This article has Open Peer Review reports available.
Risk factors of acute myocardial infarction in middle-aged and adolescent people (< 45 years) in Yantai
© Du et al. 2015
Received: 13 February 2015
Accepted: 21 September 2015
Published: 29 September 2015
Yantai is a developed medium-sized coastal city in Eastern China, having a population of 1.6845 million. With the development of economy, some middle-aged and adolescent people (< 45 years) devote themselves to work and suffer from greater stress, which makes them ignore their own health. Moreover, they have unhealthy lifestyles and lack the knowledge of cardiovascular risk factors.
To identify the risk factors for first acute myocardial infarction in middle-aged and adolescent people in Yantai, a developed medium-sized coastal city in Eastern China.
A total of 154 consecutive patients with first acute myocardial infarction (< 45 years), were enrolled in case group, and 462 patients without myocardial infarction were enrolled in control group. Three controls with the same sex and age were matched to each case. The risk factors were identified with univariate and multivariate analysis.
Unhealthy food habit (eating seafood and meanwhile drinking beer), hypertension, current smokers, self-perceived stress, diabetes mellitus, obesity, sleep insufficience, hypercholesterolaemia and fatigue were independent risk factors for first acute myocardial infarction (P < 0.05).
Besides those recognized risk factors for cardiovascular disease (hypertension, hypercholesterolemia, diabetes mellitus and smoking), eating seafood and meanwhile drinking beer, self-perceived stress, sleep insufficience, obesity and fatigue were also the risk factors for first acute myocardial infarction in middle-aged and adolescent people in Yantai.
KeywordsRisk factors Acute myocardial infarction Middle-aged and adolescent people Developed medium-sized coastal city China
As a leading cause of death in developed countries , cardiovascular disease (CVD) has an elevating incidence and prevalence in developing countries in recent years , which may be caused by urbanization, adoption of western life styles and aging of population. China has the biggest CVD burden as the biggest developing country . In 2010, Chinese population with an age greater than 40 years has about 8 million of myocardial infarction (MI) patients, and the number will increase persistently in the next two decades. Moreover, the age of onset is younger for first acute myocardial infarction (AMI) in Chinese population . However, younger patients with first AMI have rarely been researched.
Yantai is a developed medium-sized coastal city in Eastern China, having a population of 1.6845 million. With the development of economy, some middle-aged and adolescent people (< 45 years) devote themselves to work and suffer from greater stress, which makes them ignore their own health. Moreover, they have unhealthy lifestyles and lack the knowledge of cardiovascular risk factors (CVRF). Especially, many middle-aged and adolescent people like to eat seafood and meanwhile drink beer with the improvement of living standard in Yantai, which was uncommon in the before. Besides, we observed that the number of middle-aged and adolescent patients with primary AMI had an annual increase in our hospital in recent years. If the risk factors for first AMI could be identified in middle-aged and adolescent people, early prevention would be able to be administered.
The objective of the paper was to identify the risk factors for first AMI in middle-aged and adolescent people in Yantai, and then provide useful information for the prevention of primary AMI among middle-aged and adolescent people in the cities similar to Yantai.
A total of 154 consecutive patients with first AMI (< 45 years), including 127 males and 27 females, were enrolled in case group in the Yantai Yuhuangding Hospital from June 2005 to June 2013. A total of 462 patients without MI were enrolled in control group, including 381 males and 81 females. Three controls with the same sex and age were matched to each case. All the participants provided written informed consent, and the study was approved the Ethical Committee of the Yantai Yuhuangding Hospital.
1. Cardiac biomarkers had a rise (to at least one time of the upper normal value) or fall after rise (to at least one time of the upper normal value). 2. At least one of the following characteristics presented:  The patient had clinical symptoms of myocardial ischemia.  ECG showed new ST segment change or left bundle-branch block.  ECG showed pathological Q wave.  Imaging evidence showed new loss of myocardial activity or regional wall motion abnormality.
Variables and measurement
The selected factors in the study were as follows: self-perceived stress, physical activity, sleep, fatigue, smoking status, alcohol consumption, food habit, family history of coronary heart disease (CHD), body mass index (BMI), occupation, family income, education, blood pressure, blood glucose, and cholesterol. The information about the selected factors was collected by interview, physical examinations and referring to medical records.
