Atypical presentation of acute myocardial

infarction in 3 age groups

Karen L. Then, RN, PhD,a James A. Rankin, RN, PhD,a and Doreen A. Fofonoff, RN, MN,b
Calgary, Alberta, Canada, and Vancouver, British Columbia, Canada

OBJECTIVE: The purpose of this study was to compare the clinical manifestations of first-time acute
myocardial infarction (AMI) in 3 age groups of men and women who presented to the emergency
departments of 3 acute tertiary care hospitals.
DESIGN: An exploratory, descriptive design was used, and there were 2 phases to the project. Phase 1
was a retrospective chart audit of a systematic random sample of patient charts, and phase 2 included
a structured interview of a prospective random sample of emergency and intensive care unit nurses and
physicians. The data were collected by using a chart audit tool and a semistructured interview, respec-
tively.
SETTING: The study took place at a western Canada university affiliated with acute tertiary care centres.
SAMPLE: A systematic random sample of 153 (105 men and 48 women) patient charts were audited
from the health records departments of 3 acute care hospitals. All of the patients had experienced a first-
time AMI. In addition, a random sample of emergency/intensive care unit nurses (n = 60) and physi-
cians (n = 18) was interviewed.
RESULTS: The results indicate that a statistically significant number of the oldest (75 years or older)
male patients present with atypical manifestations of AMI compared with the men in the younger age
groups (P = .005). The same trend was not noted for female patients. The results of the study are lim-
ited with respect to the small number of women in each age category. Caution must therefore be exer-
cised in generalizing the results to the target population of women with AMI. The atypical manifesta-
tions are described. The results of the interviews revealed that many clinicians do not look for different
clinical manifestations when assessing older patients.
CONLUSIONS: It is essential that nurses and physicians accurately assess patients with AMI, especial-
ly patients in the older age groups who may be presenting atypically. It is also important that profes-
sional and nonprofessional public health education initiatives include information regarding both typi-
cal and atypical presentation of AMI, particularly in the older patient. (Heart Lung® 2001;30:285-93.)

C ardiovascular disease (CVD) is the leading

cause of death worldwide.1 One life-threat-
ening manifestation of coronary artery dis-
ease (CAD) is acute myocardial infarction (AMI),
From the aFaculty of Nursing, University of Calgary, and the bAdult
Congenital Heart Program.
Funded by the Faculty of Nursing, University of Calgary, and Heart
and Stroke Canada.
Reprint requests: Karen L. Then, RN, PhD, Faculty of Nursing, Uni-
versity of Calgary, 2500 University Dr NW, Calgary, Alberta, Cana-
da T2N 1N4.
Copyright © 2001 by Mosby, Inc.
0147-9563/2001/$35.00 + 0 2/1/116010
doi:10.1067/mhl.2001.116010
which, if not accurately assessed, may be fatal with-
in minutes. The pathophysiology of AMI is similar
in old and young patients; however, from a histori-
cal point of view certain ambiguity existed in the
literature with respect to the presenting clinical
manifestations in older age groups. Some authors
from 1956 to the mid-1970s suggested that older
patients with AMI present differently than younger
patients.2-4
At present, older persons comprise about 12% of
the Canadian population; however, they consume
more than one third of all health care costs.5 CAD
is the leading cause of disability and death among
the elderly.1,5,6 One aim of the research study was

