Download ATYPICAL CHEST PAIN IN THE ELDERLY: PREVALENCE

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REVIEW ARTICLE
ATYPICAL CHEST PAIN IN THE ELDERLY: PREVALENCE,
POSSIBLE MECHANISMS AND PROGNOSIS
Chung-Lieh Hung1,2, Charles Jia-Yin Hou1,2, Hung-I Yeh1,2, Wen-Han Chang2,3,4*
1
Cardiovascular Medicine and Medical Research, Mackay Memorial Hospital, 2Mackay Medicine, Nursing and
Management College and Taipei Medical University, 3Department of Emergency Medicine, Mackay Memorial Hospital,
and 4Graduate Institute of Injury Prevention and Control, Taipei Medical University, Taipei, Taiwan.
SUMMARY
Acute chest pain is a major complaint quite commonly presented at emergency departments. A differential
diagnosis of acute chest pain includes various disease entities, including some life-threatening disorders. Of
these, acute coronary syndrome garners much clinical attention and forms a specific disease that includes
a critical ST-segment elevation myocardial infarction and a less severe form of non-ST-segment elevation
myocardial infarction and unstable angina. As an urgent and life-threatening disease leading to a high morbidity and mortality, accurate diagnosis of acute coronary syndrome remains a clinical challenge. Efficient management of this syndrome may rely on a quick yet accurate diagnosis. A high misdiagnosis rate and
inappropriate discharge rate for acute coronary syndrome are still observed, especially in the elderly population, owing to a higher prevalence of atypical symptoms presented in this group. Moreover, the existence of
high comorbidities in the elderly population makes effective clinical approach complicated. A delay in the
identification and treatment may lead to worse outcomes in this patient population. The underlying pathophysiology and exact mechanisms are various. Patient evaluation strategies are currently being developed, as
are new diagnostic facilities aimed at preparing physicians for urgent intervention in a more cost-effective
manner. [International Journal of Gerontology 2010; 4(1): 1–8]
Key Words: acute chest pain, acute coronary syndrome, elderly population, myocardial infarction,
unstable angina
Introduction
Acute chest pain is one of the most common causes of
emergency department (ED) visits. In the United States,
more than 5 million people attend the ED with chest
pain each year, and more than 3 million of these
patients are hospitalized because of this condition at a
cost of more than 6 billion dollars1–3. Early recognition
of clinically life-threatening conditions, such as pulmonary embolism, aortic dissection and pneumothorax,
are crucial. Furthermore, early diagnosis and accurate
*Correspondence to: Dr Wen-Han Chang, Department of Emergency Medicine, Mackay Memorial
Hospital, 92, Section 2, Chung-Shan North Road,
Taipei, Taiwan.
E-mail: [email protected]
Accepted: May 12, 2009
International Journal of Gerontology | March 2010 | Vol 4 | No 1
© 2010 Taiwan Society of Geriatric Emergency & Critical Care Medicine.
diagnostic tools with subsequent appropriate treatment
strategies are important and can save lives, since failure to recognize such diseases at an early stage may
lead to a delay in treatment. Of all patients who present at the ED with acute chest pain, less than 25% have
acute coronary syndrome (ACS)4. A recent study revealed
that ACS actually comprised one-third of myocardial
infarction (MI) and two-thirds of unstable angina or
non-ST-segment elevation MI patients. It has been previously mentioned that approximately 4% of patients
with MI were inappropriately discharged from the ED in
a prospective multicenter trial involving 3,077 patients5.
Christenson et al.6 reported that up to 4.6% of patients
with acute MI and 6.4% of patients with unstable angina
were misdiagnosed in the ED in Canada in 2004, while
a lower rate was reported in the USA by Pope et al.7
In a prospective observational study with a focus on
the prevalence, clinical characteristics and outcomes of
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chest pain, Canto et al.8 found that in 434,877 patients
diagnosed with MI, up to 33% did not present with typical chest pain. Therefore, early and accurate diagnosis of
ACS is fundamental for subsequent effective therapy. A
recent multinational, prospective, observational study
suggested that there is a higher rate of atypical presentation in the elderly population leading to a worse prognosis9. Patients with ACS discharged from the ED without
an accurate diagnosis had a mortality rate nearly twice
the mortality rate of those admitted to a hospital10. In
fact, dyspnea has been identified as the most frequent
symptom of myocardial ischemia in patients older than
85 years11. Age itself, together with sex and a family history of early coronary artery disease, is an important risk
factor for ACS12. In addition, both the prevalence and
severity of coronary artery disease increases with the
aging process, as well as morbidity and mortality13,14.
