How should I evaluate and manage sternum pain in an elderly long-term-care resident?

Evaluation and Management of Sternum Pain in Geriatric Long-Term Care

In an elderly long-term-care resident with sternum pain, immediately obtain a 12-lead ECG within 10 minutes and measure high-sensitivity cardiac troponin, because older adults frequently present with acute coronary syndrome through atypical symptoms—including isolated chest pain without classic features—and delay in diagnosis significantly increases mortality. 1

Immediate Life-Threatening Conditions to Exclude

The priority is rapid identification of six conditions that can cause death within minutes to hours:

• Acute Coronary Syndrome (ACS): Older adults (≥75 years) often lack classic chest pressure and instead present with isolated sternum pain, shortness of breath, syncope, acute delirium, or unexplained falls 1, 2, 3
• Aortic Dissection: Sudden "ripping" or "tearing" pain radiating to the back; check for pulse differentials between extremities (present in ~30% of cases) and blood pressure differences >20 mmHg between arms 1, 3
• Pulmonary Embolism: Sudden dyspnea with pleuritic chest pain; tachycardia occurs in >90% of patients 1, 3
• Tension Pneumothorax: Unilateral absent breath sounds, tracheal deviation, hypotension 1, 3
• Cardiac Tamponade: Pleuritic pain worsened supine, jugular venous distension, hemodynamic compromise 1
• Esophageal Rupture: Severe pain after vomiting, subcutaneous emphysema 1, 3

Mandatory Initial Assessment (First 10 Minutes)

• Obtain 12-lead ECG within 10 minutes to detect STEMI (≥1 mm ST-elevation in contiguous leads), ST-depression, T-wave inversions, or pericarditis patterns 1
• Draw high-sensitivity cardiac troponin immediately—it is the most sensitive and specific biomarker for myocardial injury and remains valid regardless of age 1, 2
• Measure vital signs promptly: heart rate, bilateral blood pressures, respiratory rate, oxygen saturation—tachycardia, hypotension, or pulse differentials are critical red flags 1
• Perform focused cardiovascular examination for diaphoresis, tachypnea, pulmonary crackles, S3 gallop, new murmurs (mitral regurgitation suggests papillary muscle dysfunction; aortic regurgitation suggests dissection), unilateral absent breath sounds, subcutaneous emphysema 1, 2

Critical History Elements in Geriatric Patients

• Pain characteristics: Pressure, squeezing, gripping, heaviness, or tightness increases probability of ischemia; sharp or stabbing pain does not exclude ACS (13% of patients with pleuritic pain have acute MI) 1, 2, 4
• Radiation pattern: Pain to left arm, jaw, neck, or between shoulder blades suggests cardiac origin 2, 4
• Temporal features: Gradual onset over minutes (not instantaneous) is typical of angina; duration of several minutes (not fleeting seconds) 2, 4
• Precipitating factors: Physical exertion, emotional stress, or occurring at rest 2, 4
• Associated symptoms: Dyspnea, diaphoresis, nausea, vomiting, light-headedness, syncope, acute confusion, or unexplained falls markedly raise ACS probability in elderly patients 1, 2, 4

Algorithmic Management Based on Initial Findings

If ECG Shows STEMI or New Ischemic Changes

• Activate emergency medical services immediately and arrange urgent transfer to a 24/7 cardiac catheterization center 1, 2
• Target door-to-balloon time <90 minutes for primary PCI (preferred) or door-to-needle <30 minutes for fibrinolysis 1, 2

If Initial ECG and Troponin Are Normal but Clinical Suspicion Remains

• Repeat high-sensitivity troponin at 1–3 hours (or conventional troponin at 3–6 hours)—a single normal result does not exclude ACS 2, 4
• Obtain serial ECGs every 15–30 minutes to capture evolving ischemic changes 1, 2
• Add posterior leads (V7–V9) when suspicion is intermediate-to-high and standard ECG is nondiagnostic 2

If Both ECG and Serial Troponins Remain Normal

• Admit to monitored unit (telemetry or coronary care) for observation if intermediate-risk features present: age >75 years, diabetes, hypertension, prior MI, or ongoing symptoms 2, 4
• Consider alternative diagnoses after cardiac causes excluded: costochondritis (tenderness at costochondral junctions), pericarditis (pleuritic pain worsened supine, friction rub), pneumonia (fever, localized pain, dullness to percussion), herpes zoster (dermatomal pain, characteristic rash) 1

Physical Examination Findings by Diagnosis

Condition	Key Physical Findings
ACS	May be completely normal; diaphoresis, tachycardia, hypotension, crackles, S3, new MR murmur [1]
Aortic Dissection	Pulse differential (30%), systolic BP difference >20 mmHg between arms, new AR murmur (40–75% type A) [1]
Pulmonary Embolism	Tachycardia (>90%), tachypnea, pleuritic pain with inspiration [1]
Tension Pneumothorax	Unilateral absent breath sounds, hyperresonance, tracheal deviation [1]
Costochondritis	Reproducible tenderness at costochondral joints [1]
Pericarditis	Fever, friction rub, pain worsened supine [1]

Transport and Setting-Specific Recommendations

• If evaluated in long-term care facility without ECG capability: Refer immediately to emergency department by EMS—do not delay for additional testing 1, 5
• If clinical evidence of ACS or life-threatening cause exists: Arrange urgent EMS transport; personal automobile transport is associated with increased risk and should be avoided 1, 2
• EMS transport enables: Pre-hospital ECG acquisition, aspirin administration, defibrillation capability, arrhythmia management, and shorter travel times 2

Common Pitfalls to Avoid

• Do not assume normal physical examination excludes ACS—uncomplicated MI can present with entirely normal findings 1, 2, 4
• Do not rely on nitroglycerin response to differentiate cardiac from non-cardiac pain; esophageal spasm also responds 2, 4
• Do not dismiss symptoms based on "atypical" presentation—use terms "cardiac," "possibly cardiac," or "non-cardiac" instead 1, 2, 4
• Do not attribute symptoms to dementia or confusion without objective cardiac testing—acute delirium may be the presenting feature of ACS in elderly patients 1, 2
• A normal initial ECG does not rule out ACS—30–40% of acute MIs present with normal or nondiagnostic ECG 2, 4

Risk Stratification for Disposition

High-risk features requiring immediate coronary care unit admission: 2

• Ongoing rest pain >20 minutes
• Hemodynamic instability (SBP <100 mmHg, HR >100 or <50 bpm)
• Troponin above 99th percentile
• New heart failure signs (crackles, S3, elevated JVP)

Low-risk criteria for observation unit or outpatient follow-up: 2

• Normal or nondiagnostic ECG
• Negative troponin at presentation and 6–12 hours
• Stable vital signs
• No ongoing chest discomfort
• No clinical heart failure