Acute coronary syndrome represents a major health problem all over the world.

It’s mainly
considered a disease of middle aged and elderly, however when it manifest among young
patients it carries significant morbidity and financial burden for the patient, His family and
society.1–4 5–10% of myocardial infarctions (MI) occur in patients younger than 46 years of
age.5–7 Saudi Arabia is undergoing a major transformation as a young nation with adoption of
a western life style we have seen an increased prevalence in the cardiovascular disease risk
factors.8,9 The 2030 vision of Saudi Arabia is aspiring to improve the health care systems
through collection of relevant data in order to meet and address challenges and deliver
preventive measures and improve access to health care systems. 66.4 per cent of the total
population in Saudi Arabia is aged 15-54, with Saudis making up 60 per cent of this age.10
Due to paucity of information in young patients 45 years or less this study aims to identify the
prevalence of acute coronary syndrome in young (<45 years old) patients presenting to King
Abdulaziz Medical city-Jeddah, Saudi Arabia. Our objectives include identifying the pattern
of clinical presentation, affected coronary arteries, the risk factors and the short term outcomes
of acute coronary syndrome.
Faisal Al-Husayni MD1 Bander Alamry MD, Ali Alyami MD, Mosa Abadi MD, Akram
Ahmed MD, Amani Alsubaie MD,3 Hani Mufti MD, Saad Al Bugami MD. 2019. Acute
coronary syndrome among young patients in Saudi Arabia (Single center study). Journal of
Cardiology & Current Research, 12 (3), pp 60

Ischemic heart disease (IHD) is the most common cause of mortality worldwide with over 7
million deaths annually.1 It is estimated that 32 % of all death will be due to CAD and it will
be the leading cause of disability2 worldwide by 2020. The term acute coronary syndrome
(ACS) refers to a group of clinical symptoms consistent with new onset or worsening ischemic
symptoms and includes the spectrum of clinical conditions ranging from unstable angina (UA)
to non—ST-segment elevation myocardial infarction (NSTEMI) and ST-segment elevation
myocardial infarction (STEMI). Unstable angina and NSTEMI are closely related conditions:
their pathophysiologic origins and clinical presentations are similar, but they differ in severity.3
The proportion of ACS types varies across various studies with decrease in the STEMI
compared to NSTEMI owing to development of more sensitive markers of myocardial injury.4
Each year in the United States alone, approximately 1.36 million hospitalizations are required
for ACS (listed either as a primary or a secondary discharge diagnosis), of which 0.81 million
are for myocardial infarction (MI) and the remainder are for UA. Roughly two-thirds of patients
with MI have NSTEMI; the rest have STEMI5. While ACS has always been a significant health
problem in the developed world, it has become more difficult for developing South Asian
country like Nepal to cope with the rising burden of the disease. Meanwhile, we have limited
data on the nature and distribution of ACS.6-10
1. Mathers CD, Loncar D. Projections of global mortality and burden of disease from 2002
to 2030. PLoS Med. 2006;3(11):e4421WHO 2017. The top 10 causes of death. Available
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of disease study. Lancet 1997; 349: 1269-1276. https://doi.org/10.1016/S0140-
6736(96)07493-4
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Mann, DPZipes, P. Libby, 9th ed. Braunwald Heart disease:A text book of cardiovascular
medicine. Missouri:Elsvier, Saunders. 2011:1-20.
4. Benjamin EJ, Blaha MJ, Chiuve SE et al. Heart disease and stroke statistics-2017 update.
A report from American Heart Association. Circulation. 2017;135 (10):e146-e606.
https://doi.org/10.1161/CIR.0000000000000491
5. Lloyd-Jones D, Adams R, Carnethon M, et al. American Heart Association Statistics
Committee and Stroke Statistics Subcommittee Heart disease and stroke statistics—2009
update. a report from the American Heart Association Statistics Committee and Stroke
Statistics Subcommittee [published correction appears in Circulation. 2009;119(3):e182]
Circulation 2009 January27; 119(3):480- 486 Epub 2008 Dec 15.
https://doi.org/10.1161/circulationaha.108.191259
6. Shreshta NR, Basnet S, Bhandari R et al .Presentation and outcome of patients with acute
coronary syndromes in eastern Nepal. Swiss Med Wkly. 2011 Apr 13;141:w13174. doi:
10.4414/smw.2011.13174. eCollection 2011. https://doi.org/10.4414/smw.2011.13174
7. Gautam MP , Sogunuru G , Subramanyam G , et al. Acute coronary syndrome in an
intensive care unit of a tertiary care centre: the spectrum and coronary risk factors. J Nepal
Med Assoc. 2013 Apr-Jun;52(190):316-21. https://doi.org/10.31729/jnma.1897
8. Chhetri BK , Paudel MS, Dhungana SP et al. Clinical profile of patients with acute
coronary syndrome in Lumbini Medical College and Teaching Hospital: A prospective
study. Journal of Lumbini Medical College. Dec 30, 2013.
https://doi.org/10.22502/jlmc.v1i1.3
9. Laudari S, Dhungel S, Dubey L et al. Acute coronary syndrome in the young Nepalese
population with their angiographic characteristics. Journal of College of Medical Sciences-
Nepal, Vol-13, No 2, Apr-June 017. https://doi.org/10.3126/jcmsn.v13i2.17147
10. Paudel N, Alurkar VM, Jha GS et al. Profile of acute coronary syndrome in young
people: a hospital based observational study in western nepal. Birat journal of health
sciences. vol.3/no.1/issue 5/ jan-april 2018. https://doi.org/10.3126/bjhs.v3i1.19759

