CHEST PAIN IN THE ELDERLY

HISTORY

WHERE? WHEN? FOR HOW LONG? IRRADIATION WHAT DO YOU DO TO MAKE IT STOP? DOES IT CHANGE WHILE SHIFTING

POSITION OR DEEP BREATHING?

ETIOLOGY

ANGINA ECG RESPIRATORY ABDOMINAL BLOOD DISORDERS OSTEO-ARTICULAR OTHERS

CHEST PAIN FROM CARDIO-VASCULAR

DISEASES

ETIOLOGY

ACUTE CORONARY SYNDROME/ACUTE MYOCARDIAL INFARCTION

ANGINA ATS ANEMIA THYROID ARRYTHMIA/AV BLOCK HYPERTENSION ORTHOSTASTIC HYPOTENSION

DISSECTING AORTIC ANEURYSM ACUTE PERICARDITIS

ACUTE MYOCARDIAL INFARCTION IN ELDERLY

The onset of MI can be: typical silent (40% c): the diagnosis is usually based on ECG atypical, especially in elderly > 80 years old:

dyspnea syncope confusion stroke embolism upper abdominal pain

These symptoms might be attributed to other concomitant diseases or even to normal aging.

DIAGNOSTIS

ECG MYOCARDIAL ENZYMES ECHOCARDIO/CORONAROGRAPHY BIOCHEMISTRY

ECG

CLASSICAL ASPECT non-Q MI = is associated with a smaller necrosis area. The

patient call in too late to find the presence of troponin wrong diagnosis, wrong treatment, high mortality.

ECG modifications suggestive for non-Q MI: New ST segment supradenivelation, 1 mm high and 0,08 s

duration after J point New ST segment subdenivelation, 1 mm high and 0,08 s

duration after J point New negative T wave in DII, DIII, aVF or in at least two

consecutive precordial leads + significant CK-MB increment

LAB TESTS

Risk factors Echocardiography Coronarography Scintigraphy

COMPLICATIONS

Are more frequent and more severe: post-MI angina revascularisation techniques pericarditis NSAID Heart failure Pulmonary edema Myocardial muscle rupture cardiogenic shock

TREATMENT

ACUTE: first 24 hours CHRONIC

ACUTE PHASE Cardiovascular history Physical exam ECG Peripheric line Oxigen Aspirine orally abciximab (ReoPro) (inhibitor of glycoprotein IIb/IIIa) Nitroglycerin s.l. if the patient has chest pain; if there is no result

morphine, 2-4 mg i.v.Decision of the treatment: thrombolytic treatment or angyoplasty.

THROMBOLISIS decreases mortality with 18% Bigger benefits on the short time compared to younger patients Indicated for patients that refer to the hospital in the first 12

hours after the onset of pain and present on the ECG: ST segment supradenivelation recently installed LBBB

Elderly > 75 years old should have streptokynase and not t-PA due to lower risk of stroke.

ANGIOPLASTY

should be considered in the following situations: persistent severe ischemic modifications on the

ECG in spite of complete and correct medical treatment

hypotension cardiogenic shock The patient refers to the hospital later than 12 hours

from the onset of the chest pain

DRUGS

ASPIRINE: from the first minute to be continued for ever (prevents reinfarctization and decreases mortality)

HEPARINE i.v. or s.c. Together with t-PA ( clootting) never with streptokinaza

DRUGS

NITROGLYCERINE piv in the first 24 hours + 2-3 days (persistent ischemia, hypertension) induces hypotension should be carefully monitorized Do not use retard forms!

BETA-BLOCKERS decrease mortality give them from the beginning until at least 2

years afterwards, especially in cases associated with recurrent ischemia and arrythmia

ACE INHIBITORS From the beginning and for ever because it decreases mortality and

prevents HF

STABILE ANGINA

PARTICULARITIES

The chest pain is rare It might be replaced by:

Pain in the dorsal spine misinterpreted as rheumatological Pain in epigastrium misinterpreted as gastroenterological Dyspnea misinterpreted as pneumological Syncope misinterpreted as neurological

The intensity of the pain might be reduced or even absent because of concomitant diseases (diabetes, dementia)

The pain is NOT usually induced by exertion because elderly persons reduce their physical effort, but: Big meals Alcohol intake Cold weather

SILENT ANGINA

NO PAIN! 33-49% cases diagnosis:

Holter monitoring Effort test 6 Minutes Walk Test (very good alternative for elderly that are not able

to do effort test): The average distance in 6 minutes = 360 m Monitor BP, HR ECG before and after the test

Holter EKG monitoring: allows determination of HR variability, which is a good predictor for general risk of cardiovascular events and mortality

