Double Trouble-Hyperhomocysteinemia and Lipoprotein(a) Induced Myocardial Infarction in Very Young - A Case Report

Double Trouble-Hyperhomocysteinemia and Lipoprotein(a) Induced Myocardial Infarction in Very Young - A Case Report | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Case Report Double Trouble-Hyperhomocysteinemia and Lipoprotein(a) Induced Myocardial Infarction in Very Young - A Case Report Rupendra Saha, BHANU DUGGAL, RAGHURAJ CHAWLA This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-4934523/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Background Acute coronary syndrome is a category that includes unstable angina, non-ST-elevation myocardial infarction (NSTEMI), and ST-elevation myocardial infarction (STEMI). Currently, the most significant cause of death globally is coronary artery disease. It is generally not suspected in a young person, especially without a significant family history. Hyperhomocysteinemia and high lipoprotein(a) are important risk factors and can be used in screening tools. Case presentation A 23-year-old male presented with an evolved anterior wall myocardial infarction, which was confirmed by ECG findings and Echocardiography findings. Subsequent coronary angiography was suggestive of a Single vessel with branch vessel disease, which was successfully revascularised with bifurcation stenting. OCT study of the lesion was suggestive of fibro atheromatous lesion with thrombosis. On workup, high lipoprotein(a) and hyperhomocysteinemia were found to be the risk factors for his disease. Conclusion Thus, Lipoprotein(a) and familial hyperhomocysteinemia may not always be associated with a family history of young ASCVD and are important risk factors for screening Intracoronary imaging should be used liberally to understand pathophysiology of the disease and also optimising interventions in such cases CAD AWMI OCT IVUS LIPOPROTEIN(A) HOMOCYSTEINE Figures Figure 1 Figure 2 Figure 3 Figure 4 Figure 5 Background Acute myocardial infarction (AMI), sudden cardiac death, stable angina, and unstable angina are all symptoms of coronary artery disease, an atherosclerotic cardiovascular disease. Acute coronary syndrome is a category that includes unstable angina, non-ST-elevation myocardial infarction (NSTEMI), and ST-elevation myocardial infarction (STEMI). Currently, the most significant cause of death globally is CAD. Over 80% of the world's CVD cases are found in low- and middle-income nations. Eight low- or lower-middle-income nations comprise the South Asian region: Bangladesh, Bhutan, Sri Lanka, India, Nepal, Afghanistan, Pakistan, and the Maldives. The ethnicity of South Asians has been linked to an increased risk of developing CAD and other non-communicable diseases.( 1 ) Case presentation We are presenting a 23-year-old gentleman shopkeeper by occupation, presented with a history of sudden onset severe compressive chest pain, which lasted for five hours ten days before. The pain was reduced with medications from the local hospital but persisted with heavy exertion. He also complained of dyspnoea on mild exertion. A detailed family history didn’t reveal any risk factors, nor did he have any addictions to suggest a cause. On physical examination, he had tachycardia. His BMI was 21.4 kg/sq m. He was admitted from our OPD after admission, and ECG was suggestive of Wellens pattern type A (Fig. 1). (Fig. 1) 2D Echocardiography revealed anterior and anterolateral wall hypokinesia with an estimated ejection fraction of 35–40%. He was started on parenteral anticoagulation and goal-directed medical therapy for heart failure with reduced ejection fraction. Immediately, he was taken for angiography, which was suggestive of single vessel disease of Proximal to mid-diffuse LAD disease with early D1 ostial 100% occlusion. (Fig. 2) (Fig. 2) A blood workup revealed an elevated homocysteine level of 28.52 micromol/l with a Vitamin B12 level of 996 pmol/l and an elevated lipoprotein(a) level of 105 mg/dl. His Lipid profile was otherwise borderline, with Triglycerides of 131 mg/dl and LDL cholesterol of 101 mg/dl, HDL of 31 mg/dl, and Total cholesterol of 158 mg/dl. His RPR for syphilis was negative. He was subsequently taken up for percutaneous angioplasty under OCT guidance. OCT revealed a fibro atheromatous lesion in proximal to mid-LAD unto D2 with red thrombus with a dense lipid-rich plaque with underlying necrosis and calcium at the ostium of D1 (Fig. 3). (Fig. 3) Bifurcation stenting was done under IVUS guidance from LAD to D1. Post angioplasty, TIMI III flow was achieved ( Fig. 4). (Fig. 4) Post-procedure ECG changes reverted to deep QS complexes in anterior leads with inverted T waves in V3-V4 (Fig. 5). (Fig. 5) The patient was started on double antiplatelets and statin and ezetimibe as the patient was not affordable for other lipid-lowering therapies. Genetic workup for hyperhomocysteinemia could not be done due to financial constraints. The patient was symptomatically better with adequate cardiovascular rehabilitation. He was discharged and followed up for two weeks to be symptomatically better with a reduction of dyspnoea. He is planned for re-evaluation of lipid profile and lipoprotein(a) on further follow-up. Discussion Increased homocysteine levels and lipoprotein(a) are known to be associated with coronary artery diseases( 2 , 3 ). Lp(a) is the most common monogenetic lipid pathology in the world; around 1.4 billion persons are predicted to have a prevalence of Lp(a) > 50 mg/dL.