HEART & LUNG VOL. 30, NO. 4 285

Atypical presentation of acute myocardial infarction
to compare clinical manifestations of AMI across 3
age groups, (35-64 years, 65-74 years, and 75 years
and older) to determine whether patients in fact
presented differently depending on age.
Early recognition of and intervention in AMI has
been well documented in the literature as being
essential in decreasing size of infarction, mortality
and morbidity, complications of AMI, and length of
hospital stay. For example, there are remarkable
differences between the length of stay for young
adults and older adults with CAD. Adults between
the ages of 35 and 64 years have, on average, 11.5-
day stays, compared with adults aged 65 years or
older, who have 26.5-day stays.7 In addition, of the
45,000 Canadians who were discharged from the
hospital in 1993 to 1994 with a primary diagnosis of
AMI, 10% had 3 or more related hospital stays in the
fiscal year.8 Patients with AMI had an average of
14.6 days in the hospital.8 Consequently, the
importance of accurate nursing and medical assess-
ment of patients who present with clinical manifes-
tations of AMI has implications for mortality, mor-
bidity, and health care costs. A second aim of the
study was to identify the clinical criteria used by
nurses and physicians working in the emergency
department and the intensive care unit (ICU) in
assessing patients who have sustained an AMI.
PURPOSE
The overall purposes of the study were the fol-
lowing: to compare the presenting clinical manifes-
tations of AMI in 3 age groups, 35 to 64 years, 65 to
74 years, and 75 years or older; to identify the
length of time from onset of symptoms to presen-
tation at the emergency department (ie, duration);
to identify the length of time from presentation at
the triage desk to complete assessment by a regis-
tered nurse (RN) (ie, lag time); to identify the clini-
cal criteria used by nurses and physicians in
assessing patients who have sustained an AMI.
REVIEW OF THE LITERATURE
One of the earliest descriptions of clinical fea-
tures of AMI was proposed by Herrick9 in 1912. It is
interesting to note that Herrick9 suggested that
some patients might develop a less typical picture
than the classical AMI syndrome. There were con-
flicting reports in the literature from the 1970s and
1980s with respect to whether patients in older age
groups present with atypical or typical manifesta-
tions of AMI. Nurses and physicians have most often
relied on the typical/classical history, together with
electrocardiography changes and cardiac enzyme
values in the assessment and diagnosis of AMI.
286
Then et al
Early studies reported that chest pain was an
uncommon symptom of AMI in the elderly.2-4 On the
other hand, studies from the 1970s and 1980s
demonstrate that chest pain was a common manifes-
tation of AMI in the elderly patient.10-12 On closer
examination of the results from the studies cited
above, the average age of subjects in the early study
groups ranged from 69 to 72 years,2-4 whereas the
average age in the studies in the 1970s and 1980s was
84 years.10-12 These findings suggest that within the
age category of 65 years and above, there might be 2
subpopulations of elderly persons with respect to
AMI presentation (ie, persons who present typically
and persons who present atypically). In other words
the “young” elderly present differently from the “old”
elderly.
More recently the findings of other researchers
support the notion that the elderly present differ-
ently with AMI. Symptoms such as dyspnea, syncope
with exertion, palpitations with effort, abdominal
complaints, chronic fatigue, or unexpected behav-
iour changes, rather than chest pain, have been
reported.6,13,14 In fact, in patients who do report
chest pain it has been shown that elderly patients
complain of significantly less pain in the left arm,
right arm, and neck than younger patients.16
It has also been reported that there is a lower
incidence of typical clinical manifestations of AMI
in African Americans than in whites.17 There may
also be atypical, silent, or non–Q-wave AMI in older
patients who have comorbid conditions such as
diabetes mellitus.18,19 Brauwald19 has also suggest-
ed that painless infarcts increase with age and
elderly patients may present with sudden short-
ness of breath leading to pulmonary edema.
If elderly patients are in fact presenting differ-
ently, there is the potential for misdiagnosis of AMI
because nurses and physicians may still base their
diagnoses on the typical clinical picture. The work
of Wroblewski, Mikulowski, and Steen20 supports
this hypothesis. They found that many elderly
patients who died of AMI had their hospital treat-
ment based on other medical diagnoses. In other
words, there was incongruence between assess-
ment, diagnosis, and treatment. It is important to
note that in the Wroblewski et al20 study the aver-
age age of patients was much higher (mean, 83
years; range, 65-96 years) than in previous studies.
This adds further support to the hypothesis that
patients with AMI in older age groups present dif-
ferently than patients in younger age groups.
AMI is clearly a life-threatening condition. If
symptoms between younger and older patients are
different, it is essential that clinicians are aware of
JULY/AUGUST 2001 HEART & LUNG
Then et al Atypical presentation of acute myocardial infarction

