Malpractice Counsel: Never Too Young to Have a Heart Attack

Risk Factors for MI in Young Patients

Cigarette Smoking. When examining common risk factors in young patients who had an MI (defined as patients younger than age 45 years), cigarette smoking is the most common risk factor.^1,2 Between 76% and 91% of young patients with an MI are smokers, compared to only 40% incidence in older patients.¹ It is thought that cigarette smoking produces endothelial dysfunction and can precipitate coronary spasm.¹

Nonatherosclerotic Etiology. Interestingly, several studies of MI in young patients found a higher incidence of nonatherosclerotic causes of MI in women compared to men.² One explanation for this finding is that women experience vasospastic syndromes and hypercoagulable states, secondary to oral contraceptive use or hereditary coagulation disorders.² It has also been shown that young women have more active platelets following an MI and experience plaque erosions, rather than the plaque ruptures that occur in men and older women.^2,3

Hyperlipidemia. Hyperlipidemia is an additional risk factor for MI in the younger adult patient population. In one study of young patients who had an MI, hyperlipidemia was the most important risk factor, in the absence of other obvious risk factors.^1,4 In fact, some researchers think hyperlipidemia may be a more reliable predictor of MI in patients aged 30 to 39 years than in older patients.^1,5 Unfortunately, many of these young adults are not aware that they have hyperlipidemia until they experience a complication such as an acute coronary syndrome. With respect to the patient in this case, it is not clear from the published report whether or not she had hyperlipidemia.

Family History. Another risk factor for MI in younger patients is a positive family history of CAD in a first-degree relative younger than age 55 years.¹ Siblings of a young patient who experienced an MI have up to a 10-fold increase for developing CAD.¹ It is currently not known why a positive family history increases the risk of MI in younger patients, but it may be related to inherited disorders of lipid metabolism, blood coagulation, or other genetic factors.¹

Drug Abuse. Finally, drug abuse must be considered in young patients presenting with an MI. The use of cocaine, methamphetamine, marijuana, and K2 (synthetic marijuana) have all been associated with MI, especially in young patients,^6-9 who typically do not have cardiac risk factors and do not show evidence of atherosclerotic disease on cardiac catheterization. As for the patient in this case, we do not know if she used any illicit drugs prior to presentation.

Summary

This case underscores the importance of not excluding MI in the differential diagnosis based simply on age or sex. While MI is uncommon in a 21-year-old woman, it can and does occur. In young patients presenting with chest pain, it is important to obtain a thorough history, including smoking, family history of MI, hyperlipidemia, and illicit drug use. While MI may be low on the differential diagnosis, it still needs to be considered.