( 4 ) Increased Lp(a) levels are linked to an increased risk of atherothrombosis, and patients may exhibit a variety of clinical manifestations, such as stroke in younger age groups, ST-segment elevation myocardial infarction in young men, or calcific aortic valvular disease in older adults. In the absence of conventional risk factors, Asian Indians have been shown to have extremely high prevalence rates of coronary artery disease (CAD). In migratory Asian Indians, elevated levels of lipoprotein (a) have been linked to premature CAD. ( 3 ) Still, there is a shortage of information about Lp(a) in individuals with CAD from the Indian subcontinent. The most prevalent causes of hyperhomocysteinemia, which increases the risk of atherosclerosis, include genetic abnormalities, some medications, renal impairment, and B-vitamin deficiencies, particularly folic acid, B( 6 ), and B(12). Elevated homocysteine contributes to atherosclerosis through heightened oxidative stress, compromised endothelial function, and thrombosis induction. According to prospective studies, there is a twofold increase in the risk of cardiovascular disease and a less significant rise in the risk of cerebrovascular disease with elevated plasma homocysteine concentrations. ( 5 ) In our patient, vitamin b12 levels were normal, thus pointing towards inherited hyperhomocysteinemia as the culprit. South Asians present with their first AMI at a younger age than people from other regions, even though CAD is typically seen in adults over 60. Generally, research has found that a patient with CAD who is 45 years of age or under meets this definition. Young CAD is frequently associated with risk factors, including smoking, hypertension, diabetes, dyslipidemia, obesity, and family history. However, there is also evidence linking less frequent risk factors such as coagulation disorders, drug addiction, and vasculitis. ( 6 ) However, despite not having any significant family history of young CAD, our patient most likely suffers from a genetic predisposition of hyperhomocysteinemia and high lipoprotein(a), thus leading to such diseased coronaries Study points Lipoprotein(a) and familial hyperhomocysteinemia may not always be associated with a family history of young ASCVD In our Indian population, it is always advisable to screen out these parameters in the absence of traditional risk factors Awareness about coronary artery disease and its severity should be spread to the young population as well Intracoronary imaging helps us to understand the pathophysiology of coronary artery disease and should be used whenever CAD is suspected in a not-so-usual population Patient perspective He was surprised to be diagnosed with such a condition despite living a healthy lifestyle and with no significant family history. He was symptomatically better after proper cardiac rehabilitation and went back to his usual occupation after two weeks of discharge. Conclusion Thus, Familial hyperhomocysteinemia and high lipoprotein(a) levels can lead to fatal coronary artery disease even in healthy individuals with a healthy lifestyle. Therefore, one should be on the lookout for these traits. Abbreviations AMI Acute Myocardial Infarction NSTEMI Non-ST elevated Myocardial Infarction STEMI ST elevated Myocardial infarction CAD coronary artery disease Lp(a) lipoprotein(a) BMI Body Mass Index OCT Optical coherence tomography LDL low density lipoprotein HDL high density lipoprotein ECG Electrocardiogram LAD Left anterior descending artery D1 1st Diagonal branch IVUS Intravascular Ultrasound Declarations Ethical statement The Cardiology Departmental Ethics Committee of AIIMS Rishikesh approved the project. In addition, we confirm that all applicable rules and guidelines are executed in all processes. Informed consent was obtained from all subjects. All data was collected following sound clinical practice principles and the Declaration of Helsinki. Informed consent Informed consent was taken from the patient Consent for publication We confirm that the manuscript has been read and approved by all named authors and that no other persons have satisfied the criteria for authorship but are not listed. We further confirm that all have approved the order of authors noted in the manuscript. We confirm that we have given that there are no objections to publication, including the timing of publication, concerning intellectual property. Data availability statement The data supporting this study's findings are not openly available due to reasons of sensitivity and are available from the corresponding author upon reasonable request. Data are located in controlled access data storage at the Cardiology Department of AIIMS Rishikesh. References Yusuf S, Hawken S, Ounpuu S, et al. Effect of potentially modifiable risk factors associated with myocardial infarction in 52 countries (the INTERHEART study): case-control study. Lancet 2004; 364: 937–952. 