the differences to effectively intervene. It appears Table I

that certain subpopulations of patients present Sample sizes of men and women by age
atypically; therefore, clinicians need to be aware of group*
these differences, document them, and intervene
appropriately. A major aim of the present research Age Men Women Total
study was to highlight the differences in presenta- group (y) (n) (n) (n)
tion of AMI among patients in older age groups. 35-64 39 12 51
The practical importance of the study findings is 65-74 36 15 51
that an accurate description of clinical manifesta- ≥75 30 21 51
tions of AMI in 3 age groups will be presented from Total 105 48 153
both medical and nursing perspectives. Given the
close collaborative relationships of nurses and *Sample sizes were based on the relative proportions of
mortality from AMI for each sex and age group as cited
physicians in areas such as emergency and inten- by the Heart and Stroke Foundation Canada.1
sive care, it is anticipated that dissemination of
these findings will benefit both groups of clinicians.

RESEARCH DESIGN AND they had a primary discharge diagnosis of first-time

PROTOCOL
An exploratory, descriptive design was used. A
retrospective chart audit was completed on
patients who had a discharge diagnosis of first-time
AMI. Research assistants, who were blinded to the
purpose of the study, used a chart audit tool to col-
lect data from patient charts. The data that were
gathered included the onset of clinical manifesta-
tions and length of time to presentation at the hos-
pital, presenting signs and symptoms, risk factors,
and demographic data. The clinical criteria used by
nurses and physicians in assessing patients who
had sustained an AMI was obtained by a structured
interview questionnaire.
The chart audit tool and the interview ques-
tionnaire were developed by the researchers.
Content and face validity of the tools were estab-
lished by 2 expert cardiovascular clinicians and a
detailed review of the literature. The chart audit
tool and interview questionnaire were pilot-tested
by using convenience samples of 10 charts and 5
Faculty of Nursing professors, respectively. Both
tools were then revised before commencement of
the study.
Ethical approval to conduct the chart audit and
interview nurses and physicians was obtained from
the appropriate research and ethics committees.
Patient and clinician confidentiality was main-
tained at every stage in the research. Written con-
sent was obtained from the nurses and physicians
taking part in the interview questionnaire.
SELECTION CRITERIA
Charts of patients included in the audit met the
following criteria: they were adults aged 35 years
and older who presented to the emergency depart-
ment; they were fluent in the English language; and
AMI. Patients transferred from other hospitals were
excluded. Face-to-face interviews were conducted
with a random sample of emergency, coronary care
unit (CCU), and ICU nurses and emergency physi-
cians and cardiologists.
SAMPLE
Chart audit
The sample sizes for each sex and age group
(Table I) are proportional to the age and sex mor-
tality rates of AMI reported by Heart and Stroke
Foundation Canada.21 To avoid the bias of season-
al variation, a systematic sample (with a random
start) of 153 charts of patients diagnosed with first-
time AMI were selected from the health records
departments of 3 urban hospitals.
Interview questionnaire
A random sample of 20 nurses and 6 physicians
who worked in the emergency departments, CCUs,
and ICUs at each of the 3 sites were interviewed.
These sample sizes were chosen in accordance
with the approximate ratio of nurses to physicians.
RESULTS
Chart audit
The patient demographics (age and sex) are
reported on Table II. As may be seen, there were no
statistically significant differences among the ages of
the men and women in each of the age groups. The
presenting clinical manifestations of AMI were cate-
gorized as typical or atypical. Typical presentations
were characterized by chest pain/discomfort/heavi-
ness/pressure, whereas atypical presentations
included signs and symptoms such as indigestion,

HEART & LUNG VOL. 30, NO. 4 287

Atypical presentation of acute myocardial infarction Then et al

Table III
Typical and atypical presentation of AMI in
men and women

Age Typical Atypical

group presentation presentation

Men
35-64 y 35 (90) 4 (10)
65-74 y 28 (77.7) 8 (22.3)
≥75 y 17 (56.7) 13 (43.3)
Women
35-64 y 10 (83.3) 2 (16.7)
65-74 y 9 (60) 6 (40)
≥75 y 17 (80.9) 4 (19.1)

