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Is she really ‘one of the youngest’ with an acute myocardial infarction?

Dear Editor, A recent case report in this journal illustrated the striking convergence of traditional cardiovascular risk factors and ethnic predisposition in a 24-year-old Indigenous Australian woman with acute myocardial infarction (AMI) secondary to atheromatous coronary artery disease. The authors boldly stated their patient is ‘likely to be one of the youngest reported cases of infarction due to atheromatous coronary artery disease’; however, the authors did not consider genetic lipoprotein disorders before making this declaration. Although not the cause in the described case, children with homozygous familial hypercholesterolaemia have accelerated atherosclerosis secondary to grossly elevated low-density lipoprotein cholesterol (>15 mmol/L). The natural history of the condition is dominated by coronary artery disease, which often manifests in the first two decades of life. Children might suffer AMI as young as 5 years of age and coronary artery bypass grafting as young as 8 years. This condition is rare (often quoted as one per million); however, the heterozygous form is not (approximately one in 500) and, if present with other risk factors, might result in myocardial infarction in the third decade. As such, no discussion of premature atherosclerosis should be complete without consideration of genetic lipoprotein disorders.