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James A. Espinosa, MD

Medical and Surgical Emergencies and Urgencies in the Aging Patient: Geriatric Cardiovascular Emergencies Acute Chest Pain and ACS in the Elderly Patient. James A. Espinosa, MD

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James A. Espinosa, MD

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  1. Medical and Surgical Emergencies and Urgencies in the Aging Patient: Geriatric Cardiovascular EmergenciesAcute Chest Pain and ACS in the Elderly Patient James A. Espinosa, MD Assistant Professor, Department of Emergency MedicineUMDNJ-SOM, Stratford, New JerseyAttending Emergency Physician, Department of Emergency MedicineKennedy Health System, Stratford DivisionStratford, New Jersey

  2. Acute Chest Pain and ACS in the Elderly Patient This Care of the Aging Medical Patient in the Emergency Room(CAMPER) presentation is offered by the Department of Emergency Medicine in coordination with the New Jersey Institute for Successful Aging. This lecture series is supported by an educational grant from the Donald W. Reynolds Foundation Aging and Quality of Life program.

  3. Learning Objectives: • Identify geriatric aspects of the diagnosis, treatment and complications of chest pain in the elderly, including pneumonia, acute coronary syndrome, aortic dissection, and pulmonary embolism. • Identify potential geriatric cardiac causes of such atypical cardiac symptoms as fatigue, dyspnea, and dizziness.

  4. Introduction : • The general case for the appreciation of Geriatric Medicine finds specific importance in Geriatric Emergency Medicine! • The ED is increasingly the access point for older patients with acute medical and surgical emergencies. • The ED is increasingly the access point for older patients with chronic medical, social, or psychiatric problems. The pediatric emergency medicine movement championed the many special biological, psychological, and social needs and differences of children -- differences in clinical presentation and management of children that have become core to modern knowledge base and practice. • These issues are also on point for the ED management of the elderly. What is different about the presentation and management of the elderly? What are the special issues and needs? • Wilber, ST. New Frontiers in Geriatrics Research: An Agenda for Surgical and Related Medical Specialties. 2004: 53-83. • Katz PR, et al. Geriatric Syllabus for Specialists: A Project of the American Geriatrics Society and the Hartford Foundation. 2002.

  5. Introduction: • The emergency medicine literature is responding with discussions of the demographics, physiology, pharmacology, and psychosocial issues in elder ED care. • Central to this growing understanding is an appreciation of the way that elderly patients may present with symptoms that are atypical, in comparison to the ways that the non-elderly adult may present. • The implications of this knowledge are practical and important. Atypical presentations may be related to cognitive challenges in making the correct diagnosis -- with management, treatment and outcome implications. Such knowledge is related to patient care, risk management and patient safety. • Birnbaumer DM. Rosen’s Emergency Medicine. Concepts and Clinical Practice. 2010;2348-2352. • Hals G. Common diagnoses become difficult diagnoses when geriatric patients visit the Emergency Department: Part I. Emergency Medicine Reports 2010;31(9).  Retrieved July 22, 2010 from Health Reference Center Academic via Gale:http://find.galegroup.com/gtx/start.do?prodId=HRCA&userGroupName=umdnj • Hals G. Common diagnoses become difficult diagnoses when geriatric patients visit the Emergency Department: Part II. Emergency Medicine Reports, 2010;31(10).  Retrieved July 22, 2010 from Health Reference Center Academic via Gale:http://find.galegroup.com/gtx/start.do?prodId=HRCA&userGroupName=umdnj • Kelly BS. Clin Geriatr Med 2007;23(2):327-349.

  6. Question One: • An 89 year old female presents to the ED from a nursing home with a history of a change in mental status and weakness. She is afebrile and does not have a history of cough or sputum production. Which of the following statements is TRUE? • In patients >85 years of age, fever is absent in approximately 20% of cases. • In patients >85 years of age, fever is absent in approximately 50% of cases. • In patients >85 years of age, fever is absent in approximately 80% of cases. • In patients >85 years of age, the presence or absence of cough, fever and sputum production are no different than in younger age groups.

