Geriatric Acute Myocardial Infarction: A Challenge to Recognition, Prompt Diagnosis, and Appropriate Care

Optimizing Diagnosis and Management of Community-acquired Pneumonia in the Emergency Department

Pneumonia is split into 3 diagnostic categories: community-acquired pneumonia (CAP), health care-associated pneumonia, and ventilator-associated pneumonia. This classification scheme is driven not only by the location of infection onset but also by the predominant associated causal microorganisms. Pneumonia is diagnosed in over 1.5 million US emergency department visits annually (1.2% of all visits), and most pneumonia diagnosed by emergency physicians is CAP.

Can symptom presentation predict unstable angina/non-ST-segment elevation myocardial infarction in a moderate-risk cohort?

BACKGROUND

Accurate recognition of acute coronary syndromes (ACS) on initial presentation is key to minimizing morbidity and mortality. The wide spectrum of symptom presentation in ACS complicates recognition. Unstable angina/non-ST-elevation myocardial infarction (UA/NSTEMI) may be particularly difficult to diagnose as patients often do not exhibit initial high-risk features, leaving the clinician with symptom presentation alone, on which to base decisions regarding further investigation and treatment.

PURPOSE

The aim of this study was to compare typical symptom presentation (classic description of angina) and atypical presentation in a cohort presenting with symptoms suggestive of UA/NSTEMI.

METHOD

A prospective cohort design was used to evaluate 100 patients enrolled in an Emergency Department Chest Pain Program.

RESULTS

Although patients with typical presentation were more likely to have UA/NSTEMI, atypical presentation did not rule out this diagnosis. Of the 31 patients with UA/NSTEMI, most (n=23, 74.2%) had atypical symptoms. Male gender, symptom location, and history of ischemic heart disease were significantly associated with UA/NSTEMI. Of those with a final diagnosis of UA/NSTEMI, there was no difference in symptom presentation based on age or gender.

CONCLUSION

Clinicians should not rely on classic descriptions of angina when evaluating patients suspected of UA/NSTEMI.

Coronary heart disease. Stable and unstable syndromes

CHD in the elderly population will continue to be a source of major concern because of the increasing costs entailed and uncertainties about how the widespread array of diagnostic and therapeutic interventions, often expensive and sometimes hazardous, should be applied. Financial, political, and health policy decisions will continue to occupy much attention, but it is likely that philosophic considerations about aging and death, both from the individual and the societal perspective, will be of paramount importance of deciding how the substantial resources available to the elderly will be used. Randomized, controlled trials are unlikely to play a major role in resolution of management dilemmas in the elderly because of the extraordinary heterogeneity in this population. Registries (databases) involving carefully prospectively collected key variables are likely to be a more effective approach. Critical characterization of complications of procedures, adverse drug reactions, and collection of follow-up data on functional status are among the critical questions, and these can be answered by registry studies. Algorithms and clinical rules developed in younger cohorts are not directly transferable to the elderly cardiovascular patients, further emphasizing the need for prospectively collected, syndrome-specific data. Treatments convincingly demonstrated to reduce mortality in absolute terms more in the elderly than in the young are underused. The heterogeneity of aging emphasizes the wide variability in patients' ability to withstand the stress of procedures and complications of disease and makes clear the need to consider physiologic reserve and biologic age rather than chronology. With better characterization of biologic age and physiologic reserve, more precise estimates of outcomes of therapies and interventions can be made, and patients can be given better information and with their families have more realistic expectations. Better-informed decisions will result. Biologic age will be multifactorial, involving cognitive, emotional, physical, and nutritional attributes as well as specific organ function (lung, kidney, liver) because no single feature can characterize the total elderly patient. The concept of competing risks among the cardiovascular disease being treated, comorbidity, risks of study, and life expectancy will evolve because even the most successful therapy will have limited effect on longevity in the very old. Although important research at the cellular and molecular level will characterize and provide better understanding of the aging process, it is not likely that this basic information will be immediately useful in the management of the large number of elderly patients with major cardiovascular disease. Preventive measures, including physical exercise, mental stimulation, avoidance of depression, good nutrition, and abstinence from tobacco use, are useful approaches to postpone or ameliorate the consequences of aging and allow patients to tolerate cardiovascular diseases better when they become manifest.

Gender differences in reported symptoms for acute myocardial infarction: impact on prehospital delay time interval

A retrospective observational study using database registry of consecutive patients admitted to 16 King County hospital Coronary Care Units (CCU) was conducted to assess gender differences in symptom presentation for acute myocardial infarction (AMI) and investigate how symptom presentation relates to prehospital delay time interval from acute symptom onset to emergency department (ED) presentation. Between January 1991 and February 1993, 4,497 patients were admitted to the CCUs with diagnosed AMI. Accredited record technicians abstracted age, gender, race, transport method, symptom presentation (chest pain, sweating, nausea, shortness of breath, epigastric pain, and fainting), delay time interval between acute symptom onset and presentation to hospital ED, and discharge diagnosis from the patients' medical records. After adjusting for age and history of diabetes, no gender differences remained for frequencies of chest pain, fainting, or epigastric pain. Women reported more nausea and shortness of breath but less sweating than men as symptoms of AMI. Chest pain, sweating, and fainting were associated with decreasing delay time intervals. Age, gender, histories of AMI and diabetes, and transport choice were also significantly related to delay time interval. These results show that gender differences occur in AMI symptom experience. However, how symptoms relate to the gender gap in delay time interval is not clear. These findings suggest that health care professionals need to tailor information about possible symptoms of AMI to the patient's gender, age, and medical history.

Age-related differences in the utilization of therapies post acute myocardial infarction

OBJECTIVE

To describe the effect of age on the care of patients hospitalized with acute myocardial infarction (MI).

DESIGN

Retrospective chart review of all cases with a primary or secondary discharge diagnosis of acute MI.

SETTING

Two large community hospitals in Milwaukee, Wisconsin, from July 1, 1990 to June 30, 1991.

PATIENTS

There were 771 charts reviewed, of which, 149 cases were aged 54 years or younger, 203 were 55 to 64 years, 224 were 65 to 74 years, and 195 were aged 75 years or older.

MEASUREMENTS

Hospital charts were examined for use of diagnostic and therapeutic interventions, including medications and procedures, as well as length of stay and in-hospital mortality.

RESULTS

Older patients were more likely to be female (18%, 20%, 38%, and 56% for the four age groups, respectively, P < .001 chi-square for linear trend), more likely to present with congestive heart failure (31%, 39%, 51%, and 72%, P < .001), and had a higher in-hospital mortality rate (5%, 7%, 10%, and 18%, P < .001). Older patients had a longer length of stay in the hospital. The use of cardiac catheterization in these post-MI patients was high and did not decrease until after age 75 (85%, 88%, 88%, and 47%, P < .001). The percentage of patients receiving balloon angioplasty decreased with age (51%, 51%, 43%, and 20%, P < .001), whereas the percentage of patients receiving myocardial revascularization did not significantly differ with age (15%, 22%, 25%, and 19%, P = .46). Aspirin was less likely to be prescribed to older patients at discharge (79%, 82%, 70%, and 62%, P < .001).

CONCLUSION

A surprisingly high percentage of those older than age 65 received invasive tests and interventions. This high utilization rate coexists with our continued ignorance about the efficacy of these tests and interventions in older adults.