Table IV
Group comparisons of typical and atypical
presentation of AMI in men and women*

Group comparison P

Men
Fig 1 Duration (time period from onset of symptoms to 1 vs 2 .21
presentation at emergency department) for men and 2 vs 3 .11
women. 1 vs 3 .002
Women
1 vs 2 .24
2 vs 3 .26
Table II 1 vs 3 1.0
Mean ages of men and women for each age
group *All comparisons were performed using a Fisher exact
test. All P values are 2-tailed.
Age Men Women
group (y) (SD) (SD) P

35-64 50.9 y (7.74) 52.9 y (7.73) .44
65-74 69.3 y (2.98) 70.1 y (3.03) .40
≥75 79.5 y (3.91) 82 y (5.15) .06
epigastric or abdominal pain, shortness of breath,
back or jaw tightness/pain, nausea, vomiting and
diarrhea, and generalized feelings of “unwellness”.
A comparison of the presenting clinical manifes-
tations for men revealed a trend of increasing
atypical presentation with increasing age. Ten per-
cent of the men in group 1 (n = 39, 35-64 years old)
presented atypically; however, 43.3% of the men in
group 3 (n = 30, ≥75 years) had atypical presenta-
tions (Table III). The differences in presentation
were statistically significant between the men in
groups 1 and 3 (P = .002). Comparisons between
groups 2 and 3 and 1 and 2 did not reach statistical
significance (P = .11 and P = .21, respectively)
(Table IV).
In women there was not a clear trend of increas-
ing atypical presentation with increasing age. The
largest percentage of atypical presentation (40%)
appeared in the women in group 2 (n = 15, 65-74
years old; Table III). None of the group compar-
isons using Fisher exact test reached statistical sig-
nificance. It is emphasized that the sample sizes for
each of the age groups in the women were small;
therefore, caution should be exercised in the inter-
pretation of these data.
Duration
Duration was measured and defined as the time
from onset of symptoms to presentation at the
emergency department. As seen in Fig 1, the men
in the youngest age group (35-64 years) waited an
average of 14.5 hours from the onset of their symp-
toms to presentation at the emergency depart-
ment. The women in the same age group had a
duration that was more than twice as long as that of
the men, 34.8 hours. A similar pattern was seen in

288 JULY/AUGUST 2001 HEART & LUNG

Then et al
Fig 2 Lag time (period from arrival at triage desk to assessment by RN) for
men and women.
the second age group (65-74 years) for both men
and women. The men and women in group 2 (65-74
years) had the shortest duration time (Fig 1). The
men and women in group 3 (≥75 years) had the
longest duration time. An analysis of variance
(group by duration time) for the men and women
revealed that there were no statistically significant
differences among the groups (Men: F 2, 92 = 2.06,
P = 0.13; Females: F 2, 39 = 0.216, P = .81).
In group 3 the mean duration time for men was
83.3 hours. This average was increased because of
the presence of 2 outliers whose duration times
were 168 hours and 1440 hours. It is interesting to
note that these 2 patients presented with feeling
unwell and shortness of breath, respectively (ie,
atypical presentation). When these 2 outliers were
removed, the mean duration for group 3 decreased
to 17.8 hours. It was noted that the standard devia-
tion of the duration time for men in group 3 was
extremely high (291 hours). Because of the large
standard deviation, the nonparametric equivalent
to the ANOVA, the Kruskal-Wallis test, was comput-
ed. The Kruskal-Wallis test revealed that there was
a statistically significant difference among the men
(P = .044). Mann-Whitney U tests showed that there
were statistically significant differences in duration
between the men in group 1 and group 3 (P = .019)
and the men in group 2 and group 3 (P = .042). The
difference between the men in group 1 and group 2
HEART & LUNG VOL. 30, NO. 4
Atypical presentation of acute myocardial infarction
was not statistically significant (P =.65). For consis-
tency, a Kruskal-Wallis test was performed on the
durations for women, and the difference was not
statistically significant (P =.25). With the outliers for
men in group 3 removed, the durations for the
women in each age group are greater than those of
the men for the corresponding age group.
Lag time
Lag time was measured and defined as the time
from presentation at the triage desk to complete
assessment by an RN. As seen in Fig 2, the lag times
for men and women in groups 1 and 2 and the women
in group 3 were similar. There was a trend of an
increase in lag time with increasing age for men. The
men in group 3 had the longest lag time (16.9 minutes)
of all age groups. An analysis of variance (group by lag
time) revealed that there was a statistically significant
difference among the men (F 2, 92 = 3.47, P = .035).
Further analysis using contrasts showed that there
were statistically significant differences between the
men in groups 1 and 3 (P = .016) and groups 2 and 3 (P
= .025). The comparison between groups 1 and 2 was
not statistically significant (P = .87).
The analysis of variance among the women
showed no statistically significant difference (F 2,
43 = 0.16, P = .85). There was no noticeable trend
with respect to lag time in the women (Fig 2). A 2-
way analysis of variance showed that there was no
289
Atypical presentation of acute myocardial infarction Then et al

