Risk Factor Profile of Young Adult Myocardial Infarction (MI) Cases : A Cross-Sectional Study at Tertiary Care Centre of Gujarat, India 1 2 3

Abstract

Introduction : India has observed rapid transition from burden of communicable diseases to non-communicable diseases over the past couple of decades and Ischemic heart disease (IHD) is established as modern era's epidemic. Global and national data pointed out that as per situation in 2014, IHD ranked 1st causing deaths [1,2] and disabilities, both globally and nationally. More than half of the worldwide cardiovascular disease risk burden is estimated to be borne by Indian [3] subcontinent by 2020. Moreover migration studies showed that Indians are 3-4 times higher at risk of Coronary artery disease (CAD) than White Americans, 6 times higher than Chinese and 20 times [4,5] higher than Japanese. Not only that but Indians are [6] also prone to CAD at much younger age. Studies carried out in India, and other places suggest that Asian in general and Indians in particular are at an [7] increased risk of MI at younger age (<40 years). The Abstract : Introduction: Myocardial Infarction (MI) is a life threatening clinical condition. It is a multifactorial non-communicable disease involving interplay of many modifiable and non-modifiable risk factors. Objective: The study was conducted with objective to study socio-demographic profiles and distribution of risk factors among young adults having MI. Method: A study was conducted at tertiary care centre of Rajkot, Gujarat. One year time frame was decided for this cross-sectional study. All the patients having age <45 years admitted in Intensive Care Unit (ICU) of Medicine department with first attack of MI were interviewed and examined for various clinic-epidemiological determinants of MI. Results: Total 106 young MI cases were enrolled in the study. Relative frequency showed male preponderance (88.7%). Risk factors like tobacco uses, sedentary lifestyle and obesity were identified as risk factors relatively more frequently associated with young MI cases. In contrast to old MI cases, proven risk factors like hypertension and diabetes mellitus were found less frequently associated. About one third of the cases were lacking adequate amount of protective foods (green leafy vegetables and fruits) in their daily diet. Four patients without any risk factor except male gender were noted. 50% cases were having three or less number of risk factors. Conclusion: The findings suggest male preponderance, tobacco consumption, sedentary lifestyle and obesity as quite common risk factors of premature Coronary Artery Disease (CAD).

Full text

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RiskFactorProfileofYoungAdultMyocardialInfarction(MI)Cases:
ACross-SectionalStudyatTertiaryCareCentreofGujarat,India
1 2 3
BharatkumarM.Gohel ,RajanUpadhyay ,RajeshChudasama
1 2 3
AssistantProfessor, ResidentDoctor, AssociateProfessor,DepartmentofPreventiveandSocialMedicine,
PDUGovt.MedicalCollege,Rajkot,Gujarat,India
Correspondence:Dr.BharatkumarM.Gohel,Email:drbmgohel@gmail.com
Introduction:
 Indiahasobservedrapidtransitionfromburden
of communicable diseases to non-communicable
diseasesoverthepastcoupleofdecadesandIschemic
heart disease (IHD) is established as modern era's
epidemic.Globalandnationaldatapointedoutthatas
persituationin2014,IHDranked1stcausingdeaths
[1,2]
anddisabilities,bothgloballyandnationally. More
than half of the worldwide cardiovascular disease
risk burden is estimated to be borne by Indian
[3]
subcontinentby2020. Moreovermigrationstudies
showedthatIndiansare3-4 timeshigheratrisk of
Coronary artery disease (CAD) than White
Americans,6timeshigherthanChineseand20times
[4,5]
higherthanJapanese. NotonlythatbutIndiansare
[6]
also prone to CAD at much younger age.  Studies
carried out in India, and other places suggest that
AsianingeneralandIndians in particularareatan
[7]
increasedriskofMIatyoungerage(<40years). The
Abstract:
 Introduction:MyocardialInfarction(MI)isalifethreateningclinicalcondition.Itisamultifactorial
non-communicable disease involving interplay of many modifiable and non-modifiable risk factors.