  7. A Model for Atypical Presentation: Pneumonia in the Elderly • Pneumonia in the elderly may present with such atypical features (relative to younger patients) as: • Confusion/change in mental status • Increase in falls • Weakness • In patients >85 years of age, fever is absent in approximately 50% of cases. • The implication is the need for vigilance for pneumonia in the elderly in the absence of such classic features as fever, cough, and sputum production. Hals G. Common diagnoses become difficult diagnoses when geriatric patients visit the Emergency Department: Part I. Emergency Medicine Reports 2010;31(9).  Retrieved July 22, 2010 from Health Reference Center Academic via Gale:http://find.galegroup.com/gtx/start.do?prodId=HRCA&userGroupName=umdnj

  8. Pneumonia in the Elderly • Elderly patients with pneumonia are more likely to have advanced disease at the time of presentation/diagnosis. • Elderly patients with pneumonia are more likely to present with sepsis. • Patients in nursing homes/extended care facilities are at increased risk for resistant organisms, such as: • P. aeruginosa • K. pneumonia • Hospital-acquired MRSA Moran GJ, et al.. Rosen’s Emergency Medicine: Concepts and Clinical Practice, 7th Edition. 2010;927-938.

  9. Pneumonia in the Elderly An Example of How Process Improvement is Needed • Pneumonia is the second leading reason for Medicare beneficiary hospitalization and the fifth leading cause of death among Americans greater or equal to 65 years of age. It continues to be a source of mortality and morbidity in all age groups. • A study by Schuitema and Espinosa looked at the impact of a clinical algorithm for pneumonia treatment that embedded, inter alia, a change in mental status as a trigger for identification and treatment of patients with possible pneumonia. • In patients >65, there was a statistically significant reduction in door to antibiotic cycle time in patients greater or equal to 65 years of age (Pre-intervention average 159 min (n=225) vs. post-intervention average 116 minutes (n=158) (Student T test, p=<.01) • The percent of cases with < 4 cycle timeincreased from 89% to 96%. This increase was statistically significant (Chi-square, p<.01). Schuitema HS, Espinosa JA. Acad Emerg Med 2009;16(4,Suppl 1):89.

  10. Question Two: • An 86 year old male presents to the ED with a chief complaint of dyspnea on exertion over a two day period. He denies chest pain. He has a past medical history of hypertension. His ECG shows non-specific ST-segment changes. A troponin is positive. Which of the following statements is FALSE? • Myocardial infarction without chest pain is more common in the elderly than in younger patients. • In patients >85, the single most common presenting symptom of coronary insufficiency “angina” is actually dyspnea, not chest pain. • Elderly patients are more likely to have non-ST-segment elevation MIs than ST-segment elevation MIs. • Older patients may not receive treatment for AMI that is as aggressive as younger patients. However, older patients may have less absolute benefit for such therapy and therefore less aggressive therapy is warranted. • The diagnosis of AMI in the elderly is very dependent on measuring serum biomarkers.

  11. ACS/Focus on Myocardial Infarction Without Chest Pain in the Elderly It has been established that inside the frame of unstable angina and AMI, certain subgroups are at higher risk for misdiagnosis. Younger aged patients Diabetic patients Women Elderly Younger patients may have classic symptoms, but MI may not be considered due to age alone (e.g., patient in early 30s with chest pain). However, atypical symptoms seem to account for misdiagnosis in the remaining three subgroups. Kelly BS. Clin Geriatr Med 2007;23(2):327-349.

  12. Question 3: • An 82 year old female presents with neck and shoulder pain associated with nausea and fatigue. The patient is diabetic. On careful questioning, a history of dyspnea on exertion of two days duration is obtained. An ECG reveals non-specific ST-T changes and a troponin is positive. Which of the following statements is FALSE? • Women of all ages with AMI are more likely to present with neck and shoulder pain (in the absence of chest pain) than men. • Diabetic patients of all ages are more likely to present with clinically silent AMI, more likely to show late presentation of AMI, more likely to present with exertional dyspnea and fatigue. • Myocardial infarction without chest pain is more common in elderly patients than in younger patients. • Myocardial infarctions without chest pain in the elderly are less severe and have better outcomes than in presentations with chest pain. • Anginal equivalents in elderly include: fatigue, increase in CHF, change in mental status, and syncope.

  13. ACS/Focus on Myocardial Infarction Without Chest Pain in the Elderly • ACS in women: AMI more likely to present with neck and shoulder pain than men. More likely to present with nausea and fatigue than men. • ACS in diabetics: More likely to present with clinically silent AMI. More likely to show late presentation of AMI. More likely to present with exertional dyspnea and fatigue. • ACS in elderly: Myocardial infarction without chest pain is more common than in younger patients. Kelly BS. Clin Geriatr Med 2007;23(2):327-349.

