THE September issue of the Journal of the American College of Cardiology reviewed the current state of knowledge of coronary artery disease (CAD) in the young female patient. For the purposes of this review, an age range of 35-55 years was used. Several interesting points were raised in this article which we think are of importance to our readers.

Over the past few decades in most developed countries, there has been a decrease in the risk of myocardial infarction (heart attack) and a decreased risk of death for those patients unlucky enough to suffer from a heart attack. These improvements are the end results of an improved understanding of the mechanisms of heart disease along with the improved education and management of patients with acute and chronic heart disease. When attention is paid to the young female patient they have not benefited from these improvements and in fact display an increasing incidence of heart attack and a higher risk of death when a heart attack happens. While young female patients still represent the minority of patients with heart attacks, the numbers of these patients are increasing. Two decades ago, females represented 21 per cent of young patients with heart attacks currently they represent 31 per cent, roughly translated to one in three cases.

Characteristics of young females with heart attacks?

The risk that a young female will present with a heart attack is strongly influenced by socio-economic issues and race. Black females have the highest risk of heart attack among young female patients. The mechanism of this increased risk is an area of active research. However, co-morbidities are thought to play a significant role. Young black females have the highest prevalence of obesity which can approach 50 per cent in some areas. They have a high and increasing prevalence of type 2 diabetes and hypertension. When compared to men of the same age who present with a heart attack, the young female patient has a higher prevalence of hypertension, diabetes, and chronic kidney disease. They also have a higher prevalence of depression, stress, poor physical and mental health, and a lower quality of life. It is also thought that some risk factors may be more potent in the young female cardiac patient. For example, smoking is more strongly associated with severe heart attacks in women aged 18-49 years when compared to men of the same age or older women.

What is the outcome when young female patients present with heart attacks?

In general, female patients have a worse outcome with heart attacks when compared to male patients. This difference is magnified in the young female patient. For severe heart attacks, it is estimated that the risk of death in the young female patient is twice that of an older man. For a female patient above the age of 55 years, the risk of death is 30 per cent greater than an older man. The mechanism of this increase in mortality is complex and related to several interacting factors including a misguided under appreciation of the risks of coronary artery disease in females in general and young females in particular. The diagnosis of heart attack is often delayed in the young female patient even when abnormal cardiac results are noted in the emergency setting. Female patients with heart attack are under treated both with regards to medication and procedures when compared to male patients with the young female patient being at a particular disadvantage.

What are the causes of heart attacks in the young female patient?

As in older patients, the most common cause of heart attack in the young female patient is coronary artery disease or the deposition of cholesterol in the arteries supplying blood to the heart. However, females in general and young females in particular are more likely to have heart attacks where the coronary disease is mild (less than 50 per cent stenosis) or where no significant coronary disease is seen. In scenarios like this, spasm of the coronary artery or dysfunction of the coronary arteries that make them more likely to promote clotting or less able to maintain normal flow to heart muscle may be important factors. An important clinical finding is that even when the blood flow to the heart is normal after a definite heart attack, the patient still may experience adverse clinical events in the future. These events include recurrent heart attacks, anginal chest discomfort and increased mortality. Given this data patients with a definite heart attack who have normal coronary arteries or only mild disease should still be treated with medication to reduce future risk. A relatively new syndrome called MINOCA (heart attack without obvious blockage of the heart vessels) is increasingly being recognised and appear to occur more frequently in females. It is not surprising that even in the presence of other markers consistent with heart attack, some patients with MINOCA may fail to get adequate attention.

Another important cause of heart attack in the young female is spontaneous coronary artery dissection, also known as SCAD. This is a sudden tear in the wall of the coronary artery that results in obstruction of flow and a heart attack. This condition is the most common cause of heart attacks that occur in pregnancy and as the age of the patient falls the incidence of this disease increases to become the most common cause in the youngest patients. This disease can be difficult to diagnose particularly in the pregnant female and management has not been well defined as many of the standard heart attack therapies have been shown to be of no benefit. Of great importance in these patients is the possibility of a disease process that affects arteries generally and it is recommended that imaging be performed of all arteries from the brain to the pelvis.

In the young female patient with a heart attack, it is important to confirm the absence of drug use as several illicit drugs such as cocaine have been implicated in the causation of premature coronary artery disease including heart attacks in both males and females.

Dr Ernest Madu, MD, FACC and Dr Paul Edwards, MD, FACC are consultant cardiologists for Heart Institute of the Caribbean (HIC) and HIC Heart Hospital. HIC is the regional centre of excellence for cardiovascular care in the English-speaking Caribbean and has pioneered a transformation in the way cardiovascular care is delivered in the region. HIC Heart Hospital is registered by the Ministry of Health and Wellness and is the only heart hospital in Jamaica. Correspondence to info@caribbeanheart.com or call 876-906-2107