Table V Table VI
Patient activity at the onset of clinical symp- Demographics of RNs and MDs
toms
RNs MDs
Men Women Category (n = 60) (n = 18)
Activity (%) (%)
Average age group 31-40 y 31-40 y
At rest 22 (20.9) 11 (22.9) Average No. years 14.2 y 14.1 y
Eating 3 (2.9) 0 in profession
After eating 6 (5.7) 2 (4.2) Average No. years 8.7 y 9.9 y
Moderate activity 32 (30.4) 10 (20.8) in specialty
Strenuous activity 11 (10.5) 0
Not listed in chart 31 (29.5) 25 (52)
Totals 105 (99.9) 48 (99.9)
ICUs, and emergency departments. The average
age and clinical experience of both groups were
similar (Table VI).
significant interaction (age group by gender) effect The following questions were asked:
(F 2 ,140 = 1.04, P = .35). 1. In general, when you suspect that a patient has had
an AMI, what are the 3 main clinical manifesta-
Activities tions that you look for?
Data were also gathered regarding the patients’ The 3 main clinical manifestations cited by the
activities at the onset of clinical symptoms. The RNs were chest pain with or without radiation
activities were classified into the following 5 cate- (85%), changes in respiratory status (35%), and
gories: at rest, eating, after eating, moderate activi- diaphoresis (18.3%). The physicians cited chest
ty, and strenuous activity (Table V). As may be seen pain/discomfort (66%) as the major clinical manifes-
from Table V, 22.9% of the women were at rest at the tation they look for. There was no general consensus
onset of their symptoms, whereas 20.8% of them as to the second and third clinical manifestations
were involved in a moderate level of activity. Exam- that they look for. A variety of clinical manifesta-
ples of moderate activity include walking, driving, tions were cited, including shortness of breath,
and working in the yard. sweatiness, nausea, cold, and life-threatening
Interestingly, 31.4% of men were involved in arrhythmias.
moderate activities, whereas 21.9% were at rest. A 2. If the patient is in 1 of the following age groups (35-
further 10.5% of men were involved in strenuous 64 years; 65-74 years; ≥75 years), do you look for
activities such as weight lifting, shoveling snow, or anything different?
moving furniture. It is important to note that 28.6% In general, the majority of the clinicians (62% of
of the charts had no activity level listed for the RNs and 69% of MDs) did not look for anything dif-
male patients, whereas 52% of the charts had no ferent with respect to clinical manifestations in dif-
activity listed for the women (Table V). ferent age categories. However, it was noted that
43% of the RNs stated that they did look for differ-
Mortality ent clinical manifestations in the 35 to 64 years
The overall mortality rate in the study was 11.1%. patient age group, and 27% of the physicians
The mortality rates were 6.6% (7/105) for men and looked for differences in the same age group.
20.8% (10/48) for women. Of those persons who 3. If the patient is female, do you look for anything
died, 58.8% (10/17, 5 men and 5 women) had a dura- different?
tion time of 2 hours or more. The duration time of 4 Seventy-five percent of RNs and 80% of MDs
of the persons who died was not recorded. Of the stated they did not look for anything different if the
10 patients who died and had clinical symptoms of patient was female. It is interesting to note that 29%
2 hours or longer, 50% (5/10) presented atypically. of the females in this study presented with atypical
With respect to overall mortality in the study, 7 out clinical manifestations. The RNs and MDs who stat-
of 17 (41.2%) presented atypically. All of the ed that they did look for differences in female
patients who died were 65 years or older. patients identified factors such as increased anxi-
ety, decreased denial, increased fear, changes in
INTERVIEW QUESTIONNAIRE pain threshold, and “hormonal things.”
A total of 78 interviews (60 RNs and 18 doctors of 4. In your experience have you ever dealt with any
medicine [MDs]) were conducted in the CCUs, atypical presentations of AMI? and