  14. ACS/Focus on Myocardial Infarction Without Chest Pain in the Elderly • Focus on ACS/AMI in elderly • In patients >85, the single most common presenting symptom of coronary insufficiency, “angina,” is actually dyspnea, not chest pain. • Patients presenting without chest pain have double the mortality of those with chest pain. • Anginal equivalents in elderly include: fatigue, increase in CHF, change in mental status, syncope. Hals G. Common diagnoses become difficult diagnoses when geriatric patients visit the Emergency Department: Part II. Emergency Medicine Reports, 2010;31(10).  Retrieved July 22, 2010 from Health Reference Center Academic via Gale:http://find.galegroup.com/gtx/start.do?prodId=HRCA&userGroupName=umdnj

  15. ACS/Focus on Myocardial Infarction Without Chest Pain in the Elderly • Elderly patients: 65% of AMIs and 80% of deaths from AMI. • Elderly patients are more likely to have non-ST-segment elevation MIs than ST-segment elevation MIs. • The diagnosis of AMI in the elderly is, therefore, very dependent on measuring serum biomarkers. • Negative markers, of course, do not rule out coronary artery disease. • Patients with renal insufficiency may have elevations of Troponin T or I. The pathogenesis is unclear -- troponin elevations may reflect microinfarctions or may be due to left ventricular hypertrophy. Whatever the cause, such elevations track with increased mortality. • ECG interpretation can be confounded by baseline pathology. • Observation/rule out admissions remain an important element in this area. Hals G. Common diagnoses become difficult diagnoses when geriatric patients visit the Emergency Department: Part II. Emergency Medicine Reports, 2010;31(10).  Retrieved July 22, 2010 from Health Reference Center Academic via Gale:http://find.galegroup.com/gtx/start.do?prodId=HRCA&userGroupName=umdnj

  16. ACS/Focus on Myocardial Infarction Without Chest Pain in the Elderly • Older patients may not receive treatment for AMI that is as aggressive as younger patients. However, older patients may have greater absolute benefit from such therapy. • In the case of thrombolytic therapy for AMI, older patients are less likely to have indications for thrombolytic therapy and are more likely to have contraindications to thrombolytics. • Suggestions for geriatric research in this area have included recommendations for studies of techniques to improve ACS recognition and treatment in the elderly as well as the inclusion of older patients in trials of ACS treatment. Wilber, ST. New Frontiers in Geriatrics Research: An Agenda for Surgical and Related Medical Specialties. New York, NY: The American Geriatrics Society, 2004: 53-83.

  17. Pulmonary Embolism in the Elderly In addition to the general fund of knowledge concerning PE, there are some important key points related to PE in the elderly. These points include: Risk for PE, having risen at age 40, rises again at age 60. The risk approximately doubles for every decade after age 60. Much of this risk tracks with the rise in PE risk factors as a function of age, including COPD, immobility, cancer, etc. Elderly patients may present with painless dyspnea, at rest or with exertion. Exertional dyspnea with non-specific ST-T changes may weight the differential diagnosis in the direction of AMI. Elderly patients with PE can present with syncope (can occur at any age, especially with massive PE, but a syncope presentation for PE may be more common in the elderly). Hals G. Common diagnoses become difficult diagnoses when geriatric patients visit the Emergency Department: Part II. Emergency Medicine Reports, 2010;31(10).  Retrieved July 22, 2010 from Health Reference Center Academic via Gale:http://find.galegroup.com/gtx/start.do?prodId=HRCA&userGroupName=umdnj

  18. Pulmonary Embolism in the Elderly The theme of a shift in symptom pattern in a disease state in the elderly is found in PE. Dyspnea at rest or exertion is less likely in patients over 70 years of age in PE than in younger patients (less than 70 years of age) [66% vs 76%]. Pleuritic chest pain is less likely in patients over 70 years of age in PE than in younger patients (less than 70 years of age) [35% v 46%]. Elderly patients with PE are less likely to manifest tachypnea (> 20). Elderly patients with PE are less likely to manifest tachycardia (> 100). Stein PD, Beemath A, Matta F, et al. Am J Med 2007;120(10):871-879.

  19. Pulmonary Embolism in the Elderly Caution with physical exam in elderly patients with PE! Rales, crackles seen in approximately 25%. Such findings would possibly lead towards a diagnosis of pneumonia. Unilateral leg swelling or other signs of DVT are less likely with PE in elderly patients. Hals G. Common diagnoses become difficult diagnoses when geriatric patients visit the Emergency Department: Part II. Emergency Medicine Reports, 2010;31(10).  Retrieved July 22, 2010 from Health Reference Center Academic via Gale:http://find.galegroup.com/gtx/start.do?prodId=HRCA&userGroupName=umdnj

