Acute Coronary Syndrome in Well Trained Young Adult: A Rare Cases

Acute Coronary Syndrome (ACS) has been observed in the older population (>40 years old), sedentary lifestyle and unhealthy behavior. Recently, there is an increase of ACS reported in the younger population even without a sedentary lifestyle. We report a case of a well-trained 25-years old man that came with late presentation of ST elevation myocardial infarction (STEMI) occurred 10 minutes after vigorous exercise. His traditional risk factor was a smoker. Electrocardiogram (ECG) showed a pathological Q wave in anteroseptal lead and T wave inversion in anterior lead with elevated cardiac biomarker. Primary percutaneous coronary intervention (PPCI) was performed due to prolonged chest pain and it showed subtotal occlusion in mid left anterior descending artery (LAD) with high thrombus burden. Drug eluting stent (DES) was implanted at mid LAD and GPIIb/IIIa inhibitor and low molecule weight heparin was given with good clinical result. Case Report Acute Coronary Syndrome in Well Trained Young Adult: A Rare Cases A. A. Indah1*, P. V. Ramadhan2, V. Pratama3, Haikal3, and Irnizarifka4 1 General Practitioner, Department of Cardiology and Vascular Medicine, Indonesia Army Central Hospital Gatot Soebroto, Jakarta, Indonesia. 2 General Practitioner, Emergency Department, Tengku Rafi’an Hospital, Riau, Indonesia. 3 Cardiologist, Department of Cardiology and Vascular Medicine, Indonesia Army Central Hospital Gatot Soebroto, Jakarta, Indonesia. 4 Cardiologist, Department of Cardiology and Vascular Medicine, Sebelas Maret University, Solo, Indonesia.


Introduction
Acute Coronary Syndrome (ACS) is well known as the most likely to occur after 45 years of age especially in patients with high cardiovascular risk [1]. The incidence of ACS in young adults is increasing recently especially in people with cardiovascular risk such as smoking, dyslipidemia, diabetes, and family history of ACS [2]. However, risk of acute coronary event in young adult, can increase in healthy people with vigorous physical activity even without cardiovascular risk [3].

Case Presentation
A 25-years old man and well-trained was referred from District Hospital to Gatot Soebroto Army Central Hospital with typical chest pain, diaphoresis, nausea and vomiting that lasted for 18 September 2020 | Vol 1 | Article 6 hours before hospitalization. These symptoms occurred 10 minutes after doing vigorous exercise for one hour in the afternoon such as running, push up and pull up. One month earlier, he had the same symptoms after exercise which relieved by rest. His traditional risk factor was smoking. He routinely exercises such as running, sit up and push up 4-5 times a week for 1 hour for the last 8 years. He also performed weight lifting exercise at gym as daily activities. There was no history of alcohol consumption nor family history who had a sudden cardiac death and acute coronary syndrome.
Physical examination within normal limit with no sign of acute heart failure, his body mass index (BMI) was within the normal limit. The chest X-Ray also showed cardiomegaly. Electrocardiogram (ECG) showed sinus bradycardia 50bpm, Q wave in lead V1-V3 with T wave inversion in lead V1-V6 ( Figure 1).

Discussion
Acute Coronary Syndrome (ACS) is known globally as a major cause of disability and death. Based on international Survey of Acute Coronary Syndrome in Transitional Countries, incidence of ACS in young age was 6% which is associated with a sedentary lifestyle [4]. Regular physical activity is proven to delay the atherosclerosis process and reduce coronary heart disease incidence. 5 But vigorous physical activity could also lead to acute Myocardial Infarction (MI) and Sudden Cardiac Death (SCD) in susceptible populations [6].
In general physical activity can be categorized Vigorous exercise is defined as an absolute exercise work rate for at least 6 metabolic equivalent (METs) ( Table 1) [8]. Vigorous exercise could increase the risk of cardiovascular events during or immediately after exercise and it happens frequently in the afternoon or in early evening [9].
Vigorous-intensity-exercise or high-intensityexercise is a physical activity which requires a large amount of effort resulting in a higher heart rate, and rapid breathing, such as jogging or running [10]. In Some studies estimated that an individual's risk of AMI onset was transiently increased 5-fold within 2 hours of an episode of vigorous exercise (METs ≥ 6) and 1.6-fold within 2 hours of moderate exercise compared lower levels of exercise [12].
Interestingly, compare with indoors activity, strenuous outdoor activity was more associated with an increase of AMI symptom onset. 12 Vigorous intensity exercise has a small but measurable acute risk of cardiovascular complication. Therefore, it is important to mitigate this risk in susceptible individuals. The exact mechanism in which vigorous activity led to AMI was poorly understood. But it is thought to be a triggering mechanism including increased wall stress, coronary spasm, the thrombotic occlusion.
The increase of wall stress is causing an increase of the heart rate and blood pressure [3]. Vigorous exercise could also trigger the coronary spasm of the diseased artery segment and increase the flexing of atherosclerotic epicardial coronary arteries which lead disruption of plaque and thrombotic occlusion [13]. The other mechanism is thrombosis by deepening existing coronary fissure, augmenting catecholamine-induced platelet aggregation [14]. Mildly fissure coronary plaque requires some exacerbating event to induce coronary thrombosis [14]. not Despite an increases September 2020 | Vol 1 | Article 6 of myocardial oxygen demand, Vigorous exercise can also induce simultaneously shortening diastole and coronary perfusion time resulting in myocardial ischemia [15]. Myocardial fibrosis is a result of the extreme training with more than five-years of continuous intense training [16].
In some studies, vigorous training could also lead to cardiac hypertrophy. Interestingly, not all people who exercise vigorously lead to myocardial infarction.
It is presumed that cardiovascular risk factors play a part in this matter [6,19]. The most important risk factor observed and reported in the young adult with MI was cigarette smoking [20]. It is proven that smokers are more susceptible to myocardial infarction compared to non-smokers [21]. It was concluded based on the fact that cigarette smoking has a role in the development of atherosclerosis and vascular spasm by increasing the number of mLDL (which is the key to atherosclerosis formation), platelet aggregation, endothelial dysfunction, inflammation and decreasing number of Nitric Oxide (NO) [22,23].

Conclusion
Exercise is one of the recommended activities to prevent coronary heart disease. But, exercise vigorously or too much could also lead to myocardial infarction that could happen even in healthy young adults. It is also important to address that a cardiovascular risk factor such as cigarette smoking has a role as catalyst in the development of acute myocardial infarction. We conclude that vigorous exercise combined with cigarette smoking might be the cause of acute myocardial infarction in this young and healthy man.