290 JULY/AUGUST 2001 HEART & LUNG

Then et al
5. In your estimation what percentage of time does an
atypical presentation occur?
All of the MDs (100%) and 91.7% of the RNs stat-
ed that they had experience with atypical presen-
tation of AMI. The frequency of atypical presenta-
tion of AMI was estimated at 13.2% of the time by
RNs and 24.4% by MDs.
DISCUSSION
As previously mentioned, there is ambiguity in
the literature with respect to presenting clinical
manifestations in different age groups. In this study
there was a clear trend of increasing atypical pre-
sentation of AMI with increasing age in men. In the
total sample of men, 23.8% presented atypically.
Almost all of the physicians and nurses claimed to
have had experience of atypical AMI presentations,
yet only one third of the clinicians looked for any-
thing different in the 2 older age groups. It is impor-
tant that clinicians are cognizant of differences in
presentation of AMI, especially in older age groups.
Fewer of the clinicians looked for anything dif-
ferent when the patient was female, yet interest-
ingly 29% of the women in the study did in fact pre-
sent atypically. However, it is noted that there was
not a clear trend of atypical presentation with age
in the female sample. The lack of a clear trend in
the women may have been a result of the small
sample size, and caution needs to be used in inter-
preting the data.
The same duration pattern is seen in men and
women. The men and women in the second age
group (65-74 years) had the shortest duration time
(men, 10.2 hours; women, 32.9 hours). It is specu-
lated that persons in the second age group recog-
nize that they are in the “right” age group to have
an AMI and therefore present to emergency in the
shortest time. Within the second age grou, patients
who waited the longest to present were often the
ones with atypical symptoms.
It is further speculated that the persons in the
youngest age group (35-64 years) might have pro-
crastinated because they did not think they were
having an AMI. The persons in the oldest age group
have the longest duration time and the highest
number of atypical presentations. In other words,
older persons with atypical symptoms are the least
likely to present to the emergency department in a
timely manner. Dracup & Moser21 also demonstrat-
ed that patients with AMI in the oldest age group
(in their study, 61-86 years) had significantly longer
duration compared with younger age groups; unfor-
tunately, they did not describe the clinical presen-
tations of their sample. Tresch, Brady, Aufderheide,
HEART & LUNG VOL. 30, NO. 4
Atypical presentation of acute myocardial infarction
Lawrence, and Williams23 found that elderly
patients (>70 years old) delayed significantly
longer than younger patients in seeking attention
after the onset of symptoms, despite the fact that
50% of the elderly sample had a previous history of
CAD. It is possible that some of the elderly patients
in both of the samples described had atypical
symptoms.
It has been shown that the 30-day mortality rate
in a cohort of elderly (mean age, 76.5 years) with
AMI was 21%.24 Normand et al24 concluded that
some of the reasons for the high short-term mortal-
ity rate among the elderly include the location of
the hospital, disease severity, and differences in
quality of care. Normand et al24 add that a large
percentage of the variation in mortality in the
elderly remains unexplained. It is possible that
duration, lag time, and atypical presentation of AMI
symptoms may be contributing to the higher mor-
tality rate in the elderly.
The highest mortality rate in AMI occurs in the
first 2 hours after the onset of symptoms. It has
been demonstrated that a reduction in the dura-
tion time (from onset of symptoms to arrival in the
emergency department) can reduce mortality from
AMI.25 In the present study, of those patients who
died, most of them waited 2 hours or more to pre-
sent to emergency and all of them were 65 years of
age or older. The findings suggest a need for both
public and professional education with respect to
recognizing not only the typical signs and symp-
toms of AMI but also being aware that elderly
patients may present with atypical clinical manifes-
tations.
The men in the oldest age group had the longest
lag time, and 43.3% of them presented atypically. In
summary, within the sample of men, the ones in the
oldest age group had the longest duration and lag
time and often presented atypically. This finding
has significant implications for early assessment,
recognition, and intervention by clinicians. As pre-
viously stated, there was no noticeable trend
among the women with respect to lag time.
It is assumed by health care professionals that
AMIs often occur when the person is at rest. It is
clear from the findings of this study that approxi-
mately 42% of the men were engaged in moderate
to strenuous activity at the onset of clinical symp-
toms. In contrast, 20.8% of the women were involved
in moderate activities. However, it was found that
more than half of the women’s charts had no docu-
mentation of activity at the onset of clinical symp-
toms. It is difficult to explain the discrepancy in
charting between the women and the men.
291
Atypical presentation of acute myocardial infarction
When nurses and physicians were asked for the
main clinical manifestations of AMI, the most com-
mon response was chest discomfort/pain. Clini-
cians and laypersons have normally been taught to
