Premature Heart Disease

Premature Heart Disease

Cardiovascular disease is responsible for about one of every three deaths in the India. On average, coronary artery disease (CAD) will take a life every minute this year. Heart attacks and cardiac deaths are so common that they almost seem natural and inevitable. When a 70- or 80-year-old succumbs, it gets little attention — but eyes widen when a 30- or 40-year-old is stricken. In fact, the risk of heart disease rises steadily and sharply with age. Still, CAD is far from rare in younger men.

Why do some young men have heart attacks — and what does it tell us about heart disease in middle age and beyond.

Young at heart

As many as 10% to 15% of all heart attacks occur before age 45, and most of these strike men. It’s a reminder that men should not ignore warning symptoms just because they are “too young” to have heart disease. And since atherosclerosis can — and does — start in youth, it’s a reminder that prevention should start early in life before problems develop.

What breaks young hearts

In older men, nearly all heart attacks are caused by atherosclerotic blockages in coronary arteries. Conventional coronary artery disease also predominates in young adults, accounting for about 80% of heart attacks. About 60% of these young patients have disease of just one coronary artery, while older patients are more likely to have disease in two or three arteries.

Scientists presume that silent, undetected disorders of the heart’s pumping rhythm account for many of the sudden deaths in patients with structurally normal hearts. Other causes include drug abuse, blood clots that travel to the lungs, and brain hemorrhages. But Coronary blockage due to various reasons account for the commonest causes.

What is atherosclerosis

Doctors usually explain atherosclerosis as “hardening of the arteries,” but it’s actually much more complex. Thanks to the ancient Greeks, the name itself conveys some of that complexity: athere is Greek for “porridge,” while sclerosis means “hardening.” In fact, atherosclerosis begins with deposits of soft, fatty material; only later does this mush build up in plaques that narrow the artery and stiffen its walls.

Atherosclerosis begins in the blood, not the arteries. Excess amounts of LDL, the “bad” cholesterol, enter the inner lining of arteries, gradually building from tiny crystals into larger deposits that are visible as fatty streaks. Arteries damaged by smoking, high blood pressure, or diabetes are particularly vulnerable. The fatty streaks cause no harm, and if enough HDL, the “good” cholesterol, is in the blood, it can snatch cholesterol away from the artery, limiting damage. Reducing LDL cholesterol levels, lowering blood pressure, controlling diabetes and obesity, and avoiding tobacco can also help — but without help, the fatty streaks may slowly enlarge into plaques.

Early plaques are still small and soft. White blood cells called macrophages gobble up cholesterol, but instead of containing the damage, they add fuel to the fire by triggering inflammation. As things progress, the muscle cells in the artery wall enlarge, and the plaques grow into partial blockages.

Larger, mature plaques develop fibrous caps and stop enlarging. These stable plaques can cause the chest pain called angina, but they don’t usually trigger heart attacks. However, smaller, younger plaques that are unstable can rupture. Blood clots form on the ruptured plaques, as the body makes another attempt to contain damage. As in the case of inflammation, though, the body’s defense turns into offense: the clot completely blocks the artery, depriving a portion of the heart muscle of oxygen-rich blood. That’s what kills muscle cells and produces a heart attack.

Heart attacks are swift, occurring in a matter of minutes. But atherosclerosis itself is slow, developing over years — and it often begins in childhood.

Head start to heartache

 Fatty streaks of atherosclerosis are identified in coronary arteries as early as age 15, and became progressively more prevalent over the 20-year age span covered by the study. In all, about 2% of the youngest males and 8% of the oldest had evidence of coronary artery disease. As expected, subjects who’d had the highest LDL cholesterol levels, lowest HDL cholesterol levels, highest blood pressures, and highest blood sugars had the most disease. Even in these adolescents and young adults, smoking and obesity also increased the risk of atherosclerosis.

Children and tobacco

At all ages, smoking is the most powerful single contributor to atherosclerosis, and research continues to add to the evidence that exposure to secondhand smoke is also an important culprit. Passive smoking is hazardous to children; children who had been exposed to environmental smoke during daily life demonstrated significant impairment of their arteries’ ability to widen when their tissues needed more blood. Since the subjects were just 11 years old, it’s easy to see how continued exposure can lead to illness in early adulthood.

Staying Young at Heart.

In a study of 3,564 men, the Framingham Heart Study evaluated the cardiac impact of six major risk factors: high total cholesterol, low HDL (“good”) cholesterol, high blood pressure, diabetes, obesity, and smoking. A man who is free of all six has a remarkably low 5% risk of developing cardiovascular disease by age 95. In contrast, the risk for a man with two or more risk factors is 69%. In addition, a risk-free man can expect to enjoy 11 more years of life than a man with two or more risk factors.

Making young arteries old

The lion’s share of heart disease in young adults is caused by the same risk factors that cause coronary artery disease in older men. The culprits include a family history of heart disease, smoking, high cholesterol, hypertension and prehypertension, abdominal obesity, diabetes, the metabolic syndrome, lack of exercise, hostility, elevated levels of C-reactive protein, and low educational attainment.

Unfortunately, risk factors increase in the teen years, particularly in boys. After puberty, insulin resistance and triglycerides rise in males and HDL cholesterol levels fall, while girls enjoy opposite, and protective, changes. Hormones account for some of this, but so do health habits; for example, teenage boys smoke more and eat more fast food than girls, while the amount of exercise they get starts to decrease.

The outlook for young heart attack patients

At any age, a heart attack is a very serious event. It seems logical that the outlook would be particularly dire for a patient stricken early in life. But does the prediction hold up?

Yes and no. The short-term outlook for heart attack victims younger than 45 is actually better than for older patients, perhaps because they often have single-vessel disease and well-preserved heart muscle. But a heart attack is just the tip of the atherosclerosis iceberg, and without dramatic interventions, the disease is likely to progress. In one study of men who had a heart attack at an average age of just 36, 30% were dead within 15 years. In another study of men and women who were stricken before age 40, only 1% died within a year, but 25% died in less than 15 years.

Turning the tide

Atherosclerosis is the leading cause of death. Doctors have made great progress in treating heart disease, but prevention is the best treatment of all. Slowly but surely, men are getting the message; smoking and dietary fat intake are down, but exercise habits haven’t improved much, and obesity continues to increase.

William Wordsworth was right; in 1807, the poet wrote, “The child is father of the man.” Atherosclerosis often begins early in life, which is just when prevention should begin.