GERIATRIC UPDATE
ACUTE CORONARY SYNDROMES IN OLDER
ADULTS: A REVIEW OF LITERATURE
Authors: Nicole K. Gillis, MS, RN, ACNS-BC, Cynthia Arslanian-Engoren, PhD, RN, ACNS-BC, FAHA, FAAN, and
Laura M. Struble, PhD, RN, GNP-BC, West Bloomeld and Ann Arbor, MI
Section Editors: Nancy Stephens Donatelli, MS, RN, CEN, NE-BC, FAEN, and Joan Somes, PhD, RNC, CEN, CPEN, FAEN
Earn Up to 9.5 CE Hours. See page 292.
Introduction: Acute coronary syndromes (ACS) are the
leading cause of death in older adults, aged 65 years or older.
The clinical presentation varies, and the absence of chest pain
may occur. Our purpose was to synthesize the published
literature (20002012) to (1) examine the initial ED presentation
of older adults with conrmed ACS, (2) identify knowledge
gaps, (3) determine whether gender differences exist in the
presentation of ACS, and (4) describe recommendations for
practice and research.
Methods: A systematic review was conducted from
September 2000 to September 2012.
Results: The review suggests that older adults with ACS report
chest pain more commonly when arriving to the emergency
department. Older adults have higher in-hospital mortality rates
than adults aged younger than 65 years. However, older adults
Nicole K. Gillis, Member, Huron Valley Chapter, is Clinical Nurse Specialist,
Intensive Care Unit, Henry Ford West Bloomeld Hospital, West
Bloomeld, MI.
Cynthia Arslanian-Engoren, Member, Seagate Chapter, is Associate Professor,
University of Michigan School of Nursing, Ann Arbor, MI.
Laura M. Struble is Assistant Clinical Professor, University of Michigan
School of Nursing, Ann Arbor, MI.
This study was completed as a part of masters scholarly project for the
University of Michigan School of Nursing.
Support for this project was obtained from a Glacier Hills Student Scholarly
Project Award (Ann Arbor, MI).
For correspondence, write: Nicole K. Gillis, MS, RN, ACNS-BC, Henry Ford
West Bloomeld Hospital, 6777 W Maple Rd, West Bloomeld, MI 48322
3013; E-mail: nkblake@umich.edu.
J Emerg Nurs 2014;40:270-5.
Available online 3 May 2013.
0099-1767/$36.00
Copyright 2014 Emergency Nurses Association. Published by Elsevier Inc.
All rights reserved.
http://dx.doi.org/10.1016/j.jen.2013.03.003
270 JOURNAL OF EMERGENCY NURSING
reporting an absence of chest pain on arrival are twice as likely to
die compared with older adults with chest pain. With regard to
gender differences, we note that men are more likely to present
with chest pain whereas women are more likely to present with
nausea. Women have higher in-hospital mortality rates both with
and without chest pain presentation. Delay in time to arrival, as
well as delay to primary percutaneous intervention, is reported for
older adults with and without chest pain.
Discussion: Older adults with ACS are at risk for higher
mortality rates and delays in time to treatment modalities. Early
recognition of symptoms suggestive of ACS by the emergency
triage nurse can improve patient outcomes.
Key words: Acute coronary syndromes; Emergency department;
Emergency nurse; Older adult
cute coronary syndromes (ACS), which include
A unstable angina and acute myocardial infarction, are
the leading causes of death in older adults (aged
N 65 years). 1,2 Older patients who present to the emergency
department with ACS and a chief complaint other than
chest pain are often misdiagnosed 3 and undertreated 48
and have higher in-hospital mortality rates than adults aged
younger than 65 years with chest pain. 1,9,10 Furthermore,
individuals older than age 85 years diagnosed with ACS are
more likely to die during their hospitalization compared
with individuals younger than age 65 years (1:10 vs 1:100). 1
The risk continues 30 days to 1 year after hospitalization,
with mortality rates of 15% for older adults aged 75 to 85
years and 25% for adults aged older than 85 years. 1
Clinically, the presentation of ACS in older adults varies,
and an absence of chest pain may occur. 2,3,911 Age-
associated changes and the presence of chronic comorbid-
ities (eg, heart failure and diabetes mellitus [DM]) 2 often
account for these variations in ACS presentation. Patient
gender may also inuence symptom presentation. 4,9,12,13
VOLUME 40 ISSUE 3 May 2014

