Coronary artery bypass surgery in patients less than 40 years of age

A young soldier with syncope, shortness of breath and palpitations

Introduction. Coronary artery disease in people under 30 years is relatively uncommon, but once a disease occurs it brings a significant morbidity and psychological effects. Case report. We reported a 28-year-old patient presenting atypical symptoms after sincopa and non-specific changes on electrocardiogram at admission. After noninvasive and invasive cardiology diagnostic procedures were made, we concluded that he had a subtotal tubular stenosis in proximal segment of the left anterior descending coronary artery. Myocardial revascularization was successfully performed 24-hour after coronarography with the left internal mammary thoracic artery graft on the left anterior descending coronary artery and the patient had a prompt and satisfactory postoperative recovery. Conclusion. This case indicates the importance of a careful evaluation of young adults even if they do not experience typical anginal symptoms or do not have multiple risk factors for cardiovascular diseases.

Prevalence of metabolic syndrome in patients < or =45 years of age with acute myocardial infarction having percutaneous coronary intervention

The prevalence of metabolic syndrome (MS) was determined in patients aged < or =45 years who presented with acute myocardial infarction and underwent primary percutaneous coronary intervention. Two hundred twenty-three consecutive patients aged 18 to 45 years who underwent cardiac catheterization for acute myocardial infarction from June 2001 to December 2004 were reviewed. MS was diagnosed by National Cholesterol Education Program Adult Treatment Panel III guidelines (modified by substituting body mass index > or =28.8 kg/m2 for waist circumference). One hundred sixty-one patients met all 5 criteria for MS available for evaluation. Seventy-six of these patients (47%) met > or =3 of the 5 criteria for MS. Sixteen patients with MS (21%) and 5 patients without MS (6%) had diabetes mellitus. The prevalence of each criterion was significantly higher (p <0.05) in the MS group. Average Framingham risk scores were 7.0 and 4.5 for patients with and without MS, respectively. The prevalence of smoking, male gender, and family history of premature coronary artery disease were the same for the 2 groups. In conclusion, MS was highly prevalent in this population of young patients with acute myocardial infarction.

Left internal mammary artery improves 5-year survival in patients under 40 subjected to surgical revascularization

BACKGROUND

The population of young patients under 40 requiring coronary bypass surgery is characterized by an extremely and unusually rapid progression of coronary heart disease. The aim of the present study was to assess the clinical status and quality of life in these patients after surgery in relation to the type of conduit used to revascularize the left anterior descending artery (LAD).

METHODS

One hundred seventeen patients under 40 (range, 30-40 years) underwent coronary artery bypass grafting (CABG) at our institution between 1991 and 1999. Ninety-one patients received LIMA to LAD graft (group A), and in 26 patients the saphenous vein was used to graft this vessel (group B). Seventy-eight patients (63 in group A and 15 in group B) were assessed after a mean time of 71 +/- 26 months. They were asked to fill out a questionnaire aimed at their subjective assessment of their quality of life as compared with their preoperative status.

RESULTS

Five-year actuarial survival was higher in patients with LIMA to LAD graft (log rank test: P < .004). The functional status of patients in group B was significantly worse in comparison to group A: respectively, CCS 2.2 +/- 1.1 versus 1.5 +/- 0.7; (P = .02), NYHA 2.2 +/- 1.1 versus 1.3 +/- 0.5; (P = .002). Patients in group B more frequently required reinstitution of nitroglycerine treatment (93% versus 56%; P = .025). We failed to show differences between the 2 groups as far as subjective quality of life is concerned. In summary, 63% of patients perceived it to be worse, 29% to be better, and 8% felt it had not changed.

CONCLUSION

The use of LIMA is crucial in patients undergoing CABG under the age of 40 in order to achieve the best possible surgical results. Quicker recurrence of coronary disease symptoms is observed when a vein is used to graft the LAD. It may reflect an earlier progress of atherosclerosis in venous grafts.