Objective:Thestudywasconductedwithobjectivetostudysocio-demographicprofilesanddistributionof
riskfactorsamongyoungadultshavingMI.Method:AstudywasconductedattertiarycarecentreofRajkot,
Gujarat.Oneyeartimeframewasdecidedforthiscross-sectionalstudy.Allthepatientshavingage<45
yearsadmittedinIntensiveCareUnit(ICU)ofMedicinedepartmentwithfirstattackofMIwereinterviewed
andexaminedforvariousclinic-epidemiologicaldeterminantsofMI.Results:Total106youngMIcases
wereenrolled in thestudy.Relativefrequency showedmale preponderance (88.7%).Risk factors like
tobaccouses,sedentary life-styleandobesity wereidentifiedas risk factorsrelativelymore frequently
associatedwith youngMI cases.In contrastto oldMI cases, provenrisk factorslike hypertensionand
diabetesmellituswerefoundlessfrequentlyassociated.Aboutonethirdofthecaseswerelackingadequate
amountofprotectivefoods(greenleafyvegetablesandfruits)intheirdailydiet.Fourpatientswithoutany
riskfactorexceptmalegenderwerenoted.50%caseswerehavingthreeorlessnumberofriskfactors.
Conclusion:The findings suggest male preponderance,tobacco consumption, sedentary life-styleand
obesityasquitecommonriskfactorsofprematureCoronaryArteryDisease(CAD).
KeyWords:CoronaryArteryDisease,MyocardialInfarction,RiskFactors,YoungAge
OriginalArticle
proportionof CAD inyoung Indians isabout 12%-
[8,9]
16%.
 Althoughtheroleofconventionalriskfactorsfor
coronaryarterydiseaseisprovenforallagegroups,
younger patients show different risk factor profile,
clinicalpresentationandprognosis.Managementof
youngpatientsisachallenging taskastheyarethe
main income producer of the family. Myocardial
infarctionatanearlyageisanimportantproblemfor
theconsultingphysicianaswellbecauseitishaving
devastating effect on quality of life and survival of
young adults. So, present study was conducted to
identifythe proportion of youngMI cases and risk
factorprofileofMIcaseshavingage<45years.
Method:
 Thecross-sectionalstudydesignwasadoptedfor
presentstudy.Itwasconductedfrom1stApril2016
to 31st March 2017 at PDU Govt. Medical College
Hospital,Rajkot.Thehospitalisatertiarycarecentre
HealthlineJournalVolume11Issue1(January-June2020)

::43::
as having sedentary life style. Modified Prasad's
socioeconomic classification was used considering
AllIndiaConsumerPriceIndex(AICPI)ofApril,2017
[13]
ofRajkot.  BodyMassIndex (BMI)was calculated
and classified using World Health Organization
[14]
(WHO)classification. Cut-offpointsforhighwaist
tohipratio(W:Hratio)wereadoptedfromtheWHO
guidelinestatingW:Hratio0.90 formale and
0.85forfemaleishavingsubstantiallyincreasedrisk
[15]
ofmetaboliccomplications. Dataentrywasdonein
MicrosoftOffice Excel 2007 and analysis wasdone
usingthesoftwarepackageEpiInfo(Version7.2.2.6)
[16]
fromCDC,Atlanta,U.S.A.
Results:
 Total106youngMIpatientshavingfirstattackof
MIwereadmittedatPDUHospital,Rajkotduringone
yearperiod.It is 26.1%oftotal406casesadmitted
during this period. The youngest patient of MI in
presentstudywasof24yearsonly.Thestudyshowed
that6.6%amongyoungMIcaseswerebelowtheage
of30years.Steepriseobservedattheageof35years.
Therewasamalepreponderancewith88.7%males
and11.3%females.(Table1)
 Present study revealed that most of the cases
were from urban area, joint family and literate.
Manuallabourerwasthe singlegrouphavingmore
thanhalfofcases.Morethanhalfofthe caseswere
fromuppermiddleanduppersocio-economicclass.
