Chest Pain in the Elderly


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

  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]
  • 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
  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
  • 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
  • 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