Understanding Chest Pain in the Elderly | CAUSES, CONCERNS, AND CARE

World Heart Day, an annual observance celebrated on September 29, coming Friday, aims to raise public awareness of cardiovascular diseases, their prevention, and their global impact. This year’s theme, “Use Heart, Know Heart,” serves as a reminder for people worldwide to prioritise heart health. The campaign underscores the crucial initial step of understanding our own hearts. In this context, today, we will explore the intricacies of heart health in the elderly.

When we discuss understanding the heart, the first thing that often comes to mind is chest pain and it is a symptom that should never be taken lightly, especially when it occurs in the elderly population. While chest pain can be caused by a wide range of conditions, its significance in older adults can be a matter of life and death.

Common Causes of Chest Pain in the Elderly

Cardiovascular Causes:

The most common cause of chest pain in the elderly is Cardiovascular cause specifically angina.

a. Angina: Angina is a common cause of chest pain in the elderly, often stemming from reduced blood flow to the heart muscle due to narrowed coronary arteries. It is crucial to differentiate between stable angina and unstable angina, as the latter can be a sign of an impending heart attack.

Stable Angina:

Description: Stable angina typically presents as chest discomfort or pressure, often described as a squeezing or burning sensation.

Triggers: Symptoms are often triggered by physical activity, emotional stress, or heavy meals. The pain can come when you’re walking uphill or in the cold weather.

Relief: Rest or the use of sublingual nitroglycerin can relieve the pain within a few minutes.

Duration: Episodes of stable angina tend to be short-lived, lasting for a few minutes.

Unstable Angina:

Description: Unstable angina is characterised by chest pain or discomfort that occurs at rest, with increasing severity, or with minimal exertion. It’s typically severe and lasts longer than stable angina, maybe 20 minutes or longer.

Symptoms are similar to stable angina but more severe. The pain doesn’t go away with rest or the usual angina medications. If the blood flow doesn’t improve, the heart is starved of oxygen and a heart attack occurs. Unstable angina is often considered a medical emergency due to its association with an increased risk of a heart attack.

Myocardial Infarction (Heart Attack): Heart attacks are a significant concern for elderly individuals, as they are at a higher risk due to factors like atherosclerosis and age-related changes in the cardiovascular system.

Heart Attack Symptoms in the Elderly:

Chest Pain: Chest pain during a heart attack is often described as intense, crushing, or squeezing. It may radiate to the left arm, jaw, neck, or back.

Shortness of Breath: Elderly patients may experience profound shortness of breath during a heart attack.

Nausea and Vomiting: Nausea and vomiting are common symptoms, often accompanied by a feeling of impending doom.

Sweating: Profuse sweating, sometimes described as “clammy” or “cold” sweats, can occur.

Fatigue: Profound fatigue or weakness may be present.

Diagnostic Modalities:

Diagnosing heart related chest pain involves a combination of clinical evaluation and diagnostic tests. Your doctor will follow a structured approach to determine the underlying cause of chest pain and assess the patient’s risk. Key diagnostic steps include:

1. Medical History: A detailed medical history is obtained to assess risk factors, past medical conditions, and a description of the chest pain.

2. Physical Examination: A physical examination is conducted to assess vital signs, listen for abnormal heart sounds, and evaluate for signs of distress.

3. Electrocardiogram (ECG or EKG): An ECG is performed to record the electrical activity of the heart. Changes in the ECG, such as ST-segment depression or T-wave inversion, may indicate ischemia or cardiac stress.

4. Cardiac Enzymes: Blood tests are conducted to measure cardiac enzymes like troponin and creatine kinase-MB (CK-MB). Elevated levels of these enzymes may suggest heart muscle damage.

5. Imaging Studies:

a. Chest X-ray: A chest X-ray can help rule out other causes of chest pain, such as lung or rib issues.

b. Echocardiography: This ultrasound of the heart provides real-time images and helps assess heart function and any structural abnormalities.

