well.

CONCLUSION

Three-point mutations in the ATG16L1 gene were identified in a patient with AMI and CAE, which extended the mutation spectrum of the ATG16L1 gene. Hence, the etiology of coronary artery aneurysmal dilatation is worthy of further investigation.

Sex Disparities in the Management and Outcomes of Cardiogenic Shock Complicating Acute Myocardial Infarction in the Young

BACKGROUND

There are limited data on how sex influences the outcomes of acute myocardial infarction-cardiogenic shock (AMI-CS) in young adults.

METHODS

A retrospective cohort of AMI-CS admissions aged 18 to 55 years, during 2000 to 2017, was identified using the National Inpatient Sample. Use of coronary angiography, percutaneous coronary intervention, mechanical circulatory support and noncardiac interventions was identified. Outcomes of interest included in-hospital mortality, use of cardiac interventions, hospitalization costs, and length of stay.

RESULTS

A total 90 648 AMI-CS admissions ≤55 years of age were included, of which 26% were women. Higher rates of CS were noted in men (2.2% in 2000 to 4.8% in 2017) compared with women (2.6% in 2000 to 4.0% in 2017; P<0.001). Compared with men, women with AMI-CS were more frequently of Black race, from a lower socioeconomic status, with higher comorbidity, and admitted to rural and small hospitals (all P<0.001). Women had lower rates of ST-segment elevation presentation (73.0% versus 78.7%), acute noncardiac organ failure, cardiac arrest (34.3% versus 35.7%), and received less-frequent coronary angiography (78.3% versus 81.4%), early coronary angiography (49.2% versus 54.1%), percutaneous coronary intervention (59.2% versus 64.0%), and mechanical circulatory support (50.3% versus 59.2%; all P<0.001). Female sex was an independent predictor of in-hospital mortality (23.0% versus 21.7%; adjusted odds ratio, 1.11 [95% CI, 1.07-1.16]; P<0.001). Women had lower hospitalization costs ($156 372±$198 452 versus $167 669±$208 577; P<0.001) but comparable lengths of stay compared with men.

CONCLUSIONS

In young AMI-CS admissions, women are treated less aggressively and experience higher in-hospital mortality than men.

Myocardial Infarction With Nonobstructive Coronary Arteries

Myocardial infarction with nonobstructive coronary arteries (MINOCA) is the current term used to describe patients who have a myocardial infarction but have normal, non-obstructed coronary arteries on a coronary angiogram. There is still much debate over the definition, diagnosis, management and treatment of MINOCA. However, MINOCA is not a benign condition; prompt recognition and diagnosis can lead to better management and treatment and thus improve patient outcomes. This review article will update the most recent definition of MINOCA, discuss epidemiology and etiology, and review the diagnostic workup and management options for patients presenting with signs and symptoms of MINOCA.

Influence of electrolyte balance on the prognosis of long-term cardiovascular events after acute coronary syndrome

Aim. To assess the effect of electrolyte changes on the prognosis of long-term cardiovascular events after acute coronary syndrome (ACS).

Material and methods. The study included 105 patients with ACS who underwent coronary angiography (CA) with coronary stenting. At the study inclusion (before CA with coronary stenting), we collected data on traditional risk factors, analyzed levels of urinary sodium and potassium, kaliuresis and natriuresis. Free water clearance (FWC) and electrolyte free water clearance (EFWC), as well as fluid balance using bioelectrical impedance analysis were determined. Study endpoints (fatal and nonfatal cardiovascular events) were determined 6,2±0,2 months after CA with coronary stenting.

Results. It was found that a decrease in urinary sodium (χ2=5,64, p=0,02, Constanta B0 =-0,62, Estimate =-16,5) and natriuresis (χ2=4,1, р=0,044, Constanta B0 =-1,38, Estimate =-5,2) increase the death risk. Urinary sodium of 0,2 mol/L and natriuresis of 0,5 mol are threshold levels of increased risk of death. Urinary potassium decrease was associated with an increase in death risk (threshold level — 0,5 mol/L, χ2=4,99, р=0,025, Constanta B0 =-0,63, Estimate =-70,4) and acute myocardial infarction (threshold level — 0,06 mol/L, χ2=3,93, р=0,04, Constanta B0 =-0,99, Estimate =-58,0) in the long-term period. Increase in EFWC increased the likelihood of long-term transient ischemic attack after ACS (χ2=4,61, р=0,03, Constanta B0 =-2,95, Estimate =-1,0). There were no significant relationships in the matter of FWC (p>0,05). However, with a decrease in intracellular fluid volume compared to normal values and a decrease in FWC or an increase in EFWC, the likelihood of longterm composite endpoints after ACS increases.

Conclusion. As a result of the study, risk markers for long-term fatal and non-fatal cardiovascular events after ACS were established: decrease in urinary sodium <0,2 mol/l and potassium <0,5 mol/l; decrease in FWC and increase in EFWC with or without cellular dehydration. The established markers can complement the current cardiovascular risk score methods in patients with ACS.

Pregnancy-Associated Myocardial Infarction: Prevalence, Causes, and Interventional Management

Pregnancy-associated myocardial infarction is a primary contributor to maternal cardiovascular morbidity and mortality. Specific attention to the cause of myocardial infarction, diagnostic evaluation, treatment strategies, and postevent care is necessary when treating women with pregnancy-associated myocardial infarction. This review summarizes the current knowledge, consensus statements, and essential nuances.