(Table2)
cateringentireSaurashtraregionofGujarat.Thereis
disparity in literature for the cut-off age of young
Myocardial Infarction (MI) case varying from <30
yearsto<55years.Cut-offpointof45yearsagewas
[10]
usedtodefineyoungMIpatient. Thestudysubject
enrolledinthestudywereselectedfromthepatient
admittedintheIntensiveCareUnit(ICU)ofMedicine
department having first attack of MI. Following an
attackofMI,person'shabitsandriskfactorsprofile
might be altered because of post-MI life-style
modifications. So, only the persons having first
knownMIincident wereenrolledinstudy.Patients
below 45 years of age who were conscious, co-
operative,wellorientedwereenrolledafterinformed
consent. Patientsseriously ill, unconscious ornon-
willingtoparticipatewereexcludedfromthestudy.
 Forthisstudyapersonwasconsideredasacaseof
MI, if any two of the following three criteria were
satisfied:(1)ECGshowingSTsegmentelevation,(2)
risein CK-MB levels >25 IU/l or (3) symptoms of
ischemialasting for> 20 minutes(complain ofleft
sidedchestpainwhichwascompressiveinnature,ill
localized,radiatingtoupperextremity,mandibularor
epigastricregion;mayormaynotbeassociatedwith
nausea,vomiting,palpitation,excessivesweatingor
[11,12]
difficulty in breathing).  Patients were admitted
and treated by the treating physician of Medicine
department,PDUHospital,Rajkot.Allinvestigations
weredoneonthebasisofphysician'sdescription.
 Thestudywasapprovedbyinstitutional ethical
committee.Datacollectionwasdonebyaninterview
technique using preformed, pretested and semi-
structured questionnaire. Questionnaire included
information regarding socio-demographic profile,
riskfactorprofile,addictionhistory,dietprofileand
notes on examination measurements. Clustering of
riskfactorswasanalysedusingtenriskfactorsnamed
male sex, positive family history, hypertension,
di a b et e s,  t o ba c c o c o n su m p ti o n , a l c oh o l 
consumption, history of OC pills consumption,
sedentary life style, stress due to acute life event,
obesity and frequency of protective diet intake<5
days per week. Persons having continuous daily
physicalexerciseoflessthan30minutesadayfor5
days a week were considered physically active.
Personsnotfittinginthedefinitionwereconsidered
Table1:Ageandsexdistributionofyoung
myocardialinfarctioncases
Age
(inyears)
Male
(%)
Female
(%) Total(%)
2(1.9) 0(0.0) 2(1.9)
5(4.7) 0(0.0) 5(4.7)
13(12.3) 1(0.9) 14(13.2)
32(30.2) 6(5.7) 38(35.8)
42(39.6) 5(4.7) 47(44.3)
Total 94(88.7) 12(11.3) 106(100.0)
21-25
26-30
31-35
36-40
41-45
Goheletal, RiskFactorProfileofYoungAdult.....

::44::
Variable Frequency(%)
Residence
Urban 79(74.5)
Rural 27(25.5)
Maritalstatus
Married 105(99.1)
Unmarried 1(0.9)
Literacystatus
Illiterate 15(14.2)
Literate 91(85.8)
Occupation
Service 34(32.1)
Manuallabour 56(52.8)
Household 12(11.3)
Agriculture 4(3.8)
Socio-economicclass
ClassI&II 58(54.7)
ClassIII 36(34.0)
ClassIV&V 12(11.3)
Typeoffamily
Nuclear 42(39.6)
Joint 64(60.4)
Table2:Socio-demographicproileofyoung
myocardialinfarctioncases
 In present study it was found that all the
frequentlyrelatedriskfactorsofMIweremodifiable
riskfactorsexceptmalepreponderanceandpositive
family history of CAD among first order relatives.
Sedentary life-style (68.9%), tobacco consumption
(61.3%) and obesity (46.2%) ranked on first 3
positions while hypertension (4.7%) and diabetes
mellitus(4.7%)bothstoodasatthelowestrankas
relatedriskfactorsamongyoungMIcases.(Figure1)
Figure1:Comparisonofriskfactorspresentin
youngmyocardialinfarctionpatients
 FamilyhistoryofCADwaspresentin26.4%cases
while tobacco consumption was present in 61.3%
cases. Consumption of leafy vegetables for <5
days/week (35.8%) were identified as other
frequentlyrelatedriskfactorsinyoungMIpatients.