2004/09/15. DOI: 10.1016/s0140-6736(04)17018-9 . Tripathi R, Tewari S, Singh PK, Agarwal S. Association of homocysteine and methylene tetrahydrofolate reductase (MTHFR C677T) gene polymorphism with coronary artery disease (CAD) in the population of North India. Genet Mol Biol. 2010;33(2):224–8. doi: 10.1590/S1415-47572010005000026 . Epub 2010 Jun 1. PMID: 21637473; PMCID: PMC3036870. Mohan V, Deepa R, Haranath SP, Premalatha G, Rema M, Sastry NG, Enas EA. Lipoprotein(a) is an independent risk factor for coronary artery disease in NIDDM patients in South India. Diabetes Care. 1998;21(11):1819-23. doi: 10.2337/diacare.21.11.1819 . PMID: 9802727. Tsimikas S, Stroes ESG. The dedicated “Lp(a) clinic”: A concept whose time has arrived? Atherosclerosis. 2020;300:1–9. doi: 10.1016/j.atherosclerosis.2020.03.003 . Epub 2020 Mar 13. PMID: 32234580. Guthikonda S, Haynes WG. Homocysteine: role and implications in atherosclerosis. Curr Atheroscler Rep. 2006;8(2):100-6. doi: 10.1007/s11883-006-0046-4 . PMID: 16510043. Agrawal A, Lamichhane P, Eghbali M, Xavier R, Cook DE, Elsherbiny RM, Jhajj LK, Khanal R. Risk factors, lab parameters, angiographic characteristics and outcomes of coronary artery disease in young South Asian patients: a systematic review. J Int Med Res. 2023;51(8):3000605231187806. doi: 10.1177/03000605231187806 . PMID: 37555333; PMCID: PMC10413899. Additional Declarations No competing interests reported. Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-4934523","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Case Report","associatedPublications":[],"authors":[{"id":353637527,"identity":"dde8d666-1604-44ed-bd6f-ec94abb89e8f","order_by":0,"name":"Rupendra 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Report\u003c/p\u003e","fulltext":[{"header":"Background","content":"\u003cp\u003eAcute myocardial infarction (AMI), sudden cardiac death, stable angina, and unstable angina are all symptoms of coronary artery disease, an atherosclerotic cardiovascular disease. Acute coronary syndrome is a category that includes unstable angina, non-ST-elevation myocardial infarction (NSTEMI), and ST-elevation myocardial infarction (STEMI). Currently, the most significant cause of death globally is CAD. Over 80% of the world's CVD cases are found in low- and middle-income nations. Eight low- or lower-middle-income nations comprise the South Asian region: Bangladesh, Bhutan, Sri Lanka, India, Nepal, Afghanistan, Pakistan, and the Maldives. The ethnicity of South Asians has been linked to an increased risk of developing CAD and other non-communicable diseases.(\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e)\u003c/p\u003e"},{"header":"Case presentation","content":"\u003cp\u003eWe are presenting a 23-year-old gentleman shopkeeper by occupation, presented with a history of sudden onset severe compressive chest pain, which lasted for five hours ten days before. The pain was reduced with medications from the local hospital but persisted with heavy exertion. He also complained of dyspnoea on mild exertion. A detailed family history didn\u0026rsquo;t reveal any risk factors, nor did he have any addictions to suggest a cause. On physical examination, he had tachycardia. His BMI was 21.4 kg/sq m. He was admitted from our OPD after admission, and ECG was suggestive of Wellens pattern type A (Fig.\u0026nbsp;1).\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003e(Fig.\u0026nbsp;1)\u003c/h2\u003e \u003cp\u003e \u003cdiv class=\"BlockQuote\"\u003e \u003cp\u003e2D Echocardiography revealed anterior and anterolateral wall hypokinesia with an estimated ejection fraction of 35\u0026ndash;40%. He was started on parenteral anticoagulation and goal-directed medical therapy for heart failure with reduced ejection fraction. Immediately, he was taken for angiography, which was suggestive of single vessel disease of Proximal to mid-diffuse LAD disease with early D1 ostial 100% occlusion. (Fig.\u0026nbsp;2)\u003c/p\u003e \u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec4\" class=\"Section2\"\u003e \u003ch2\u003e(Fig.\u0026nbsp;2)\u003c/h2\u003e \u003cp\u003e \u003cdiv class=\"BlockQuote\"\u003e \u003cp\u003eA blood workup revealed an elevated homocysteine level of 28.52 micromol/l with a Vitamin B12 level of 996 pmol/l and an elevated lipoprotein(a) level of 105 mg/dl. His Lipid profile was otherwise borderline, with Triglycerides of 131 mg/dl and LDL cholesterol of 101 mg/dl, HDL of 31 mg/dl, and Total cholesterol of 158 mg/dl. His RPR for syphilis was negative. He was subsequently taken up for percutaneous angioplasty under OCT guidance. OCT revealed a fibro atheromatous lesion in proximal to mid-LAD unto D2 with red thrombus with a dense lipid-rich plaque with underlying necrosis and calcium at the ostium of D1 (Fig.