The Atypical is Typical for ACS in Older Adults

With Dr. Amal Mattu

Christina Shenvi

Chest pain is one of the most common reasons why people present to the ED. The chief complaint of “Chest Pain” typically triggers an automatic EKG, and potentially a workup for acute coronary syndrome (ACS). However, many patients who are having ACS do not present with chest pain. Instead, they may have dyspnea, diaphoresis, nausea, vomiting, abdominal pain, or other non-specific symptoms. Which patients are most likely to present this way? Older adults. In this GEMCAST, Amal Mattu talks about ACS presentations, workup, and management in older adults, and why the atypical is typical!

And the older the patient, the more likely they are to be chest-pain free when they present with an NSTEMI or STEMI. So it is up to the medical provider to be vigilant, consider possible angina equivalents, and order the right workup. Dr. Mattu talks us through some of the statistics of how often MIs occur without chest pain with age, how EKG interpretation may differ, and how management should differ vs how it does differ. Patients presenting with atypical symptoms are less likely to receive an aspirin or thrombolytics/PCI, and their mortality is higher.


  1. Mattu A, Grossman SA, Rose PL. Geriatric emergencies – A discussion-based review. Wiley Blackwell; 2016. Available on Amazon.
  2.  Glickman SW, Shofer FS, Wu MC, et al. Development and validation of a prioritization rule for obtaining an immediate 12-lead electrocardiogram in the emergency department to identify ST-elevation myocardial infarction. Am Heart J. 2012;163(3):372-382.
  3. Brieger D, Eagle KA, Goodman SG, et al. Acute coronary syndromes without chest pain, an underdiagnosed and undertreated high-risk group: Insights from the global registry of acute coronary events. Chest. 2004;126(2):461-469.
  4. Cannon AR, Lin L, Lytle B, Peterson ED, Cairns CB, Glickman SW. Use of prehospital 12-lead electrocardiography and treatment times among ST-elevation myocardial infarction patients with atypical symptoms. Acad Emerg Med. 2014;21(8):892-898.
  5. Alexander KP, Newby LK, Cannon CP, et al. Acute coronary care in the elderly, part I: Non-ST-segment-elevation acute coronary syndromes: A scientific statement for healthcare professionals from the american heart association council on clinical cardiology: In collaboration with the society of geriatric cardiology. Circulation. 2007;115(19):2549-2569.
  6. Canto JG, Rogers WJ, Goldberg RJ, et al. Association of age and sex with myocardial infarction symptom presentation and in-hospital mortality. JAMA. 2012;307(8):813-822.

Image credit [1].

This podcast uses sounds from by Jobro and HerbertBoland

This entry was posted in Cardiology and Pulmonology. Bookmark the permalink.

Hosted by

Christina Shenvi


Dr. Christina Shenvi is an associate professor of Emergency Medicine at the University of North Carolina. She is fellowship-trained in Geriatric Emergency Medicine and is the founder of GEMCast. She is the director of the UNC Office of Academic Excellence, president of the Association of Professional Women in Medical Sciences, co-directs the ACEP/CORD Teaching Fellowship, is on the Annals of EM editorial board, is on the Geriatric ED Accreditation board of governors, and she teaches and writes about time management at

Join the mailing list to get the latest GEDC updates in your inbox!