Open Access

Original Article

Risk factors for coronary heart disease in

patients below 45 years of age
Mansoor Nadeem1, Syed Shahzad Ahmed2, Sarah Mansoor3, Sidra Farooq4
ABSTRACT
Objective: To examine the traditional risk factors and biochemical profile of patients with established CAD
(coronary artery disease), and compare the trends of these in specified age groups of different populations
as depicted in various studies.
Methodology: All consecutive patients below 45 years of age, having classical history of Ischemic heart
disease and also having definite ECG changes consistent with coronary artery disease were enrolled. These
patients were admitted to CCU/Intermediate Coronary Care Unit of Pakistan Ordinance Factories (POF)
Hospital Wah Cantonment from April 2007 to December 2011. Patients who had doubtful history as regards
CHD and those having ECG changes not classically consistent with CAD were excluded. Information collected
through Performa included history including family history and details of risk factors. Clinical examination
was carried out and relevant investigations including the serial ECG changes were recorded. Blood samples
were collected after an overnight fast of 14 hours and tests were done for total cholesterol and HDL
cholesterol by using Pioneer-USA, linear chemical kits by cholesterol oxidase and enzymatic calometric
method.
Results: A total of 109 cases were included. Cigarette smoking (46%) Family history (43%), Hypertension
(37%), Dyslipidemia (33%), Diabetes mellitus (18%) and above normal BMI (63.3%) are the most common
risk factors in our patients. Increased abdominal girth has appeared to be an important risk factor and at
occasions is documented to be independent of obesity. Casual dietary habits and sedentary life style are
the other less important risk factors. The majority of risk factors were equally prevalent in males as well
as females except smoking which was less prevalent in females.
Conclusions: Our study shows that Family history, Smoking, Hypertension, increased BMI, increased
Abdominal girth, Dyslipidemia and Diabetes Mellitus are the main risk factors. Considering the increasing
incidence of the coronary heart disease in our society it is essential to assess and evaluate these risk
factors at national level.
KEY WORDS: Risk Factors, Coronary Artery Disease.

doi: http://dx.doi.org/10.12669/pjms.291.2828
How to cite this:
Nadeem M, Ahmed SS, Mansoor S, Farooq S. Risk factors for coronary heart disease in patients below 45 years of age. Pak J Med Sci
2013;29(1):91-96. doi: http://dx.doi.org/10.12669/pjms.291.2828
This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0),
which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

1. Mansoor Nadeem, MBBS, MCPS, FCPS, INTRODUCTION

Associate Professor, Department of Medicine,
2. Syed Shahzad Ahmed, MBBS,
House Officer, Department of Medicine
Coronary artery disease (CAD) remains the
3. Sarah Mansoor, MBBS, commonest cause of mortality world wide.1
House Officer, Department of Radiology,
4. Sidra Farooq, MBBS,
South Asians are prone to develop advanced
PGT FCPS Part II, Department of Medicine, atherosclerosis and highest mortality rate due to
2-4: POF Hospital, Wah Medical College,
Wah Cantonment, Punjab, Pakistan.
its complications compared to other ethnic groups
Correspondence: studied.2 It has been documented that younger age
Mansoor Nadeem, MBBS, MCPS, FCPS, group people are developing the diseases frequently
E-mail: [email protected]
than before in last couple of years.3 Various studies
* Received for Publication: August 16, 2012
* Revision Received: September 6, 2012
show that in comparison with older patients
* Revision Accepted: November 26, 2012 these patients have single vessel disease4, has

Pak J Med Sci 2013 Vol. 29 No. 1 www.pjms.com.pk 91

Mansoor Nadeem et al.