\u0026nbsp;3).\u003c/p\u003e \u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003cdiv class=\"BlockQuote\"\u003e \u003cp\u003e \u003cb\u003e(Fig.\u0026nbsp;3)\u003c/b\u003e \u003c/p\u003e \u003c/div\u003e \u003c/p\u003e \u003cp\u003eBifurcation stenting was done under IVUS guidance from LAD to D1. Post angioplasty, TIMI III flow was achieved ( Fig.\u0026nbsp;4).\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec5\" class=\"Section2\"\u003e \u003ch2\u003e(Fig.\u0026nbsp;4)\u003c/h2\u003e \u003cp\u003ePost-procedure ECG changes reverted to deep QS complexes in anterior leads with inverted T waves in V3-V4 (Fig.\u0026nbsp;5).\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec6\" class=\"Section2\"\u003e \u003ch2\u003e(Fig.\u0026nbsp;5)\u003c/h2\u003e \u003cp\u003eThe patient was started on double antiplatelets and statin and ezetimibe as the patient was not affordable for other lipid-lowering therapies. Genetic workup for hyperhomocysteinemia could not be done due to financial constraints. The patient was symptomatically better with adequate cardiovascular rehabilitation. He was discharged and followed up for two weeks to be symptomatically better with a reduction of dyspnoea. He is planned for re-evaluation of lipid profile and lipoprotein(a) on further follow-up.\u003c/p\u003e \u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003eIncreased homocysteine levels and lipoprotein(a) are known to be associated with coronary artery diseases(\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e). Lp(a) is the most common monogenetic lipid pathology in the world; around 1.4\u0026nbsp;billion persons are predicted to have a prevalence of Lp(a)\u0026thinsp;\u0026gt;\u0026thinsp;50 mg/dL.(\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e) Increased Lp(a) levels are linked to an increased risk of atherothrombosis, and patients may exhibit a variety of clinical manifestations, such as stroke in younger age groups, ST-segment elevation myocardial infarction in young men, or calcific aortic valvular disease in older adults. In the absence of conventional risk factors, Asian Indians have been shown to have extremely high prevalence rates of coronary artery disease (CAD). In migratory Asian Indians, elevated levels of lipoprotein (a) have been linked to premature CAD. (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e) Still, there is a shortage of information about Lp(a) in individuals with CAD from the Indian subcontinent. The most prevalent causes of hyperhomocysteinemia, which increases the risk of atherosclerosis, include genetic abnormalities, some medications, renal impairment, and B-vitamin deficiencies, particularly folic acid, B(\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e), and B(12). Elevated homocysteine contributes to atherosclerosis through heightened oxidative stress, compromised endothelial function, and thrombosis induction. According to prospective studies, there is a twofold increase in the risk of cardiovascular disease and a less significant rise in the risk of cerebrovascular disease with elevated plasma homocysteine concentrations. (\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e) In our patient, vitamin b12 levels were normal, thus pointing towards inherited hyperhomocysteinemia as the culprit. South Asians present with their first AMI at a younger age than people from other regions, even though CAD is typically seen in adults over 60. Generally, research has found that a patient with CAD who is 45 years of age or under meets this definition. Young CAD is frequently associated with risk factors, including smoking, hypertension, diabetes, dyslipidemia, obesity, and family history. However, there is also evidence linking less frequent risk factors such as coagulation disorders, drug addiction, and vasculitis. (\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e) However, despite not having any significant family history of young CAD, our patient most likely suffers from a genetic predisposition of hyperhomocysteinemia and high lipoprotein(a), thus leading to such diseased coronaries\u003c/p\u003e \u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003eStudy points\u003c/h2\u003e \u003cp\u003e \u003cul\u003e \u003cli\u003e \u003cp\u003eLipoprotein(a) and familial hyperhomocysteinemia may not always be associated with a family history of young ASCVD\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003eIn our Indian population, it is always advisable to screen out these parameters in the absence of traditional risk factors\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003eAwareness