Geriatric patients are at increased risk for serious morbidity and mortality from life-threatening causes of chest pain. This article covers 5 life-threatening causes of chest pain in the elderly: acute coronary syndrome, aortic dissection, pulmonary embolism, pneumothorax, and esophageal rupture. Atypical presentations, frailty, and significant comorbidities that characterize the elderly make the diagnosis and treatment of these already complicated conditions even more complicated. The emergency provider must be vigilant and maintain a low threshold to test. When a diagnosis is made, treatment must be aggressive. The elderly benefit from optimal care.
Key points
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Causes of chest pain in the elderly are common and life threatening. Acute coronary syndromes are the leading cause of death worldwide. Aortic dissection is rare but life threatening.
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This article discusses presentation, diagnosis, and treatment of acute coronary syndromes, aortic dissection, pulmonary embolism, pneumothorax, and esophageal perforation in the elderly.
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The elderly frequently present atypically and suffer greater morbidity and mortality owing to being frail and comorbid, but benefit from aggressive treatment.
Chest pain is the second most common chief complaint accounting for more than 6 million visits annually to emergency departments (EDs) in the United States. The elderly make up a significant percentage of our population comprising 14.1% of the US population in 2013. This percentage is expected to increase as the United States ages and longevity increases. Fifteen percent of all ED visits are made by those over 65 years of age. An extensive differential diagnosis from benign illnesses to life-threatening disorders must be considered in patients with chest pain. Many disease entities tend to present in an atypical fashion in the elderly.
The evaluation and management of chest pain must be initiated rapidly. Within 10 minutes of arrival, in addition to vital signs, the elderly patient with chest pain should receive an electrocardiogram, the single most important test in identifying life threats. If unstable, stabilization should be initiated using basic life support and advanced cardiac life support. In stable patients, the physician should complete a thorough history and physical examination. Based on the results of the initial evaluation, appropriate testing and treatment should be started. While these tests are being performed, additional history and chart review can be performed to narrow and reorder the differential diagnosis.
The elderly typically have multiple comorbidities and less physiologic reserve—the elderly are often frail—increasing morbidity and mortality for many conditions. Consequently, a more extensive diagnostic workup is usually required in the elderly patient with a complaint of chest pain and often the final cause of chest pain will not be established in the ED, but will require additional evaluation. The careful ED physician should maintain a high index of suspicion for acute, life-threatening emergencies.
The differential diagnosis for chest pain in the elderly is broad. Table 1 lists a complete differential organized by acuity and organ system. Several diagnoses are far more likely in the elderly than in younger patients. Cardiac etiologies are not the most common cause but account for the greatest mortality. The remainder of this article focuses on the presentation, diagnosis, and management of 5 causes of chest pain: acute coronary syndrome (ACS), aortic dissection, pulmonary embolism (PE), pneumothorax, and esophageal rupture.
| Organ System | High Acuity | Lower Acuity |
|---|---|---|
| Cardiovascular | Acute coronary syndrome | Angina |
| Aortic dissection | Pericarditis | |
| Aortic aneurysm | Myocarditis | |
| Pulmonary | Tension pneumothorax | — |
| Pneumonia | ||
| GastroIntestinal | Esophageal perforation | GERD/gastro-peptic |
| Esophagitis | Biliary disease | |
| Chest wall | — | Costochondritis |
| Rib fractures/trauma | ||
| Herpes zoster |
Acute coronary syndrome
Ischemic heart disease is the leading killer in the world claiming 7,000,000 lives annually and accounting for 12.7% of all deaths. Its incidence and lethality increases dramatically with age. The elderly over age 75, account for 33% of all episodes of ACS and 60% of deaths. Age is a powerful predictor of adverse events from ACS with the risk of death increasing by 70% with each decade increase of age. Being both common and deadly, the emergency provider must consider ACS early and evaluate carefully in geriatric patients with chest pain. The diagnosis and management of ACS in the elderly is similar to that in younger patients, focusing on accurate, early diagnosis and aggressive management.