Self-perceived stress was defined as yes or no according to the question “how many days have you felt stressful or depressive in a week?” Yes was determined if participants have felt stressful or depressive on three or more days, and no was determined if participants have felt stressful or depressive on two or less days. Physical activity was defined as active or inactive according to the question “have you had an activity of 30 min on five or more days in a week?” Sleep was defined as sufficient or insufficient according to the question “how many days have you had at least six hours of sleep duration in a week?” Sufficient was determined if participants had at least six hours of sleep duration on five or more days, and insufficient was determined if participants had at least six hours of sleep duration on four or less days. Fatigue was defined as yes or no according to the question “have you experienced fatigue on three or more days in a week?” Smoking status was defined as current smokers, ex-smokers or non-smokers according to the question “how many cigarettes have you smoked per day?” The people that answered at least one cigarette per day were defined as current smokers, and the people that answered at least one year of smoking cessation was defined as ex-smokers. Alcohol consumption was defined as yes or no according to the question “have you drunk at least 100 g of distillate spirit or 500 g of beer on three or more days in a week?” Food habits were defined as unfavorable or favorable according to the question “how many times have you eaten seafood and meanwhile drunk beer in a meal in a week?” Unfavorable was determined if participants had at least two times of eating seafood and meanwhile drinking beer in a meal, and favorable was determined if participants had at most once. Family history of CHD was defined as yes or no according to the question “have you had one more parent or sibling with diagnosed CHD?” BMI was calculated according to the formula that weight (kg) was divided by squared height (m2). BMI (18.5-24.9 kg/m2) was defined as normal, (25–29 kg/m2) was defined as overweight, and (≥30 kg/m2) was defined as obesity. Occupation was defined as physical work or intellectual work. According to family income, all the participants were categorized into three groups: low income group (< 10,000 RMB/year), middle income group (10,000–20,000 RMB/year) and high income group (> 20,000 RMB/year). According to the time of education completed, all the participants were categorized into three groups: primary (1–8 years), secondary (9–12 years), and postsecondary (≥13 years).
Hypertension was determined if blood pressure was ≥140/90 mmHg  and/or the patient was receiving antihypertensive drugs. Diabetes mellitus was determined if fasting plasma glucose was ≥7.0 mmol/L or 2 h oral glucose tolerance test (OGTT) glucose was ≥11.1 mmol/L  and/or the patient was receiving antidiabetic drugs. Hypercholesterolaemia was determined if total serum cholesterol was ≥ 5.16 mmol/L (200 mg/dl)  and/or the patient was receiving cholesterol lowering treatment.
All the statistical analyses were carried out with the SPSS version 17.0 for Windows (SPSS Inc., USA). The quantitative variables were expressed as mean ± SD, and the qualitative variables were expressed as percentage. The quantitative variables were analyzed with Student's t test. The qualitative variables were analyzed with chi-square test or Fisher exact test. The variables with a P value less than 0.10 in univariate analysis were included in the multivariate analysis with a backward stepwise logistic regression model. Multivariate logistic regression analyses were then performed to determine the risk factors correlated with the death of the elderly patients with AOSC. Significance was set at P < 0.05.
Results and discussion
The average age was 36.8 ± 5.2 years for the cases, and men accounted for 82.5 %. The difference was not significant in the age of first onset between men and women (36.5 ± 5.1vs37.7 ± 5.5 years, P > 0.05). Coronary catheterization was performed in all the cases.
Results of univariate analysis of the risk factors for first AMI
Self-perceived stress (yes)
Alcohol consumption (yes)
Eating seafood and meanwhile drinking beer
Family history of CHD
Low family income
Results of multivariate analysis of the risk factors for first AMI
95 % CI
Eating seafood and meanwhile drinking beer
smoking status (compared with non-smokers)
BMI (compared with normal)
As a coastal city in Eastern China, Yantai had a rapid development of economy in the past two decades, which led to dietary and lifestyle changes , especially in middle-aged and adolescent people. These changes could increase the risk for CVD. In our study, other factors were associated with first AMI in middle-aged and adolescent people in Yantai, except for physical activity, alcohol consumption, family history of CHD, occupation, family income and education.