about coronary artery disease and its severity should be spread to the young population as well\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003eIntracoronary imaging helps us to understand the pathophysiology of coronary artery disease and should be used whenever CAD is suspected in a not-so-usual population\u003c/p\u003e \u003c/li\u003e \u003c/ul\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec9\" class=\"Section2\"\u003e \u003ch2\u003ePatient perspective\u003c/h2\u003e \u003cp\u003eHe was surprised to be diagnosed with such a condition despite living a healthy lifestyle and with no significant family history. He was symptomatically better after proper cardiac rehabilitation and went back to his usual occupation after two weeks of discharge.\u003c/p\u003e \u003c/div\u003e"},{"header":"Conclusion","content":"\u003cp\u003eThus, Familial hyperhomocysteinemia and high lipoprotein(a) levels can lead to fatal coronary artery disease even in healthy individuals with a healthy lifestyle. Therefore, one should be on the lookout for these traits.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cdiv class=\"DefinitionList\"\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eAMI\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eAcute Myocardial Infarction\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eNSTEMI\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eNon-ST elevated Myocardial Infarction\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eSTEMI\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eST elevated Myocardial infarction\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eCAD\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003ecoronary artery disease\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eLp(a)\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003elipoprotein(a)\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eBMI\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eBody Mass Index\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eOCT\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eOptical coherence tomography\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eLDL\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003elow density lipoprotein\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eHDL\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003ehigh density lipoprotein\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eECG\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eElectrocardiogram\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eLAD\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eLeft anterior descending artery\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eD1\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003e1st Diagonal branch\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eIVUS\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eIntravascular Ultrasound\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003c/div\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthical statement\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe Cardiology Departmental Ethics Committee of AIIMS Rishikesh approved the project. \u0026nbsp;In addition, we confirm that all applicable rules and guidelines are executed in all processes. Informed consent was obtained from all subjects. All data was collected following sound clinical practice principles and the Declaration of Helsinki.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eInformed consent\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eInformed consent was taken from the patient\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWe confirm that the manuscript has been read and approved by all named authors and that no other persons have satisfied the criteria for authorship but are not listed. We further confirm that all have approved the order of authors noted in the manuscript. We confirm that we have given that there are no objections to publication, including the timing of publication, concerning intellectual property.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData availability statement\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe data supporting this study\u0026apos;s findings are not openly available due to reasons of sensitivity and are available from the corresponding author upon reasonable request. Data are located in controlled access data storage at the Cardiology Department of AIIMS Rishikesh.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eYusuf S, Hawken S, Ounpuu S, et al. Effect of potentially modifiable risk factors associated with myocardial infarction in 52 countries (the INTERHEART study): case-control study. Lancet 2004; 364: 937\u0026ndash;952. 