Acute Myocardial Infarction at 25 Years of Age

Abstract

A 25-year-old black woman was found to have systemic hypertension when she was 18 years of age. She had 2 children in her early 20s; during both pregnancies, her blood pressure was extremely high, and both children were delivered early because of the hypertension. At age 24 she discontinued her antihypertensive medicines for unclear reasons. About 48 hours before hospital admission, she experienced various types of substernal chest pain, which occasionally radiated to her arms. In the emergency department, her blood pressure was 240/130 mm Hg and her serum troponin was 2.7 mg/mL. The electrocardiogram showed tall T waves anteriorly but no Q waves or S-T segment changes. The drug screen was positive for marijuana but negative for cocaine. She stated that she had never used cocaine but often used marijuana. She smoked about 20 cigarettes a day and was not aware of ever having her blood cholesterol tested. Her mother had diabetes mellitus and high blood pressure. Her father had died at age 51 of acute myocardial infarction. When admitted to the ward, the patient's blood pressure was 140/90 mm Hg. She weighed 252 pounds and was 63 inches tall (body mass index 44 kg/m 2). Her lungs were clear. No precordial murmurs or abnormal sounds were heard. The cardiac silhouette on chest radiograph was of normal size. The lung fields were clear. On chest computed tomography, the aorta appeared to be of normal size, and no dissection was present. The serum alanine aminotransferase was 33 U/L; aspartate aminotransferase, 61 U/L; and alkaline phosphatase, 73 U/L. The serum total protein was 7.8 g/dL; albumin, 3.1 g/dL; and globulin, 4.7 g/dL. The urine was negative for glucose, but a trace of protein was present. The serum total cholesterol was 375 mg/dL; the low-density lipoprotein cholesterol, 311 mg/dL; the high-density lipoprotein cholesterol, 47 mg/dL; the very-low-density lipopro-tein cholesterol, 17 mg/dL; and the triglycerides, 83 mg/dL. The erythrocyte sedimentation rate was 89 mm/hour. Cardiac catheterization during her first day in the hospital disclosed a large left main coronary artery, which contained a narrowing in its most distal portion, a relatively normal left anterior descending artery, and a totally occluded left circumflex coronary artery. The right coronary artery was the dominant one, and its interior lining was "ragged" with narrowing >90% in diameter. The distal left circumflex artery was filled by collaterals from the distal right coronary artery (Figure). A left ventricular angiogram showed the posterobasal portion of the left ventricular wall to be akinetic and the other portions of the left ventricular wall to contract well. The ejection fraction was estimated to be 50%. During the cardiac catheterization, the totally obstructed obtuse marginal branch of the left circumflex coronary artery Figure. Coronary angiograms in the patient described. (a) Right coronary artery with numerous narrow-ings. (b, c, d) Injection of contrast material into the left main coronary artery showing total occlusion of the left circumflex (arrow) and multiple lesser narrowing in the left anterior descending artery.