Characteristics of patients less than 45 years of age compared with older patients undergoing coronary artery bypass grafting

BACKGROUND

Coronary artery disease (CAD) was not recognized as common among young patients until the study by Yater in 1948. Subsequent studies further elucidated the nature of the disease, which had become more apparent in the younger groups.

HYPOTHESIS

The study was undertaken to determine the prevalence of risk factors and severity of coronary disease among young patients aged < or = 45 years undergoing coronary artery bypass grafting (CABG) compared with older patients.

METHODS

In all, 112 young patients aged < or = 45 years (Group 1) and 798 older patients aged > 45 years (Group 2) were analyzed for trends to hypertension, smoking, diabetes, family history of heart disease, hypercholesterolemia, obesity, and history of previous myocardial infarction (MI). The severity of disease was examined in terms of number of diseased vessels, vessel size, number of grafts performed, performance of endarterectomies, and left ventricular function.

RESULTS

Group 1 had a higher incidence of positive family history (68.5 vs. 51.2%, p < 0.05), and lower incidences of hypertension (62.7 vs. 81.5%, p < 0.05), obesity (42.9 vs. 83.9%, p < 0.05), and history of previous MI (54.5 vs. 94.6%, p < 0.05). Group 2 had a higher incidence of left main disease (22.6 vs. 11.4%, p < 0.05). The distribution of the affected vessels of the young patients was most commonly the left anterior descending (90.4%) followed by the right coronary (79.8%) and circumflex arteries (69.2%). Group 2 had more grafts per patient (3.82 vs. 3.37, p < 0.05). The size of the diseased vessels measured intraoperatively was similar (1.56 vs. 1.58 mm, p = NS) in both groups. Endarterectomy was performed almost three times more often in Group 1 patients (8.2 vs. 3.0%, p < 0.05). Operative mortality was less in Group 1 mean (1.8 vs. 6.3%, p < 0.05). Group 2 had a greater mean left ventricular ejection fraction (53.8 vs. 49.7%, p < 0.05).

CONCLUSION

Compared with the older population, patients < or = 45 years of age who underwent CABG had (1) a higher incidence of positive family history of CAD, (2) a higher likelihood of requiring an endarterectomy, and (3) lower operative mortality rate despite a slightly poorer ventricular function.

Late outcome of coronary artery bypass grafting in young versus older patients

BACKGROUND

We compared long-term results of coronary artery bypass grafting between 1976 and 1988 in 176 patients 40 years old or younger with a matched control group of 176 patients 25 to 30 years older.

METHODS

Mean age was 37.4 +/- 2.7 years (+/- standard deviation) in the study group and 64.2 +/- 2.9 years in the control group. Matching criteria were age, sex, left ventricular ejection fraction, number of bypass grafts, and year of operation.

RESULTS

The study group had more smokers (p = 0.000) and more patients with hypercholesterolemia (p = 0.026), unstable angina (p = 0.003), and preoperative myocardial infarction (p = 0.009); fewer patients had hypertension (p = 0.000) and diabetes (p = 0.005) in this group than in the control group. The internal mammary artery was used in 31% of the study patients and in 30% of the controls. The actuarial survival rates after 5, 10, and 15 years were 92%, 86%, and 72% in the study group and 92%, 86%, and 66% in the control group (p = 0.202). Young age was a predictor of cardiac reoperation.

CONCLUSIONS

Late survival is similar for young and older patients, but the reintervention rate is higher in the younger group. The absence of unstable angina, a left ventricular ejection fraction greater than 0.45, and the use of internal mammary artery grafts increase survival in all patients.

Coronary revascularisation in young adults

OBJECTIVE

To evaluate the long-term outcome of coronary artery bypass surgery (CABG) in patients < 40 years old and to determine factors predictive of adverse outcomes.

METHODS

Retrospective review of data on 220 patients who underwent isolated CABG at Green Lane Hospital, New Zealand from 1970 to 1992.