recognize typical manifestations of AMI. While it is
appropriate for nurses and physicians to look for
common clinical manifestations of AMI, it is evi-
dent from this study that atypical presentation is
not uncommon especially in the older age groups.
It was also apparent from the study that the major-
ity of nurses and physicians do not look for differ-
ent clinical manifestations in different age groups.
The findings of this study demonstrate that atypi-
cal presentations do occur, and therefore it is
essential that clinicians and laypersons be made
aware of the constellation of symptoms that con-
stitutes clinical manifestation of an atypical pre-
sentation.
The clinicians in this study tended not to look for
anything different if the patient was female, and yet
29% of the women in the study presented atypical-
ly. There appears to be an apparent contradiction
in the results in that 90% of nurses and 100% of
physicians stated that they had had experience
with atypical presentation of AMI. Despite this,
approximately two thirds of the clinicians stated
that they do not look for anything different with
respect to clinical manifestations in different age
categories or genders.
LIMITATIONS
The results of the study are limited because of
the small samples of women in each age category.
Caution must therefore be used in generalizing the
results to the target population of women with AMI.
A systematic random sample of a predominantly
white population was selected; however, comorbid
conditions were not identified. As with any retro-
spective study, there are limitations placed on the
findings of the research because of illegible or
missing chart documentation.
CONCLUSION
It is concluded from the study that there is an
increase in atypical presentations of AMI with
greater age in men. The oldest men had the
longest duration and lag time and often present
atypically. There was no discernible trend of atyp-
ical presentation in the women; however, further
research with larger sample sizes of women is indi-
cated. We are extending our research by increasing
the sample sizes of men and women and control-
ling for race and comorbid conditions (eg, dia-
betes mellitus).
292
Then et al
There is a need for professional education for
clinicians to be aware of atypical presentations,
especially in older age groups. It is obviously
important to institute community intervention pro-
grams that educate the public about the symptoms
of a coronary event in an attempt to reduce dura-
tion time.26 However, the present findings would
suggest that educational interventions should also
include the recognition of other clinical manifesta-
tions that are not characteristic of the typical pre-
sentation of AMI.
We acknowledge the contribution of our research
assistants, Darlene Dawson, RN, BN, Jodi Miller, RN, BN,
Kari Thunberg, RN, BN, and Laurinda Zboya, RN, BN.
REFERENCES
1. Heart and Stroke Foundation of Canada. Heart disease and
stroke in Canada. Ottawa: Heart and Stroke Foundation of
Canada; 1997.
2. Parhy MS. Clinical presentation of myocardial infarction in the
elderly. Br Heart J 1967;29:190-9.
3. Rodstein M. The characteristics of non-fatal myocardial infarc-
tion in the aged. Arch Intern Med 1956;98:84-90.
4. Uretsky BF. Symptomatic myocardial infarction without chest
pain. Am J Card 1977;40:498-503.
5. Gerber RM. Coronary artery disease in the elderly. J Cardiovasc
Nurs 1990;4,4:23-34.
6. Wei JY, Gersh BJ. Heart disease in the elderly. Curr Probl Card
1987;12:1-65.
7. Statistics Canada. Canadian centre for health information.
Causes of death. Health Rep 1990;2:1-3.
8. Johansen H, Nair C, Taylor G. Current and future hospitaliza-
tion after heart attack. Health Rep 1998;10,2:21-28.
9. Herrick DB. Clinical features of sudden obstruction of coro-
nary arteries. JAMA 1912;59:2015-20.
10. Tinker GM. Clinical presentation of myocardial infarction in
the elderly. Age Ageing 1981;10:237-40.
11. MacDonald JB, Baillie J, Williams BO, Ballantyne D. Coronary
care in the elderly. Age Ageing 1983;12:17-21.
12. Willams BO, Begg TG, Semple T, McGuiness JB. The elderly in
a coronary care unit. Brit Med J 1997;2,6033:451-3.
13. Tresch DD. Atypical presentation of cardiovascular disorders
in the elderly. Geriatrics 1987;42:31-46.
14. O’Rourke RA, Chatterjee K, Wei JY. Coronary heart disease. J
Am Coll Card 1987;10:52A-6A.
15. Wei JY. Heart disease in the elderly. Cardiovasc Med
1984;9:971-82.
16. Everts B, Karlson BW, Wahrborg P, Hedner T, Herlitz J. Local-
ization of pain in suspected acute myocardial infarction in
relation to final diagnosis, age and sex and site and type of
infarction. Heart Lung 1996;25,6:430-7.
17. Lee H. Typical and atypical clinical signs and symptoms of
myocardial infarction and delayed seeking of professional
care among blacks. Am J Crit Care 1997;6,1:7-15.
18. Vokonas PS, Kannel WB. Diabetes mellitus and coronary heart
disease in the elderly. Clin Ger Med 1996;12:69-78.
19. Antman EM, Braunwald E. Acute myocardial infarction. In
Fauci AS, Braunwald E, Isselbacher KJ, Wilson JD, Martin
JB, Kasper DL, et al, editors. Harrison’s principles of
internal medicine. 14th ed. New York: McGraw Hill; 1998.
p. 1352-1364.
20. Wroblewski M, Mikulowski P, Steen B. Symptoms of myocar-
dial infarction in old age: clinical case, retrospective and
prospective studies. Age Ageing 1986;15:99-104.
JULY/AUGUST 2001 HEART & LUNG
Then et al Atypical presentation of acute myocardial infarction