It remains very difficult to decide whether patients
should stay longer in the ED or if more extensive investigations are warranted, especially for the elderly with
multiple potential comorbidities. According to previous
studies, patients with ACS inappropriately discharged
from the ED generally have a worse prognosis owing to
a possible delay in the implementation of effective therapeutics and the risk of sudden death8,15,16.
In this article, we sought to review the prevalence
and prognosis of atypical chest pain in the elderly population. In addition, we discussed the possible underlying mechanisms and recent advances in diagnostic
tools and strategies that may help early identification
of the higher risk groups. These innovations should help
minimize the potential for misdiagnosis and inappropriate discharge of elderly patients with ACS who present with atypical symptoms.
Differential Diagnosis of Acute Chest Pain
in the ED
Common causes of chest pain include those stemming
from cardiac or noncardiac causes. Simple history taking, including gathering information about lifestyle,
smoking and past medical history, provides important
hints to discern possible acute coronary events during
the preliminary assessment. Disorders related to the
pulmonary, gastrointestinal and musculoskeletal systems and cardiac origins are all possible causes of chest
pain symptoms. A cost-effectiveness analysis revealed
that esophageal sources especially gastroesophageal
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C.L. Hung et al
Table.
Clinical features that increase the likelihood of
acute myocardial infarction*
Clinical features
Pain in chest or left arm
Chest pain radiation
Left arm
Both left and right arms
History of myocardial infarction
Likelihood ratio
(95% confidence interval)
2.7†
2.8 (1.7–3.1)
7.1 (3.6–14.2)
1.5–3.0‡
Association with nausea
or vomiting
1.9 (1.7–2.3)
Association with diaphoresis
2.0 (1.9–2.2)
Hypotension (systolic blood
pressure < 80 mmHg)
3.1 (1.8–5.2)
*Adapted from reference 18; †data not available to calculate confidence interval; ‡in heterogeneous studies, the likelihood ranges are
reported as ranges.
reflux diseases were identified most frequently in patients presenting with acute chest pain in EDs17. Chest
pain suggestive of cardiac origin may refer to those
with a sensation of chest compression, squeezing, or a
penetrating sensation in the internal side or localized
behind the sternum. Panju et al.18 reported the likelihood ratios for ACS based on clinical features including
location, past medical history, associated symptoms,
and hemodynamic findings (Table). In addition, pain
radiating to the left shoulder, neck, jaws, teeth or arm
regions with aggravated intensity or accompanied with
sweating over a period of time may indicate an ischemic nature7,19. Swap and Nagurney20 reported that pain
that radiated to both arms/shoulders or exacerbated
by exertion or physical efforts may show a likelihood
ratio of ischemic coronary events of 2.3–4.7. Conversely, atypical chest pain may refer to a sharp, tingling, “burning” sensation or may be associated with
meals, localized to a small point or area or pain that
can be elicited by direct pressure, touch or postural
changes. Pain accompanied by fever or a history of past
chest pain not originating from a cardiac source may
help identify noncardiac causes. Recent guidelines from
the American College of Cardiology and American Heart
Association provide some useful information on identifying noncardiac origin ischemic episodes21.
Common causes of chest pain emanating from
cardiac causes other than coronary events include
pericardial or valvular heart diseases. Patients with pericarditis accompanying pleuritis may experience sharp
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Atypical Chest Pain in the Elderly
pain during breathing and coughing. Valvular heart
diseases such as severe aortic valve stenosis or subaortic stenosis may also induce chest pain in the elderly,
whereas a young subject suffering atypical chest pain
with palpitations may have mitral valve prolapse disease22. Common noncardiac causes of chest pain include
pulmonary, vascular and gastrointestinal disorders. Of
all noncardiac causes presenting with acute chest pain,
pulmonary embolism, aortic dissection and pneumothorax are common life-threatening emergencies seen
in the ED. By differentiating the location of the pain, a
physician can identify the underlying disease easily.
