Clinical profile of acute myocardial infarction in elderly patients

 

J Satyanarayan Rao

 

Assistant Professor, Department of General Medicine, Kamineni Medical College and Research Centre, LB Ngar. Hyderabad, Telangana, INDIA.

Email: jinaga_satyanarayanrao@yahoo.com

 

Abstract              Background: Acute myocardial infarction is a common medical emergency. It is consequent to atherosclerotic narrowing of coronary arteries. The risk factors for coronary artery disease are hypertension, diabetes mellitus, smoking, low high density cholesterol[HDL] and high levels of low density cholesterol (LDL) Acute myocardial infarction in elderly is likely to present with 1) pain which is more likely to be termed “atypical” because the description differs from the classical one of substernal pressure with exertion. The chest pain is usually described as a substernal pressure sensation that is also perceived as squeezing, aching, burning, or even sharp. In some patients, the symptom is epigastric, with a feeling of indigestion or of fullness and gas. When pain is the presenting complaint, it may be different in character or location, and sometimes appears as an upper abdomen pain rather than a crushing or squeezing subesternal sensation.. Often they are unfit for interventions 2) Cardiovascular complications including cardiogenic shock, a trial fibrillation, and heart failure are more common in elderly 3) elderly patients arrive late for treatment late arrival for treatment/interventions Methodology: In this retrospective study 100 patients admitted with Acute myocardial infarction in ICCU during 2016/2017 in Kamineni Hospital, L.B. Nagar, Hyderabad were included They were divided into two groups Group A > 60yrs of either sex Group B < 60 years of either sex Their progress was followed from admission to discharge by going through case records. Results: In group A fewer patients underwent interventions like PTCA 27 patients, (54%) and 23 patients {46%} were managed conservatively. On the other hand in group B 33 Patients underwent PTCA and 17 patients were managed conservatively. In group A the male to female ratio was 1; 1.7 while in group B it was 4:1.In group A diabetes mellitus was present in 31% meanwhile 40 % in group B were patients of diabetes mellitus. Hypertension was present in 31 Patients [63%] In Group A but in group B 24 patients [68%] had hypertension. Atypical chest pain was more common in group A ie 19 patients[38%] compared to 16 patient [32%] in group B. Similarly in group A atypical symptoms like sweating was noted in 20 patients [40 %], breathlessness 17 patients[34%], nausea /vomiting 9 patients[15%] and giddiness in 4 patients[18%]. Typical chest pain was seen in 31 patients in group A and 34 pts in group B. It is by far the predominant symptom in acute myocardial infarction. They were less frequent in group B where in sweating was seen in 33 patients [66%], breathlessness 11 patients [22%], and nausea\vomiting 5 patients [10 %]. In group A 4 patients[8%] were brought within 3 hours, 16 patients [32%] within 3-12 hours,9 patients [18%] in 13-48 hours. In group B 9 patients, 18% were brought within 3-12 hours, 11 patients [ 22%] within 13-48 hours. Here more patients were brought within the first 12 hours. AALWMI 18% and ASWMI, 34% were more common in group A, while ALWMI 32% was more common in group B. Conclusion: Atypical features like sweating and breathlessness more common in elderly group although chest pain was predominant symptom in both groups, while nausea/ vomiting and palpitations was more common in elderly group.

Key Words: acute myocardial infarction.

 

INTRODUCTION

Acute myocardial infarction is a common medical emergency from among conditions grouped under ACS i.e. acute coronary syndromes. The elderly have the highest incidence of cardiovascular disease and frequently present with Acute Coronary Syndrome. This number can be expected to increase over time because society is aging. Older adults often sustain unfavorable outcomes from Acute Coronary Syndrome because of atypical presentation and delay in recognition. In addition, elderly patients commonly do not receive optimal guideline-directed Acute Coronary Syndrome treatment. Owing to their high baseline risk of ischemic complications, the elderly also fare worse even with optimal Acute Coronary Syndrome treatment as they frequently have more complex coronary disease, more comorbidities, less cardiovascular reserve, and a higher risk of treatment complications. They are also subjected to a broader range of pharmacologic treatment F1000Res. 2017 Oct 2;6:1791.doi:10.12688/f1000 research.11064.1.eCollection 2017. Engberding N, Wenger NK Coronary heart disease is the single largest cause of death in developed countries. Guidelines exist for the management of acute myocardial infarction (AMI), yet despite these, significant inequalities exist in the care of these patients Acute myocardial infarction is consequent to atherosclerotic narrowing of coronary atherosclerosis. the risk factors for coronary artery disease are hypertension, diabetes mellitus,, smoking, low high density cholesterol and high levels low density cholesterol. Presenting symptoms of acute MI differ in the elderly differ from those in younger patients. They are more likely to be termed “atypical” because the description differs from the classical one of subesternal pressure with exertion. When pain is the presenting complaint, it may be different in character or location, and sometimes appears as an upper abdomen pain rather than a crushing or squeezing subesternal sensation. Elderly patients have changes in pain perception and altered ischemic thresholds, but the exact explanation for atypical pain syndromes is not known.