(Table3)
 One fifth (20.8%) cases were found having
clustering of one or two risk factors. Maximum
numbersofpatients(66%)werehavingclusteringof
threetofiveriskfactors.(Table4)
Discussion:
 Coronary Artery Diseases (CAD) in India is not
only tolling country's economy by the mean of
lifelongmedicationsandincidentaladmissionsplus
interventions but also affecting physically and
mentallyproductiveagegrouphavingresponsiblyof
family and at workplace. Risk factors involved in
prematureMIaredifferentfromthatofoldMIcases
andsoarethepreventivemeasures.
 Presentstudyreportedtwoyoungestcasesatthe
ageof24yearswithmeanage40.08years.Fewother
studiesalsoreportedMIcasesatyoungerageof22
[17,18]
years. OtherGujaratbasedstudiesreportedmean
[19,20]
ageofyoungMIcasesas 35years. Lowermean
ageinthesestudieswasbecauseoflowercut-offage
(<40years)indefiningyoungMIcase.Itisalsofound
inpresentstudythat19.8%caseswereasyoungas
below35yearsofage.
 The study found male preponderance having
88.7%malecases.Male: Femaleratiowasfoundas
highas7.8:1inpresentstudy.Inpreviousstudiesthe
genderdistributionofyoungMIinmenreportedtobe
[17-19,21,22]
between72-99%.
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::45::
Table3:RiskfactorproileofyoungMIcases
Risk factor Frequency (%)
Family history of myocardial infarctionPresent
Hypertension Present
Diabetes Mellitus Present
Tobacco consumption Present
Alcohol consumption Present
History of oral contraceptive pills use Present*
Sedentary life-style Present
Green leafy vegetable consumption <5 days/week
28 (26.4)
5 (4.7)
5 (4.7)
65 (61.3)
9 (8.5)
7 (58.3)
73 (68.9)
38 (35.8)
Fruit consumption <5 days/week
Acute life event during last year Present
Type of personality Type A
Body Mass Index (BMI) BMI25 kg/m2
Waist : Hip(W:H) ratio  0.90 for male
and  0.85 for female
9 (8.5)
21 (19.8)
33 (31.1)
19 (17.9)
49 (46.2)
*onlyfemalecasesconsideredindenominator(n=12)
Table4:Clusteringofdifferentriskfactorsamong
youngmyocardialinfarctioncases
Numberof
riskfactors
Frequency
(%)
Cumulative
frequency(%)
14(3.8) 4(3.8)
218(17.0) 22(20.8)
330 (28.3) 52(49.1)
423(21.7) 75(70.8)
517(16.0) 92(86.8)
611(10.4) 103(97.2)
71(0.9) 104(98.1)
82(1.9) 106(100.0)
 Fre q ue n cy  d is t ri b ut i on  re ve a le d  th a t
demographically more number of cases was noted
from urban area (74.5%), literates (85.8%), upper
socio-economic class (54.7%) and joint family
(60.4%). North India based study at tertiary care
centre reported 71% cases from rural area. It was
because the hospital was rural area based tertiary
[21]
carecentre. Italsonoticedthat105(99.1%)cases
weremarried personsandthe findingisconsistent
with our study. Our study reported 52.8% manual
labourer cases which were higher than 34% cases
reported in North India based study. The probable
reasonisusingdifferentclassificationofoccupational
[21]
divisionsbythestudy.
 Familyhistoryof CADamongfirstdegreeblood
relatives was present in about one fourth (26.4%)
patients.OtherGujaratbasedstudiesfromBhavnagar
andAhmedabadreportedpositivefamilyhistory of
Goheletal, RiskFactorProfileofYoungAdult.....

::46::
[19,20]
CADin13% and 19%casesrespectively.  Lower
numberofpositivefamilyhistoryinBhavnagarbased
studywouldbebecauseoflimitedsamplesizeof30
cases.
 Tob acc o co ns u mp tio n is  an  i mp ort ant 
independent risk factor for CAD in young adults.
Tobacco consumption was found to be as high as
61.3% among cases. Similar finding (58.7%) was
[23]
noted by Mukherjee et al.  Narang et al. found
88.24% young MI cases having habit of tobacco
[21]
consumption. InsameNorthIndiabasedstudythey
found70.58%casestakingalcoholwhilealcoholuse
as we found in our study was only in 8.5% cases.