more profound hypercholesterolemia4, significant family history and details of risk factors. Clinical
positive family history4 and history of smoking.5 examination was carried out and relevant investi-
There are a number of such studies from developed gations including the serial ECG changes were re-
countries but only a few from Pakistan. corded. Blood samples were collected after an over-
Coronary heart disease mortality is generally night fast of 14 hours and tests were done for total
accepted as an indicator of socio-economic cholesterol and HDL cholesterol by using Pioneer-
conditions. In a changing social environment, USA, linear chemical kits by cholesterol oxidase
early detection and treatment of youths at risk of and enzymatic calometric method.
premature IHD offers the greatest promise and The patients were considered suffering
an opportunity for age-specific interventions.6 from hypertension once the patient was on
Moreover, the potential gains from controlling antihypertensive medications at the time of
major established risk factors could be substantial admission or the past medical history / record
in South Asians and greater than that in Europeans.7 documented raised BP at multiple occasions or
The purpose of this study was to evaluate the BP was recorded higher (>140/90 mmHg) at
different risk factors prevailing in patients below 45 separate occasions while remained admitted.
years of age suffering from coronary heart disease. Diabetes Mellitus was considered to be present
when either patient was taking any anti-diabetic
METHODOLOGY agents or blood glucose was found to be > 126 mg/
All consecutive patients age below 45 years, dl fasting or > 200 mg/dl at random sample at more
having classical history of Ischemic heart disease and than 02 occasions.
also having definite ECG changes consistent with Cigarette smoking was labeled if the patient
coronary artery disease (recent / old) were enrolled. had smoked within last 03 years. Family history
These patients were admitted to CCU/Intermediate of ischemic heart disease was considered positive
Coronary Care Unit of Pakistan ordinance factories when any close relative <55 years of age in males or
(POF) Hospital Wah Cantonment from April 2007 <65 years in female had history of angina pectoris
to December 2011. POF Hospital Wah Cantonment or myocardial infarction in past.
is 620 bedded tertiary care centre for the employees Dyslipidemia was considered when total choles-
and their dependents, civilians living at POF Wah terol was found more than 5.2 - 6.5mmol/L (200
cantonment and tertiary care referral hospital mg/dl) and high density lipoproteins (HDL) <1.0
for POF Sanjwal cantonment and POF Havelian mmol/L (≤ 40 mg/dl). The data was processed on
cantonment. SPSS Statistics v16.
In total one hundred and nine (109) patients were RESULTS
included in the study. Patients who had doubtful
history as regards coronary heart disease and those The study comprised of 109 patients with mean
having ECG changes not classically consistent with age 41 years. There were 67 males (61%) and 42 fe-
CAD were excluded. The patients were divided males (39%) (Table-I). Males mean age was 42 years
into 4 groups on the bases of age; group1, <30 years; and females mean age was 41 years. Further divi-
group2, between 31-35 years; group3, between 36- sions of patients were made according to age in 4
40 years and group 4 between 41- 45 years. groups. Group 1, age < 30 years had a total of 04 (02
A detailed comprehensive Performa was filled males & 02 female). Group 2, ages from 31- 35 years
by our trained doctors regarding history including had a total of 11 (08 males and 03 females), group

Table-I: Distribution according to gender & age.

Total Gender
Male Female
Count % Count Table N % Count Table N %
Age Category(years) <=30 4 3.7% 2 1.8% 2 1.8%
31-35 11 10.1% 8 7.3% 3 2.8%
36-40 24 22.0% 12 11.0% 12 11.0%
41-45 70 64.2% 45 41.3% 25 22.9%
Total 67 61.5% 42 38.5%

92 Pak J Med Sci 2013 Vol. 29 No. 1 www.pjms.com.pk

 Risk factors for coronary heart disease

Table-II: Distribution of risk factors according to gender.

S. No. Gender
Male Female Total
Count Table N% Count Table N% Count %
a. Smoking Yes 47 43.1% 3 2.8% 50 45.9%
No 20 18.3% 39 35.8% 59 54.1%
b. Family History Positive 28 25.7% 19 17.4% 47 43.1%
Negative 39 35.8% 23 21.1% 62 56.9%
c. Hypertension Yes 22 20.2% 18 16.5% 40 36.7%
No 45 41.3% 24 22.0% 69 63.3%
d. Dyslipidemias Yes 21 19.3% 12 11.0% 33 30.3%
No 46 42.2% 30 27.5% 76 69.7%
e. Diabetes Mellitus Yes 15 13.8% 5 4.6% 20 18.3%
No 52 47.7% 37 33.9% 89 81.7%
f. BMI (Kg/m2) <18.50 1 0.9% 0 0.0% 1 0.9%
Normal (18.5-24.9) 30 27.8% 9 8.3% 39 35.8%
Overweight (25-29.9) 25 23.1% 24 22.2% 49 45.0%
Class I Obesity (30-34.9) 8 7.4% 9 8.3% 17 15.6%
Class II Obesity (35-39.9) 1 0.9% 0 0.0% 1 0.9%
Class III Obesity >40 1 0.9% 0 0.0% 1 0.9%
g. Abdominal Girth (inches) 31-35 18 18.6% 2 2.1% 20 18.3%
36-40 30 30.9% 34 35.1% 64 58.7%
41-45 8 8.2% 3 3.1% 11 10.1%
46-50 2 2.1% 0 0.0% 2 1.8%
h. Diet Good 29 26.6% 13 11.9% 42 38.5%
Bad 38 34.9% 29 26.6% 67 61.5%
i. Lifestyle Active 29 26.6% 5 4.6% 34 31.2%
Sedentary 38 34.9% 37 33.9% 75 68.8%
j. Work/Job Executive 10 9.2% 1 0.9% 11 10.1%
Office work 24 22.0% 4 3.7% 28 25.7%
Manual work 32 29.4% 0 0.0% 32 29.4%
Housewife 0 0.0% 38 34.0% 38 34.9%

