63: Addressing Chest Pain in Older Adults

Older patients are more likely than younger patients to have a cardiac event in the absence of chest pain or present to medical care with an atypical clinical presentation of chest pain. Fewer than half of patients whose ultimate diagnosis is acute myocardial infarction (MI) are admitted for acute MI. The National Registry of Myocardial Infarction (NRMI) showed that only 40% of older patients’ chief complaints were chest pain, compared to 77% of patients presenting with MI age 65 years or younger. Patients may present with nausea, fatigue, or delirium. The lack of typical symptoms can lead to treatment delay and increased morbidity and mortality in the older patient population (see Chapter 7, “Atypical Presentations of Illness in Older Adults”). For adults age 65 years or older, ischemic heart disease accounts for 81% of mortality, and should therefore be the first diagnosis considered when an older adult presents for medical care with chest pain. However, chest pain in older patients can also be noncardiac in origin or of a cardiac etiology other than coronary artery disease. Noncardiac origins of chest pain include pulmonary and esophageal. Although not all causes of chest pain in the older adult will lead to fatal events, timely diagnosis based on a history of associated factors and a targeted physical exam can improve an older patient’s health outcomes in the short-term, as well as longer-term quality of life, functionality, and health outcomes. It is therefore essential that clinicians take a thorough history, perform a targeted physical exam, and have a high level of suspicion to make the correct diagnosis in a timely manner.

Symptoms & Signs

Typical angina at any age presents as substernal chest pain, often described as “pressure like,” with radiation to the jaw, neck, or arm. If a patient has experienced an MI in the past, asking the patient if this pain is similar to that experienced during a previous MI can be an important clue. Descriptions of chest pain radiating to the back, may be more suggestive of aortic dissection or gastrointestinal pathology such as esophageal reflux. If patients complain that they feel chest pain after eating or when lying flat, one should consider gastroesophageal reflux as a possible diagnosis.

Features suggesting acute coronary syndrome include diaphoresis, cool clammy skin, new or progressive shortness of breath, and/or exertional shortness of breath. 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. Most older adults with acute coronary syndrome present to medical professionals with dyspnea, diaphoresis, nausea/vomiting, and/or syncope, and not necessarily with chest pain. In addition, given that older adults have a higher prevalence of comorbidities, concurrent disease processes may cloud the presentation of acute coronary syndrome. Moreover, patients with delirium or dementia may have trouble communicating their symptoms accurately to their clinician.

Physical examination—

Physical examination should begin with vital signs, with special attention to blood pressure, heart rate, and oxygen saturation, to assess the clinical stability of the patient.

Next, the clinician should assess the cardiovascular system. Check blood pressure in both arms, a discrepancy of more than 20 mm Hg systolic between readings, without a history of vascular compromise in either limb should raise suspicion of aortic dissection, especially if the patient describes a “ripping” or “tearing” quality to his chest pain. If heart sounds are muffled on cardiac auscultation, cardiac tamponade should be considered as a cause of distress. Additional signs and symptoms of cardiac tamponade include pulsus paradoxus (a decrease in systolic pressure of >10 mm Hg during inspiration), and hypotension. Cardiac tamponade is more common in the setting of certain chronic illnesses including autoimmune disease, malignancy, or a recent history of acute trauma to the chest. If a cardiac rub is present, a diagnosis of pericarditis should be entertained. A loud new holosystolic murmur, is suggestive of acute coronary pathology and possibly mitral valve papillary dysfunction. Elevated jugular venous pressure and an S₃ gallop suggest congestive heart failure. New congestive heart failure in the setting of chest pain should be considered a medical emergency and prompt swift work up to rule out serious diagnoses such as acute coronary syndrome. In the setting of chest pain that varies with respiration with or without the presence of hemoptysis, pulmonary embolism should be considered. Pain on palpation of the chest wall may indicate musculoskeletal pain or costochondritis and can provide reassurance to the clinician and patient. Lower-extremity edema that is symmetric in both limbs and acute or subacute may be suggestive of right heart failure; however, if there is unilateral swelling, one must suspect venous thromboembolism and consider evaluation for pulmonary thromboembolism as a cause of chest pain. In this scenario, chest pain may also be associated with hypoxia and tachycardia and be exacerbated by respiration.

