Most people associate heart disease with the elderly but a heart condition can strike at any age. By Michael Lim

MR A was a healthy young man in his late teens who exercised regularly and looked every inch the personification of fitness, except that he was troubled by multiple fainting episodes. The first thing that had to be considered was a heart rhythm disorder.

He was put on a continuous ambulatory recording of his heart rhythm, which showed that his heart rate was generally slow but nevertheless still considered normal. The next thing that had to be considered was whether there was a structural abnormality of his heart, such as a heart muscle disorder, a valve disorder or a congenital heart disorder.

Fortunately, the ultrasound of his heart did not show any structural abnormalities. His doctors had considered doing a coronary angiogram, a test involving inserting a tube into his heart arteries under X-ray imaging, to look for congenital abnormalities of his heart arteries.

However, he decided on another safer option, magnetic-resonance imaging (MRI) of the heart arteries, which had no X-ray radiation and it didn’t need injection of any contrast into the body. Again, there were no abnormalities seen.

The test that eventually led to the diagnosis was a tilt table test, where he was strapped to a table that was elevated vertically and given medication which resulted in a reflex response leading to the complete cessation of the heart beat for seven seconds and total loss of consciousness.

He had “malignant vasovagal syncope”. This is a serious type of fainting attack where the heart can stop beating completely although transiently. It meant that he should refrain from strenuous physical activity and should avoid activities such as driving where a fainting attack can put the people around him in danger. In serious cases, a pacemaker may have to be inserted as the cessation of the heartbeat can sometimes last more than 30 seconds.

Palpitations

Another common complaint by the young is palpitations. Mr B, who was in his late teens, was troubled by transient episodes of fast heartbeat, but despite multiple tests done on him by his doctors, no abnormalities of the heart were detected.

His father was concerned as Mr B was involved in strenuous physical activity. Finally, his cardiologist arranged for him to have a mobile phone device that was able to record his heart’s electrical rhythm whenever he felt the presence of palpitations.

The device eventually recorded episodes of abnormal fast heart rhythm, supraventricular tachycardia, that correlated with his symptoms. With this documentation, his father was relieved that Mr B was excused from strenuous physical activity by his doctor.

Ms C, who was in her early twenties, was also troubled by transient episodes of fast heartbeat and was diagnosed by her physician to have an abnormal fast heart rhythm, ventricular tachycardia, which arose from an abnormal focus in the left lower chamber of the heart. An ultrasound of the heart revealed an abnormal bulging of the wall of the left lower heart chamber. She was given an MRI scan of the heart which showed the presence of an abnormal ballooning of the left lower heart chamber called ventricular diverticulum. The abnormal heart rhythm was potentially life-threatening.

The common thread among these three young individuals was that they all had a significant heart condition that was either potentially life-threatening or had a significant impact on their quality of life.

While most people assume that heart disease mainly afflicts the elderly, there are conditions of the heart which can potentially cause sudden death in the young. These can be broadly divided into two main categories: those that are due to abnormal heart muscle or arteries and those that are due to abnormal development of the electrical system in the heart.

For the first category, the commonest cause is a condition called hypertrophic cardiomyopathy, which is a genetic condition that results in abnormal thickening of the heart muscle and life-threatening heart rhythms. Malformation of the wall of the heart muscle resulting in replacement of healthy heart muscle by fibrous and fatty tissue (ventricular dysplasia) disrupts the electrical activity and creates irritable foci which can cause life-threatening heart rhythms. Abnormal development of the heart muscle wall also results in conditions such as that in Ms C.

Anomalous origin of the coronary or heart arteries is a condition with multiple variants of which some can potentially be life-threatening. Not uncommon are virus infections of the heart which severely damage the heart muscle, resulting in a very swollen heart with poor function. Unlike the earlier conditions where mainly abnormal fast heart rhythms are present, those with viral infection of the heart may have “flu” symptoms but they may later develop breathlessness on exertion when the “flu” clears. Those with abnormalities of the electrical system of the heart may include those with long QT syndrome, Brugada syndrome, and malignant vasovagal syncope. These are all potentially life-threatening conditions.

The warning symptoms are not difficult to identify. Recurrent palpitations, recurrent fainting episodes, exertional chest pain or shortness of breath on physical exertion in a teenager or young adult may be the harbinger of underlying heart disease. In most cases, an electrocardiogram (ECG or electrical recording of the heart) or an ultrasound study of the heart will be sufficient to diagnose an underlying heart problem. Where it is relevant, the doctors may order an MRI scan of the heart to look for structural abnormalities. The MRI is a useful diagnostic tool as there is no X-ray radiation and in most cases, no contrast injection is required. Hence, do remember that one is never too young to have heart disease.

There are conditions of the heart which can potentially cause sudden death in the young. These can be broadly divided into two main categories: those that are due to abnormal heart muscle or arteries and those that are due to abnormal development of the electrical system in the heart.