3, ages from 36-40 years had a total of 24 (12 males noted in 20 patients (18.3%). Males were 15 (13.8%)
and 12 females). Group 4, ages from 41- 45 years and females 5 (4.6%). Seventy percent of the
had a total of 70 (males 45 and females 25). Majority diabetics were in age group 4. (Table II & III)
of the patients were in group 4 (64.2%). (Table-I) Forty five percent were overweight with BMI 25-
Smoking was documented in 50 patients (45.9%). 29.9 Kg/m2. Majority of these patients were in age
Forty seven (43.1%) were males and only 3 (2.8%) groups 3 and 4. A reasonable number of patients
were females. Eighty percent of the smokers were (15.6%) had class I obesity (BMI 30- 34.9 Kg/m2).
in age group 4. Strong family history for CAD was Only 35.8% patients had normal weight and had
noted in 47 patients (43.1%), 28 (25.7%) were males normal BMI (18-24.9 Kg/m2). (Table-IV)
and 19 (17.4%) was females. (Table II & III) Abdominal girth was noted to be an important
Hypertension was noted in 40 patients (36.7%). risk factor and at times operate independent of obe-
Twenty two (20.2%) were males and 18 (16.5%) were sity (Increased BMI). Fifteen cases with 36-40 inches
females. Seventy five percent of the hypertensive abdominal girth were noted with normal BMI (18-
patients were in age group 4. Dyslipidemia was 25 Kg/m2), 37 patients had girth of 36-40 inches
noted in 33 (30.3%) patients and of these 21 (19.3%) while having BMI 26-30 Kg/m2 and 08 patients had
were males and 12 (11%) females. Average serum abdominal girth of 36 - 41 inches while having BMI
cholesterol was 5.85 mmol/L and HDL was 1.005 of 26-30 Kg/m2. Only 04 patients had 41-45 inches
mmol/L. Fifty eight percent of the patients with of abdominal girth. (Table-IV)
dyslipidemias were in age group 3 and 15% of Casual dietary habits were noted in 67 (61.5%),
patients were in group 2. Diabetes Mellitus was of these 38 (34.9%) were males and 29 (26.6%) were

Pak J Med Sci 2013 Vol. 29 No. 1 www.pjms.com.pk 93

Mansoor Nadeem et al.

Table-III: Distribution of risk factors according to age group.

