Cardiolgy - Evaluating ACS In The Elderly

Question 1

T/F: Many disease entities appear in an atypical fashion in the elderly.

Answer 1

True

Note: From “Evaluation & Management of Chest Pain in the Elderly” from Emerg Med Clin N Am (2016)

Question 2

Patients over 75 years of age account for ___ of ACS in the ED and ___ of ACS deaths.

Answer 2

33%; 60%

Question 3

Outline the table of causes of CP in the elderly

Answer 3

Organ System High Acuity Low Acuity
CV ACS Angina
Aortic Dissec. Pericarditis
Aortic Aneurysm Myocarditis

Pulmonary T. pneumothorax —
Pneumonia

GI Esoph. Perf GERD
Esophagitis

Chest Wall — Costocondritis
Rib Frac/Trauma
Herpes Zoster

Question 4

What major change to classification of cardiac conditions occurred in 2014?

Answer 4

A combining of unstable angina (UA) and non-STEMI into the NSTE-ACS (Non ST-Elevation Acute Coronary Syndrome) term.

Question 5

T/F: In the elderly, ACS presents primarily with chest pain.

Answer 5

False!!!

In the GRACE study, 49% of elderly ACS patients present with a C/C of dyspnea and without chest pain

Question 6

What common presentations of ACS occur in the elderly?

Answer 6

• dyspnea
• diaphoresis
• N/V
• syncope
• weakness
• delirium

Question 7

T/F: Chest pain that is reproducible with palpation is a rule-out test for ACS?

Answer 7

False. Though TTP of the chest wall does decrease the likelihood of ACS in the elderly, it does not entirely exclude it!

Question 8

In a National Registry of MI study, patients under the age of 65 presented with a non-diagnostic ECG ___% of the time, even when experiencing an MI.

A. 23%
B. 34%
C. 42%
D. 57%

Answer 8

A. 23%

Question 9

In a National Registry of MI study, patients over the age of 85 presented with a non-diagnostic ECG ___% of the time, even when experiencing an MI.

A. 23%
B. 34%
C. 43%
D. 57%

Answer 9

C. 43%

Question 10

T/F: The prognosis of elderly patients with ACS is significantly worse than those younger patients.

Answer 10

True.

They have multiple co-morbidities, underlying conditions, and less physiologic reserve.

Question 11

Aortic dissection is a rare, but extremely lethal condition. It commonly occurs in what decade of life in the elderly?

A. 60s
B. 70s
C. 80s
D. 90s

Answer 11

B. 70s

Question 12

According to the International Registry of Aortic Dissection (IRAD), ___ is common in 70% of patients with aortic dissection.

A. Dyspnea
B. Chest pain
C. Hypertension
D. Thrombus

Answer 12

C. HTN

Question 13

T/F: The most common description of aortic dissection is a “tearing” or “ripping” pain.

Answer 13

False. Most commonly it is described as a “sharp” pain.

Hallmark to check for aortic dissection.

Question 14

This type of aortic dissection presents with back or abdominal pain.

A. Type A
B. Type B

Answer 14

B. Type B

Question 15

What are some other common C/Cs with aortic dissection aside from chest/back/abdomen pain?

Answer 15

• Migratory pain
• Syncope
• Focal neurologic deficits

Question 16

This type of aortic dissection presents typically with anterior chest pain.

A. Type A
B. Type B

Answer 16

A. Type A

Question 17

Unequal/delayed pulses (a “pulse deficit”) are present in ____% of aortic dissection patients.

Answer 17

15%

Question 18

T/F: There are significant ECG changes in the aortic dissection patient.

Answer 18

False.

ECGs have most utility in ruling out common diagnoses like STEMI.

Question 19

Outline the risk table of aortic dissection

Answer 19

Risk factors:

• Marfan syndrome
• Connective tissue disease
• Family Hx of aortic disease
• Known aortic valve disease
• Recent aortic manipulation
• Known thoracic aortic aneurysm

High risk pain:
- Chest/abd pain described as “abrupt, severe at onset” and a “ripping/tearing/sharp/stabbing” quality

High risk exam features:

• Pulse deficit
• SBP deficit
• Focal stroke deficit
• Aortic murmur
• Shock state/hypoTN

Question 20

Start with pulmonary embolism stuff

Answer 20

Okay!

Question 21

What is the “classic” sign of pulmonary embolism in the elderly?

Answer 21

• dyspnea at rest and/or exertion

Dyspnea in all patients occurs 76% of the time, EXCEPT in the those over 70 years, where it only occurs 66% of the time.

Remember, the elderly may have atypical presentations!

Question 22

How does presentation of a spontaneous pneumothorax differ in the elderly than in the young?

Answer 22

Pleuritic chest pain occurs in the elderly PE patient only 20% of the time, where it occurs in the younger patient 66% of the time.

Question 23

What is the most common objective finding in the elderly pneumothorax patient?

Answer 23

Sinus tachycardia

Question 24

A pneumothorax should be immediately suspected in the elderly patient with ______.

A. Chest pain
B. Decompensated COPD/asthma
C. Dyspnea

Answer 24

B. Decompensated COPD/asthma

Question 25

Do we allow for standing orders of decompression for spontaneous pneumothorax?

Answer 25

Check our protocols

Question 26

You must maintain a high index of suspicion for what in the elderly chest pain patient?

A. Esophageal perforation
B. ACS
C. Tension pneumothorax
D. Aortic aneurysm

Answer 26

A. Esophageal perforation

• It is rare, but has both high morbidity and mortality.

S/S:

• rapid onset of severe chest pain
• radiation to back/neck/shoulder
• worsening with swallowing HALLMARK
• vomiting/hematemesis

Question 27

What must be evaluated for in suspected esophageal perforation?

Answer 27

• recent procedural history, especially recent endoscopy or surgical procedures near the esophagus

Question 28

What is Boerhaave’s syndrome?

Answer 28

A spontaneous esophageal rupture, usually caused by increased intra-abdominal pressure 2/2 vomiting.