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(Chest. 2001;120:1953-1958.)
© 2001 American College of Chest Physicians

Myocardial Infarction in Young Adults With Low-Density Lipoprotein Cholesterol Levels <= 100 mg/dL*

Clinical Profile and 1-Year Outcomes

Kwame O. Akosah, MD; Ross M. Cerniglia, BS; Paul Havlik, MS and Ana Schaper, PhD(c)

* From the Gundersen Lutheran Medical Center, La Crosse, WI.

Correspondence to: Kwame O. Akosah, MD, Gundersen Lutheran Medical Center, 1836 South Ave, La Crosse, WI 54601; e-mail: kakosah{at}gundluth.org


   Abstract
TOP
 Abstract
Introduction
 Materials and Methods
 Results
 Discussion
 Conclusion
 References
 
Study objectives: To define the clinical profile of young adults with optimal low-density lipoprotein (LDL) cholesterol levels who present with acute myocardial infarctions (MIs); to compare and contrast differences in the clinical profiles of young adults admitted to the hospital with MIs who have LDL cholesterol levels <= 100 mg/dL and those with LDL cholesterol values >= 160 mg/dL; and to evaluate the clinical outcomes for the two groups at 1 year.

Design: A retrospective chart review was conducted on all young men (55 years) and women (65 years) admitted to the hospital for MIs within a 2-year period (n = 232). A history of cardiovascular risk factors and 1-year outcomes were obtained.

Setting: Rural community medical center serving a tri-state area in the midwestern United States.

Patients: Patients were included in this analysis if (1) a lipid profile was drawn within 24 h of hospital admission and (2) the patient was not receiving a statin medication on hospital admission.

Measurements and results: Of the 183 patients who met the inclusion criteria, as many as 68% (124 patients) had LDL cholesterol levels of <= 130 mg/dL, 29% (53 patients) had LDL cholesterol level of <= 100 mg/dL, and only 14% (26 patients) had LDL cholesterol levels of >= 160 mg/dL. Patients were categorized into group 1 if their LDL cholesterol level was <= 100 mg/dL and were categorized into group 2 if their LDL cholesterol level was >= 160 mg/dL. In group 2, 92% of patients were placed on a statin medication. By 1 year, the mean LDL cholesterol level had decreased from 188 to 106 mg/dL. The rate of coronary artery bypass graft and percutaneous coronary intervention procedures was similar between groups. Hospital readmission rates (43.4% vs 50%, respectively) and 1-year mortality rates (9% vs 8%, respectively) were not different between groups group 1 and 2.

Conclusions: Young adults experiencing acute MIs typically have acceptable cholesterol levels (ie, <= 130 mg/dL) or optimal values (ie, <= 100 mg/dL). In those patients with abnormal cholesterol levels, a combined strategy of aggressive intervention and adherence to secondary prevention protocols including lipid control is successful in improving outcomes.

Key Words: low-density lipoprotein cholesterol • myocardial infarction • premature coronary artery disease


   Introduction
TOP
 Abstract
 Introduction
Materials and Methods
 Results
 Discussion
 Conclusion
 References
 
There is a strong association between coronary heart disease (CHD) risk and age as well as increased serum lipid concentrations.1 Previous re-ports2 3 suggest that myocardial infarctions (MIs) in young adults are rare. The available literature on premature CHD suggests that this is particularly true in young men and women without diabetes, cocaine abuse, or familial hypercholesterolemia.4 5 6 This perception, however, is in discordance with reports from pathologic studies7 8 9 10 11 that consistently show alarming rates of coronary plaques in young, apparently healthy, individuals who have died from noncardiac causes. Until recently, clinical studies providing proof that these pathologic lesions were associated with clinical events were lacking. We recently published an article12 in which we reported a high admission rate for coronary events in young adults. In that article, we reported that the majority of young adults with diagnosed coronary artery disease (CAD) did not have high low-density lipoprotein (LDL) cholesterol levels.

To date, the cornerstone of preventive treatment for CHD has been the control of cholesterol levels. While there is ample proof of the benefit for treating abnormal cholesterol levels in patients with established disease in secondary prevention,13 preventing the development of CHD in the first place remains a major health challenge. Current methods of risk assessment and management, including the National Cholesterol Education Program guidelines, seem to miss a large number of people with established disease who are at risk for future events. Although hypercholesterolemia has been thought to be obligatory in the development of CHD,14 15 our recent experience suggests that many young adults presenting with acute coronary syndrome do not meet the criteria for high cholesterol.