S. No. Age Category (years)
<=30 31-35 36-40 41-45
Count Table N % Count Table N % Count Table N % Count Table N %
a. Smoking Yes 1 0.9% 2 1.8% 7 6.4% 40 36.7%
No 3 2.8% 9 8.3% 17 15.6% 30 27.5%
b. Family History Positive 1 0.9% 5 4.6% 11 10.1% 30 27.5%
Negative 3 2.8% 6 5.5% 13 11.9% 40 36.7%
c. Hypertension Yes 2 1.8% 1 0.9% 7 6.4% 30 27.5%
No 2 1.8% 10 9.2% 17 15.6% 40 36.7%
d. Dyslipidemias Yes 1 0.9% 5 4.6% 3 2.8% 24 22.0%
No 3 2.8% 6 5.5% 21 19.3% 46 42.2%
e. Diabetes Mellitus Yes 0 0.0% 2 1.8% 4 3.7% 14 12.8%
No 4 3.7% 9 8.3% 20 18.3% 56 51.4%
f. BMI (Kg/m2) <18.50 0 0.0% 0 0.0% 0 0.0% 1 0.9%
Normal 1 0.9% 5 4.6% 11 10.2% 22 20.4%
(18.5-24.9)
Overweight 3 2.8% 6 5.6% 7 6.5% 33 30.6%
(25-29.9)
Class I Obesity 0 0.0% 0 0.0% 6 5.6% 11 10.2%
(30-34.9)
Class II Obesity 0 0.0% 0 0.0% 0 0.0% 1 0.9%
(35-39.9)
Class III Obesity 0 0.0% 0 0.0% 0 0.0% 1 0.9%
(>40)
g. Abdominal 31-35 1 1.0% 2 2.1% 5 5.2% 12 12.4%
Girth (inches) 36-40 3 3.1% 4 4.1% 12 12.4% 45 46.4%
41-45 0 0.0% 0 0.0% 4 4.1% 7 7.2%
46-50 0 0.0% 0 0.0% 0 0.0% 2 2.1%
h. Diet Good 2 1.8% 3 2.8% 9 8.3% 28 25.7%
Bad 2 1.8% 8 7.3% 15 13.8% 42 38.5%
i. Lifestyle Active 2 1.8% 4 3.7% 7 6.4% 21 19.3%
Sedentary 2 1.8% 7 6.4% 17 15.6% 49 45.0%
j. Work/Job Executive 1 0.9% 2 1.8% 0 0.0% 8 7.3%
Office work 0 0.0% 4 3.7% 8 7.3% 16 14.7%
Manual work 1 0.9% 2 1.8% 5 4.6% 24 22.0%
Housewife 2 1.8% 3 2.8% 11 10.1% 22 20.2%

females. Eighteen percent patients with casual study there were 61% males compared to 39% fe-
dietary habits had BMI in normal limits while 42% males. In studies done earlier in Pakistan the female
of patients had increased BMI above the normal population was lower which was probably due to
(<24.9Kg/m2). sample selection bias as the patients were recruited
Active lifestyle was noted in 34 (31.2%) patients, from angiography units and not from the coronary
29 (26.6%) were males and 5 (4.6%) were females. care units.8,9
Majorities (68.8%) of the patients had sedentary life Smoking is important and modifiable risk factor
style and were distributed equally in both sexes. known for CAD.10 Our data shows that the smok-
Thirty four percent of males and only 5% females ing was the dominant risk factor (46%). Only 3%
were employed in executive or sedentary office jobs. females smoked. Several other studies have shown
Thirty eight (95%) females were housewives. Thirty smoking as the most important risk factor among
two patients were manual workers and belonged to the younger patients with CAD.11 Pais et al has
lower socio-economic class. shown it to be the most dominant risk factor in
Indian population studied.12 Our study also dem-
DISCUSSION onstrates that cigarette smoking was the dominant
The prevalence of coronary heart disease has risk factor predisposing to an earlier onset of CAD,
been tremendously increasing in last decade. In this in line with previous studies.13,14