2004/09/15. DOI: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1016/s0140-6736(04)17018-9\u003c/span\u003e\u003cspan address=\"10.1016/s0140-6736(04)17018-9\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eTripathi R, Tewari S, Singh PK, Agarwal S. Association of homocysteine and methylene tetrahydrofolate reductase (MTHFR C677T) gene polymorphism with coronary artery disease (CAD) in the population of North India. Genet Mol Biol. 2010;33(2):224\u0026ndash;8. doi: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1590/S1415-47572010005000026\u003c/span\u003e\u003cspan address=\"10.1590/S1415-47572010005000026\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e. Epub 2010 Jun 1. PMID: 21637473; PMCID: PMC3036870.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMohan V, Deepa R, Haranath SP, Premalatha G, Rema M, Sastry NG, Enas EA. Lipoprotein(a) is an independent risk factor for coronary artery disease in NIDDM patients in South India. Diabetes Care. 1998;21(11):1819-23. doi: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.2337/diacare.21.11.1819\u003c/span\u003e\u003cspan address=\"10.2337/diacare.21.11.1819\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e. PMID: 9802727.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eTsimikas S, Stroes ESG. The dedicated \u0026ldquo;Lp(a) clinic\u0026rdquo;: A concept whose time has arrived? Atherosclerosis. 2020;300:1\u0026ndash;9. doi: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1016/j.atherosclerosis.2020.03.003\u003c/span\u003e\u003cspan address=\"10.1016/j.atherosclerosis.2020.03.003\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e. Epub 2020 Mar 13. PMID: 32234580.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGuthikonda S, Haynes WG. Homocysteine: role and implications in atherosclerosis. Curr Atheroscler Rep. 2006;8(2):100-6. doi: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1007/s11883-006-0046-4\u003c/span\u003e\u003cspan address=\"10.1007/s11883-006-0046-4\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e. PMID: 16510043.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAgrawal A, Lamichhane P, Eghbali M, Xavier R, Cook DE, Elsherbiny RM, Jhajj LK, Khanal R. Risk factors, lab parameters, angiographic characteristics and outcomes of coronary artery disease in young South Asian patients: a systematic review. J Int Med Res. 2023;51(8):3000605231187806. doi: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1177/03000605231187806\u003c/span\u003e\u003cspan address=\"10.1177/03000605231187806\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e. PMID: 37555333; PMCID: PMC10413899.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":true,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"CAD, AWMI, OCT, IVUS, LIPOPROTEIN(A), HOMOCYSTEINE","lastPublishedDoi":"10.21203/rs.3.rs-4934523/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-4934523/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003eAcute coronary syndrome is a category that includes unstable angina, non-ST-elevation myocardial infarction (NSTEMI), and ST-elevation myocardial infarction (STEMI). Currently, the most significant cause of death globally is coronary artery disease. It is generally not suspected in a young person, especially without a significant family history. Hyperhomocysteinemia and high lipoprotein(a) are important risk factors and can be used in screening tools.\u003c/p\u003e\u003ch2\u003eCase presentation\u003c/h2\u003e \u003cp\u003eA 23-year-old male presented with an evolved anterior wall myocardial infarction, which was confirmed by ECG findings and Echocardiography findings. Subsequent coronary angiography was suggestive of a Single vessel with branch vessel disease, which was successfully revascularised with bifurcation stenting. OCT study of the lesion was suggestive of fibro atheromatous lesion with thrombosis. On workup, high lipoprotein(a) and hyperhomocysteinemia were found to be the risk factors for his disease.\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e \u003cp\u003eThus, Lipoprotein(a) and familial hyperhomocysteinemia may not always be associated with a family history of young ASCVD and are important risk factors for screening Intracoronary imaging should be used liberally to understand pathophysiology of the disease and also optimising interventions in such cases\u003c/p\u003e","manuscriptTitle":"Double Trouble-Hyperhomocysteinemia and Lipoprotein(a) Induced Myocardial Infarction in Very Young - A Case Report","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-10-01 12:36:27","doi":"10.21203/rs.3.rs-4934523/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"7d55ff18-2b54-45f7-9c5c-365b53692ac1","owner":[],"postedDate":"October 1st, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2024-10-18T08:53:12+00:00","versionOfRecord":[],"versionCreatedAt":"2024-10-01 12:36:27","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-4934523","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-4934523","identity":"rs-4934523","version":["v1"]},"buildId":"cBFmMYwuxLRRLfASyISRj","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}