Ischaemic heart disease (IHD)is the most common form of heart disease and the single most
important cause of
premature death worldwidedespite major breakthroughs in management [1]. According to the
World Health Organization, IHD was responsible for 8.1 million deaths worldwide in 2013
(95% uncertainty interval, 7.3–8.8
million) and there was an increase of 42% in the number of IHD deaths since 1990. According
to the Annual health bulletinof Sri Lanka in2013 increasing trend was seen in hospitalizations
per 100,000 population due to ischaemic heart diseases; 494.9 in 2012 and 506.1 in 2013.
Ischemic heart disease isranked as the leading cause of hospital deaths in Sri Lanka since 1995
having great clinical and financial impact. It accounted for 29.1 deaths per 100,000 population
in 2013, including 14.7% hospital deaths with a case fatality rate of 5.76 [1]. Acute coronary
syndrome (ACS) includes Unstable Angina (UA) and evolving Myocardial Infarction (MI)
which is usually divided into ST-segment elevation Myocardial Infarction (STEMI) or new
onset Left Bundle Branch Block (LBBB), and ACS without ST-segment elevation (NSTEMI)
[2]. Several studies have been published on epidemiology, risk factors andthe outcome of ACS
in Western countries. Studies have shown that South Asians experience higher mortality rates
and premature deaths accounting to IHD (deaths occurring at least 10–15 years before
expected) than is experienced by people in Western countries [3, 4]. However, there are only
limited studies
which relate to IHD in the Sri Lankan population. ACS often reflects a degree of damage to
the coronary arteries by atherosclerosis; plaque rupture, thrombosis, and inflammation.
Advanced age, male gender and a family history of ischemic heart disease have been identified
as non-modifiable risk factors.Smoking, hypertension (HT), diabetes mellitus (DM),
dyslipidemia, obesity and a sedentary lifestyle were identified as modifiable risk factors [2].
However, the data is limited on the association of family history of non-communicable diseases
and ACS. The risk factors contributing to the development of IHD were summarized by the
Framingham Heart Study providing crucial information regarding intervention for primary and
secondary prevention of IHD [5]. According to previousstudies,the management of IHD in
developing countries is generally suboptimal compared to developed countries. This is true for
Sri Lanka and regionally [6–8]. Even though clinical trials provide evidence of current
management practices(medication and intervention) for diseases, only observational studies
provide details of epidemiology, risk factors, shortcomings in management and differences in
outcomes among different regions of the world and within the country itself [9, 10]. However,
since Sri Lanka does not currently have a cardiac registry the outcomes of ACS following the
index admission are not known. The aim of the current study is to determine the epidemiology
and risk factors of patients with Acute Coronary Syndrome presenting to a tertiary care hospital
in Sri Lanka.

