What typical findings are often absent in older patients with myocardial infarction (MI)?

From the Guidelines

Older patients with myocardial infarction (MI) often lack the typical findings seen in younger patients, making diagnosis challenging, and may present with atypical symptoms such as dyspnea, syncope, malaise, and confusion, rather than the classic chest pain, as noted in the 2021 ESC guidelines for the management of acute coronary syndromes 1. The clinical presentation of MI in older patients can be more subtle, with symptoms such as shortness of breath, confusion, fatigue, or syncope, rather than the typical chest pain radiating to the left arm, which is frequently missing in this population. Some key points to consider in the diagnosis of MI in older patients include:

• Atypical presentations, such as dyspnea, are more common in older patients, as stated in the 2021 ESC guidelines 1
• Electrocardiogram (ECG) changes may be less pronounced or difficult to interpret due to pre-existing abnormalities, as mentioned in the 2021 ESC guidelines 1
• Elderly patients might not develop the expected elevation in cardiac enzymes like troponin to the same degree as younger patients, as noted in the 2021 ESC guidelines 1
• Older individuals often don't exhibit the autonomic symptoms such as diaphoresis (sweating) or nausea that typically accompany MI in younger populations, as discussed in the 2014 AHA/ACC guideline for the management of patients with non-ST-elevation acute coronary syndromes 1 This atypical presentation occurs because aging can alter pain perception, the autonomic nervous system response, and the body's inflammatory reaction to cardiac damage, as explained in the 2013 ACCF/AHA focused update incorporated into the ACCF/AHA 2007 guidelines for the management of patients with unstable angina/non-ST-elevation myocardial infarction 1. The absence of these typical findings contributes to delayed diagnosis and treatment in older patients with MI, potentially leading to worse outcomes, as highlighted in the 2007 ACC/aha guidelines for the management of patients with unstable angina/non ST-elevation myocardial infarction 1. Therefore, it is essential to maintain a high index of suspicion for MI in older patients, even in the absence of typical symptoms, and to consider the use of high-sensitivity troponin assays and other diagnostic tools to aid in the diagnosis, as recommended in the 2021 ESC guidelines 1.

From the Research

Typical Findings Not Found in Older Patients with MI

Some typical findings that are often absent in older patients with myocardial infarction (MI) include:

• ST elevation on electrocardiogram (ECG) 2, 3
• Typical chest pain symptoms, with older patients more likely to present with atypical symptoms such as shortness of breath or fatigue
• Significant changes on ECG, with some older patients having normal or unremarkable ECG reports despite having an NSTEMI 4
• High levels of troponin, with some older patients having lower levels of troponin despite having an MI

Clinical Presentation

Older patients with MI may have a different clinical presentation compared to younger patients, with:

• More frequent presentation with non-ST elevation MI (NSTEMI) rather than ST-elevation MI (STEMI) 2, 5
• Higher incidence of prior cardiac events and comorbidities 2, 5
• More frequent presentation with shock or hemodynamic instability 2

Diagnostic Challenges

The diagnosis of MI in older patients can be challenging due to:

• Atypical symptoms and presentation 4
• Normal or unremarkable ECG reports 4
• Lower levels of troponin 4
• Higher incidence of comorbidities and prior cardiac events, which can make it difficult to diagnose MI 2, 5