Definition
ACS applies to a spectrum of diseases resulting from abrupt reduction in blood flow to the myocardium that cause symptoms attributable to myocardial ischemia, dysfunction, and infarction. ACS refers to diseases that are high risk, that mandate aggressive therapy, but that cannot always be distinguished at initial presentation. The term encompasses (1) unstable angina (UA), acute ischemia without infarction; (2) non–ST-elevation myocardial infarction, a similar pathophysiology in which ischemia progresses to infarction, and (3) ST-elevation myocardial infarction (STEMI), the acute closure of a coronary vessel causing transmural infarction and that is amenable to emergent reperfusion. In their 2014 guideline update, the American Heart Association (AHA) and American College of Cardiology (ACC) combined UA and non–STEMI, using the term non–ST-elevation ACS (NSTE-ACS), thus recognizing that UA and non–STEMI exist on a continuum with indistinguishable initial presentations and identical management.
Presentation
Chest pain is the most frequent chief complaint of elderly patients with ACS. Features of the pain that suggest ACS include radiation to both arms, pain similar to episodes of prior ischemia, and a changing pattern of pain over the prior 24 hours. Response of the pain to nitroglycerin is not helpful in ruling in or out ACS. A pleuritic description reduces the risk. The frequency of chest pain at presentation decreases substantially in the elderly. In the National Registry of Myocardial Infarction, chest pain as chief complain decreases from 77% of patients younger than 65 years, to 50% between 65 and 75, to only 40% in patients greater than 85 years of age. In the Global Registry of Acute Coronary Events (GRACE) the frequency of atypical presentation defined as not having chest pain at presentation increases from 5.3% in patients less than 65 years, to 12.3% between 65 and 75, to 14.3% in patients greater than 85 years of age.
Importantly, ACS in the elderly often presents with other complaints. In the GRACE dataset, primary complaints in the elderly without chest pain include dyspnea (49%), diaphoresis (26%), nausea and vomiting (24%), and syncope (19%). Other common complaints include weakness and delirium. In the elderly, atypical presentations of ACS are common. The physician must maintain a high index of suspicion.
The diagnosis of myocardial infarction (MI) is also complicated by the presence of comorbid conditions. ACS can develop in the elderly who have hemodynamic stress from another acute illness such as exacerbation of congestive heart failure (CHF), sepsis, pneumonia, exacerbation of chronic obstructive pulmonary disease (COPD), or a fall. The clinical presentation of the acute illness may predominate.
Traditional risk factors for coronary artery disease include smoking, hypertension, hyperlipidemia, and diabetes mellitus. Age is an important independent risk factor. Although traditional risk factors adequately assess for lifetime risk of coronary artery disease, they are less useful at predicting an ACS. The most predictive risk factors are a history of abnormal prior stress test and peripheral artery disease.
The physical examination findings for ACS are nonspecific. Hypotension may signal the presence of cardiogenic shock, an ominous sign. Signs of acute CHF, including crackles, greater jugular venous distention, and peripheral edema may indicate severe ischemic compromise and increase risk of mortality. Reproducible pain on palpation does decrease the likelihood of ACS, but does not exclude it.
Diagnostic Testing
Electrocardiograph
The single most important test to diagnose an ACS is the electrocardiograph (ECG). It should be obtained and interpreted in every elderly patient with chest pain within 10 minutes of presentation. It should also be obtained early in elderly patients with a variety of other complaints, as detailed above. The diagnosis of STEMI is made based on the ECG. The diagnosis of NSTE-ACS may be suggested. A normal ECG reduces the risk of an ACS but does not rule it out.
Interpretation of the ECG in the elderly can be challenging because the elderly tend to have abnormalities at baseline. Prior MI, left ventricular hypertrophy, bundle branch blocks, nonspecific ST-T changes, and atrial fibrillation complicate ECG analysis. An old ECG should be obtained for comparison to determine whether abnormalities are new. The proportion of NSTE-ACS patients in the National Registry of Myocardial Infarction presenting with nondiagnostic ECGs increases from 23% in patients less than 65 years to 43% in patients greater than 85 years.