94 Pak J Med Sci 2013 Vol. 29 No. 1 www.pjms.com.pk

 Risk factors for coronary heart disease

Table-IV: Body Mass Index (BMI) vs Abdominal Girth. Increased cholesterol was noted in 33 (33%)
Count patients. Hypercholesterolemia mainly increased
BMI <= 18.50 Abdominal 31-35 1 LDL and decreased HDL are important risk factors.
(Kg/m2) Girth (inches) 36-40 0 It is documented that South Asians have total
41-45 0 cholesterol, LDL-C levels comparable to Afro-
46-50 0 Caribbean’s and whites but they do have higher
Normal Abdominal 31-35 23 Triglycerides and low HDL-C levels.12 In another
(18.5-24.9) Girth (inches) 36-40 15 study done in India has shown that mean TC in
41-45 1 Indians is usually below 200 mg/dl12 but ratio of
46-50 0 TC/HDL-C is significantly lower.14 In our patients
Overweight Abdominal 31-35 8
hypercholesterolemia was highest (73%) in group
(25-29.9) Girth (inches) 36-40 37
41-45 4 4, which is comparable to the findings of Yildirim
46-50 0 et al.14 In another study, no graded strength of
Class I obesity Abdominal 31-35 0 association of hypercholestrolemia with coronary
(30-34.9) Girth (inches) 36-40 11 artery disease could be observed.18 It has also been
41-45 5 observed that in South Asians, CAD occurs at a
46-50 1 much lower level of total cholesterol than other
Class II obesity Abdominal 31-35 0 populations.19
(35-39.9) Girth (inches) 36-40 0 The mechanism of such an observation could be
41-45 1
explained by a study showing that the serum HDL
46-50 0
Class III Abdominal 31-35 0 cholesterol of South Asians is comparable to that
Obesity >40 Girth (inches) 36-40 0 of other populations, only the small HDL particle
41-45 0 size is predominant in them, which does not confer
46-50 1 protection against CAD.20
The Framingham study shows the mechanism Strong family history was noted in 47% of patients
of this correlation; that cigarette smoking is which was equally noted in both males and females
strongly associated with “atherogenic” lipoprotein and appears to be another important risk factor.
cholesterol profiles in young adults.15 This signifies This fact was also highlighted in another study
the fact that cessation of smoking may be the most done in India.21
cost effective approach in primary and secondary There have been several studies to explain the
prevention. mechanism of this correlation. In a study to detect
We have observed that hypertension was the the cardiovascular risk in young adults, it was found
second commonest risk factor (37%) and was equally that young subjects with a positive family history
distributed in both sexes. The exact mechanism of CAD had greater sub-clinical atherosclerosis
through which systemic hypertension induces MI (IMT) compared to those with negative history. The
has not been studied in detail, but there is evidence association between the number of risk factors and
that Hypertension causes LV Hypertrophy and IMT was stronger in subjects with a family history
progression of atherosclerosis resulting in CAD.16 than those without.22 It has also been observed
Diabetes mellitus was noted in 17%. The disease that subjects with a family history of CAD had
is more prevalent in males (14%) compared to higher prevalence of coronary artery calcium in
females (4%) and in older patients as compared to the presence of metabolic risk factors than those
younger patients. This fact has been documented in without a family history.23
a number of previous studies.13,14 Therefore overall evidence suggests that risk
Higher BMI was documented in 46% of patients. of atherosclerotic coronary vascular disease is
Sixteen were obese. There was no statistical differ- increased among those with a family history of
ence comparing males with females. Asians have diabetes; suggesting that genetic factors associated
a higher body fat percentage for a given BMI than with occurrence of familial diabetes may increase
other ethnic groups. Prevalence of obesity and over- risk of CAD beyond the risk among people without
weight is low, while DM and HTN occur at a lower family history of diabetes.24
level of BMI compared to western population. It Life style of the patients was not an important risk
has been suggested that Asians have a different fat factor as sedentary life style was noted in only 39%
distribution pattern and are more prone to central of patients and the majority were males. Similarly
obesity at low BMI levels.17 the nature of job also seems to be an un-important

Pak J Med Sci 2013 Vol. 29 No. 1 www.pjms.com.pk 95

Mansoor Nadeem et al.