6. Stress Testing: Stress tests may be performed to provoke angina symptoms under controlled conditions. This can include exercise treadmill tests or pharmacological stress tests. Changes in the ECG during stress can reveal underlying coronary artery disease.

7. Coronary Angiography: Invasive coronary angiography involves injecting contrast dye into the coronary arteries to visualise blockages. It provides detailed information about the location and severity of coronary artery disease.

Atypical symptoms of Heart Attack in the elderly

Atypical symptoms of a heart attack in the elderly can be subtle or different from the classic symptoms of chest pain and discomfort. Recognizing these atypical symptoms is essential because they may lead to a delayed or missed diagnosis if not properly understood. Some atypical symptoms of a heart attack in the elderly include:

Shortness of Breath: Elderly individuals may experience sudden and unexplained shortness of breath, even without chest pain. This symptom can be mistaken for other respiratory conditions like asthma or chronic obstructive pulmonary disease (COPD).

Fatigue: Profound and unexplained fatigue or weakness, especially if it’s out of the ordinary for the person, can be a sign of a heart attack.

Nausea and Vomiting: Some elderly individuals may feel nauseous or vomit during a heart attack, often without any prior digestive symptoms.

Dizziness or Lightheadedness: Feeling dizzy or lightheaded, particularly when standing up, can occur as a symptom of a heart attack in the elderly. This may be attributed to a drop in blood pressure.

Indigestion or Heartburn: Heart attack symptoms can mimic gastrointestinal discomfort, leading to confusion. Elderly individuals may mistake their symptoms for indigestion or heartburn.

Pain in the Jaw, Neck, or Upper Back: Some heart attack patients, especially women and the elderly, may experience pain or discomfort in the jaw, neck, or upper back instead of the chest. This can be misleading and result in delayed diagnosis.

Cold Sweats: Sudden, unexplained cold sweats that are not related to physical activity or heat can be indicative of a heart attack.

Confusion or Cognitive Changes: Older adults experiencing a heart attack may become confused, disoriented, or exhibit changes in mental clarity. This can be mistaken for cognitive issues or dementia.

Pain in the Upper Abdomen: Some elderly individuals may experience discomfort or pain in the upper abdomen, which can be confused with gastrointestinal issues.

Risk factors for Heart attack:

Elderly individuals are at an increased risk of heart attacks due to various factors. Understanding these risk factors can help in prevention and early intervention. Common risk factors for heart attacks in the elderly include:

Age: Advancing age is a significant risk factor for heart disease and heart attacks. The risk increases significantly for individuals aged 65 and older.

Gender: Men have a higher risk of heart attacks throughout their lives, but the risk for women increases after menopause.

Family History: A family history of heart disease, particularly if a first-degree relative (parent or sibling) has had a heart attack, increases the risk.

Smoking: Smoking is a major risk factor for heart attacks in the elderly and can accelerate the development of atherosclerosis (narrowing of the arteries).

High Blood Pressure (Hypertension): Elevated blood pressure puts extra strain on the heart and increases the risk of heart attacks. Hypertension is more common in older adults.

High Cholesterol: Elevated levels of LDL (low-density lipoprotein) cholesterol, often referred to as “bad” cholesterol, can lead to the buildup of plaque in the arteries.

Diabetes: Older adults with diabetes are at a higher risk of heart attacks. Diabetes increases the likelihood of developing atherosclerosis and other cardiovascular complications.

Obesity: Excess body weight, especially if concentrated around the abdomen, is a risk factor for heart disease. It can lead to conditions like metabolic syndrome and insulin resistance.

Physical Inactivity: Lack of regular physical activity can contribute to obesity and increase the risk of heart attacks. Engaging in regular exercise can help maintain cardiovascular health.

Diet: A diet high in saturated and trans fats, sodium, and processed foods can contribute to the development of atherosclerosis and hypertension.

Alcohol: Alcohol consumption can raise blood pressure and contribute to heart disease.