Because symptoms often indicate the presence of disease, older
adults with ambiguous symptoms may not be immediately
recognized by ED personnel as having ACS. Emergency nurses
are often the rst health care providers to assess and triage older
adults for ACS and initiate evidence-based protocols (eg,
aspirin or oxygen). Inasmuch as older adults account for more
than 23% of ED visits, 14 emergency nurses must be
knowledgeable and vigilant in their assessment of ACS in this
at-risk population. Even though optimal treatment modalities
for ACS have been extensively studied, few studies have
specically addressed ACS symptom presentation in older
adults. 15,16 Therefore the purposes of this article are to (1)
synthesize the published literature (20002012) to examine
the initial ED presentation of older adults with conrmed
ACS, (2) identify knowledge gaps in the literature, (3)
determine whether gender differences exist in ACS
presentation, and (4) describe recommendations for practice
implications for emergency nurses and future research.
Methods
We conducted a comprehensive search of the literature
using the following electronic databases: Cumulative Index
to Nursing and Allied Health Literature, Nursing and
Allied Health Source, PubMed, Joanna Briggs Institute,
and Cochrane Collaborative. The search is limited to
September 2000 to September 2012. The following search
terms were used in combination and isolation to identify
literature that met the inclusion criteria: older adults,
elderly, ACS, myocardial infarction, symptoms, emergen-
cy department, emergency nurse, chief complaint, and
presentation. Included were articles describing the presen-
tation of ACS symptoms in men and women aged at least
65 years and written in English. Excluded were literature
reviews, meta-analyses, case studies, dissertations, and
masters theses.
A total of 149 articles were initially identied; we
excluded 134 articles that failed to describe older adults chief
complaint upon ED arrival. Of the remaining 15 articles, 4
were excluded because of the type of study (literature reviews,
meta-analysis, and case study). A total of 11 articles met the
inclusion criteria and are presented (Figure).
Articles are reviewed for initial presenting symptoms,
patient demographics, medical history, and time to
presentation. Cardiac interventions and mortality rates are
also noted. Initial symptoms include the following: presence
or absence of chest pain, shortness of breath (SOB),
diaphoresis, nausea, back pain, and left or right arm pain.
Medical history variables include hypertension, DM, family
history of cardiac disease, previous myocardial infarction,
and smoking. Cardiac interventions (primary percutaneous
May 2014 VOLUME 40 ISSUE 3
Gillis et al/GERIATRIC UPDATE
Studies retrieved from (N=149)
Cumulative Index of Nursing and Allied Health (n=9)
Nursing and Allied Health Source (n=6)
PubMed (n=134)
Joanna Briggs Institute (n=0)
Cochrane Collaborative (n=0)
Studies excluded (N=134)
No chief complaints reported
Research studies (N=15)
Studies excluded (N=4)
Literature reviews (n=2)
Case studies (n=1)
Meta-analyses (n=1)
Systematic review final (N=11)
FIGURE
Inclusion and exclusion criteria search strategies.
coronary intervention [PCI] and coronary artery bypass
graft) and mortality outcomes (in hospital and 30 day) are
also described.
Results
Of the articles reviewed, 8 of the 11 studies 24,913 had a
body of evidence with low initial quality according to the
Grading of Recommendations Assessment, Development,
and Evaluation (GRADE) criteria. 17,18 All 8 studies had
observational designs with low bias. Only 1 of the studies
had a moderate- to low-quality body of evidence because of
the secondary analysis of randomized controlled trials, 19
whereas the remaining 2 studies had a very low-quality
body of evidence because of the descriptive and secondary
analysis design. 20,21
Chest pain is the most frequent symptom of older adults
with ACS (Table 1). 24,913,1921 The 3 common chief
complaints of older adults are chest pain, SOB, and
diaphoresis. 2,1113,19,20 Of older adults, 50% to 80% report
chest pain, 24,913,1921 40% to 60% report SOB, and 15%
to 56% report diaphoresis. 2,3,12,1921 Approximately 20%
of older adults report nausea and back pain. 2,3,12,13,1921
Left arm pain occurs more frequently (23%-35%) than right
arm pain (6%-15%). 12,20 Whereas 6 studies report chest
pain, 2 report that up to 24% of older adults do not report
chest pain when presenting to the emergency department
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272

TABLE 1
Initial ED characteristics of older adults with ACS (N = 11)
JOURNAL OF EMERGENCY NURSING