  20. Pulmonary Embolism in the Elderly D-dimer in elderly Elevations sensitive, but not specific for PE Many other conditions, which increase as a function of age, cause d-dimer elevations AMI, neoplasm, sepsis, etc. Imaging studies for PE in elderly Underlying renal disease may limit the use of contrast Hals G. Common diagnoses become difficult diagnoses when geriatric patients visit the Emergency Department: Part II. Emergency Medicine Reports, 2010;31(10).  Retrieved July 22, 2010 from Health Reference Center Academic via Gale:http://find.galegroup.com/gtx/start.do?prodId=HRCA&userGroupName=umdnj

  21. Pulmonary Embolism in the Elderly The incidence of PE rises with age Elderly patients with PE show an increased morbidity and mortality Co-existing disease (e.g., COPD, pneumonia, CHF) may increase the difficulty in making the diagnosis of PE in elderly patients Kelly BS. Clin Geriatr Med 2007;23(2):327-349.

  22. Thoracic Aortic Dissection in Elderly General axioms: Difficult diagnosis in all age groups Diagnostic delays are common TAD diagnosis often made in course of advanced imaging procedures intended to identify other diagnoses Kelly BS. Clin Geriatr Med 2007;23(2):327-349.

  23. Thoracic Aortic Dissection in Elderly General axioms: Tearing/ripping pain description is relatively specific but is very insensitive (50% overall). However, identification of the quality, onset intensity, and migratory nature/radiation of pain may provide crucial clues. ECG changes of AMI do not exclude TAD Type A: surgical intervention (generally) Type B: medical intervention (generally) Kelly BS. Clin Geriatr Med 2007;23(2):327-349.

  24. Thoracic Aortic Dissection in Elderly • Average patient is a man in his 70s • However: • In patients older than age 70 with Type A dissections, 52% are women • In patients older than age 70 with Type B dissections, 38% are women • Hagan PC, Nienaber CA, Isselbacher EM, et al. JAMA 2000;283(7):897-903. • Hals G. Common diagnoses become difficult diagnoses when geriatric patients visit the Emergency Department: Part II. Emergency Medicine Reports, 2010;31(10).  Retrieved July 22, 2010 from Health Reference Center Academic via Gale:http://find.galegroup.com/gtx/start.do?prodId=HRCA&userGroupName=umdnj

  25. Thoracic Aortic Dissection in Elderly The risk factors are similar in patients of all age groups: Hypertension (72% of patients) Atherosclerosis (31% of patients) Prior cardiac surgery (18%) Known aortic aneurysm (16%) • Hagan PC, Nienaber CA, Isselbacher EM, et al. JAMA 2000;283(7):897-903. • Hals G. Common diagnoses become difficult diagnoses when geriatric patients visit the Emergency Department: Part II. Emergency Medicine Reports, 2010;31(10).  Retrieved July 22, 2010 from Health Reference Center Academic via Gale:http://find.galegroup.com/gtx/start.do?prodId=HRCA&userGroupName=umdnj

  26. Thoracic Aortic Dissection in Elderly Another distinction with age = Pulse deficits in TAD Core concept: Pulse deficits found in 30% of all age patients with Type A dissection and in 20% of Type B patients However: In patients > age 70 with Type A dissection, only 24% have a pulse deficit (vs 33% less than 70 years of age) In patients > age 70, with Type B dissection, only 15% have a pulse deficit (vs 24% less than 70 years of age) Hagan PC, Nienaber CA, Isselbacher EM, et al. JAMA 2000;283(7):897-903.

  27. Thoracic Aortic Dissection in Elderly Elderly patients (>70) with Type A dissections are less likely to present with abrupt onset chest pain than patients < age 70 (76% vs 88%) In some elderly patients ultimately diagnosed with TAD, the only symptom may be syncope However: No difference in abrupt onset chest pain frequency in Type B dissections • Nallamothu BK, Mehta RH, Saint S, et al. Am J Med 2002;113(6):468-471. • Mehta RH, Bossone E, Evangelista A, et al. Ann Thorac Surg 2004;77(5):1622-1629. • Mehta RH, O'Gara PT, Bossone E, et al. J Am Coll Cardiol 2002;40(4):685-692.

  28. Thoracic Aortic Dissection in Elderly Pervasive challenge in diagnosis: TAD can present with a remarkably wide variety of symptoms related to branch of aorta affected or to regional compression. Including , but not limited to: cardiovascular presentations: MI, CHF, hypertension, hypertension, hypotension neurologic complaints (e.g., syncope, stroke, paralysis) renal failure limb ischemia gastrointestinal presentations: (e.g., mesenteric ischemia, hemorrhage) Hals G. Common diagnoses become difficult diagnoses when geriatric patients visit the Emergency Department: Part II. Emergency Medicine Reports, 2010;31(10).  Retrieved July 22, 2010 from Health Reference Center Academic via Gale:http://find.galegroup.com/gtx/start.do?prodId=HRCA&userGroupName=umdnj

  29. Thoracic Aortic Dissection in Elderly Diagnostic issues: CXR may be helpful, but imaging required CXR normal in at least 10% of patients with TAD CT, TEE, CT angiography, MRI Entire aorta should be imaged when considering dissection Laboratory testing has had a limited role D-dimer shows poor specificity Several interesting laboratory tests are under investigation, including smooth muscle myosin heavy chains and soluble elastin fragments Kelly BS. Clin Geriatr Med 2007;23(2):327-349.