risk factor as the disease appears to be equally 10. Farmer JA, Gotto AM. Dyslipidemia and other risk factors
prevalent in persons employed at different jobs. for coronary artery disease. In: Braunwald E (ed), Heart
Disease. A Textbook of Cardiovascular Medicine, 5th ed.
CONCLUSIONS Philadephia: WB Saunder, 1997:1126-1160.
11. Gupta Sr, Gupta SK, Reddy KN, Moorthy JS, Abraham KA.
Our study shows that Family history, smoking, Coronary artery disease in young Indians subjects. Indian
Heat J. 1987;39:284-287.
Hypertension, increased BMI, Increased abdominal 12. Pais P, Pogue J, Gerstein H, Zachariah E, Savitha D,
girth, Dyslipidemia and Diabetes Mellitus are Jayprakash S, et al. Risk factors for acute myocardial
the main risk factors. There is no notable gender infarction in Indians: a case control study. Lancet.
difference in frequency of various risk factors except 1996;348(9024):358-363.
13. Ma E, Iso H, Takahashi H, Yamagishi K, Tanigawa T. Age-
in smoking which is almost exclusively noted in Period-Cohort Analysis of Mortality due to Ischemic Heart
males. However there is very limited data available Disease in Japan, 1955-2000. Circ J. 2008;72(6):966-972.
in the form of formal studies from our country. 14. Yildirim N, Arat N, Dogan MS. Comparison of traditional
Considering the increasing incidence of the coronary risk factors, natural history and angiographic findings
between coronary heart disease patients with age <40 and
heart disease in our society it is essential to assess >or=40 years old. Anaolu Kardiyol Derg. 2007;7(2):124-127.
and evaluate these risk factors prevalent at national 15. Wilson PW, Garrison RJ, Abbott RD. Factors associated
level. It will enable us in formulating policies for with lipoprotein cholesterol levels. The Framingham Study.
promoting healthy lifestyles, frequent and early risk AHA J. 1983;3:273-281.
16. Rakugi H, Yu H, Kamitani A, Nakamura Y, Ohishi
assessment and age specific preventive strategies. M, Kamide K, et al. Links between hypertension and
myocardial infarction. Am Heart J. 1996;132(1):213-221.
REFERENCES 17. McKeigue PM, Shah B, Marmot MG. Relation of central
1. Ridker MP, Genest J, Lippy P. Risk factors for atherosclerotic obesity and insulin resistance with high diabetes
heart disease. In: Braunwald E, Zipes DP, Libby P, editors. prevalence and cardiovascular risk in South Asians. Lancet.
Heart Disease: A Textbook of Cardiovascular Medicine 6th 1991;337(8738):382-386.
ed. Philadelphia: W.B: Saunders Company; 2001:1010–1039. 18. Ubbink JB, Vermaak WJH, Bennet JM, Becker PJ, van Staden
2. Kuppuswamy V, Gupta S. Coronary heart disease in South DA, Bissbort S. The prevalence homocysteinemia and
Asians. Practitioner. 2003;247:181-182. hypercholestrolemia in agiographically defined coronary
3. Perski A, Olsson G, Landou C, de Faire U, Theoreli heart disease. J Molecular Medicine. 1991;69(12):527-534.
T, Hamsten A. Minimum heart rate and coronary 19. Goel PK, Bharti BB, Pandey CM. A tertiary care hospital-
atherosclerosis: independent relations to global severity based study of conventional risk factors including lipid
and rate of progression of angiographic lesions in men profile in proven coronary artery disease. Indian Heart J.
with myocardial infarction at a young age. Am Heart J. 2003;55(3):234-240.
1992;123(3):609-616. 20. Bhalodkar NC, Blum S, Rana T. Comparison of levels
4. Chouhan L, Hajar HA, Pomposiello JC. Comparison of of large and small high density lipoprotein cholesterol
thrombolytic therapy for acute myocardial infarcion in Asian Indian men compared with Caucasian men
in patients aged <35 and >55 years. Am J Cardiol. in the Framingham Offspring Study. AM J Cardiol.
1993;71:157-159. 2004;94(12):1561-1563.
5. Gordon T, Castelli WP, Hjortland MC, Kannel WB, 21. Zimmerman FH, Cameron A, Fisher LD, Ng G. Myocardial
Dawber TR. Predicting coronary heart disease in middle- infarction in young adults: angiographic characterization,
aged and older persons: the Framingham study JAMA. risk factors and prognosis (Coronary Artery Surgery Study
1977;238:497-499. Registry). J Am Coll Cardial. 1995;26:654-661.
6. Toro K, Rausz E, Keller E. Sudden death due to ischemic 22. Juonala M, Viikari AS, Rasanen L. Young Adults
heart disease among adolescents and young adults before with family history of CAD have increased arterial
and after the socio-economic changes in 1989 of Hungary. vulnerability to metabolic risk factors: the cadiovascular
Arch Med Sadowej Kryminol. 2007;57(4):394-398. risk in young Finns study. Arterioscler Thromb Vasc
7. Bhopal R, Fischbacher C, Vartiainen E. Predicted and Biol. 2006;26(6):1376-1382.
observed cardiovascular disease in South Asians: 23. Michos ED, Nasir K, Rumberger JA, Vasamreddy C,
application of risk. J Public Health (Oxf). 2005;27(1):93-100. Braunstein JB, Budoff MJ, et al. Relation of family history
8. Shah SS, Noor L, Shah SH, Shahsawar, Din SU, Awan ZA, of premature coronary heart disease and metabolic risk
Hafizullaht M. Myocardial infarction in young versus older factors to risk of coronary arterial calcium in asymptomatic
adults: Clinical characteristics and angiographic features. J subjects. Am J Cardiol. 2005;95(5):655–657.
Ayub Med Coll Abbottabad. 2010;22(10):187-190. 24. Park JW, Yun JE, Park T. Family history of diabetes and risk
9. Ahmad I, Shafique Q. Myocardial infarction under age 40: of atherosclerotic cardiovascular disease in Korean men
risk factors and coronary arteriographic findings. Ann King and women. Atherosclerosis. 2008;197(1):224-231.
Edward Med Coll. 2004;9:262–265.

96 Pak J Med Sci 2013 Vol. 29 No. 1 www.pjms.com.pk