Characteristics Arslanian- Brieger Canto Canto Han Hwang Pelter Milner Milner Ryan Soiza
Engoren et al12 et al3 et al9 et al4 et al10 et al20 et al 19 et al 2 et al 13 et al 21 et al 11
(2006) (2004) (2000) (2012) (2007) (2006) (2012) (2001) (2004) (2007) (2005)
(n = 949) (n = 1,235) (n = 112,672) (n = 743,717) (n = 1,157) (n = 96) (n = 163) (n = 95) (n = 1,355) (n = 626) (n = 305)
Study design OBS OBS OBS OBS OBS SA SA SA OBS SA OBS
Demographic (%)
Age
65 y 49 27.3 * 25.8 * 65 11.4 40 49 18 66 57 55
6575 y 43.3 * 33.9 *
Female gender 44 42 * 49 * 50 54.1 54.2 35 52 52 40.9 46
Race
White 87.6 * 74 91 91 83.4
Black 8.4 * 32.9 19.8 10.8
Initial symptom (%)
CP 67.7 81.7 72 58 83.4 67
SOB 49.3 * 65.3 23 45 51.9 18
Sweating 26.2 * 53.7 4 19 56.8
Nausea 24.3 * 31.6 7 17 45.3
Back pain 25.8 7 5 29.4
Left arm 29.4 35.8
Right arm 15.6
Absence of CP 33 *
Medical history (%)
HTN 61.4 * 54.6 * 68.1 63 63 47
DM 32 * 32.6 * 37.2 26 31 23
Family history 17.8 * 48.4 73 18
Previous MI 32.2 * 26.4 * 30.6 60 51

VOLUME 40 ISSUE 3

Smoker 51.6 * 15.8 * 29.8 11 18

Interventions (%)
PCI 17.7 * 6.2 * 60
CABG 6.4 * 0.4 *
Mortality rate (%)
In hospital 13 * 23.3 * 22
30 d 2.7
May 2014

CABG, Coronary artery bypass graft; CP, chest pain; DM, diabetes mellitus; HTN, hypertension; MI, myocardial infarction; OBS, observational study; PCI, percutaneous coronary intervention; SA, secondary analysis; SOB, shortness of breath.
* Percentages represent older adults without chest pain.
 Gillis et al/GERIATRIC UPDATE

TABLE 2
Initial ED characteristics of older adult men and women with ACS (n = 3)
Characteristics Arslanian-Engoren et al 12 Milner et al 13 (2004) (%) Canto et al 4 (2012) (%)
(2006) (%)
Men (n = 536) Women (n = 413) Men (n = 257) Women (n = 185) Men (n = 150,281) Women (n = 174,786)
Initial symptom
CP 85 78 65 61.1
SOB 50 52 19.8 20
Sweating 33 28 14.8 18.4
Nausea 23 25 14.8 18.4
Back pain 14.8 18.4
Left arm 25 23 14.8 18.4
Right arm 6 8 14.8 18.4
Absence of CP 20 * 24 *
Medical history
HTN 71 80 59.3 71.1 57.3 * 66.3 *
DM 31 32 31.2 39.5 34 * 34 *
Family history 14.5 * 13.4 *
Previous MI 46 42 44.1 37.4 30.9 * 23.8 *
Smoker 65 39 12.7 * 8.8 *
Interventions
PCI 7.8 * 5.9 *
CABG 0.6 * 0.3 *
Mortality rate
In hospital 22.0 * 21.2 *
30 d

CABG, Coronary artery bypass grafting; CP, chest pain; DM, diabetes mellitus; HTN, hypertension; MI, myocardial infarction; PCI, percutaneous coronary intervention; SOB, shortness of breath.
* Percentages represent older adults without chest pain.

with ACS. 4,9 Hypertension is the most common comor-
bidity, 24,9,1113,20 followed by DM, 24,9,1113,20 myocar-
dial infarction, family history of cardiac disease, and
smoking. 24,9,1113,19,20
Older adults with ACS wait longer to present to the
emergency department after initial symptom onset com-
pared with adults aged younger than 65 years. 12,20 More
than half of older adults (56.2%) wait 2 hours to 2.5 days to
seek care at the emergency department. 20 Only 10% to
14% present to the emergency department within 1 hour of
symptom onset. 12,20
Older adults with ACS who present without chest pain
are more likely to die in the hospital compared with patients
aged younger than 65 years with chest pain. 3,4,911 In fact,
older women with chest pain or discomfort are twice as
likely to die in the hospital compared with younger women
with the same complaint (13% vs 3.7%, P b .001). 4
Similarly, older men with chest pain are twice as likely to die
in the hospital as men aged younger than 65 years with chest
pain (6.6% vs 2.4%, P b .001). 4
Older women with ACS who present without chest pain
have a 6-fold increase in hospital mortality rate compared to
women less than age 65 years with chest pain (21.2% vs
3.7%, P b .001). 4 Furthermore, older men without chest
pain are more likely to die in the hospital compared with
men aged younger than 65 years with chest pain (22% vs
2.4%, P b .001). 4 High mortality rates may be due to delays
in PCI with fewer lifesaving treatments. Primary PCI for
older adults with ACS is between 6% and 60%. 3,4,911 The
time to primary PCI of up to 162 minutes 4,9 exceeds the
recommended 90 minutes. 22
GENDER DIFFERENCES
Gender differences are noted in symptom presentation
(Table 2). Chest pain is more common in men, whereas

