ALTERED MENTAL STATUS AS A NOTABLE

PRESENTATION OF ACUTE MYOCARDIAL INFARCTION

Solomon Sallfors (ACP Associate); Emmanuel Elueze (ACP Fellow)
Good Shepherd Medical Center/UT Health Northeast, Longview, TX

Introduction

Data

Conclusion

Altered Mental Status (AMS) is a fairly

common, if rarely understood or
appreciated, presentation of Acute
Myocardial Infarction (AMI), especially in
the elderly.

Physicians caring for the elderly need to be

more attuned to atypical presentations for
AMI.
Indeed, the elderly appear to be undertreated in AMI compared to their younger
counter-parts, presumably due to providers
less sympathetic attitude toward the
complaints of the elderly.

This well-documented phenomenon comes

as a surprise even to some experienced
cardiologists.
In patients >85, it can present in 20% of
cases, often as the only presenting
symptom.

Case Presentation
A 87 year old woman with HLD, MI, mild
cognitive decline, comes to the ER due to
AMS.
She is completely non-responsive, with
only automotic neurological findings.

Discussion
AMI is commonly under-recognized in the
elderly, especially when presenting atypically.
In recent years, greater attention has been
placed on atypical presentations of AMI,
namely those of women and diabetics. AMS
in the elderly, evidence suggests, needs to
be more commonly recognized as an
anginal equivalent of cardiac chest pain.

She is treated with core measures for

NSTEMI, including enoxaparin, statin,
aspirin. Subsequently, she would regain
consciousness over the next few days.

Clinical features of AMI vary by age. Patients

>75yo more likely:
NOT to report chest pain
Silent or unrecognized AMI
NSTEMI rather than STEMI
Atypical presentation
Presenting symptoms: syncope, weakness,
or confusion (delirium)
higher in-hospital mortality (19 vs 5%)

On review of records, she had presented in

a very similar manner one year before,
during which she was also found to be
having an AMI.

Failure to recognize this presentation causes:

Delays in diagnosis
Delays in therapy.

Routine troponins are found to be elevated.

EKG showed inverted T-waves. Over the
next 24 hours, her troponins would remain
high in the range of 2.5.

Additionally: worse outcomes can be

attributed in part (after comorbidities) to a
lower likelihood of receiving potentially
beneficial therapies. BBs, PCI, and CABG
are all utilized to a lesser degree in elderly
patients.
A retrospective review found that patients
75 years who received more recommended
advanced interventional therapies had lower
in-hospital mortality rates than those who did
not older age alone should not be reason
to withhold recommended therapy.

Research shows that the elderly benefit from

more aggressive treatments, like PCI and
CABG, but are also less likely to receive
them.
Elderly patients with non-ST elevation ACS
(defined as >75 years) should receive the
same treatment as younger patients with a
few conditions (Breall)

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