Clinical vignette

Unexpected severe coronary artery disease in a young patient with only one modifiable risk factor

Jan W Pęksa1Artur Pawlik2Artur Dziewierz23Barbara Zawiślak4
1Clinical Department of Cardiology, Interventional Electrocardiology and Hypertension, University Hospital, Kraków, Poland
2Clinical Department of Cardiology and Cardiovascular Interventions, University Hospital, Kraków, Poland
32nd Department of Cardiology, Jagiellonian University Medical College, Kraków, Poland
4Intensive Cardiac Care Unit, University Hospital, Kraków, Poland

Correspondence to:

Jan W Pęksa, MD, MPH,>

Department of Cardiology, Interventional Electrocardiology and Hypertension,

University Hospital,

Jakubowskiego 2, 30–688 Kraków, Poland,

phone: +48 12 400 21 00,


Copyright by the Author(s), 2022

DOI: 10.33963/KP.a2022.0224

Received: April 7, 2022

Accepted: September 9, 2022

Early publication date: September 23, 2022

A 34-year-old man was referred to a catheterization laboratory for urgent diagnosis and treatment of ST-segment elevation myocardial infarction (STEMI) of the anterior wall. The symptoms began two days before the admission and were typical of myocardial ischemia. The vital signs were in the normal range. A family history of premature heart disease was negative, and the patient had no chronic diseases. The only reported cardiovascular (CV) risk factor was heavy smoking. Coronary angiography showed an occlusion in the left ascending artery (LAD). Immediate percutaneous coronary intervention was performed with deployment of a drug-eluting stent (Figure 1).

Figure 1. A. Baseline angiography of the right coronary artery. B. Baseline angiography of the left coronary artery with an occlusion in the mid-left descending coronary artery (LAD, the arrow). Diffuse non-significant disease of remaining vessels. C. The final result of percutaneous coronary intervention within LAD

Transthoracic echocardiography revealed a decreased left ventricular ejection fraction of 45%–48%, driven by regional contractility abnormalities of the anterior wall and interventricular septum. Further hospitalization in the intensive cardiac care unit was uneventful. Surprisingly, the lipid profile did not appear abnormal (Supplementary material, Table S1). During the hospital stay, the patient was rehabilitated and mobilized without any signs or symptoms of cardiac ischemia. He was discharged home after 5 days on 1 × 75 mg aspirin, 2 × 90 mg ticagrelor, 1 × 1.25 mg bisoprolol, 1 × 5 mg perindopril, 1 × 20 mg rosuvastatin, and 1 × 20 mg pantoprazole. He was referred to a further cardiac rehabilitation program.

Based on the guidelines of the European Society of Cardiology (ESC) for the management of STEMI, an immediate coronary invasive diagnosis and treatment were performed in the presented case [1]. Although the patient was young, physically active, without elevated blood pressure, with a normal lipidogram and without a family history of premature ischemic heart disease, severe atherosclerosis of LAD was confirmed.

In 2021, new ESC guidelines on CV prevention were released. Those recommend using the updated SCORE algorithm SCORE2/SCORE2-OP to estimate an individual’s 10-year risk of fatal and non-fatal CV events (myocardial infarction, stroke) in apparently healthy people aged 4089 years with risk factors that are untreated or have been stable for several years [2]. Although our patient’s estimated CV risk might have been low, this case report suggests that more attention should be paid to younger patients. The introduction of dedicated scales to assess CV risk in such patients might be justified.

There are few differences in epidemiology of CV risk factors between younger and older patients with coronary artery disease. Dyslipidemia is more common among patients <45 years with coronary artery disease than among older counterparts. It was also found that the younger population had a less extensive coronary disease and a better prognosis [3]. Nonetheless, despite a recent decline in tobacco use, smoking remains the strongest modifiable risk factor of ischemic heart disease in young individuals. Quitting smoking reduces CV risk and is essential in cardiological assessment and treatment. According to the Centers for Disease Control and Prevention, most smokers want to cease smoking. However, without professional medical support, only 4% of cigarette users succeed in quitting [4]. Non-pharmacological methods (e.g. “very brief advice”, mood-management therapies in patients with current or past depression) and pharmacological methods (nicotine-replacement therapy, bupropion, varenicline, and cytisine) can be used to increase the chance of quitting [2, 4]. It is important to educate all patients after percutaneous coronary intervention [5].

Certainly, in addition, a family history of premature CV disease and suspected familial hypercholesterolemia should also receive close attention [2].

Supplementary material

Supplementary material is available at

Article information

Conflict of interest: None declared.

Funding: None.

Open access: This article is available in open access under Creative Common Attribution-Non-Commercial-No Derivatives 4.0 International (CC BY-NC-ND 4.0) license, allowing to download articles and share them with others as long as they credit the authors and the publisher, but without permission to change them in any way or use them commercially. For commercial use, please contact the journal office at


  1. Ibanez B, James S, Agewall S, et al. 2017 ESC Guidelines for the management of acute myocardial infarction in patients presenting with ST-segment elevation: The Task Force for the management of acute myocardial infarction in patients presenting with ST-segment elevation of the European Society of Cardiology (ESC). Eur Heart J. 2018; 39(2): 119177, doi: 10.1093/eurheartj/ehx393, 28886621.
  2. Visseren FLJ, Mach F, Smulders YM, et al. 2021 ESC Guidelines on cardiovascular disease prevention in clinical practice. Eur Heart J. 2021; 42(34): 32273337, doi: 10.1093/eurheartj/ehab484, 34458905.
  3. Arantes C, Martins J, Braga CG, et al. Acute coronary syndrome in young adults. European Heart Journal. 2013; 34(suppl 1): P3134, doi: 10.1093/eurheartj/eht309.p3134.
  4. Centers for Disease Control and Prevention. Smoking & Tobacco Use. 2022).
  5. Wójcicki K, Krycińska R, Tokarek T, et al. Knowledge and prevalence of risk factors for coronary artery disease in patients after the first and repeated percutaneous coronary intervention. Kardiol Pol. 2020; 78(2): 147153, doi: 10.33963/KP.15070 31761895.


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