Which patient is most likely to exhibit classic signs of ST-elevated Myocardial Infarction (ST-MI)?

Which Patient is Most Likely to Exhibit Classic Signs of STEMI?

The 60-year-old man (Option A) is most likely to present with classic signs of ST-elevated myocardial infarction, as younger to middle-aged men typically present with the typical chest pain syndrome, while elderly patients, women, and those with diabetes or COPD are significantly more likely to present with atypical symptoms.

Evidence-Based Rationale

Classic vs. Atypical Presentations

Elderly patients (Option B - 75-year-old woman) are specifically identified as high-risk for atypical presentations:

• Older persons who develop acute coronary syndromes are more likely to present with atypical symptoms, including dyspnea and confusion, rather than with the chest pain typically experienced by younger patients 1
• Women tend to present more often with atypical symptoms, up to 30% in some registries, and tend to present later than men 1
• The combination of advanced age and female sex creates the highest likelihood of atypical presentation 1

Diabetic patients (Option C) have well-documented atypical presentations:

• MI may occur with atypical symptoms or even without symptoms in diabetics, women, the elderly, or post-operative and critically ill patients 1
• Patients with diabetes are specifically listed among those who frequently present without classic chest discomfort 1

Elderly patients with COPD (Option D) face multiple confounding factors:

• Noncardiac comorbidities such as chronic obstructive lung disease are more frequent in elderly patients and may be associated with chest pain at rest that can mimic classic symptoms of UA/NSTEMI 1
• Successful recognition of true myocardial ischemia in the elderly is often more difficult than in younger patients due to these competing diagnoses 1

Classic STEMI Presentation Features

The typical presentation includes:

• Chest discomfort with radiation to the neck, lower jaw, or left arm, lasting more than 20 minutes 1
• The discomfort is typically diffuse, not localized, nor positional, nor affected by movement, and may be accompanied by diaphoresis, nausea, or syncope 1
• A history of coronary artery disease and radiation of pain to specific locations are important diagnostic clues 1

Age and Sex Considerations

Middle-aged men represent the prototypical STEMI patient:

• STEMI is relatively more common in younger than in older people, and more common in men than in women 1
• Young patients (≤55 years) with myocardial infarction are equally likely to present with chest pain as older patients, with chest pain remaining the predominant symptom (87-89.5% of young patients) 2
• The 60-year-old man falls into the age range where classic presentations predominate before the increased likelihood of atypical symptoms seen in the elderly 1

Clinical Pitfalls to Avoid

Do not dismiss cardiac symptoms in atypical populations:

• Despite higher rates of atypical presentations, elderly patients, women, and diabetics can still have STEMI and require the same urgent evaluation 1
• Risk assessment tools may underestimate risk, particularly in women, requiring careful clinical judgment 2

Maintain high clinical suspicion across all demographics:

• The absence of classic symptoms does not exclude STEMI in high-risk populations 1
• Repeated ECG recordings should be obtained when the initial ECG is equivocal, regardless of patient demographics 1