Most heart attacks occur in patients over the age of 40 but more and more younger men and women are presenting with heart attack. Most cardiologists use an age cut off of 40–45 years to define young patient with heart blockages or acute heart attack. Therefore, anybody who gets a heart attack before 40 in India is considered as a young age heart attack said Padma Shri, Dr. B C Roy National and DST National Science Communication Awardee, Dr. KK Aggarwal, President, Heart Care Foundation of India Senior National Vice President, Indian Medical Association. Definite data regarding heart blockages in the young is inadequate. Most data come from autopsy reports of victims of accidents, suicides or homicides.
In the age group of 15–20 years, 2% of the men have been shown to be suffering from advanced coronary blockages. Coronary blockages have been shown to be present in 20% of men and 8% of women at age 30–35 years and out of them 90% of men and 8% of women have coronary blockages in the left artery of more than 40%. In India, we note that heart attack occurs 10 years earlier than in the west.
In the west, upto 10% heart attacks occur in people who are younger than 40 years of age but the same in India will be much higher and can be upto 30–40%. The traditional risk factors are age, high cholesterol, high upper blood pressure and severe smoking. For every six year increase in age, the risk of heart attack increases by 1.63; for over 40 mm rise in cholesterol, the risk factors increase by 1.42, for every 20 mmHg rise in upper blood pressure, the heart attack risk increases by 1.32 and for additional 10 cigarettes smoking in a day, the risk increases by 1.36.
Younger people usually have multiple risk factors. About 90–97% of them will have at least two risk factors. Smoking is most common amongst multiple risk factors in younger patients. It is seen in upto 90% of young heart attack compared to 60% of heart attack patients who are above the age of 45. In India, these factors are much more important as passive smoking gets added to active smoking.
Younger patients with heart attack often have positive family history of premature heart disease. Upto 40% of them will have the history compared to 12% in the patients who are above the age of 45. If a father had a heart attack at the age of 45, it is very likely that the son will have the heart attack at the age of 35 and if not prevented in time.
Abnormal cholesterol levels are common in young patients whose prevalence is same to that of older patients. But in India, diabetic younger people who get heart attack are the ones who have abnormally low good cholesterol levels and abnormal high LDL bad cholesterol levels, high triglycerides and low HDL cholesterol level is typically associated with pot belly obesity, abdominal circumference of 90 cm in men and 80 cm in women. Younger people from BMI point of view may be within normal weight criteria but if one takes the history, they will be found have gained more than 20kg weight in the last two decades. This special group comprises normal weight abdominal obesity.
In young women on oral contraception, the chances of heart attack increase if they smoke. Smoking marijuana also triggers heart attack.
Psychological factors such as anger can be important in development of premature heart disease. Marital disharmony and job dissatisfaction are the two most common stress factors associated with premature heart disease. Trio of anger, aggression and hostility are now upcoming as new risk factors for heart disease in younger people.
Not walking or exercising can lead to insulin resistance which can add to future heart attack. Vitamin D deficiency, which is seen in upto 80% young people, can also add to the process of developing of blockages in the heart vessels.
The clinical presentation of heart attack in younger patients may also differ from that in older patients. High proportion of young heart attack patients may not experience chest pain. Most of the young patients will present with acute coronary syndrome or acute impending heart attack rapidly ending up in acute massive heart attack if left untreated.
Younger patients often will be found with fewer blockages and more clouts. Their angiography may show normal coronary arteries with mild luminary irregularities and single vessel blockage compared to older patients.
One cannot give or accept heart attack as a gift as one has to work against the law of the nature for over a decade to get a heart attack. The process of heart blockages usually starts right at the age of 20–25 years; therefore, all prevention must start right in high school or early college levels.
The number one risk factor for younger patients is metabolic syndrome due to insulin resistance which is associated with pot belly obesity, high triglycerides and low LDL good cholesterol levels. It is basically because of eating refined carbohydrates – white sugar, white rice and white maida. If these foods are eaten multiple times in a day for years together, one can end up with insulin resistance with resultant high blood pressure, blood sugar, pot belly obesity and stickier cholesterol, endothelial dysfunction leading to formation of blockages in the heart vessels.
Between the age 30–40, if one has an abdominal circumference of more than 80 cm, he should go for further evaluation including lipid profile, high sensitivity CRP test (if positive, it makes the cholesterol more stickier leading to thickening of the wall of the neck artery).
The first manifestation is seen in the neck artery, which shows thickened wall; this can be detected by a simple ultrasound test. At this stage, it is reversible. All high risk patients who think they can end up with heart attack in young age should also learn and make sure that family members are taught CPR 10 mantra which shows that even after sudden cardiac death, the deceased person can be revived.
The formula can be remembered in English – “To revive a person from sudden cardiac death, within 10 minutes of death (earlier the better), at least for the next 10 minutes (longer the better), compress the centre of the chest of the dead person by 1 ½” distance continuously with a speed of 10×10 i.e. 100 per minute.”
In Hindi it can be remembered as – “Marne ke dus minute ke andar (jitna jaldi utna behtar), kam se kam agle dus minute tak (jitni der tak utna behtar, 10×10=100 ki gati se, apni chhati peetne ke bajaye mare hue aadmi ki chhati peeto.”
All high risk patients should be vaccinated for flu and pneumonia as it can reduce the chances of heart attack. Nobody should eat trans fats – vanaspati and dalda, as they can reduce the levels of good HDL cholesterol.
About HCFI : The only National Not for profit NGO, on whose mega community health education events, Govt. of India has released two National Commemorative stamps and one cancellation stamp, and who has conducted one to one training on” Hands only CPR” of 86664 people since 1st November 2012.
The CPR 10 Mantra is – “Within 10 minutes of death, earlier the better; at least for the next 10 minutes, longer the better; compress the centre of the chest of the dead person continuously and effectively with a speed of 10×10 i.e. 100 per minute.”