 

MATERIAL AND METHODS

In this study 100 patients admitted with acute myocardial infarction in ICCU of Kamineni hospital and research centre, LB Nagar during 2017/2016 were grouped as

1. Age more than/equal to 60 years
2. Age less than 60 years

Inclusion Criteria

1. More than 18 years of either sex
2. Acute myocardial infarction proved by typical symptoms of acute myocardial infarction
3. Typical ECG pattern ST segment elevation>0.11 mu in at least two consecutive limb leads Or ST segment elevation >0.2mu in at least two chest leads
4. Elevated cardiac enzymes CK-MB, Troponin T/I

Exclusion Criteria

1. Age less than 18 yrs of either sex
2. Patients with stable angina
3. Patients with unstable angina
4. Sudden cardiac arrest

 

RESULTS

Sex appears comparable in elderly group ie male 54% female 46%.It predominantly lies in favor of men in younger age group i.e. 80% male and 20% female. In elderly 19% patients had atypical chest pain compared with 16% in younger group. Atypical symptoms like nausea/vomiting in [9%,] giddiness in [4%], sycope in [5%], pain in abdomen in [9%,] and altered sensorium [3%] were more common in elderly group. Antero- lateral wall myocardial infarction was more common in elderly group[48%] anteroseptal was more common in younger group. in elderly group there were male 54% female 46%.It was predominantly in favor of men in younger age group i.e.80% male and 20% female.

Table 1: Age distribution of pts

 

Table 2: Sex distribution

 

Table 3: Diabetes mellitus

 

Table 4: Hypertension

 

Table 5: Diabetes and hypertension

 

Table 6: Chest pain

 

Table 7: Associated symptoms

 

Table 8: Duration of symptoms

Table 9: Types of Acute myocardial infarction

ALWMI-anterolateral wall myocardial infarction, ASWMI-antero septal myocardial infarction AWMI-anterior wall myocardial infarction, ILWMI-inferolateral wall myocardial infarction, PWMI-posterior wall myocardial infarction, IWMI-inferior wall myocardial infarction, LWMI-latreral wall myocardial infarction, RWMI-right ventricular wall myocardial infarction

 

DISCUSSION

Elderly patients presented with typical chest pain in 62% and atypical chest pain in 38%.younger patients presented with 68% and atypical chest pain in 32%.Elderly patients presented with sweating, 44%, breathlessness 22%,nausea/vomiting 9%, and giddiness 4%.Anterolateral wall myocardial infarction [AlWMI ]was more common inn elderly 48% to32%,while anteroseptal [ASWMI]was more common in younger group,42%compared to 34% In this study 50 patient with acute myocardial infarction age>60years group A were compared with 50 patients with acute myocardial infarction age<60 years group B. In group A 54 % were male and 46% were females while in group B 80% were males and 20% were females. this observation is similar to Holey et al. Here male to female ratio was 1.37 :1 in elderly and 3:1 in younger patients. Here chest pain was most common symptom as 62% of group A reported it as compared to 68% in younger age group. Atypical symptoms were more common in elderly in elderly 20 % complained of sweating, 17 % complained of breathlessness,9% complained of nausea or vomiting,4% complained of giddiness, while in younger age group 33 % complained of sweating, 11% complained of breathlessness 9% complained of palpitation. In a study done by Woon V C, 5 et al compared elderly and younger acute myocardial infarction patients, similar clinical scenario was observed where atypical symptoms were seen in elderly. [33% /11.7%] In a study by Holey et al 29.6% in elderly and 12.5% in young presented with chest pain. Applegate et al showed that pts, more than 65 yrs were more likely to have complications compared to younger pts. C C Wood et al study In our study ALWMI was seen in 44% % and ASWMI in 34% and IWM Iin 8% in elderly group. whereas in younger group ALWMI was seen in 32%, ASMI in 42% and ALMMWI in 5%. In study done by is hihaara et al had compared elderly with young AMI acute myocardial infarction, had a non- diagnostic ecg in 50%. similar observation was noted by trasch et al¹⁸ where 40% of elderly and very elderly did not have typical ST elevation

 

CONCLUSION

A number of elderly patients reported 12hrs. After experiencing chest pain, compared to younger ones who appeared much earlier, a typical symptoms like breathlessness and nausea/vomiting were more common in elderly. Acute myocardial infarction attracts attention and scrutiny as it is a disease that causes significant mortality and morbidity. In this condition age is a risk factor and its clinical profile varies as displayed in our study in 100 patients. Better management of co-morbid condition like diabetes melitus, hypertension, obesity etc. and better access to treatment facilities for diagnosis and intervention thereof are need of the hour. A number of elderly patients reported 12hrs after experiencing chest pain, compared to younger ones who appeared much earlier, a typical symptoms like breathlessness nausea/vomiting were more common in elderly.