In an effort to better characterize our population and to develop ancillary guidelines for risk stratification, we undertook this study for the following reasons: (1) to determine the extent of acute MI in young adults with optimal LDL cholesterol levels (ie, <= 100 mg/dL); (2) to compare and contrast the clinical profiles of young adults with optimal LDL levels who have experienced acute MIs with those of young adults with moderately high LDL levels (ie, >= 160 mg/dL) who have experienced MIs; and (3) to determine clinical outcomes 1 year following the MI.


   Materials and Methods
TOP
 Abstract
 Introduction
 Materials and Methods
Results
 Discussion
 Conclusion
 References
 
Patient Selection
This is a retrospective study of young adults presenting with MIs who were admitted to the coronary-care unit at the Gundersen Lutheran Medical Center in La Crosse, WI, over a 2-year period (January 1, 1998, to December 31, 1999). Information on the hospital catchment area and the demographic profile of the community has been published previously.12 The age criteria for young adults were defined as follows: men, patients aged <= 55 years; and women, patients aged <= 65 years. Acute MI was defined based on two of the following conditions: angina; ECG changes; or elevated enzyme levels (ie, creatine kinase and creatine kinase myocardial band isoenzyme). An additional inclusion criterion was a fasting lipid profile drawn within 24 h of hospital admission. Patients were excluded if they were receiving a statin medication at hospital admission.

Data Source and Variables
The medical records of all eligible patients were reviewed. The presence of traditional cardiovascular risk factors was noted. Body mass index (BMI) was calculated for all patients and was expressed as weight in kilograms divided by the square of height in meters. Overweight was defined as a BMI of >= 25.0 kg/m2, and obesity was defined as a BMI >= 30.0 kg/m2 for both men and women. Cigarette smoking (yes or no) was ascertained for current use, which was defined as chronic cigarette smoking up to 4 weeks prior to the acute MI. A history of hypertension was defined as a systolic BP of >= 140 mm Hg, or a diastolic BP of >= 90 mm Hg, or the current use of an antihypertensive medication. A family history of premature CAD was defined as CAD in a first-degree relative at age <= 55 years for men and <= 65 years for women. A history of hypercholesterolemia was taken from physician’s hospital admission notes or from the results of previous laboratory tests. A history of diabetes was considered to be present if the individual was receiving therapy with either insulin or an oral hypoglycemic agent or if hospital records indicated diet-controlled diabetes. An additional criterion was a fasting blood sugar level of >= 126 mg/dL. The documentation of cocaine use in this population was negligible and was not included in the analysis. The results of coronary angiography was considered to be abnormal for significant disease if the luminal diameter of the stenotic segment was >= 70% by visual inspection.

Statistical Analysis
The data were analyzed with computer software (SPSS, version 9.0 for Windows; SPSS; Chicago, IL). For the univariate analysis, the categoric variables were compared using the two-tailed Fisher’s Exact Test, Pearson’s {chi}2 test, or a test for linear trends. The continuous variables, which are expressed as the mean ± SD, were compared by the Student’s t test, paired t test, and binomial Z approximations. A p value of <= 0.05 was considered to be significant.


   Results
TOP
 Abstract
 Introduction
 Materials and Methods
 Results
Discussion
 Conclusion
 References
 
General
In the calendar years 1998 and 1999, there were a total of 960 admissions to our hospital for acute MI. Among the patients admitted, there were 232 young adults (24.2%). Among the 232 young adult patients, a total of 204 patients (87.9%) had lipid profiles drawn within 24 h of admission, of whom 21 patients were excluded from the study because they were already receiving therapy for dyslipidemia. Of the remaining 183 patients, 68% had LDL cholesterol levels of <= 130 mg/dL, 41% of those patients had LDL cholesterol levels of <= 100 mg/dL. Only 14% of patients had LDL levels that were considered to be moderately high (ie, >= 160 mg/dL) [Fig 1 ].



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  		Figure 1.. Distribution of LDL cholesterol levels in young adults admitted with acute MIs.

 
Patients were categorized into two groups. Group 1 (n = 53) was composed of patients with an optimal LDL cholesterol level of <= 100 mg/dL. The mean LDL cholesterol level in group 1 was 81 ± 5 mg/dL. Group 2 (n = 26) was composed of patients with moderately high LDL cholesterol levels of >= 160 mg/dL. The mean LDL cholesterol level in group 2 was 188 ± 16 mg/dL. Table 1 contains complete data for both groups.


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  		Table 1.. Demographics Profile by Group*

 
Risk Factors
Table 2 provides a summary of the details of the risk factor distribution in group 1 and group 2. As expected, the rate of history of hypercholesterolemia was significantly higher in group 2 than that in group 1 (p = 0.007). Interestingly, 25% of the people with optimal lipid profiles reported a history of hypercholesterolemia even though they had low total and LDL cholesterol levels and had not been treated previously with a statin medication. The distribution of all other risk factors was similar among the groups. Of particular importance, however, is that the rates of obesity and smoking were very high in our population.


