Advances in medicine over the last decade have reduced deaths from heart disease.  However, death from heart disease continues to be the top or second highest cause of death in most countries, and in the United States (US), it is the number one cause of death. In the US, death rates from heart disease have fallen by about 50% during the period from 1980 to 2002. While it is generally assumed that the benefit has extended across the population, a study published in August 2015 in the prestigious Circulation journal showed findings that were surprising enough for the journal to publish an editorial entitled “Heart Disease Prevention in Young Women: Sounding an Alarm”.

The beneficial decline in death from heart disease has not been seen across to the same extent for all demographic groups. In the US, annual rate of decline of death from heart disease among the younger adults (35 to 54 years) had slowed down rapidly, with an annual decrease of 5.4% in 1980 to 1989 and reversing the trend to an annual increase of 1.5% in 2000 to 2002 for females.

A similar trend was seen in males where the annual decrease slowed from 6.2% to 0.5% during the same period. The US is not the only country with this trend of stagnation or increased in death from heart disease in the young.

In the United Kingdom, Canada and Australia, similar trends were observed in younger adults. There was an increase in death from heart disease in males in 2002 in United Kingdom for the first time in 2 decades, while in Canada, from 2000 to 2009, there was a 1.7% annual increase in hospitalization following a heart attack in young adults.  From the period between 1996 and 2007, there was a 4.0% annual increase in heart attacks in females in Australia.

In this study published in Circulation, the researchers  found that over a slightly more than 3 decades period spanning from 1979 to 2011, younger adults less than 55 years benefitted from a substantial decrease in death from heart disease until 1990 when this  beneficial decline petered out with minimal improvement subsequently.

This was in contrast to older adults where the annual decrease was even more substantial in the recent decade as compared to the period prior to 2000.

Alarm bells for women

While the general perception is that heart attacks are rare in the young, they account for 22% of all hospital admissions for acute heart conditions in the United States and according to a publication by Gupta and his researchers from Yale University that was published in the Journal of the American College of Cardiology in 2014, among the young with hospitalisation for acute heart attacks, women account for about 25% of the heart attack admissions between 2001 to 2010 in the United States.

In addition, females tend to have more associated medical conditions, longer period of hospital stay, and higher death rates in hospital when compared to males.

In the decade from 2001 and 2010 in the US, while there was a more than 20% reduction in hospitalisation for the older adults, there was no appreciable decrease in hospitalisation for heart attacks in younger adults.

A similar disappointing trend in hospitalisation for heart attacks in the young was also seen in Australian and Canadian studies. In both the Australian and Canadian studies, not only was no significant change for males but for females, there was a significant increase in hospitalisation rates for heart attacks.

Reasons for dismal trend

This dismal trend appears to be due to an increase in the incidence of heart disease among the young. One possible explanation for this trend is that the current guidelines used by physicians may have underestimated the risk in the young as the risks for heart disease in the young may not be completely reflected by current risk factors used for older adults. In the past 3 to 4 decades, the obesity epidemic and a parallel increase in the incidence of diabetes have afflicted mainly the younger adults.

In addition, since the 1980s, the highest increase in diabetes and obesity is seen in young women. Recent research data have also shown that young women with obesity related conditions or diabetes have about 5 times increase in risk of a heart attack as compared to other groups of non-diabetic adults.

At any age, women when compared to men tend to be underdiagnosed and undertreated.  One of the main reasons is that in the broader social context, women tend to be primarily responsible for the needs at home and hence may tend to neglect their health needs for various reasons. Ongoing results from the Framingham study show that the risk scores for heart attacks for young women have increased.

The Framingham study was initiated in 1948 by the United States health authorities in response to the startling findings that apparently healthy men in their forties and fifties who had just returned from World War II were dying from sudden heart attacks. The Framingham Heart study in Massachusetts, which is now into third generation subjects, sought to study the risk factors that would predispose those people to heart attacks.

Heart screening for the young

Most physicians have always been lulled into a false sense of confidence that there is no need to screen the young, especially women, for heart disease. This study and its accompanying editorial provides us with a wake-up call. Given the results of the data, the editorial in the widely read Circulation journal suggests that “requiring cardiovascular disease screening in women, and in men, over age 25 years seems warranted”.

In summary, the current data suggests that there is an increasing incidence of heart attacks in the younger in more recent years and it is time for physicians to pay more attention to younger adults, especially women, for risk factors of heart disease.

Hence, if you have risk factors for heart disease such as high blood pressure, diabetes mellitus, high cholesterol levels, obesity, family history of heart disease or smoking, you should consult your doctor for advice on further screening for heart disease. Being young does not mean that you will not have any heart disease.

Finally, I am reminded of Mr A, a young man whose 2 main risk factors for heart disease were high cholesterol and a family history of heart artery disease. His father who had heart artery disease and was a patient of mine insisted that he come for an annual checkup.  Since the age of 28 years, he has been faithfully coming for his annual assessment which included a treadmill test.

When he saw me in February this year, he completed his treadmill test with flying colours, having completed stage 5 of the treadmill test with no chest pain and no abnormal findings.

In May this year, he suddenly came again to see me and for the first time he complained of severe chest pain on exertion for a few days. The usual tests such as an electrocardiogram (ECG) and even an ultrasound scan of the heart showed no abnormalities.

Given his typical symptoms, a computed tomography (CT) scan of his heart arteries was performed and to his family’s surprise, he had severe blockage of his 3 main heart arteries with 100% occlusion of 2 major heart arteries and 90% occlusion of the remaining major heart artery.

Not surprisingly both the patient and his mother were shocked at the findings. Fortunately, the blocked heart arteries could still be opened with balloons and cylindrical meshes called stents. Increasingly, MR A is no longer an exception and more and more young people are being diagnosed with severe heart artery disease.

The take home message from Mr A’s case is that being young and having no symptoms does not mean that you have no heart artery disease. This recent study and the editorial are timely reminders to younger adults, especially women, to be more proactive in reducing their risks for heart attacks.