For example, lateralizing pain may be associated with
a pulmonary embolism or pneumothorax. Precordial
chest pain location can be associated with ACS, ascending aortic dissection and interscapular back pain, which
is typical of aortic dissections of the descending aorta.
Gastrointestinal system disorders with a “burning
sensation” linked to meal behavior may indicate a lesion
arising from the esophagus or stomach, such as gastroesophageal reflux disease, ulcers or even MalloryWeiss tears. Furthermore, chest pain arising from
musculoskeletal causes, cervical disc diseases or even
skin lesions may be easily diagnosed by the pain characteristics and physical examination.
Prevalence, Risk Factors and Prognosis of
Atypical Chest Pain in the Elderly
Previously published studies on the prevalence, risk
factors and prognosis of atypical chest pain in the elderly showed a 20–60% rate of unrecognized MI reflecting
possible differences in race, population, study design
and the definition used for MI diagnosis23–27. Specific
subgroups, including the elderly, persons with diabetes,
women and the very young, have been found to have a
higher misdiagnosis rate28. In the first three subgroups,
atypical symptoms are common, whereas the final
group is not usually considered owing to a generalized
low prevalence. In a large, prospective, populationbased cohort study with 4- to 20-year follow-up focusing on males in the Reykjavik area in Iceland,
nearly 30% of MIs were unrecognized16. The prevalence
increased steeply with age by up to 47% in the group
aged 75–79 years. Although there were no significant
differences in the risk profiles in the Reykjavik study,
increasing age (odds ratios, OR, 1.08; 95% confidence
interval, CI, 1.05–1.10), serum cholesterol level (OR,
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1.06; 95% CI, 1.01–1.10), heavy smoking behavior (OR,
5.2; 95% CI, 1.6–15.2), cardiomegaly (OR, 2.0; 95% CI,
1.1–3.8), baseline angina symptoms (OR, 4.7; 95% CI,
2.8–7.7) and diuretics usage (OR, 6.2; 95% CI, 2.6–14.9)
were associated with a higher probability of unrecognized MI incidence. For those with unrecognized
MI, nearly one quarter of patients experienced sudden
death in the subsequent clinical course. In the
Honolulu, Hawaii, Heart Program published in 1989,
patients with unrecognized MI were associated with a
history of hypertension, diabetes or impaired glucose
tolerance, and higher levels of smoking behavior26.
In that study, the 10-year prognosis in terms of allcause mortality and associated cardiovascular disease
tended to be worse in the unrecognized group. Of
all 9,509 healthy adults followed for 5 years in the
Israeli Heart Attack study, age, left axis deviation by
electrocardiography (ECG), left ventricular hypertrophy,
smoking behavior, blood pressure, and the existence of
peripheral vascular disease after multivariate analysis
remained independent risk factors for the development
of unrecognized MI with a subsequent higher mortality
during 7-year follow-up25. In the Framingham Heart
study, nearly 53% of patients with unrecognized MI had
had a silent infarction with 47% having some atypical
symptoms with a 10-year mortality rate of up to 58%29.
Although the authors in that study failed to identify
any major predisposing risk factors for the onset of
unrecognized MI compared with those with recognized MI, they did notice that a history of diabetes,
hypertension and abnormal electrocardiograms were
associated with an increased incidence of unrecognized
MI. In the National Registry of Myocardial Infarction 2,
which enrolled 1,674 USA hospitals, 33% of patients
who had suffered an MI did not have the typical presentation of chest pain30. Similarly, those without chest
pain tended to be older, and there was a higher proportion of women, diabetics and heart failure comorbidities. Furthermore, patients with atypical presentations
were less likely to be treated with coronary angiography and percutaneous coronary intervention and had
a lower chance of anticoagulants, aspirin and β-blocker
usage in the same study. In a prospective, 8-year study
focusing on the prevalence, incidence and prognosis
of recognized and unrecognized MI in the aging population, about 34.7% of MI patients were older than
75 years. Around 7.9% of subjects had a history of
MI without ECG changes (existence of Q wave), and
6.4% of subjects had ECG evidence without having a
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clinical MI history. Authors in that study concluded
that there was a higher prevalence of unrecognized
Q-wave MI in the old-old population aged 75–94 years31.