RISK FACTORS

diabetes dyslipidemia hyperuricemia anemia polyglobulia hyperthyroidism

CORONAROGRAPHY

TREATMENT

1. LIFE STYLE ADJUSTEMENTS: Diet should adapt to possible concomitant diseases Quit smoking! Fight obesity and sedentary life Adequate treatment for diabetes (when needed) BP as normal levels as possible Lipid profile as normal as possible Physical effort

:DRUGS Nytroglicerine: very efficient, s.l. and orally as retard

forms Molsidomine (NO pro-drug), when Nytroglicerine is not

tolerated (headache, flush, hypoBP) Beta-blockers: never stopp them abrubtly rebound Ivabradine, when HR is not well enough lowered by BB Calcium-channel blockers: when nytro + BB is not enough

Beta-blockers are favorites in: hypertension hypertrophic cardiomyopathy post-MI angina hyperthiroidism arrythmias

ANGINA PECTORALĂ STABILĂTRATAMENT

Calcium channel blockers are favorites in: Printzmetal angina non-Q MI: DILTIAZEM (90-300 mg/day), reduces re-

infarction Whenever we can’t use BB

Asthma HF (not verapamil or diltiazem) Diabetes Arteriopathies DON’T use them in:- WPW syndrom- Sick synus syndrome

REVASCULARIZATION PROCEDURES

Coronary artery by-pass graft (CABG) : diabetic patients in patients with multiple coronary problems In patients with LV failure

Percutaneous transluminal coronary angioplasty (PTCA): > 70 years old females emergency surgery HF

CAUSES FOR CHEST PAIN AGGRAVATION

ANEMIA

Hb < 12 g/dl in females and < 13 g/dl in males Geriatric emergency because it can aggravate the

evolution of concomitant diseases: HF angina Orthostatic hipotension Cognitive defficiencyThe most frequent hematolog disease in elderly (10-20%)

EMERGENCY TREATMENT

Oxygenotherapy (for hypoxia) Saline piv (for hypovolemia) Blood transfusion:

Concomitant MI needs it when Hb < 10 g/dl The rest Hb < 7 g/dl

ARRHYTHMIAS

HYPERTENSION

> 50% of elderly patients have high BP Isolated Systolic Hypertension, ISH is specific to elderly

and is defined by BP systolic 140 mmHg while BP dyastolic < 90 mmHg.

The prevalence increases with age: 5% in the group 60-69 10% in the group 70-79 20% in the group > 80

Systolic BP 160 mmHg increases mortality by cardiovascular diseases by 2-5 times and stroke by 2,5 times

The Conference from Yalta: The future of Europe was decided by 3 hypertensive politicians; Roosevelt survived less than 1 year

EMERGENCY TREATMENT BP>200/115 mm Hg Furosemide 20 mg i.v Clonidine, 0,150 mg i.v in 10 min or i.m Urapidil 12,5 mg i.v Enalapril i.v. Metoprolol 5-10 mg i.v TA = 160/100 mm Hg

DO NOT TRY TO BRING BP TO NORMAL VALUES TOO QUICKLY!

ORTHOSTATIC HYPOTENSION

Decrease of systolic BP with 20 mmHg or dyastolic BP with 10 mmHg while going from sitting to standing position

Very frequent in elderly, 50% of the persons residing in nursing homes have this phenomenon

Consequences: Fall Syncope Stroke

DISSECTING AORTIC ABDOMINAL ANEURYSM - CT

DISSECTING AORTIC THORACAL ANEURYSM - MRI

ACUTE PERICARDITIS

RESPIRATORY CHEST PAIN

ETIOLOGY

PULMONARY EMBOLISM PLEURAL EFFUSION CONCOMITENT

LUNG DISEASE MEDIASTINAL SYNDROME PNEUMOTHORAX

ABDOMINAL CAUSES FOR CHEST PAIN

ETIOLOGY

GALLBLADER STONES CARDIAC HEPATOMEGALY GASTRIC/DUODENAL ULCER MESENTERIC ISCHEMIA ACUTE PANCREATITIS

MESENTERIC ISCHEMIA

One of the most important causes (70-90%) of acute abdominal pain in elderly

Risk factors: AF, ATS, HF Excrutiating pain, resistant to pain killers

REUMATOLOGIC CAUSES FOR CHEST

PAIN

ETIOLOGY

SPONDILOSYS OSTEOPOROSIS TIETZE SYNDROME RIB FRACTURE

OTHERS

INTERCOSTAL NEURAL PAIN ZONA ZOSTER BREAST CANCER SKIN CANCER