Heart attacks under the age of 40 years!

When an individual who is considered relatively young suffers from coronary artery disease, it can lead to significant psychological effects and higher economic burden for the patient and the family. Although its prevalence in people under 40 to 45 years of age is reported to be 3-10%, which is lower in comparison to the senior populations, it is nevertheless a serious concern.

Asiri Group of Hospitals Consultant General and Interventional Cardiologist Dr. Chamara Ratnayake

In this regard, we spoke to Asiri Group of Hospitals Consultant General and Interventional Cardiologist Dr. Chamara Ratnayake.

Following are excerpts of the interview.

Have you come across many heart attack cases in younger patients?

To answer this question, we must first define what “young” means. Generally, as a rule of thumb, we usually define a young patient with a heart attack as someone under the age of 40. This is quite arbitrary, with no real reason to apply that cut-off. But to answer the question, yes, I have come across quite a few “young” patients in the recent past. However, I must say, they are still not the majority.

We see heart attacks in young people we wouldn’t consider unhealthy – those who are athletic, not dangerously overweight, etc. What might be the reason for this observation?

That’s a good question, and to answer that, we should go back to the basics of what causes heart attacks. The underlying cause of heart attacks in the majority of cases is a process called atherosclerosis. This basically means a plaque made of cholesterol and other cells lining the coronary arteries. The causes can be divided into two categories: (i) Modifiable – high blood pressure, high cholesterol, diabetes, cigarette smoking, obesity, and sedentary lifestyle and (ii) non-modifiable – age, male gender, and genetics (family history).

The causes are the same, whatever the age. However, in younger people who “appear” healthy externally, they may still be having any one of the above risk factors which puts them at risk of developing a heart attack.

Occasionally, we do come across certain “non-traditional” risk factors causing heart attacks in young people. Recreational drug use and blood clotting disorders probably are the primary causes in most cases.

Do symptoms of heart trouble appear differently in young people? What should they be looking out for?

The simple answer is “no”. The symptoms of a heart attack generally don’t change with age. Classic symptoms such as a severe chest pain in the centre of the chest lasting a few minutes – which gets worse over time, may radiate to the arms, jaw, or back, and is associated with sweating, for example – is what would make us suspect a heart attack. What I do notice, though, is younger people tend to ignore these symptoms more often than their older counterparts, usually putting it down to something else like gastritis. This sometimes leads to late presentations and complications.

Hence, my advice is never to ignore chest pain and to seek the advice of a doctor immediately to rule out a heart attack.

How can we engage with young people on heart health?

That’s a very important question and something we as cardiologists are paying attention to as well. Interestingly, the theme for this year’s World Heart Day was “Use Heart to Connect” – essentially, encouraging cardiologists to engage more with patients, young and old, on heart health and prevention of cardiac diseases.

The most important aspect of this is identifying the risk factors, especially the modifiable risk factors I mentioned before. If we identify them early on and control them to an optimal level, it would certainly prevent heart trouble in the future. Hence, we advise screening at an early age, especially for those who have a significant family history of heart disease. Simple things like getting their blood pressure checked regularly as well as doing blood tests to check cholesterol and sugar will be very useful.

I must also mention that there is a misconception that if you have high blood pressure or cholesterol, you will “feel” it. This is not always the case and actually, most of the time, these are found incidentally without symptoms, through screening.

The other important factor is lifestyle modification at a young age. For example, advising on healthy eating, avoiding junk food and processed food, avoiding smoking, and engaging in regular exercise at an early age will go a long way in preventing heart disease in the future.

When one comes with chest pain to a hospital, what tests would identify if it’s a heart attack?

When someone comes to a hospital with chest pain, the cardiologist will usually run through a few tests to determine if it’s due to a heart attack. These vary from basic tests to more complex investigations.

The first is usually an ECG, which will show changes if there is a heart attack. The next is a blood test called “Troponin”, which would increase if there is heart muscle damage due to a heart attack. After this, an echocardiogram (scan of the heart) is performed to assess the function of the heart and identify any areas where the blood supply is compromised. These three basic investigations will generally help in diagnosing a major heart attack.

If there is still a doubt, more complex investigations such as a CT coronary angiogram may be used in determining the cause of the chest pain.

Once a heart attack is diagnosed, what treatment options are available?

There are different types of heart attacks. Hence, the treatment options may change accordingly.

The initial medical treatment is the same for all. Aspirin, another blood thinner (Clopidogrel), and a cholesterol lowering tablet (Statin) is given.

If the patient has a major heart attack called ST elevation myocardial infarction, the best treatment, then, whatever the age, isto proceed with primary percutaneous angioplasty (preceded by a coronary angiogram). If this facility is not available, a clot busting medication (Streptokinase/Tenecteplase) can be injected.

Following a heart attack, how soon can someone get back to usual activities?

It will depend on a few factors, but it’s mainly determined by the extent of the heart muscle damage and the success of the treatment administered.

The usual recommendation, however, is a gradual and slow reintroduction to normal activities. There will be certain restrictions as well. Climbing stairs should be avoided for a week. A minimum two to four weeks off work is recommended. Driving a light vehicle is usually not recommended for one month. Sexual activities are also not recommended for six to eight weeks.

The best way to get back on their feet is to follow a good cardiac rehabilitation plan. These programmes engage with patients from day one, and progressively educate them on how to get back to normal activities, including exercise programmes.

How important is psychological support following a heart attack?

Very important. We notice especially young patients struggling to cope with a heart attack as it’s usually unexpected. This usually causes mental distress and depression at times. Assessing psychological wellbeing is very important in the rehabilitation of any patient following a heart attack. Mental wellbeing through mindfulness exercises has been proven to benefit the recovery following heart attacks in clinical trials as well.

Take home message

According to Dr. Ratnayake, the most important message to young people is not to neglect symptoms, as there is no age limit to develop a heart attack. Simple tests, which usually don’t take up a long time, can help exclude a heart ailment. Identifying potential risk factors early will also go a long way in preventing heart attacks. There is no age limit to start being heart-health-conscious. Regular exercise and good dietary habits at a young age will certainly help prevent heart attacks, whatever the age.