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  		Table 2.. Frequency of Risk Factors by Group*

 
Angiographic Disease
Fifty-one of 53 patients (96%) in group 1 underwent diagnostic cardiac catheterization. Similarly, 25 of 26 patients (96%) in group 2 underwent the procedure. Four patients (7.5%) in group 1 and two patients (7.7%) in group 2 had either negative or insignificant levels of residual plaques. The distribution of significant coronary stenosis in the remainder was as follows: one-vessel CAD in group 1, 43.4%; one-vessel CAD in group 2, 30.8% (difference not significant); multivessel CAD in group 1, 45.3%; multivessel CAD in group 2, 57.7% (difference not significant; Table 3 ).


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  		Table 3.. Severity of Disease*

 
Hospital Course and Outcomes
Group 1 and group 2 had similar lengths of stay in the hospital (5.0 ± 4 vs 4.8 ± 2 days, respectively; difference not significant). The percentage of people treated with coronary artery bypass graft surgery also was similar (group 1, 25%; group 2, 20%; difference not significant). As stated above, angiography was performed in 96% of the patients in both groups. Similarly, the percentage of patients treated with percutaneous coronary interventions (PCIs) was not different (group 1, 55%; group 2, 65%). In other words, as many as 80% of patients in group 1 and 85% of those in group 2 underwent an invasive procedure or surgical treatment.

On hospital admission, 9.4% of group 1 and 3.8% of group 2 (difference not significant) were already receiving an angiotensin-converting enzyme inhibitor (ACEI), and 22.6% of group 1 and 11.5% of group 2 (difference not significant) were already receiving ß-adrenergic blocking agents. On hospital discharge, 45.3% of patients in group 1 and 42.3% of those in group 2 (difference not significant) were receiving ACEIs. Similarly, 90.6% of patients in group 1 and 92.3% of those in group 2 (difference not significant) were prescribed ß-adrenergic blocking agents. Despite a mean LDL level of 81 ± 5 mg/dL, 37.7% of patients in group 1 were prescribed statins at hospital discharge. The rate of the prescription of statins for patients in group 2 was 92.3% at hospital discharge (Table 4 ).


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  		Table 4.. Medication Management of MI Patients*

 
The mortality rate at 30 days was similar for both groups (group 1, 5.7%; group 2, 3.8%; difference not significant). Similarly, the 1-year mortality rate was 9.4% for group 1 and 7.7% for group 2 (difference not significant). The rates of medication prescription at 1 year were high for both groups and are displayed in Table 4 . There were no statistical differences in outcomes among the group 1 patients who were prescribed statins compared to patients not treated with statins. The readmission rates for group 1 and group 2 were similar (43.4% vs 50.0%, respectively; difference not significant). However, among group 1 patients there was a trend toward lower hospital admission rates for patients prescribed a statin at hospital discharge vs those not receiving a statin (30% vs 52%, respectively) and a trend toward lower death rates at 30 days (0% vs 9%, respectively) and at 1 year (5% vs 12%, respectively).


   Discussion
TOP
 Abstract
 Introduction
 Materials and Methods
 Results
 Discussion
Conclusion
 References
 
The significant findings of our study include the following. First, many young adults presenting with acute MIs have low levels of LDL cholesterol. Second, young adults experiencing acute MIs despite having normal cholesterol levels are not distinguishable from those patients with abnormal cholesterol levels in terms of clinical and risk factor profiles. Third, a combined management strategy consisting of interventions and evidence-based medical therapy improves outcomes at 1 year.

Cholesterol remains a very important aspect of both the primary and the secondary prevention of CHD.13 14 16 17 Several studies have documented the relationship between abnormal cholesterol levels and the risk of CHD.16 17 18 Furthermore, treating high-risk patients who have abnormal cholesterol levels is associated with reductions in future cardiac events.19 The downside is that our obsession with cholesterol seems to have caused many patients to ignore other risk factors that also contribute to CHD. Indeed, an elevated cholesterol level has been considered to be an obligatory risk factor for the development of CHD.4 15 Our study suggests that this may not be true for all patient groups, especially young adults. The finding that MI occurs in the setting of low LDL cholesterol levels is not particularly surprising. Other investigators20 21 have reported that there is significant overlap in cholesterol levels when LDL cholesterol is analyzed for CHD patients when compared to people who are free of disease. What is surprising is how low the lipid profiles were in the majority of young adults who presented with MIs. The sheer number of the patients experiencing MIs despite optimal cholesterol levels is a concern. This obviously raises the question of how best to identify young adults who are at risk for imminent cardiac events. When analyzed in terms of traditional cardiovascular risk factors, there were no distinguishing features between the many patients with low cholesterol levels and those few with high cholesterol levels.