1. Medical Statistics Unit, Sri Lanka. 2013. Annual Health Bulletin 44–46,184–194.
2. Longmore M, 2014. Oxford handbook of clinical medicine (Oxford medical handbooks).9th
Edition.Oxford University press.
3. Hughes LO, Raval U, Raftery EB. First myocardial infarctions in Asian and whitemen. BMJ.
1989;298(6684):1345–50. https://doi.org/10.1136/bmj.298. 6684.1345.
4. Ghaffar A, Reddy KS, Singhi M. Burden of non-communicable diseases in South Asia. BMJ.
2004;328(7443):807–10. https://doi.org/10.1136/bmj.328. 7443.807.
5. Mahmood SS, Levy D, Vasan RS, Wang TJ. The Framingham Heart Study and the
Epidemiology of Cardiovascular Diseases: A Historical Perspective. Lancet.
2014;383(9921):999–1008.
6. Constantine GR, Thenabadu PN. Time delay to thrombolytic therapy--a Sri Lankan
perspective. Postgrad Med J. 1998;74(873):405–7. https://doi.org/10. 1136/pgmj.74.873.405.
7. Constantine GR, Herath JI, Chang AA, Suganthan P, Hewamane BS, Thenabadu PN.
Management of acute myocardial infarction in general medical wards in Sri Lanka. Postgrad
Med J. 1999;75(890):718–20. https:// doi.org/10.1136/pgmj.75.890.718.
8. Mohanan PP, Mathew R, Harikrishnan S, Krishnan MN, Zachariah G, Joseph J, et al.
Presentation, management, and outcomes of 25 748 acute coronary syndrome admissions in
Kerala, India: results from the Kerala ACS registry. Eur Heart J. 2013;34(2):121–9.
9. Eagle KA, Goodman SG, Avezum A, Budaj A, Sullivan CM, Lopez-Sendon J. Practice
variation and missed opportunities for reperfusion in ST-segmentelevation myocardial
infarction: findings from the global registry of acute coronary events (GRACE). Lancet.
2002;359(9304):373–7. https://doi.org/10. 1016/S0140-6736(02)07595-5.
10. Fox KA, Goodman SG, Anderson FA, Granger CB, Moscucci M, Flather MD, et al. From
guidelines to clinical practice: the impact of hospital and geographical characteristics on
temporal trends in the management of acute coronary syndromes. The global registry of acute
coronary events (GRACE). Eur Heart J. 2003 Aug;24(15):1414–24.

Data World Health Organization (WHO) pada tahun 2016 menunjukkan bahwa penyakit
kardiovaskular merupakan penyebab kematian nomor satu secara global dengan persentase
sebesar 31%, pada tahun 2015 angka kematian akibat penyakit jantung koroner adalah 20 juta
jiwa dan di tahun 2030 mendatang diprediksi akan meningkat kembali dengan pencapaian angka
23,6 juta jiwa penduduk..
Coronary artery disease (CAD) is a leading cause of global morbidity and mortality (1,2). Its acute (and most ominous)
manifestation, acute coronary syndrome (ACS), is associated with >2.5 million hospitalizations annually worldwide (3).
Unstable angina (UA) and non-ST segment elevation myocardial infarction (NSTEMI) share similar clinical
presentations, but differ in severity and are collectively referred to as non-ST elevation ACS (NSTE-ACS). Together,
they account for over 60% of ACS cases (4,5).
The risk of ACS increases with age and the co-existence of risk factors such as hypertension and smoking (4,6,7). In
Australia, the recorded cases of ACS increased by 79% from 1993 to 2008 for acute myocardial infarction (AMI) and
33% for UA, resulting in over 90,000 hospitalizations in 2008 (8). More than 8,000 Australians died from AMI in 2016,
among whom over 80% were aged 65 years and over (9). In 2009, the direct healthcare costs associated with ACS in
Australia exceeded AUD $1.8 billion (10).
ACS clinical guidelines are largely based on trials in which the elderly and people with comorbidities were under-
represented (11,12). However, the majority of ACS patients seen in routine clinical practice are likely to belong to this
group. In Sweden, around half of cardiologists reported treating elderly NSTE-ACS patients with multimorbidity daily
(13). Approximately 60% of patients with ACS in England and Wales were found to have multimorbidity (14). One in
every 3 patients hospitalized for ACS in Switzerland had two or more other cardiovascular conditions (15). In Australia,
similar patterns are observed (16,17).
To optimize the clinical management of patients with ACS, better knowledge of the impact of comorbidities is vital
(18,19). Prior studies that have utilized comorbidity indices such as the Charlson comorbidity index (CCI) and the CAD-
specific comorbidity index have associated higher global comorbidity with poorer outcomes among patients with ACS
(20,21). However, the extent of, and the impact of NCCs on outcomes experienced by ACS patients has not been well
studied. Defining the burden of and the effect of NCCs among ACS patients might help to raise awareness about the
clinical relevance of NCCs among clinicians which could improve the assessment of patients’ vulnerability, and also
inform decision making about the care delivered to such patients.
In this study, we sought to characterize the patterns and impact of NCCs on the length of stay (LOS) and mortalityamong
older adults hospitalized for NSTE-ACS.

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