 

REFERENCES

1. Madsen RC, Jensen G,KP Brel, Melchior, T Torp PC Hildebrand P, age related mortality, clinical heart failure, and ventricullar fibrilation in 4259 Danish patients after myocardial infarction. Eur Heart J1997;18;1426-31.
2. Lee, K Woodlief H Topo EJ,.predictors of 30 day mortality in the era of reperfusion for acute myocardial infacrtion; results from an international trial of 41021 pts.Circulation1995;91;1659-68
3. Krumholz HM, Chen J, Wang Y, Radford MJ, Chen YT, Maerchiniak TA, comparing AMI mortality among hospitals in pts 65 yrs of age and older ;Evaluating methods of risk adjustment.Circulation 1999;99;2986-92
4. Ormand SLT, Glickman ME, sharma GVRK, Mcneil BJ, using admision charectristics to predict short term mortality from AMI in elderly pts.; results from the Cooperative cardiovascular project.Jama 1996,275;1322-28
5. Bueno H, Videm T, Almazan A, Sendon JLL, Delcan JLL Influence of sex on the short term outcome of elderly patients with a first acute myocardial infarction. CIRCULATION 1995;92;1133-40
6. Woon VC,Lim KH. acute myocardial infarction in elderly-the differences compared with the young.Singapore Med J 2003;44[8];414-18
7. Kincaid DT,Botti RE. acute myocardial infarction in elderly. Chest 1973;64]2];170-72
8. Becker RC, Terin M, Ross R, Knatterud GL, Nickens PD, Gore JM, et al. Comparison of clinical outcomes for men and women after AMI, Ann of int med 1994;120[8];638-45
9. Cheng CL,Yeh KH ,Chang HW, Yu TH, Chai HT .comparison of baseline charecteristics, clinical features, angiographicsresults and early outcome in men versus women with acute myocardial infarction undergoing PCI, Chest 2004;126;47-53
10. Heberden W, comentaries on the history and cause of disese, Boston,Wells and Lily 1818;292
11. Bean WB ,Masquerades of AMI,LANCET 1977,1;1044-46
12. Kannel wb ,abott RD, incidence and prognosis of unrecognised myocardial infarction.an update of framingham study.N Eng J Med 1984;311;1144-47
13. Holey MP,Janabandhu A,javahirani a,pandharipande ms suryavanshi sd.clinical profile of acute myocardial infarction in elderly prospective study,japi 12007 march;55;188-192
14. Gonzolo suarez et al, prediction an admision of in hospital mortality in patients older than 70 yrs with acute myocardial infarction,american colege of chest physicians,1995;108;83-88
15. Woon vc, lim kh, acute myocardial infarction in the elderly the diferences compared with the young.singapore med j 2003;44[8];414-18
16. Applegate wb,graves s,colins t,zwag rv,akins d. acute myocardial infarction in.southern medical journal medical journal 1984;77[9];1127-29;
17. Ishihara, masaharu,sato,hikaru,tateushi,hoironobou et al.clinical impolication of cigarete smoking in acute myocardial infarction acute angiographic findings and long term prognosis.AM HEART J 1997;134[5];955-60
18. Tesch DD,Brady WJ,Auferhiede TP,Lawgence SW,Wiliams KJ,Comparision Of elderly and younger patients with out of hospital chest pain.clinical chareteristics of acute myocardial infarction, Therapy and outcomes,Arch inern med 1996;156;1089-93
19. Amrisa J leal,newton fernando stadier de souza filho,herminio haggi filho et al. acute myocardial infarction in elderly patients.comparative analysis of predictiors of mortality,the elderly versus the young.Ars. Bras.Cardiol.oct.2002;79[4];428-430.
20. Dang A,Dias, A diferences in risk factors and mortality,in young and individuals with acute myocardial infarction in Goa.journal clinical and diagnostic research.April 2008;2[2];715-719
21.  F1000Res. 2017 Oct 2;6:1791. doi: 10.12688/f1000research.11064.1.eCollection 2017.Engberding N¹, Wenger NK
22. Acute Coronary Syndromes in the Elderly Niels Engberding¹ and Nanette K. Wen F1000 research :10.12688/f1000research.11064.1
23. Aging Dis. 2011 Apr; 2(2): 116–137.Published online 2010 Dec 23. PMCID: PMC3295051 Myocardial Infarction in the Elderly Amelia Carro and Juan Carlos Kaski
24. International Journal of Scientific Study September 2015 | Vol 3 | Issue 6. Clinical Profile of Acute Myocardial Infarction in. Elderly Patients: A Cross-Sectional Study. Akshatha Savith. Assistant Professor, Department of Internal Medicine, Vydehi Institute of Medical Sciences and Research Centre, Bengaluru, Karnataka, India
25. [Sharma A, Kumar R, Ashotra S, Thakur S. Comparative evaluation of clinical profile, risk factors, and outcome of acute myocardial infarction in elderly and nonelderly patients. Heart India [serial online] 2016 [cited 2018 Jan 18];4:96-9.]
26. World J Cardiology 2015 Dec 26;7(12):895-901. doi: 10.4330/wjc.v7.i12.895. Inequalities in care in patients with acute myocardial infarction.
27. Shi Wen Wang, Guo Chun Ren, Shu-Fun Shio, Shu-Yuan YU, Fu-Ying Zhen Japanese heart journal Volume 29 (1988) Issue 3 {Rashid s,simms sa.batin p, kurien j,gale co}