Stress: Chronic stress can contribute to heart disease by elevating blood pressure and increasing the risk of unhealthy behaviours like overeating or smoking. Too much anger can raise blood pressure and surges of hormones produced during stress can narrow the arteries and worsen angina.

Sleep Apnea: Sleep apnea, a condition characterised by interrupted breathing during sleep, is more common in older adults and can increase the risk of heart disease.

Chronic Conditions: Other chronic health conditions common in the elderly, such as chronic kidney disease or peripheral artery disease, can increase the risk of heart attacks.

Medications: Certain medications used to treat chronic conditions may have side effects that affect heart health. Regular medication reviews with your doctor is important.

Substance Abuse: Illicit drug use or abuse of prescription medications can increase the risk of heart attacks.

Chest pain in the elderly, especially when related to cardiovascular causes like angina or myocardial infarction, requires prompt and accurate diagnosis. Understanding the nuances of these conditions and utilizing appropriate diagnostic modalities are crucial in providing timely and effective care for elderly patients experiencing chest pain. Early intervention can significantly improve outcomes and reduce the risk of complications in this vulnerable population.

Other causes of chest pain in the elderly:

Respiratory Causes:

Infections like pneumonia can lead to chest pain in the elderly. It may be accompanied by coughing, fever, and difficulty breathing.
b. Pulmonary Embolism: A blood clot in the lungs (pulmonary embolism) can cause chest pain, particularly when breathing deeply. Elderly individuals with risk factors such as immobility or a history of deep vein thrombosis are more susceptible.

Gastrointestinal Causes:

Gastroesophageal Reflux Disease (GERD):
Chronic acid reflux can lead to a burning sensation in the chest, often mistaken for cardiac chest pain.
b. Esophageal Disorders: Conditions like esophageal spasms or esophagitis (swelling or inflammation of food pipe) can cause chest pain, particularly when swallowing.

Musculoskeletal Causes:

Inflammation of the cartilage that connects the ribs to the breastbone can result in sharp chest pain, especially during movements or deep breaths.

Muscle Strain:
Strained chest muscles or intercostal muscles can lead to chest discomfort in the elderly.

Chest Pain and Concerns in the Elderly Population

Atypical Symptoms: Elderly individuals may not always exhibit typical chest pain symptoms during cardiac events. Instead, they might experience shortness of breath, fatigue, or confusion. This atypical presentation can delay diagnosis and treatment.

Underlying Health Conditions: The elderly often have multiple comorbidities, such as diabetes, hypertension, and chronic kidney disease, which can complicate the evaluation and management of chest pain.

Polypharmacy: Medication regimens in the elderly are often complex, and drug interactions can contribute to chest pain or exacerbate underlying conditions.

Reduced Functional Reserve: Older adults may have limited functional reserve, making them more susceptible to complications from acute medical conditions.

Communication Challenges: Communication difficulties, such as hearing impairment or cognitive impairment, can hinder an elderly patient’s ability to describe their symptoms accurately.

Assessment and Care

Urgent Evaluation: Any chest pain in the elderly, particularly when associated with shortness of breath, sweating, or radiating pain, should be evaluated urgently. Quick assessment is vital, as timely intervention can be life-saving.

Differentiating Cardiac and Non-Cardiac Causes: Thorough evaluation, including an electrocardiogram (ECG), cardiac enzymes, and imaging studies, can help differentiate between cardiac and non-cardiac causes of chest pain.

Risk Stratification: Risk stratification tools, such as the TIMI (Thrombolysis in Myocardial Infarction) or GRACE (Global Registry of Acute Coronary Events) scores, can assist in assessing the likelihood of adverse cardiac events.

Multidisciplinary Approach: Given the complexity of care in the elderly, a multidisciplinary approach involving cardiologists, geriatricians, and other specialists may be necessary to address comorbidities and optimise care.

Medication Review: A comprehensive review of medications is essential to identify potential culprits for chest pain and drug interactions.

