How does age impact the management of chest pain in patients?

Age Impact on Chest Pain Management

Age significantly impacts the evaluation and management of chest pain, with older patients requiring more extensive diagnostic workup and heightened suspicion for atypical presentations of acute coronary syndrome (ACS). 1

Age-Related Risk Assessment

• Increased age is a significant risk factor for ACS, with patients >75 years accounting for approximately 33% of all ACS cases 1
• The likelihood of angina increases substantially with age: for men from 67% in ages 30-39 to 94% in ages 60-69; for women from 26% to 90% across the same age ranges 1
• Older patients are more likely to have positive noninvasive tests and more coronary artery calcification than younger people 1

Age-Specific Presentation Differences

Older Patients (>75 years)

• ACS should be strongly considered when chest pain is accompanied by:
  • Shortness of breath
  • Syncope or acute delirium
  • Unexplained falls 1
• Atypical presentations are more common in elderly patients, including:
  • Symptoms on either side of the chest
  • Sharp or stabbing pain
  • Discomfort in the throat or abdomen 1
• Alternative diagnoses remain more common than cardiac causes of chest pain in this age group, necessitating more extensive diagnostic workup 1

Younger Patients (≤55 years)

• Young patients with myocardial infarction are equally likely to present with chest pain as older patients (87-89.5%) 2
• Young women more frequently report associated symptoms compared to young men (61.9% vs. 54.8%), including:
  • Epigastric symptoms
  • Palpitations
  • Pain in jaw, neck, arms, or between shoulder blades 2
• Risk assessment tools may underestimate risk in younger patients, particularly women 2

Age-Based Management Approach

For Older Patients (>75 years):

• Maintain a lower threshold for suspecting ACS, especially with atypical presentations 1
• Consider comorbidities that may present with similar symptoms 1
• When positive stress test results are found, recognize the increased risk of cardiovascular death or MI compared to younger patients 1
• Be vigilant for non-cardiac causes that are also more common in this age group 1

For Younger Patients:

• Despite lower baseline risk, maintain appropriate suspicion for ACS 2
• Consider associated symptoms, particularly in women 2
• Evaluate for non-atherosclerotic causes of ACS that may be more common in younger patients 1

Common Pitfalls in Age-Based Assessment

• Underdiagnosis in elderly patients due to atypical presentations - Always consider ACS in elderly patients with vague symptoms or unexplained deterioration 1
• Underestimation of risk in younger patients - Particularly young women may have their symptoms attributed to non-cardiac causes 2
• Over-reliance on "typical" symptoms - The classic presentation of crushing chest pain may be absent in elderly patients 1
• Failure to recognize referred pain - Persistent symptoms thought to be referred pain may indicate another critical condition 3

Diagnostic Approach by Age

• For all patients regardless of age, an ECG should be acquired and reviewed within 10 minutes of arrival when acute chest pain is present 1
• In primary care settings, if ECG is unavailable for patients with stable chest pain, they should be referred to the ED 1
• Cardiac troponin should be measured as soon as possible in all patients with suspected ACS 1
• For older patients, a more comprehensive evaluation may be needed due to higher prevalence of both cardiac and non-cardiac causes 1

By recognizing how age impacts the presentation and risk profile of chest pain, clinicians can optimize their diagnostic approach and improve outcomes for patients across all age groups.