The diagnosis of STEMI is equally complicated in the elderly. In the National Registry of Myocardial Infarction, ST segment elevation was present on the ECG of 96.3% of STEMI patients younger than age 65 but only 69.9% of those greater than age 85. An left bundle branch block, obscuring ECG analysis, was present in 5% of younger patients but 33.8% of those greater than 85 years of age.
Cardiac enzymes
Biochemical markers provide useful diagnostic and prognostic information in the elderly. A low threshold should be maintained to check biomarkers given the variability of presentation. Released after myocardial cell necrosis, enzyme elevation distinguishes MI from UA and a pattern of rising biomarkers over hours marks the acuity.
Troponin I and T are contractile proteins found only in cardiac myocytes. Being exquisitely sensitive and reasonably specific for acute MI, troponins have become the gold standard for the diagnosis of MI. Troponins appear within 6 hours of infarction and remain elevated for 4 to 8 days. Sensitivity is only 50% when measured within 4 hours of symptom onset, but increases to greater than 95% after 8 hours.
Troponin assays are excellent diagnostic tools, but elevated levels must be interpreted in the clinical setting and do not diagnose ACS independently. Ischemic elevation not owing to ACS may result from demand ischemia from tachyarrhythmias, hypoxia, hypoperfusion, and sepsis. Nonischemic elevation may be owing to CHF, hypertension, stroke, PE, or renal failure.
Providing prognostic information in addition to diagnostic, troponin elevation in ACS is associated independently with worse outcomes, including death. A metaanalysis of almost 19,000 ACS patients, both STEMI and NSTE-ACS, found a 30 day odds ratio of 3.4 for death or MI with elevated troponin.
Risk Stratification
The immediate goal of every chest pain evaluation is to rapidly decide whether a patient is having an ACS. The decision is not an easy one. Missed or mistreated ACS is the leading cause of malpractice payout against emergency physicians. Consequently, most emergency physicians make the decision conservatively. After the initial evaluation patients should be placed into 1 of 4 working groups: definite ACS, probable ACS, probably not ACS, or definitely not ACS.
With a working diagnosis of definite or probable ACS, the EP must further risk stratify to optimally treat. Patients with an STEMI are in the highest risk group. The NSTE-ACS patients should be further risk stratified using validated scoring instruments such as the HEART score and the GRACE score.
The HEART score is a prospectively derived and widely validated scoring system that can be used to risk stratify undifferentiated chest pain patients predicting the 6-week risk of major adverse cardiovascular events. The score is calculated by awarding points for features of H istory, E CG changes, A ge, R isk factors, and initial T roponin and varies between 0 and 10 points. Scores from 0 to 3 are considered low risk and predict less than 2% risk of major adverse cardiovascular events and may be managed as outpatients. Elderly patients receive 2 points just for being older than 65 years. Most elderly patients have at least 1 risk factor and so very few elderly patients are classified as low risk.
The GRACE 2.0 score is another well-validated scoring system designed to predict in-hospital, 1-year, and 3-year mortality in patients with ACS. Containing 8 variably weighted inputs, including age, heart rate, systolic blood pressure, CHF severity, creatinine, ECG changes, cardiac arrest, and cardiac enzyme elevation, the GRACE score is best calculated using an online calculator (eg, the one at http://gracescore.org ). The GRACE score does not help to determine whether an undifferentiated ED patient has an ACS; rather, in patients with definite or probable ACS, it predicts risk and guides therapy. The ACC/AHA guidelines recommend GRACE score cutoffs when selecting therapy.
Risk stratification is a dynamic process. Accurate risk stratification guides the speed, type, and invasiveness of therapy matching higher risk, higher resource intensity therapy with higher risk patients. Patients in the probably not ACS and definitely not ACS category should be evaluated for alternate causes of chest pain.
Management
Detailed guidelines have been published jointly by the ACC/AHA for the treatment of STEMI and NSTE-ACS. The guidelines are up to date, evidence based, and widely available. There is a paucity of data to guide treatment of ACS in the elderly. Table 2 summarize the classification of recommendations in the guidelines.
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