We found that eating seafood and meanwhile drinking beer was positively associated with first AMI. Firstly, consumption of seafood can increase the prevalence of hyperuricemia, which possibly results from the high content of purine in seafood . Secondly, a recent study shows that heavy alcohol consumption of wine can increase the prevalence of hyperuricemia , and another study shows that alcohol consumption is directly associated with hyperuricemia . Thirdly, drinking beer and spirits can increase the risk for gout, whereas a moderate consumption of wine cannot . Eventually, hyperuricemia is associated with severity of coronary artery disease (CAD) . However, our study showed that alcohol consumption was not associated with first AMI. The possible reason is that moderate alcohol consumption can reduce the risk for CVD  and people tend to drink heavily when they eat seafood.
It is reported that hypertension [15-17], hypercholesterolemia , diabetes mellitus [17, 19] and smoking  are the risk factors for CVD. Our study showed that hypertension, current smoking, diabetes mellitus and hypercholesterolemia were the risk factors for first AMI in middle-aged and adolescent people in Yantai. Moreover, we found that smoking cessation could reduce the risk for first AMI compared with current smoking, but the result needed to be further confirmed by a larger sample.
A study shows that work stress is a risk factors for CVD , and another study shows that stress is directly associated with coronary heart disease .We found that self-perceived stress was positively associated with first AMI. However, some studies show that stress is not associated with CVD [22-24]. We found that sleep insufficience was associated with first AMI, which was consistent with the previous study . We also found that obesity and fatigue were associated with first AMI, but overweight was not.
The limitations of the study included:  The participants were chose from a small population (inpatients);  The relationship was not studied between HIV infection and first AMI because only 5 participants had HIV infection among all the participants;  The risk factors of first AMI were not studied in the population > 45 years.
In conclusion, besides those recognized risk factors for CVD (hypertension, hypercholesterolemia, diabetes mellitus and smoking), eating seafood and meanwhile drinking beer, self-perceived stress, sleep insufficience, obesity and fatigue were also the risk factors for first AMI in middle-aged and adolescent people (< 45 years) in Yantai. In a next study, the risk factors of first AMI will be comprehensively studied for inhabitants in Yantai, and a prospective cohort study will be performed, aiming to assess the outcome associated with these emerging risk factors.
Open AccessThis article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.
- Roger VL, Go AS, Lloyd-Jones DM, Adams RJ, Berry JD, Brown TM, et al. Heart disease and stroke statistics 2011 update: a report from the American Heart Association. Circulation. 2011;123:e18–e209.View ArticlePubMedGoogle Scholar
- Yusuf S, Reddy S, Ounpuu S, Anand S. Global burden of cardiovascular diseases, part I: general considerations, the epidaemiologic transition, risk factors, and impact of urbanization. Circulation. 2001;104:2746–53.View ArticlePubMedGoogle Scholar
- Zhai F, Wang H, Du S, He Y, Wang Z, Ge K, et al. Prospective study on nutrition transition in China. Nutr Rev. 2009;67 Suppl 1:S56–61.View ArticlePubMedGoogle Scholar
- Cao CF, Ren JY, Zhou XH, Li SF, Chen H. Twenty-year trends in major cardiovascular risk factors in hospitalized patients with acute myocardial infarction in Beijing. Chin Med J. 2013;126:4210–5.PubMedGoogle Scholar
- National High Blood Pressure Education Program Coordinating Committee. Seventh report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure. Hypertension. 2003;42:1206–52.View ArticleGoogle Scholar
- American Diabetes Association. Standards of medical care in diabetes-2008. Diabetes Care. 2008;31(1):S12–54.View ArticleGoogle Scholar
