Catching Heart Trouble: Understanding Acute Coronary Syndrome

A 72-year-old man presents with substernal chest pain, shortness of breath, and diaphoresis. What is the most likely diagnosis?

• A. Acute coronary syndrome
• B. Boerhaave syndrome
• C. Gastroesophageal reflux disease
• D. Pulmonary embolism

Answer: (A)

The presentation of substernal chest pain, shortness of breath, and diaphoresis in a 72-year-old man is highly indicative of acute coronary syndrome (ACS). ACS encompasses a range of conditions, including unstable angina and myocardial infarction, which are characterized by the sudden onset of chest discomfort, often accompanied by other symptoms such as dyspnea, sweating, nausea, or lightheadedness. In older patients, especially those with risk factors such as hypertension, diabetes, or a history of smoking, the likelihood of coronary artery disease leading to ACS is significantly increased. The substernal nature of the pain is classic for cardiac issues; this is often described as a feeling of pressure or heaviness. The additional signs of shortness of breath and diaphoresis further support the diagnosis, as they are common autonomic responses to the stress induced by cardiac ischemia. While other options present alternative medical conditions, they do not correlate as strongly with the symptom profile provided. For instance, Boerhaave syndrome typically involves esophageal rupture due to severe vomiting, which may present with chest pain but is usually accompanied by other specific symptoms like severe retrosternal pain or signs of sepsis. Gastroesophageal reflux disease (GERD) can cause similar chest

When an elderly patient walks into the emergency department with symptoms like substernal chest pain, shortness of breath, and that dreaded sweaty feeling—often a sign of something serious—it’s important to take these presentations seriously. Understanding the urgency behind these symptoms is crucial, especially when preparing for exams like the ROSH Geriatrics Practice Test. So, let’s break down the pathophysiology and differential diagnosis that guides clinicians in these high-stakes situations.

First off, let's consider our patient: a 72-year-old man. This age marker already tips us off that there are underlying concerns we shouldn't overlook. When you hear ‘substernal chest pain,’ it sends up a red flag—especially in someone with potential risk factors like hypertension, diabetes, or a history of smoking. There’s an old saying in medicine: “When you hear hoofbeats, think horses, not zebras.” Here, the “horse” is acute coronary syndrome (ACS).

Acute coronary syndrome encompasses a spectrum of cardiac events, including unstable angina and myocardial infarction (often called a heart attack). What defines these scary conditions is the sudden onset of discomfort, which could feel like pressure or tightness, sometimes radiating to the arm, jaw, or back. In our case, substernal pain combined with shortness of breath and diaphoresis (that’s medical jargon for sweating profusely) strongly points toward ACS.

You might be wondering, what are the other possibilities? Let’s take a quick peek at some alternatives. There’s Boerhaave syndrome, which involves esophageal rupture and is typically sparked by severe vomiting—a whole different presentation that wouldn't fit this scenario. Then we have Gastroesophageal reflux disease (GERD). While GERD can mimic chest pain, it usually doesn't come along with such dramatic physiologic responses like diaphoresis or the intensity of discomfort seen in ACS. Lastly, Pulmonary embolism is a real contender as well, especially with the shortness of breath; however, the classic triad of pain, heaviness and sweating leads us back to the likely culprit: acute coronary syndrome.

Now, why does this matter in the grand scheme of geriatric care? It’s not just about making the right diagnosis; it's about being aware of the significant risks that older adults face. The chances of coronary artery disease increase exponentially with age and can present in subtle ways that even seasoned clinicians might overlook. Remember, the heart in a 72-year-old doesn’t necessarily act the same way as a younger person’s heart. It’s crucial to have a high index of suspicion and consider ACS in older adults whenever they present with those hallmark signs.

As we prep for the ROSH Geriatrics Practice Test, keep in mind the myriad ways that the elderly can present with cardiac issues. This age group might masquerade their symptoms differently, sometimes presenting with atypical symptoms that can confuse the untrained eye. Therefore, honing in on understanding how age plays a role in symptom presentation could be the linchpin to effective diagnosis and treatment.

In essence, knowing that the classic signs of ACS are paramount among older patients could save a life. So, let's take this knowledge into our studies and future practice. Always stay curious, dig deep into patient presentations, and let that curiosity guide your clinical reasoning. Knowledge is not just power; it’s a lifeline for those depending on us.