During an average follow-up of 76.2 months, the total
mortality rate was borderline higher for subjects with
some evidence of MI at baseline than that of the control group (5.9/100 person-years vs. 3.9/100 personyears; p = 0.059). Of all 20,881 participants in the recent,
prospective Global Registry of Acute Coronary Events
study involving 14 countries, atypical presentations of
ACS (8.4% in the whole cohort) increased with age and
with a higher female sex proportion9. Similarly, a significantly higher prevalence of congestive heart failure and diabetes was observed in the atypical group in
which the patients were also undertreated. Among all
atypical presentations in that study, about 50% presented with dyspnea and approximately one-fourth
presented with diaphoresis or gastrointestinal symptoms. In that study, painless presentations of unstable
angina carried the highest incidence of developing
subsequent in-hospital morbidity and mortality (OR,
2.2; 95% CI, 1.4–3.5). All hospital outcomes including
congestive heart failure, pulmonary edema, major
arrhythmias, acute renal failure and mortality were
higher in the atypical group than the group with typical
symptoms (13% vs. 4.3%; p < 0.0001). In a populationbased cohort, named the Rotterdam study, men and
women aged 55 or older from 1990–1993 had an incidence rate of unrecognized MI of around 3.8 per 1,000
person years, compared with that of recognized MI at
about 5.0 per 1,000 person years32. In the Rotterdam
study, the proportion of unrecognized MI was lower in
men (33%) than in women (54%). However, age did not
play a major role in the incidence of unrecognized MI
in men compared with women.
Mechanisms of Atypical Chest Pain
The major underlying reasons why patients develop
ACS without chest pain are not clear or heterogeneous,
although several possible mechanisms may play a
role. Different theories of such atypical chest pain in
patients with ACS have been proposed; but to date, no
single mechanism satisfactorily explains the full spectrum in this clinical phenomenon. Chest pain may
arise from the stimulation of either visceral or somatic
pain fibers. Visceral fibers originate from the heart,
esophagus, blood vessels and visceral pleura, which
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enter the spinal cord at multiple levels. Stimulation of
these fibers from any cause produces symptoms that
are poorly localized and often difficult for patients to
describe. In contrast, somatic pain fibers originate from
musculoskeletal structures, the dermis and parietal
pleura, which may produce pain following a dermatomal pattern that is well localized and easily described33.
It has been suggested that the lack of nerve innervations in a donor heart not linked to the host’s nerve
system may be the main reason for developing silent
ischemia34. The repeated silent ischemic episodes after
MI may be due to the deprivation of afferent innervations created by critically placed infarctions35. The
elderly appear to have a somewhat reduced pain perception and tend to have more comorbidities such as
diabetes36. Haro et al.37 reported that elderly patients
may actually present more frequently with complaints
of fatigue, worsening congestive heart failure or even
altered mental status, lightheadedness and syncope.
Diabetes itself, which is associated with autonomic
nerve dysfunction, has been proven to be a predisposing factor for asymptomatic myocardial ischemic
events4. Moreover, diabetic patients are also more
likely to present with exercise intolerance and severe
fatigue, which may be confused with heart failure
symptoms or lightheadedness38.
The higher incidence of atypical chest pain in the
female population is due to higher simultaneous symptoms such as neck and shoulder pain, nausea, fatigue,
and dyspnea. In addition, the female population tends
to have postmenopausal coronary artery disease, which
may lead to higher comorbidities like diabetes or hypertension39. The elderly may suffer from more comorbidities, and it is very likely that the aging process
results in a higher incidence of diabetes40,41. It has also
been mentioned that an altered threshold to pain perception or various noxious stimuli (such as electrical
shock, pressure or cold) known as the “defective warning system” has been shown by Droste et al.42,43 to be
related to silent infarcts. An increased incidence and
link between silent MI or sudden death with diabetes has
been suggested, although some epidemiologic studies
failed to demonstrate this point very well7,44. Psychologic factors have also been proposed as a possible
mechanism in silent infarcts associated with diabetes.
Furthermore, an excess of endogenous endorphins or
possibly a particular biochemical inflammatory system
activation pattern involving microenvironmental balance between proinflammatory and anti-inflammatory
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Atypical Chest Pain in the Elderly
cytokines have also been reported to be possible causes
of silent myocardial ischemia45,46.
