Chest Pain in the Elderly

Aka: Chest Pain in the Elderly, Chest Pain in Older Adults, Geriatric Chest Pain, Acute Coronary Syndrome in Older Adults, Acute Coronary Syndrome in Elderly

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II. Symptoms: Elderly Presentations of Acute Coronary Syndrome

  1. Most common presentations
    1. Dyspnea
    2. Syncope
    3. Generalized weakness
    4. Nausea or Vomiting, or indigestion
    5. Altered Mental Status
  2. Chest Pain is presenting symptom in only 24% of Acute Coronary Syndrome (ACS) age >75 years
    1. In age over 65 years, Chest Pain is present in 50% of women and 60% of men
    2. Mortality is higher in ACS for those without Chest Pain
  3. References
    1. Brieger (2004) Chest 126(2): 461-9 [PubMed]

III. Precautions

  1. Geriatric patients with ACS are more likely to have delay to first EKG and door-to-needle times
  2. Have a low threshold to obtaining EKG in older patients
    1. Presenting symptoms triggering EKG should include Dyspnea, Nausea, Abdominal Pain, weakness

IV. Differential Diagnosis: Chest Pain

  1. See Chest Pain Causes
  2. Pulmonary Embolism
    1. See Pulmonary Embolism Pretest Probability (e.g. Wells Clinical Prediction Rule for PE, Revised Geneva Score)
    2. D-Dimer discriminatory values increase with age (See D-Dimer)
    3. Common presentations in older adults with Pulmonary Embolism
      1. Dyspnea
      2. Syncope
    4. Variable presentations
      1. Tachycardia is often absent
    5. Uncommon presentations in older adults with Pulmonary Embolism
      1. Pleuritic Chest Pain
      2. Hemoptysis
  3. Aortic Dissection
    1. Insidious onset of Chest Pain is more common in older adults than the sudden Chest Pain in younger adults
    2. Tearing, ripping or sharp Chest Pain is often absent in older adults
    3. Hypotension is a more common presentation in older adults

V. Diagnostics

  1. Electrocardiogram (EKG)
    1. Non-diagnostic (LBBB, Pacemaker, Old Q Waves) in up to 43% in over age 85 years with Myocardial Infarction
    2. Left Bundle Branch Block is present in 34% of older adults
    3. Old comparison Electrocardiogram is key

VI. Management: Acute Coronary Syndrome

  1. See Acute Coronary Syndrome Immediate Management
  2. See Acute Coronary Syndrome Adjunctive Therapy
  3. See High Risk Acute Coronary Syndrome Management
  4. See Moderate Risk Acute Coronary Syndrome Management
  5. See Low Risk Acute Coronary Syndrome Management
  6. See Myocardial Infarction Stabilization
  7. See Post Myocardial Infarction Medications
  8. Early Percutaneous Coronary Intervention (PCI) in STEMI and NSTEMI is preferred in elderly as with younger patients
    1. Reduced risk of death at 1 and 6 months
    2. Amsterdam (2014) J Am Coll Cardiol 64(24): e139-228 [PubMed]
  9. Medication Management is elderly is similar to younger ACS patients with precautions
    1. Aspirin
    2. Nitroglycerin
      1. Exercise caution and avoid in Hypotension, RV infarction and Phosphodiesterase Inhibitors (Viagra)
    3. Beta Blockers
      1. Exercise caution due to risk of worsening Cardiogenic Shock
      2. Avoid IV Beta Blockers in acute phase of ACS
    4. Antiplatelet agents
      1. See Antiplatelet Therapy for Vascular Disease

VII. References

  1. Spangler (2021) Crit Dec Emerg Med 35(2): 3-10
  2. Shevni and Beck-Esmay in Herbert (2021) EM:Rap 21(5): 17-8

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