CHEST PAIN IN THE ELDERLY

1. CHEST PAIN IN THE ELDERLY

2. HISTORY • WHERE? • WHEN? • FOR HOW LONG? • IRRADIATION • WHAT DO YOU DO TO MAKE IT STOP? • DOES IT CHANGE WHILE SHIFTING POSITION OR DEEP BREATHING?

4. ETIOLOGY • ANGINA ECG • RESPIRATORY • ABDOMINAL • BLOOD DISORDERS • OSTEO-ARTICULAR • OTHERS

5. CHEST PAIN FROM CARDIO-VASCULAR DISEASES

6. ETIOLOGY • ACUTE CORONARY SYNDROME/ACUTE MYOCARDIAL INFARCTION • ANGINA • ATS • ANEMIA • THYROID • ARRYTHMIA/AV BLOCK • HYPERTENSION • ORTHOSTASTIC HYPOTENSION • DISSECTING AORTIC ANEURYSM • ACUTE PERICARDITIS

7. 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.

8. DIAGNOSTIS • ECG • MYOCARDIAL ENZYMES • ECHOCARDIO/CORONAROGRAPHY • BIOCHEMISTRY

9. 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 wavein DII, DIII, aVF or in at least two consecutive precordial leads + significant CK-MB increment

14. LAB TESTS • Risk factors • Echocardiography • Coronarography • Scintigraphy

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

16. TREATMENT • ACUTE: first 24 hours • CHRONIC

17. ACUTE PHASE • Cardiovascular history • Physical exam • ECG • Peripheric line • Oxigen • Aspirineorally 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.

18. 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 havestreptokynaseand nott-PA due to lower risk of stroke.

19. ANGIOPLASTY • should be considered in the following situations: • persistentsevere 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

20. 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) • neverwith streptokinaza

21. 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

22. STABILE ANGINA

23. PARTICULARITIES • The chest pain is rare • It might be replaced by: • Pain in the dorsal spine  misinterpreted as rheumatological • Pain in epigastrium misinterpreted asgastroenterological • Dyspnea  misinterpreted aspneumological • Syncope  misinterpreted asneurological • 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

24. 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

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

27. RISK FACTORS • diabetes • dyslipidemia • hyperuricemia • anemia polyglobulia • hyperthyroidism

28. CORONAROGRAPHY

29. 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

32. :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

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

34. 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

35. 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

38. CAUSES FOR CHEST PAIN AGGRAVATION

39. 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 defficiency The most frequent hematolog disease in elderly (10-20%)

40. 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

41. ARRHYTHMIAS

48. HYPERTENSION • > 50% of elderly patients have high BP • Isolated Systolic Hypertension, ISH is specific to elderly and is defined byBP systolic 140 mmHg whileBP dyastolic < 90 mmHg. • The prevalenceincreases 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 andstroke by 2,5 times

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

50. 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!