Laboratory findings—

The standard cardiac chemistry panel includes creatinine kinase (CK), creatinine kinase–myocardial bound (CK-MB), and troponin I. CK is leaked out of injured muscle cells and is not specific to myocardial injury. CK-MB as an isoenzyme is more specific to myocardial injury; additionally, when a ratio to CK is performed, if >4.5% of the total CK it is suggestive of myocardial injury. Troponin I is more specific and sensitive to myocardial injury; however, it can take up to 8 hours from initial event to abnormal rise in number. In the case of recurrent injury, CK-MB has a shorter half-life and if it were to rise again in a presumed acute setting, would be a more reliable marker of repeat myocardial injury. Other diagnostic tests that may be of use include D-dimer for work up of pulmonary embolism (see Chapter 32, “Peripheral Arterial Disease & Venous Thromboembolism”).

Diagnostic tests and imaging studies—

Electrocardiogram (ECG) is the first step in the chest pain work up of an older patient. It is important to obtain a previous ECG for comparison; in this age group, patients may already have significant cardiac history, thereby further confounding acute findings, particularly without a comparison study. S-T elevations in a specific coronary territory raises concern for acute coronary plaque rupture and ST-segment elevation MI. Diffuse S-T elevations or depressions may be more suggestive of pericarditis in the appropriate clinical context. ECG findings of cardiac tamponade include blunting of the voltage of QRS complexes, in association with dyspnea and the presence of electrical alternans—a beat to beat variation of QRS complexes in an alternating pattern.

On chest radiography, the presence of a widened mediastinum, if clinical history suggests, should raise suspicion of an aortic dissection. Suspicion for pulmonary thromboembolism or aortic dissection should prompt the clinician to order a CT chest with contrast for diagnostic purposes.

Special tests—

Progressive dyspnea that accompanies chest pain with exertion (angina) should be evaluated with a stress test, either an exercise stress test with an imaging modality such as echocardiogram or nuclear imaging. An imaging modality is absolutely necessary as baseline abnormalities on ECG can confound results during stress testing. Frail older patients may be limited by their functional capacity and unable to complete an exercise stress test. In appropriate patients, using a bicycle instead of a treadmill can sometimes compensate for these functional deficits, for patients who are unable to reach target heart rate with exercise, pharmacologic testing is a viable alternative.

Gastrointestinal causes of chest pain can be mistaken for angina. If the patient notes a correlation of symptoms to food, consider an empiric trial of acid suppression, or if clinically indicated, a barium swallow exam which may show multiple strictures in corkscrew pattern if the patient is suffering from esophageal spasm. Upper endoscopy may be helpful in the diagnosis of esophagitis (see Chapter 35, “Gastrointestinal & Abdominal Complaints,” for further discussion of work-up for esophageal and other gastrointestinal disorders).

The differential diagnosis of chest pain in older patients is as broad as it is in younger adults, with the potential added complication of coexisting medical comorbidity. Initial assessment includes assessment of cardiogenic and pulmonary stability. Once established, chest pain should be assessed for its likelihood of being cardiac or noncardiac, followed by initial assessment for diagnoses associated with the highest mortality or complication rates. Cardiovascular causes of chest pain include acute coronary syndrome, unstable angina, pericarditis, and aortic dissection. The Thrombolysis In Myocardial Infarction (TIMI) risk score is a widely used prognostic scale for risk stratification of chest pain and likelihood for ischemic chest pain. The 7 components include age greater than 65 years, 3 or more risk factors for coronary artery disease, known coronary artery disease, ST-segment deviation on ECG, 2 episodes within 24 hours of presentation, aspirin use in the last 7 days, or elevation of cardiac biomarkers at time of presentation. A higher TIMI risk score reflects an elevated risk of cardiac etiology and is used to guide therapy such as additional anticoagulation and early invasive strategies versus conservative strategies for further testing.