Preventive Measures: For those with cardiovascular risk factors, preventive measures such as statins, antiplatelet agents, and lifestyle modifications should be considered.

Palliative Care: In cases where chest pain is related to advanced, life-limiting illnesses, palliative care can help improve the patient’s quality of life and alleviate pain.

Treatment for heart related chest pain:

The treatment modalities for heart-related chest pain, including angina and coronary artery disease, typically involve a combination of lifestyle modifications, a heart-healthy diet, medications, and, in some cases, medical procedures. Here is an overview of the treatment approach:

1. Lifestyle Modifications:

Smoking Cessation: If the patient smokes, quitting is essential to reduce the risk of further heart problems.

Regular Exercise: Engaging in regular physical activity can help improve cardiovascular health. Consult with a healthcare provider to determine a suitable exercise plan.

Stress Management: Stress reduction techniques such as deep breathing, meditation can help manage emotional stress, which can trigger chest pain.

Weight Management: Maintaining a healthy weight through diet and exercise is crucial for managing heart-related conditions.

2. Heart-Healthy Diet:

Low-Fat, Low-Cholesterol Diet: Reducing saturated and trans fats in the diet can help lower LDL (bad) cholesterol levels.

High-Fiber Foods: A diet rich in fruits, vegetables, whole grains, and legumes can help lower cholesterol and improve heart health.

Limit Sodium (Salt) Intake: Reducing salt intake can help control blood pressure.

Avoid Alcohol Consumption: Any amount of alcohol in any form is injurious to health including heart health.

Monitoring Carbohydrates: For individuals with diabetes, managing carbohydrate intake is crucial to control blood sugar levels.

3. Medications:

Antiplatelet Medications: Medications like aspirin or clopidogrel may be prescribed to reduce the risk of blood clots and improve blood flow in the coronary arteries.

Nitroglycerin: Nitroglycerin tablets or sprays can help relieve angina symptoms by relaxing blood vessels and increasing blood flow to the heart.

Beta-Blockers: These medications slow the heart rate and reduce blood pressure, reducing the workload on the heart.

Calcium Channel Blockers: These medications relax and widen blood vessels, improving blood flow and reducing angina symptoms.

ACE Inhibitors or ARBs: These medications are used to control blood pressure and may be prescribed if hypertension is a contributing factor.

Statins: Statin medications are used to lower LDL cholesterol levels and reduce the risk of plaque buildup in the arteries.

Antianginal Medications: Some medications, like ranolazine, are specifically used to treat chronic angina.

Getting recommended vaccines to avoid heart complications: Studies have indicated that Influenza and pneumococcal infections are associated with a heightened risk of cardiovascular morbidity and mortality especially in elderly. Vaccination against these infections appears to be a cost-effective preventive measure, enhancing survival rates and decreasing the occurrence of cardiovascular events.

4. Medical Procedures:

Angioplasty and Stent Placement: In some cases, a procedure called angioplasty is performed to open narrowed or blocked coronary arteries. A stent may be inserted to keep the artery open.

Coronary Artery Bypass Grafting (CABG): CABG surgery may be recommended if multiple coronary arteries are severely blocked. It involves rerouting blood flow around blocked arteries using grafts.

Note: Treatment plans for heart-related chest pain are individualised based on the patient’s specific condition, risk factors, and medical history. It is only their doctor who can develop a comprehensive treatment strategy that addresses their unique needs and goals. Regular follow-up appointments and adherence to the prescribed treatment plan are essential for managing heart-related chest pain effectively.

Take home message: Understanding the symptoms of chest pain is crucial for the elderly. A multifaceted approach to treating heart-related conditions, which includes adopting a heart-healthy diet, engaging in regular exercise, quitting smoking and alcohol, and proper medication management, is essential. It’s important to note that medication alone is never sufficient in managing these conditions effectively.

Prof Upendra Kaul is Founder Director Gauri Kaul Foundation and Dr Zubair Saleem is Senior Geriatric Consultant and Gerontologist

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