Status of Gujarat being dry state and alcohol
consumption banned by law could be reason for
same.
 Amongfemalecasesoutoftotal12morethanhalf
(58.3%)gavethehistoryofOCpillsusage.OCpillsuse
isconsideredasoneamongtheriskfactorsmostof
thestudies doneon MIof allages. Buttwo studies
done on young MI cases showed none of the
[ 1 9 , 2 4 ]
participant was using OC pills.  Socio-
demographicandculturalbackgroundcould bethe
possiblereasonbehindit.
 High blood pressure and high blood sugars are
keydeterminants and provenrisk factors of MI. In
presentstudyoutof106casesonly5(4.7%)reported
hypertension and same number of patients were
foundtobediabetics.Similarfindingswerefoundin
Pakistanbasedstudyhaving6.6%hypertensiveand
[24]
3.3% diabetic cases in young MI.  Gupta et al.
reported higher number of young MI cases having
[19]
hypertension(33%)and diabetes(37%).  Gujarat
based study reported 16% hypertensive and 11%
[20]
diabetic.  Narang et al. also reported 11.76%
hypertensive and 23.53% diabetic in their
[21]
study. Kolkata based study also reported 24%
[20]
diabeticand18%hypertensive.
 Sedentary life style was found in 68.9% cases.
Considering active and productive younger
populationgroupthisfigureisquietsignificant.Other
studyalso supported thefinding having significant
[19]
number of cases with sedentary life style.  With
higherW:Hratio46.2%casesfound obese.Obesity
among young MI using BMI criteria was as low as
17.9%only.Thisclearlyindicatescentralobesity is
moreimportantriskfactorthanhigherBMI.
 Stressfullifecondition in termof occurrenceof
anyacutelifeeventinpastoneyearwaspresentin
19.8%cases. Naranget al.too intheir studyfound
insignificantnumberofcases(11.77%)havingroleof
[21]
stressasriskfactor.
 InUKbasedprospectiveanalysisbyCroweetal.
showed that risk of MI is 32% less among
[25]
vegetarians.  In present study we found that
inclusion of fruits and green leafy vegetables in
regulardietasprotectivefoodweremissingin8.5%
and35.8%casesrespectively.InSaurashtraregionas
a cultural practise vegetarian diet is predominant
one. The families having predominant non-
vegetariandietarelessin number. Sootherfactors
mightbeplayingroleasariskfactors.
 Inourstudy4(3.8%)youngMIcaseswerehaving
onlyoneriskfactorandthatwasthemalegender.It
indicates occurrence of MI at younger age even
withoutanyestablishedknownriskfactors.Pakistan
basedstudyshowedonly1(0.01%)casehadsingle
[24]
riskfactor. wefound50%caseshavingclusteringof
more than 3 risk factors. Similar findings were
[26]
suggestedinstudybyAkhtaretal.
Conclusion:
 Male gender, tobacco consumption, sedentary
life-style and obesity are the major risk factors
associatedwithCADinyoungerage.Patientsbelow
theageof30yearsarealsoreportedwhichindicates
needofattentionevenbeforetheageof30years.Very
fewpersonswerehavinghypertensionanddiabetes
atyoungeragewhichindicatesthelikelychancesof
missingattentiontootherriskfactorsandlifestyle
modifications.Exceptmalegenderandfamilyhistory
of MI all the frequently associated risk factors like
tobaccoconsumption,sedentarylifestyleandobesity
arewellmodifiableriskfactorsinthisparticularage
group.
Recommendations:
 Screeningatyoungeragenotonlyforhighblood
pressure and high sugar level but also for early
warning sign and symptoms should be done. Non-
sedentary life style with obesity prevention and
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::47::
tobaccofreeyouthshouldbegivenmoreimportance
atyoungerageandmustbeaddressedasprimordial
andprimarypreventionagenda.
Limitations:
 The study included only one tertiary care unit
whichcanposeaproblemofselectionbias.Thisstudy
isa descriptivestudy withfrequency analysisonly,
comparative studies can help more in determining
levelofsignificanceforanyparticularriskfactor.
Declaration:
Funding:Nil
ConflictofInterest:Nil
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