21. Heart and Stroke Foundation of Canada. Cardiovascular dis-
ease in Canada: 1991. Ottawa: Heart and Stroke Foundation of
Canada; 1991.
22. Dracup K, Moser DK. Beyond sociodemographics: factors
influencing the decision to seek treatment for symptoms of
acute myocardial infarction. Heart Lung 1997;26,4:253-62.
23. Tresch DD, Brady WJ, Aufderheide TP, Lawrence SW, Williams
KJ. Comparison of elderly and younger patients with out-of-
hospital chest pain. Arch Intern Med 1996;156:1089-93.
24. Normand ST, Glickman ME, Sharma RG, McNeil BJ. Using
admission characteristics to predict short-term mortality from
myocardial infarction in elderly patients. JAMA 1996;275:1322-
8.
25. The United Kingdom Heart Attack Study (UKHAS) Collabora-
tive Group. Effect of time from onset to coming under care on
fatality of patients with acute myocardial infarction: effect of
resuscitation and thrombolytic treatment. Heart 1998;80:114-
20.
26. Simons-Morton DG, Goff DC, Osganian S, Raczynski JM,
Finnegan JR, Zapka J, et al. Rapid early action for coronary
treatment: rationale, design, and baseline characteristics.
Acad Emerg Med 1998;5:726-38.

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