RESULTS

The actuarial survival after surgery was 91, 74 and 50% at 5, 10 and 15 years, respectively. Recurrence of ischaemic symptoms occurred at a median time of 72 months, and only 20% of patients remained asymptomatic 10 years after CABG. Univariate analysis of potentially adverse surgical factors showed that patients who had prolonged bypass time (> or = 100 min, P < 0.007) had increased late mortality. There were two distinct operative eras with respect to the use of IMA conduits (4% pre 1985, 87% post 1984) The relationship between IMA conduits use and survival was significant on time independent analysis (P < 0.02), but was not using the log-rank test. Preoperative clinical characteristics associated with increased late mortality were impaired left ventricular function (end-systolic volume (ESV) > or = 80 ml, P = 0.008; ejection fraction < 40%, P = 0.0005), and lack of aspirin use either pre- or post-operatively (P < 0.0001). Multivariate analysis indicated that reduced ejection fraction (P = 0.04) and prolonged bypass time (P = 0.05) was associated with an increased risk of late death. Aspirin therapy (P = 0.001) was associated with decreased late mortality. Cumulative events rate of reintervention and mortality was reduced in female patients (P = 0.0009). At review, 45% of patients had total cholesterol > 6.5 mmol/l.

CONCLUSION

To avoid the early recurrence of symptoms, the need for reintervention and late mortality, young patients should receive IMA conduits, cardioplegia as myocardial protection, aspirin and therapy to modify/ameliorate their risk factors including dyslipidaemia, diabetes and left ventricular dysfunction.

Coronary artery bypass grafting in patients in their third decade of life

BACKGROUND AND AIM

Coronary artery disease (CAD) and coronary artery bypass grafting (CABG) in young patients are different than their older counterparts. The purpose of this study is to more fully define the issues of CABG in patients in their third decade of life.

METHODS

The medical records from all patients under forty years of age undergoing CABG at Allegheny University Hospital, Hahnemann Division, Philadelphia, PA from July 1990 to June 1995 were examined. Surgical outcome, psychosocial, and sexual issues were examined. Lipid analyses were compared perioperatively.

RESULTS

There were 43 male and 9 female patients. The mean age was 35 years (23 to 39 years). Risk factors included 43 (83%) patients with a history of smoking, 34 (65%) with familial hypercholesterolemia, 25 (48%) with a family history of CAD, 23 (44%) with hypertension, and 11 (21%) with diabetes. The mean preoperative serum cholesterol was 241 mg/dL. There were no hospital mortalities. Morbidities were found in 18 (35%) patients, including 9 (17%) cardiac, 5 (10%) pulmonary, 3 (6%) infectious, and 1 (2%) renal. In follow-up, three cardiac-related mortalities occurred within five years of surgery. Sixteen patients were readmitted to a hospital for cardiac related causes. Thirty-two (62%) patients failed to return to work, twenty-five (48%) failed to engage in regular exercise, and twenty-four resumed smoking. Psychosocial changes were found postoperatively in thirty (58%) patients. Eight (15%) patients admitted to sexual changes following surgery. Postoperative lipid profiles were minimally altered from preoperative values.

CONCLUSIONS

Surgical revascularization is successful in alleviating symptoms with minimal risk. Postoperatively, a number of cardiac related events occurred. A significant number of patients resume smoking, fail to engage in regular exercise, fail to resume work, and fail to take prescribed lipid-lowering agents. Psychosocial and sexual dysfunctions are prominent.

Angiographic and coronary risk factor analyses of Japanese patients with ischemic heart disease before age 40--a multicenter cooperative study