  30. Conclusions: Summary • The ED is a common point of entry to medical care for older adults. • Older patients may present with atypical symptoms of serious disease. • Several disease states have been discussed in which atypical symptoms are seen in elderly patients. • Research recommendations in elderly patients have been suggested in the literature. These include the pursuit of process improvement changes to improve outcomes, as well as continued research into diagnostic and treatment interventions to improve outcomes in ED patients with high-risk, common complaints.

  31. References/Resources Birnbaumer DM. The elder patient. In: Marx JA, Hockberger RS, Walls RM (eds): Rosen’s Emergency Medicine. Concepts and Clinical Practice. Philadelphia, PA: Mosby Elsevier, 2010;2348-2352. Hagan PC, Nienaber CA, Isselbacher EM, et al. The International Registry of Aortic Dissection (IRAD): New insights into an old disease. JAMA 2000;283(7):897-903. Hals G. Common diagnoses become difficult diagnoses when geriatric patients visit the Emergency Department: Part I. Emergency Medicine Reports 2010;31(9). Retrieved July 22, 2010 from Health Reference Center Academic via Gale:http://find.galegroup.com/gtx/start.do?prodId=HRCA&userGroupName=umdnj Hals G. Common diagnoses become difficult diagnoses when geriatric patients visit the Emergency Department: Part II. Emergency Medicine Reports, 2010;31(10). Retrieved July 22, 2010 from Health Reference Center Academic via Gale:http://find.galegroup.com/gtx/start.do?prodId=HRCA&userGroupName=umdnj Katz PR, Grossberg GT, Potter JF, Solomon DH. Geriatric Syllabus for Specialists: A Project of the American Geriatrics Society and the Hartford Foundation. 2002. Kelly BS. Evaluation of the elderly patient with acute chest pain. Clin Geriatr Med 2007;23(2):327-349. Madsen TE, Bledsoe J, Bossart P. Appropriately screened geriatric chest pain patients in an observation unit are not admitted at a higher rate than nongeriatric patients. Crit Pathways in Cardiol 2008;7(4):245-247. Marx JA, Hockberger RS, Walls RM, eds. Rosen’s Emergency Medicine: Concepts and Clinical Practice, 7th Edition. Philadelphia, PA: Mosby Elsevier, 2010.

  32. References/Resources Mehta RH, Bossone E, Evangelista A, et al. Acute Type B aortic dissection in elderly patients: Clinical features, outcomes, and simple risk stratification rule. Ann Thorac Surg 2004;77(5):1622-1629. Mehta RH, O'Gara PT, Bossone E, et al. Acute Type A aortic dissection in the elderly: Clinical characteristics, management, and outcomes in the current era. J Am Coll Cardiol 2002;40(4):685-692. Meldon SW, Ma OJ, Woolard R. Geriatric Emergency Medicine. New York, NY: McGraw-Hill Professional, 2004. Moran GJ, Talan DA. Pneumonia. In: Marx JA, Hockberger RS, Walls RM, eds. Rosen’s Emergency Medicine: Concepts and Clinical Practice, 7th Edition. Philadelphia, PA: Mosby Elsevier, 2010;927-938. Nallamothu BK, Mehta RH, Saint S, et al. Syncope in aortic dissection: Diagnostic, prognostic, and clinical implications. Am J Med 2002;113(6):468-471. Schuitema HS, Espinosa JA. Computer simulation enriched process re-engineering in antibiotic delivery cycle time in patients with community acquired pneumonia in geriatric patients. Acad Emerg Med 2009;16(4,Suppl 1):89. Stein PD, Beemath A, Matta F, et al. Clinical characteristics of patients with acute pulmonary embolism: Data from PIOPED II. Am J Med 2007;120(10):871-879. Wilber, ST. Geriatric emergency medicine. In: Solomon DH, LoCicero J, Rosenthal RA (eds). New Frontiers in Geriatrics Research: An Agenda for Surgical and Related Medical Specialties. New York, NY: The American Geriatrics Society, 2004: 53-83.

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