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GERIATRIC UPDATE/Gillis et al
nausea is more common in women. 12,13 Diaphoresis is the
least common chief complaint of both genders. 12,13
Arslanian-Engoren et al 12 (2006) report that men are more
likely to smoke (65% vs 39%, P b .01) whereas women are
more likely to have hypertension (80% vs 71%, P b .01).
In addition to gender differences in chief complaints
and medical history, differences exist in the time to initial
ED electrocardiogram. Older women wait longer (34.4 mi-
nutes [SD, 32.9 minutes]) than older men (31.1 minutes
[SD, 31.7 minutes]) (P b .001) 4 to receive the initial ED
electrocardiogram. Gender differences are also noted in the
time to primary PCI. Older adult women wait longer for
primary PCI (155.6 minutes [SD, 113.1 minutes]) than
age-matched men (151.4 minutes [SD, 121.2 minutes])
(P b .001). 4 Moreover, older adult women with chest pain
are more likely to die during initial hospitalization
compared with age-matched men with similar complaints
(8.6% vs 6.9%, P b .001). 4 Older women and men who
present without chest pain are at an increased risk of dying
(19.3% vs 18.9%, P b .001), 4 although women are twice as
likely to die compared with men. 4
Discussion
Older adults with conrmed ACS commonly present with
chest pain as their chief complaint 24,913,1921 but are
less likely to report chest pain compared with younger
adults. 24,1013,19,20 There is a higher incidence of smoking in
men, 4,12 and smoking is linked to cardiopulmonary diseases
that cause chest pain. 23 One explanation for the absence of
chest pain is DM and age-related changes. 1,6 There is a higher
occurrence of DM in women, and DM is linked to
autonomic neuropathies that contribute to no chest pain. 24,25
Older adults also have higher in-hospital mortality rates
than their younger counterparts. 3,4,911 Although there may
be multiple factors contributing to this elevated mortality
rate, one explanation is the delay to primary PCI. Older
adults with and without chest pain frequently exceed 4,26 the
American College of Cardiology Foundation and American
Heart Association guidelines for door-to-balloon time of 90
minutes. 24 Reperfusion delays increase the risk for cardiac
muscle damage and death. 26 Older adults do not always
recognize ACS symptoms and sometimes delay ED
evaluation, 20 and this contributes to delays in PCI and
increased mortality rates.
More than half of women with and without chest pain
wait more than 6 hours to present after the initial onset of
symptoms compared with age-matched men. 12 Further-
more, older adults report common factors that contribute to
delays, including a false perception of not being ill enough
274 JOURNAL OF EMERGENCY NURSING
to call 911, feelings of guilt when calling family to help
when living alone, and lack of association of their symptoms
with the symptoms of ACS. 20
Implications for Emergency Nurses
It is critical that emergency nurses promptly recognize and
triage older adults for ACS. By understanding the different
symptoms in older adults, nurses can use this knowledge to
elicit pertinent information to determine triage priority. 2729
Although older adults are a heterogeneous group, they may
present with cognitive and sensory decits that may make the
initial triage assessment more challenging.
Strategies to augment this process include providing a
quieter environment, facing the patient when speaking and
using short and clear sentences, and allowing time for the
patient to process the question and respond. 30,31 Ques-
tions include asking patients how they normally function
and if this has changed, whether they are able to perform
their usual activities of daily living, and what specic
symptoms brought them to the emergency department for
evaluation. The emergency nurse must be cognizant
that changes in function may be the only indicator of
ACS in older adults. Using these strategies, emergency
nurses can augment effective communication with older
adults, increasing the likelihood of early recognition of
ACS, reducing treatment delays and improving hospital
mortality rates.
Limitations
There are 2 limitations to this study: the preponderance of
observational studies (n = 8) and the lack of studies
that reported all the variables of interest. Of the 11
studies included in the review, 8 incorporated observational
designs 24,913; only 1 analyzed data from a randomized
controlled trial. 19 Moreover, not all of the studies reported all
of the variables of interest, thereby limiting our ability to
compare key variables across studies. However, a noted
strength of the review is that data are primarily from large
ACS 4,9,13,1921 and acute myocardial infarction regis-
tries, 2,3,1012 thereby increasing the generalizability of
our ndings.
Conclusions
Older adults are a vulnerable population with high
mortality rates and variable ACS presentation. Findings
from this review can help emergency nurses identify and
VOLUME 40 ISSUE 3 May 2014

accurately triage older adults for ACS, reducing treatment
delays and improving mortality rates.
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Submissions to this column are encouraged and may be sent to
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somes@blackhole.com
or
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question4gene@gmail.com
WWW.JENONLINE.ORG 275
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