Pulmonary causes of chest pain include acute pulmonary embolism and pleuritis. Pleuritic chest pain, caused by inflammation of the pleural lining of the lung, occurs with inspiration and can lead to chest pain. This inflammation can be caused by any pathologic process causing inflammation or fluid accumulation, including pneumonia or less commonly, a smaller distal pulmonary embolism. A history of chest pain exacerbated by inspiration and associated with fever and/or sputum production would suggest pneumonia. Chest pain can also be the first sign or chief complaint of an older patient who is ultimately found to have lung cancer.

The most common musculoskeletal cause of chest pain is costochondritis or Tietze syndrome (a swelling of the costal cartiladges). Chest pain caused by gastrointestinal diseases is generally related to esophageal reflux, esophagitis or esophageal spasm. Chemical esophagitis (or pill esophagitis) related to medications such as bisphosphonates may be particularly prevalent in older patients, especially those with a high daily pill burden. Suspicion of pill esophagitis should prompt a close examination of the patient’s medication list for possible contributors to esophagitis.

Treatment is specific to the underlying cause of chest pain. In the case of an ST-elevation MI, rapid diagnosis by ECG and clinical history can lead to prompt activation of the cardiac catheterization team. If no cardiac catheterization is available at location of presentation, and if the patient can be transported to a hospital with cardiac catheterization capabilities within 90 minutes of presentation, then arrangement for transfer should be made immediately. If catheterization is not possible, then pharmacologic thrombolysis can be considered. TIMI risk score can then guide therapy with antiplatelet agents (see Chapter 28, “Coronary Disease”).

At presentation, if clinical history of aortic dissection is confirmed by a CT scan, or in some cases, by ECG, this is a surgical emergency, and preparations to take patient to the operating room should be made, after consideration of comorbid disease, functional capacity, life expectancy, patient goals, and advance directives.

Pericarditis requires additional work up after diagnosis to establish the etiology. In addition to treatment of the underlying cause, most cases can be treated with nonsteroidal antiinflammatory agents or aspirin, if there are no contraindications. The antigout medication, colchicine is also very effective in the treatment of pericarditis.

If the diagnosis of pulmonary embolism is definitively made with CT scan or with ventilation perfusion scan, the patient should be started on anticoagulation therapy if no absolute contraindications are present. If the patient experiences recurrent thromboembolic events, consideration can be given to inferior vena cava filter placement.

Pleuritic chest pain is a nonspecific symptom that can have a variety of causes including infectious, autoimmune or other systemic illnesses. Management includes antiinflammatory agents in addition to goal-directed therapy against the underlying cause.

Inflammation and strain of the muscles of the rib cage can lead to chest pain causing significant distress. Once all life-threatening causes of chest pain are effectively ruled out and the physical exam is consistent with costochondritis (such as positional chest pain, and pain reproducible on palpation) the patient can be reassured and pain relief can generally be achieved with an antiinflammatory agent.

Gastrointestinal manifestations of chest pain such as gastroesophageal reflux disease and esophagitis can be managed with antihistamine-1 blockers or with proton pump inhibitors (see Chapter 35, “Gastrointestinal & Abdominal Complaints”). With the diagnosis of esophageal spasm, a calcium channel blocker and avoidance of triggers can effectively manage symptoms.

Ischemic heart disease is a significant cause of morbidity and mortality in older adults. Age alone puts older adults at higher risk of having cardiac ischemia when chest pain is present. However, in this population, heart disease may not initially present with chest pain, or it may present with atypical chest pain. In addition, when chest pain is present, it may not represent cardiac pathology. It is important for clinicians to differentiate cardiac from noncardiac chest pain and risk stratify patients immediately upon presentation so that proper treatment is not delayed. Tools to accomplish this include physical exam, thorough history, electrocardiography, cardiac biomarkers, and chest rdiography on initial evaluation.