Coronary angiographic and risk factor (RF) characteristics were analyzed in 133 Japanese patients with ischemic heart disease (IHD) who were less than 40 years old and who had undergone coronary angiography (CAG) during the past 10 years at six university hospitals in the Tokyo area. We compared the coronary angiographic characteristics of the subject group with those of 216 controls with coronary sclerosis detected by CAG who were more than 40 years old (older control group) and the RF characteristics with those of 133 sex- and age-matched volunteers (younger control group). Sixty seven percent of the subjects (89 cases) were diagnosed as having myocardial infarction (MI) and 33% (44 cases) had angina pectoris (AP). Coronary artery disorders in this group consisted of 103 (77%) cases of coronary sclerosis, 20 (15%) cases of coronary spasm and 10 (8%) cases of miscellaneous diseases, eg, possible vasculitis with connective tissue disease, congenital anomalies, etc. The incidences of significant (> or = 75%) sclerotic narrowing in 0 vessels (31%) and 1 vessel (49%) in the subject group were significantly (p < 0.01) higher than those in the older control group, while the incidence of multivessel disease was significantly (p < 0.05) less in the subject group than in the older control group. The incidences of the following coronary risk factors were significantly (p < 0.05) higher in the subjects than in the younger controls: smoking (83% vs 35%), hypercholesteremia (44% vs 10%), obesity (31% vs 9%), hypertension (29% vs 3%), familial IHD (28% vs 7%) and diabetes mellitus (19% vs 2%). Thus, zero- or single-vessel disease predominated in the younger subject group and the prevalence of coronary risk factors was significantly higher in the subject.

Myocardial infarction in young adults: risk factors and clinical features

To define the risk factors and clinical presentation of patients under age 40 who present to the emergency department (ED) of a community hospital with an acute myocardial infarction (MI), a retrospective cross-sectional study was conducted over a 7-year period. Two hundred and nine consecutive cases of initial MI who met World Health Organization criteria (chest pain, ECG changes, and serum enzyme rises) and were admitted to one of five participating hospitals were reviewed. The mean age of patients was 34.8 years (range, 17-39); 81% were male. The major risk factor was tobacco use (81%), followed by family history (40%), hypertension (26%), and hyperlipidemia (20%). One hundred and eighty-three patients (87.6%) had ECG evidence of cardiac ischemia, injury, or infarction in the ED. Approximately 24% of patients had multi-vessel coronary atherosclerosis as documented by angiography; 62% had single vessel disease; and 14% had normal coronary arteries. The most common anatomical location for the MI was the inferior wall. This study characterized the epidemiology of acute MI in young adults: 1) smoking emerged as the main coronary risk factor; 2) atherosclerosis continues to be the major etiology; 3) a common finding on angiography was single-vessel disease causing infarction of the inferior wall; and 4) the complication rate was comparable to older populations, but the in-hospital mortality was only 1.9%.

Late outcome after coronary artery bypass graft surgery in patients < 40 years old

BACKGROUND

Randomized trials confirm the long-term efficacy of coronary artery bypass graft surgery (CABG), although there are no randomized data in patients < 40 years old. Because these patients have been reported to have an early recurrence of symptoms, the long-term postoperative outcome was examined.

METHODS AND RESULTS

The long-term outcome of patients (n = 221) < 40 years old undergoing CABG at Green Lane Hospital, New Zealand, from 1970 to 1992 was determined. The 30-day mortality rate was 1.8% for initial and 9.5% for redo CABG. The median times to angina or myocardial infarction (recurrent ischemic event), further intervention, and death were 6.0, 9.6, and 14.2 years, respectively. Factors associated with increased late mortality on univariate analysis included end-systolic volume (ESV) > or = 80 mL (P = .004; 10-year mortality 19% versus 39% ESV > or = 80 mL), no internal mammary conduit (P = .01), no lipid-modifying therapy (P = .005), and no postoperative aspirin use (P = .0002); the latter was also associated with increased recurrent ischemic events (P = .04) or increased reintervention (P = .02). On stepwise logistic regression analysis, factors associated with increased late mortality were increasing ESV (P = .004), no internal mammary artery conduit (P = .009), diabetes (P = .04), and no postoperative aspirin (P = .02); the latter was also associated with increased recurrent ischemic events (P = .02). Hypercholesterolemia (> or = 6.5 mmol/L) was present in 65% of patients at presentation and 45% at follow-up.

CONCLUSIONS

To attempt to prevent recurrent ischemia or late death, patients < 40 years old who require CABG should receive internal mammary conduits, aspirin, lipid-modifying therapy, therapy to inhibit ventricular dilatation, and strict diabetes management.