Evolution of and Advances in Diagnostic
Tools for ACS
Although much effort has been made to assist the early
detection of ACS, the misdiagnosis and inappropriate
discharge rates remain high (up to 10%) as shown in
previous studies5,6,20. It has been shown that elderly
patients with ACS are less likely to have typical ECG
findings than younger patients. Moreover, they are less
likely than younger patients to present with ST segment
elevations (31.4% vs. 50.1%; p < 0.05) and are more
likely to present with left bundle branch block (8.0%
vs. 0.6%; p < 0.05)47. Elderly patients are also more likely
to have pacing rhythms from a previous pacemaker
implant as well as a previous MI history, both of which
may lead to more frequent non-diagnostic ECGs of
acute myocardial injury. Comparison with previous ECGs
is thus necessary48. A flowchart based on a prospective
protocol as a predictive model implemented on ECG
and clinical variables further aids the decision strategy
in cardiac care unit admission with a similar sensitivity
compared with physicians and an even higher specificity49. Chest radiography is a cost-effective diagnostic
tool that may influence the management strategy in
up to 23% of patients presenting at the ED with chest
pain50. In patients with pneumothorax or pneumomediastinum, chest radiography may be conclusive and
diagnostic, and may also provide a hint for the diagnosis of aortic dissection. Cardiac biochemical markers such as creatine kinase and creatine kinase MB are
key in the establishment of MI, whereas a more sensitive marker, troponin I, provides a more sensitive and
prognostic tool for ACS51,52. The utility of the D-dimer
marker test in elderly patients with acute chest pain has
been shown to provide a high sensitivity and a negative predictive value in the diagnosis of pulmonary
embolism53. Systematic and well-designed diagnostic
strategies combining serial cardiac markers and ECG may
help identify patients suffering from ACS when compared with routine methods54. In the detection of wall
motion abnormalities related to a specific coronary artery
territory, cardiac echography is also a useful and reliable
tool in the diagnosis of acute myocardial ischemia55,56.
A triage algorithm, developed by Pelliccia et al.57, based
on a scoring system including serial cardiac enzymes
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follow-up, ECG, resting echocardiography and clinical
features has further improved the accurate diagnostic
rate and treatment in the elderly population, resulting
in comparable outcomes with the younger age group.
Using resting sestamibi perfusion images based on initial ECG and cardiac enzymes for the effective identification of initially unsuspected, high-risk patients who
may require a prompt intervention from those who
are truly at low risk has also been proposed58. ECG is
efficient as a rapid and convenient bedside test for the
detection of wall motion abnormalities at rest or
under stress test in the diagnosis of ACS55,59. Recently,
it has been shown that cardiac biomarkers, such as
brain-type natriuretic peptide and N-terminal fragment
of the prohormone brain natriuretic peptide, released
from the ischemic myocardium as a clinical predictive
value after ACS may actually reflect the severity of
myocardial ischemia or be related to ventricular wall
stress and systolic dysfunction after infarct60. White
et al.61 reported that in a study of 69 patients who underwent 16-slice computed tomography, in the patients
with cardiac or non-cardiac chest pain presenting in
the ED compared with those diagnosed by traditional
methods, the sensitivity and specificity were high for
the establishment of cardiac cause (83% and 96%, respectively) of chest pain and all (including cardiac and
noncardiac) causes (87% and 96%, respectively). A recently developed “triple rule-out” strategy using a
64-slice computed tomography examination protocol
for evaluation of acute MI, pulmonary embolism and
aortic pathology on a single, 12-second study has also
been proposed with acceptable diagnostic accuracy62–64.
The widespread application of such imaging modalities implemented on traditional diagnostics, however,
poses its own disadvantages and shortcomings such as
radiologic exposure and contrast load. However, White
et al.61 have further expanded the current diagnostic
and treatment triage leading to potentially better outcomes in the elderly population.
Conclusion
The incidence of atypical symptoms in the elderly population with ACS presenting at the ED is high, and
accurate diagnosis and urgent therapeutic intervention remain a challenge. Comorbidities are common
in this population who has a higher risk of being misdiagnosed or inappropriately discharged, leading to
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worse outcomes. Efficient triage and further integration
of clinical features, biomarkers and emerging diagnostic
cardiovascular imaging in the future may help improve the accuracy of the diagnostic rate with subsequent better outcomes in this patient population.
15.
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International Journal of Gerontology | March 2010 | Vol 4 | No 1