II. Symptoms: Elderly Presentations of Acute Coronary Syndrome
- Most common presentations
-
Chest Pain is presenting symptom in only 24% of Acute Coronary Syndrome (ACS) age >75 years
- In age over 65 years, Chest Pain is present in 50% of women and 60% of men
- Mortality is higher in ACS for those without Chest Pain
- References
III. Precautions
- Geriatric patients with ACS are more likely to have delay to first EKG and door-to-needle times
- Have a low threshold to obtaining EKG in older patients
- Presenting symptoms triggering EKG should include Dyspnea, Nausea, Abdominal Pain, weakness
IV. Differential Diagnosis: Chest Pain
- See Chest Pain Causes
-
Pulmonary Embolism
- See Pulmonary Embolism Pretest Probability (e.g. Wells Clinical Prediction Rule for PE, Revised Geneva Score)
- D-Dimer discriminatory values increase with age (See D-Dimer)
- Common presentations in older adults with Pulmonary Embolism
- Variable presentations
- Tachycardia is often absent
- Uncommon presentations in older adults with Pulmonary Embolism
-
Aortic Dissection
- Insidious onset of Chest Pain is more common in older adults than the sudden Chest Pain in younger adults
- Tearing, ripping or sharp Chest Pain is often absent in older adults
- Hypotension is a more common presentation in older adults
V. Diagnostics
-
Electrocardiogram (EKG)
- Non-diagnostic (LBBB, Pacemaker, Old Q Waves) in up to 43% in over age 85 years with Myocardial Infarction
- Left Bundle Branch Block is present in 34% of older adults
- Old comparison Electrocardiogram is key
VI. Management: Acute Coronary Syndrome
- See Acute Coronary Syndrome Immediate Management
- See Acute Coronary Syndrome Adjunctive Therapy
- See High Risk Acute Coronary Syndrome Management
- See Moderate Risk Acute Coronary Syndrome Management
- See Low Risk Acute Coronary Syndrome Management
- See Myocardial Infarction Stabilization
- See Post Myocardial Infarction Medications
- Early Percutaneous Coronary Intervention (PCI) in STEMI and NSTEMI is preferred in elderly as with younger patients
- Reduced risk of death at 1 and 6 months
- Amsterdam (2014) J Am Coll Cardiol 64(24): e139-228 [PubMed]
- Medication Management is elderly is similar to younger ACS patients with precautions
- Aspirin
- Nitroglycerin
- Exercise caution and avoid in Hypotension, RV infarction and Phosphodiesterase Inhibitors (Viagra)
- Beta Blockers
- Exercise caution due to risk of worsening Cardiogenic Shock
- Avoid IV Beta Blockers in acute phase of ACS
- Antiplatelet agents
VII. References
- Spangler (2021) Crit Dec Emerg Med 35(2): 3-10
- Shevni and Beck-Esmay in Herbert (2021) EM:Rap 21(5): 17-8