Immediate and long-term clinical outcome of coronary angioplasty in patients aged 35 years or less

OBJECTIVE

To study the immediate and long-term clinical success of percutaneous transluminal coronary angioplasty in patients aged 35 years or less.

DESIGN

Patients undergoing percutaneous transluminal angioplasty were prospectively entered into a dedicated database. Clinical and angiographic data on all patients aged 35 years or less were reviewed. Follow up data were collected by interview during outpatient visits, by questionnaire, or from referring physicians.

SETTING

A tertiary referral cardiac centre.

PATIENTS

57 patients aged 35 years or less (median 33, range 22-35) underwent coronary angioplasty because of unstable angina (32 patients), stable angina (23 patients), acute myocardial infarction (1 patient), and documented ischaemia in a cardiac transplant patient.

RESULTS

The primary clinical success rate (reduction in diameter stenosis to < 50% without in-hospital events) was 88%. A major procedure related complication occurred in 5 patients (9%): one patient died, two patients sustained an acute myocardial infarction, two patients underwent emergency bypass surgery, and in three patients repeat angioplasty was performed before hospital discharge. In 2 patients (4%) coronary angioplasty did not significantly reduce the diameter stenosis but there were no associated complications. A total of 60 lesions were attempted (balloon angioplasty in 57, directional atherectomy in 2). The initial angiographic success rate was 92%. The median (SD) follow up was 4.7 (3.0) years. During follow up 7 patients (12%) died, 10 sustained a myocardial infarction (18%), and 28 patients (49%) underwent repeat revascularisation (coronary artery bypass grafting in 7 (12%) and repeat angioplasty in 21 (37%)). The estimated 5 year survival and event-free survival (Kaplan-Meier method) was 87 (9)% and 50 (13)%, respectively. Multivariate logistic regression analysis showed that hypertension and the extent of vessel disease were the only independent predictive factors for event free survival.

CONCLUSIONS

In young patients coronary angioplasty had a high immediate success rate but many needed repeat revascularisation procedures during the follow up period and survival was not improved. Coronary angioplasty in young patients should be regarded as a palliative procedure.

Long-term follow-up after coronary angioplasty in patients younger than 40 years of age

Over an 11-year period, the initial and late outcomes of percutaneous transluminal coronary angioplasty (PTCA) were studied in 140 consecutive patients younger than 40 years of age (mean, 34 +/- 3 years; range, 23 to 39 years; 132 men). Before the procedure, 28% of the patients had unstable angina, and 44% had a history of prior myocardial infarction. Mean left ventricular ejection fraction was 64% +/- 10%, and 75% of the patients had one-vessel disease. Primary success was 86% (77% for the first 70 patients vs 93% for the last 70, p < 0.02). Complications were nine periprocedural myocardial infarctions, eight emergency coronary surgical procedures, and no deaths. During follow-up (mean, 6 +/- 3 years; range, 1 to 12 years), 39 (28%) of the 104 patients who had repeat coronary angiography had angiographic restenosis (all < 6 months after PTCA). Late events were 13 elective coronary surgical procedures (11 for restenosis, one for failed PTCA, and one for progression of coronary artery disease), 13 PTCAs on a new site, five deaths, and four nonfatal myocardial infarctions. Ten-year survival was 96% +/- 1%, and 10-year event-free survival (without myocardial infarction, elective coronary surgery, or repeat PTCA) was 58% +/- 6%. Among survivors, 88% were free of angina, and 93% had returned to work. In patients younger than 40 years of age, PTCA yields excellent long-term survival, provided that the eventuality of repeat procedures during the first months is accepted. In addition, PTCA for progression on a new site is not unusual after several years.