- National Cholesterol Education Program (NCEP) Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults (Adult Treatment Panel III). Third Report of the National Cholesterol Education Program (NCEP) Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults (Adult Treatment Panel III) final report. Circulation. 2002;106:3143–421.Google Scholar
- Miao ZM, Li CG, Chen Y, Zhao SH, Wang YG, Wang ZC, et al. Dietary and lifestyle changes associated with high prevalence of hyperuricemia and gout in the Shandong coastal cities of Eastern China. J Rheumatol. 2008;35:1859–64.PubMedGoogle Scholar
- Choi HK, Atkinson K, Karlson EW, Willett W, Curhan G. Purine-rich foods, dairy and protein intake, and the risk of gout in men. N Engl J Med. 2004;350:1093–103.View ArticlePubMedGoogle Scholar
- Guasch-Ferré M, Bulló M, Babio N, Martínez-González MA, Estruch R, Covas M, et al. Mediterranean diet and risk of hyperuricemia in elderly participants at high cardiovascular risk. J Gerontol A Biol Sci Med Sci. 2013;68:1263–70. doi:10.1093/gerona/glt028.View ArticlePubMedGoogle Scholar
- Nakamura K, Sakurai M, Miura K, Morikawa Y, Yoshita K, Ishizaki M, et al. Alcohol intake and the risk of hyperuricaemia: a 6-year prospective study in Japanese men. Nutr Metab Cardiovasc Dis. 2011;22:989–96.View ArticlePubMedGoogle Scholar
- Choi HK, Atkinson K, Karlson EW, Willett W, Curhan G. Alcohol intake and risk of incident gout in men: a prospective study. Lancet. 2004;363:1277–81.View ArticlePubMedGoogle Scholar
- Qureshi AE, Hameed S, Noeman A. Relationship of serum uric acid level and angiographic severity of coronary artery disease in male patients with acute coronary syndrome.Pak J Med Sci 2013; 29:1137–41.doi: http://dx.doi.org/10.12669/pjms.295.4029
- Estruch R. Anti-inflammatory effects of the Mediterranean diet: the experience of the PREDIMED study. Proc Nutr Soc. 2010;69:333–40.View ArticlePubMedGoogle Scholar
- Centers for Disease Control and Prevention. Million hearts: strategies to reduce the prevalence of leading cardiovascular disease risk factors - United States, 2011. MMWR Morb Mortal Wkly Rep. 2011;60:1248–51.Google Scholar
- Centers for Disease Control and Prevention. Vital signs: awareness and treatment of uncontrolled hypertension among adults - United States, 2003–2010. MMWR Morb Mortal Wkly Rep. 2012;61:703–9.Google Scholar
- Teo KK, Liu L, Chow CK, Wang X, Islam S, Jiang L, et al. Potentially modifiable risk factors associated with myocardial infarction in China: the INTERHEART China study. Heart. 2009;95:1857–64.View ArticlePubMedGoogle Scholar
- Centers for Disease Control and Prevention. Prevalence of cholesterol screening and high blood cholesterol among adults-United States, 2005, 2007, and 2009. MMWR Morb Mortal Wkly Rep. 2012;61:697–702.Google Scholar
- American Diabetes Association. Diagnosis and classification of diabetes mellitus. Diabetes Care. 2010;33 Suppl 1:S62–9.View ArticlePubMed CentralGoogle Scholar
- Li Y, Cao J, Lin H, Li D, Wang Y, He J. Community health needs assessment with precedeproceed model: a mixed methods study. BMC Health Serv Res. 2009;9:181.View ArticlePubMedPubMed CentralGoogle Scholar
- Chandola T, Britton A, Brunner E, Hemingway H, Malik M, Kumari M, et al. Work stress and coronary heart disease: what are the mechanisms? Eur Heart J. 2008;29:640–8.View ArticlePubMedGoogle Scholar
- Folta SC, Goldberg JP, Lichtenstein AH, Seguin R, Reed PN, Nelson ME. Factors related to cardiovascular disease risk reduction in midlife and older women: a qualitative study. Prev Chronic Dis. 2008;5:A06.PubMedGoogle Scholar
- Gillison F, Greaves C, Stathi A, Ramsay R, Bennett P, Taylor G, et al. Waste the Waist': the development of an intervention to promote changes in diet and physical activity for people with high cardiovascular risk. Br J Health Psychol. 2012;17:327–45.View ArticlePubMedGoogle Scholar
- Kiawi E, Edwards R, Shu J, Unwin N, Kamadjeu R, Mbanya JC. Knowledge, attitudes, and behavior relating to diabetes and its main risk factors among urban residents in Cameroon: a qualitative survey. Ethn Dis. 2006;16:503–9.PubMedGoogle Scholar
- Xie DF, Li W, Wang Y, Gu HQ, Teo K, Liu LS, et al. Sleep duration, snoring habits and risk of acute myocardial infarction in China population: results of the INTERHEART study. BMC Public Health, 2014; 14: 531. http://www.biomedcentral.com/1471-2458/14/531.