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Chest pain is the most common reason for emergency department visits in patients older than 65 years of age in the United States. The differential diagnosis encompasses both benign and life-threatening diseases. Although not all causes of chest pain in the older adult will lead to fatal events, timely diagnosis can improve a patient’s health outcomes in the short term, as well as long term, including quality of life and functional status.

It is essential that clinicians take a thorough history, perform a targeted physical exam, and have a high level of suspicion in order to choose the most appropriate diagnostic laboratory tests and imaging studies to make the correct diagnosis in a timely manner.


A. Symptoms & Signs

The onset of chest pain should be clarified first, followed by a description and evolution of the symptom. Typical angina at any age presents as substernal chest pain, often described as “pressure like,” with radiation to the jaw, neck, or arm. Clinicians should also ask about associated cardiopulmonary symptoms such as diaphoresis, cool clammy skin, new or progressive shortness of breath, and/or exertional shortness of breath. If a patient has a history of acute coronary syndrome (ACS) in the past, asking if the pain is similar to that experienced previously can be an important clue.

Descriptions of chest pain as radiating to the back, abrupt onset, severe in intensity, or tearing, stabbing, or sharp in quality may be more suggestive of aortic dissection. Pleuritic chest pain occurs with inspiration and is caused by inflammation of the pleural lining of the lung. If patients feel chest pain after eating or when lying flat and with a burning quality, one should consider a gastroesophageal etiology.

Older patients are typically more likely to delay seeking medical care or be more inclined to attribute their symptoms to “normal aging,” which can lead to increased adverse outcomes or death if the etiology of the chest pain is serious in nature. Moreover, patients with delirium, severe depression, or cognitive impairment may have trouble communicating their symptoms accurately. In addition, given that older adults have a higher prevalence of chronic conditions, concurrent disease processes may cloud the presentation.

1. Physical examination

The first step should be to obtain vital signs to assess the clinical stability of the patient with special attention to heart rate, blood pressure in both arms, and oxygen saturation. Next, the clinician should assess the cardiovascular system. If heart sounds are muffled on cardiac auscultation, pulsus paradoxus is present (a decrease in systolic pressure of >10 mm Hg during inspiration), or there is hypotension, then cardiac tamponade should be considered. A loud new holosystolic murmur is suggestive of acute coronary pathology and possibly mitral valve papillary dysfunction. Elevated jugular venous pressure, hepatojugular reflux, ...

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