Comparison of thrombolytic therapy for acute myocardial infarction in patients aged < 35 and > 55 years

There are differences in the risk factor profile and coronary anatomy of young patients who develop coronary artery disease compared with those of older ones. There is an absence of data in published reports regarding the response to thrombolytic therapy and the outcome of acute myocardial infarction in young patients. Sixty-two patients aged < 35 years (group 1) were compared with 58 aged > 55 years (group 2) who presented with acute myocardial infarction and were treated with intravenous streptokinase. Group 1 had a significantly higher incidence of smoking (p = 0.0009) and a lower incidence of diabetes mellitus (p = 0.002) than did group 2. Fifty-eight patients in group 1 and 40 in group 2 were studied by angiography at a similar time (5 to 6 days) after admission. Patients in group 1 had a better left ventricular ejection fraction (55 +/- 13% vs 49 +/- 13%; p = 0.03), but similar patency rates of the infarct vessel (74 vs 73%) compared with those of group 2. Group 1 also had a higher incidence of insignificant disease (22.5 vs 2.5%; p = 0.008) and a lower incidence of 3-vessel disease (10 vs 37.5%; p = 0.004). This suggests that there are differences in the risk factor profiles and coronary anatomy of young patients compared with those of older ones. Despite similar benefits from thrombolytic therapy in the form of a patient infarct vessel, there may be differences in the long-term outcome among these patients.

Coronary artery bypass surgery in young patients

Coronary atherosclerosis is being increasingly observed in young patients. However results of surgery in such patients have so far been disappointing both in terms of operative mortality, symptomatic relief and long-term survival. Reasons given for this include the increased prevalence of risk factors in young patients and a higher incidence of graft occlusion. In the treatment of Asian patients, a further negative factor is the belief that coronary artery disease is more often diffuse and the vessels smaller. Between January 1987 and May 1991, a total of 66 patients under the age of 45 years at the time of surgery had coronary artery bypass grafting performed. The demographic, clinical, angiographic and operative data were analysed. Eighty-nine per cent of the patients were male and their racial distribution was 63% Chinese, 8% Malays, 26% Indians and 3% Others. Their mean age was 40.8 years. The presence of risk factors was high: 45.6% had hypertension; 34.8% were smokers; 21.2% had diabetes mellitus; and 12.1% had hyperlipidaemia. The main indication in these patients was either angina or a previous myocardial infarction (53%). There were no patients with perioperative infarction diagnosed by the presence of new Q wave. There was no hospital death. The stay of the patients ranged from 6 to 28 days with a mean of 10 days. Follow-up ranged from 3 to 54 months. There were no late deaths. It was concluded that there is a high incidence of risk factors among young patients with coronary artery disease, which follows the pattern of many other studies. The operative risk in these patients is low and morbidity is minimal.(ABSTRACT TRUNCATED AT 250 WORDS)

Coronary angioplasty in young adults: initial results and late outcome

The initial and late outcome of coronary angioplasty was studied in 148 patients less than 40 years of age (mean 36.4 +/- 3). Angioplasty was performed on a single vessel in 70% of patients and on multiple vessels in 30%; it was performed on a totally occluded vessel in 20%. Angioplasty was successful in 90.5% of patients, unsuccessful but uncomplicated in 7.4% and complicated by myocardial infarction in 0.7%, emergency bypass surgery in 0.7% and death in 0.7%. At late (mean 3.7 +/- 3 years; range 0.5 to 11.5) follow-up study after successful angioplasty, 94% of patients were alive, 79% were free of angina and 85% had returned to work; late myocardial infarction occurred in 4%. Actuarial survival at 5 years was 95%, and 85% of patients were free from death, infarction or bypass surgery. A second angioplasty was performed in 29 patients (22%) (mean 6.1 +/- 8.4 months) and was successful in 27 (93%), with no deaths. Elective coronary bypass surgery was performed in 8.5% of patients, with perioperative infarction in 9% and no deaths. By univariate analysis, late death was more likely to occur in hypertensive patients (15% versus 2.5%; p less than 0.01) and diabetic patients (21.4% versus 3.6%; p less than 0.01). Cox proportional hazard regression analysis identified hypertension (p = 0.007) and diabetes (p = 0.04) as independent time-related predictors of subsequent death. Thus, early and late results after coronary angioplasty in young adults are favorable, but certain risk factors are important predictors of outcome. Late revascularization procedures (repeat angioplasty or surgery) for restenosis or disease progression are common.