Don’t miss cardiac symptoms in the elderly
Approximately 85% of people who die of coronary heart disease are age 65 and older, notes Odette Comeau-Luis, RN, MS, CNS, a clinical specialist in cardiac care at Loma Linda (CA) University Medical Center.
"There are many health care issues unique to the elderly, and cardiovascular disease is no exception," she emphasizes.
Half of all heart attacks occur in the elderly, but 80% of deaths occur in that population, so there is a much higher mortality rate, says Stephen Meldon, MD, an attending physician in the ED at Metrohealth Medical Center in Cleveland. "Be aware that this is a unique population, and they don’t play by the rules."
Cardiovascular system changes
Here are some ways in which elderly patients are unique:
• There are age-related changes in the cardiovascular system.
According to Comeau-Luis, age-related changes in the cardiovascular system include the following:
— Hypertrophy becomes evident as age increases. The left ventricular wall may have increased in thickness by 25% by age 80, compared to age 30.
— There is decreased compliance of the ventricular wall, causing a potential decrease in cardiac output.
— Heart valves become stiffer and thicker.
— There is a reduced heart rate response to stress, possibly due to reduced catecholamine response.
— There is decreased resiliency of arteries, promoting hypertension.
• Squeezing or pressure may not be present.
Elderly patients present with different symptoms, stresses Meldon. "Classic chest pain presentation, such as squeezing or pressure, occurs with decreasing frequency as you age," he says. "In ages 65 to 75, about 60% have classic presentation; in ages 75 to 85, only half have a classic presentation, and the percentage decreases to 40% in patients over 85. In elderly patients, it’s less common to have chest pain with an MI."1
Don’t overlook life-threatening cardiac conditions, warns Meldon. "If you just dwell on chest pain, you’re going to miss it," he says.
Signs and symptoms include dyspnea, vomiting, diaphoresis, syncope, weakness, and delirium.
• A higher index of suspicion is needed.
In the elderly, typical chest pain becomes less frequent with age, Meldon says. "With any elderly person with weakness or vomiting, you need to ask yourself, Does this represent myocardial ischemia?’" he advises. "Obtaining an EKG may be the most important assessment you do."
• There are different risk factors.
While risk factors continue to be an important prognostic indicator of cardiovascular risk, their relative importance changes with age, says Comeau-Luis.
For example, the predictive value of cigarette smoking compared to other risk factors is unclear, Comeau-Luis notes. Risk factors with strong predictive value for coronary artery disease in the elderly include hypertension, serum lipid abnormalities, diabetes, and obesity, she adds.
• Elderly patients may present late in the course of the disease.
This late presentation is because many elderly patients have limited physical activity, according to Comeau-Luis. For example, unstable angina or congestive heart failure may be the initial presentation in a patient with coronary artery disease.
• Dyspnea on exertion is a common manifestation of disease in the elderly.
Aging causes an increase in stiffness of the left ventricle and end-diastolic volume. Those factors may lead to an increase in ventricular pressure produced by myocardial ischemia, causing dyspnea with activity.
• Description of the pain course may be misleading.
A misleading description is due to an inability to remember details and confusion with discomfort from other medical problems, such as arthritis and peptic ulcer disease.
• Unique triage guidelines are needed.
At Loma Linda’s ED, triage guidelines for emergency cardiac patients include those for the "atypical" presentations of the elderly. In addition to chest, epigastric, and nontraumatic arm pain, any patient 65 years of age or older presenting with shortness of breath and/or syncope is "fast-tracked" to the cardiac room for immediate treatment and diagnostic workup, including an immediate 12-lead EKG.
A computerized 12-lead EKG retrieval system then allows for immediate comparison with previous EKGs, Comeau-Luis explains.
• Elderly patients have a higher incidence of complications with acute myocardial infarction (MI).
Those complications include pericarditis, arrhythmias, conduction disturbances, congestive heart failure, myocardial rupture, cardiogenic shock, cerebrovascular accidents, pneumonia, phlebitis, and drug toxicity, says Comeau-Luis. (See related story on contraindications for thrombolytics, p. 50.)
Watch for silent MIs
There are other considerations of elderly patients presenting with acute MI, Comeau-Luis stresses. "The incidence of silent MIs is higher in the elderly population, and a history of silent MI confers a three-fold risk of future MI."
While chest pain is still a common symptom of acute MI, it is less common in the elderly compared to younger patients, says Comeau-Luis. "Dyspnea is a very common presenting symptom. Other common symptoms include syncope, mental confusion, and gastrointestinal complaints. In contrast, diaphoresis is an uncommon symptom in the elderly patient with an acute MI."
Reference
1. Bayer AJ, Chadha JS, Farag RR, et al. Changing presentation of myocardial infarction with increasing old age. J Am Geriatr Soc 1986; 34:263-266.
For more information about cardiac care and the elderly, contact:
• Odette Comeau-Luis, RN, MS, CNS, Loma Linda University Medical Center, 11234 Anderson St., Room A126, P.O. Box 2000, Loma Linda, CA 92354. Telephone: (909) 824-0800 ext. 42302. Fax: (909) 824-4641. E-mail: [email protected].
• Stephen Meldon, MD, Metrohealth Medical Center, Emergency Department. 2500 Metrohealth Drive, Cleveland, OH 44109. Telephone: (216) 778-8912. Fax: (216) 778-5349. E-mail: [email protected].
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