MI is a major end point for atherosclerotic disease that has developed over decades. Although CAD is virtually ubiquitous by early adulthood,22 the rate of disease progression is dependent on the presence and extent of risk factors.10 A recent study23 of direct in vivo visualization of the coronaries of young potential heart transplant donors with intravascular ultrasound also showed a high percentage of young adults with occult but significant levels of coronary plaques. This study extends our previous report12 that young adults comprise a significant proportion of patients presenting with acute coronary syndromes, including MI, and that the majority do have optimal cholesterol levels. In these patients, prevention algorithms based on lipid levels will miss the vast majority of those patients who are at risk. The mean triglyceride, total cholesterol, HDL cholesterol, and LDL cholesterol levels were all normal in group 1 patients, making cholesterol-based primary prevention models insensitive in these patients. Other risk predictor models, including global risk scores, also are suboptimal because they are graded according to age (our patients are young) and cholesterol levels. The Framingham risk appraisal model, which is based on mathematical scores, is perhaps one of the most extensively validated.24 However, because of the very low total cholesterol levels (159 mg/dL) and young age, all of our group 1 patients with MIs would have scores too low to appreciate their risk.

Follow-up shows that patient outcomes in terms of mortality and hospital readmissions were similar for the two groups at 30 days and at 1 year. Similar findings have been reported in the past by other investigators such as Jee et al.25 The similarities of their patient group and ours are interesting in that both studies involved patients with low cholesterol levels and high rates of smoking. However, Jee et al25 interpreted the similar rates of cardiac events between the low-cholesterol and high-cholesterol groups to mean that low cholesterol confers no benefits against smoking-related atherosclerotic cardiovascular disease. We propose an alternative explanation. In their study, Jee et al25 did not evaluate treatment effects. In our study, a high percentage of patients (group 1, 80%; group 2, 85%) had the benefit of either PCI or coronary artery bypass graft surgery. Similarly, the rate of prescriptions for ß-adrenergic blocker therapy was high (group 1, 92%; group 2, 91%). The ACEI prescription rate was similar for group 1 and group 2, respectively. However, 92% of patients in group 2 were prescribed statins compared to 38% in group 1. The improved outcomes may represent reduced excess cardiac events in group 2. Not only were the prescription rates for statins high, but the mean LDL cholesterol level in group 2 at follow-up had decreased from the baseline values (baseline, 188 mg/dL; follow-up, 106 mg/dL), implying that treatment was efficacious.

Limitations
This is a retrospective analysis, which requires the necessary caution in the interpretation of our results. The question as to whether other novel risk factors may be responsible for the development of premature CAD in young adults with optimal LDL cholesterol levels remains to be answered. For this reason, we regret the lack of information in our patient groups for emerging risk factors such as homocysteine, lipoprotein(a), small dense LDL, and C-reactive protein. A current ongoing prospective study in our institution hopefully will provide further answers. Additionally, because of our methodology, we are unable to determine the true incidence of MI in individuals with low LDL cholesterol levels. However, our study shows that one of three young adults presenting with early MI do have LDL cholesterol levels that are < 100 mg/dL and that half of the population is obese (49%) or smokes (51%). Lipid profiles drawn within 24 h of hospital admission were not available in 12% of patients for various reasons. Most of these patients were transferred from other facilities after their coronary events. In other patients, lipid profiles were drawn at the local hospitals prior to transfer, and the results were not available to us.


   Conclusion
TOP
 Abstract
 Introduction
 Materials and Methods
 Results
 Discussion
 Conclusion
References
 
We have shown that contrary to popular belief a large number of young adults presenting with acute MI have optimal LDL cholesterol levels (ie, <= 100 mg/dL). These individuals are not distinguishable from a similar group of young adults presenting with MIs and high LDL cholesterol levels based on risk factor assessment. In addition, the angiographic profiles in the two groups were similar. These findings have important implications in the current strategies for prevention and management. The development of ancillary tests for the noninvasive detection of underlying CHD to improve the sensitivity of the current prevention protocols may be most helpful in young adults. A combined strategy including PCIs and surgical therapy as well as high adherence to secondary prevention protocols, as per evidence-based medicine, represents the best strategy for young adults presenting with acute MIs.


   Footnotes
 
Abbreviations: ACEI = angiotensin-converting enzyme inhibitor; BMI = body mass index; CAD = coronary artery disease; CHD = coronary heart disease; LDL = low-density lipoprotein; MI = myocardial infarction; PCI = percutaneous coronary intervention

Received for publication January 12, 2001. Accepted for publication May 4, 2001.


   References
TOP
 Abstract
 Introduction
 Materials and Methods
 Results
 Discussion
 Conclusion
 References
 

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