title: The elder patient with suspected acute coronary syndromes in the emergency department.
abstract: OBJECTIVE
  To describe the evaluation and outcomes of elder patients with suspected acute coronary syndromes (ACS) presenting to the emergency department (ED).
  
  
  METHODS
  This was a post hoc analysis of the Internet Tracking Registry for Acute Coronary Syndromes (i*trACS) registry, which had 17,713 ED visits for suspected ACS. First visits from the United States with nonmissing patient demographics, 12-lead electrocardiogram results, and clinical history were included in the analysis. Those who used cocaine or amphetamines or left the ED against medical advice were excluded. Elder was defined as age 75 years or older. ACS was defined by 30-day revascularization, Diagnosis-related Group codes, or death within 30 days with positive cardiac biomarkers at index hospitalization. Multivariable logistic regression analyses were performed to determine the association between being elder and 1) 30-day all-cause mortality, 2) ACS, 3) diagnostic tests ordered, and 4) disposition. Multivariable logistic regression was also performed to determine which clinical variables were associated with ACS in elder and nonelder patients.
  
  
  RESULTS
  A total of 10,126 patients with suspected ACS presenting to the ED were analyzed. For patients presenting to the ED, being elder was independently associated with ACS and all-cause 30-day mortality, with adjusted odds ratios of 1.8 (95% confidence interval [CI] = 1.5 to 2.2) and 2.6 (95% CI = 1.6 to 4.3), respectively. Elder patients were more likely to be admitted to the hospital (adjusted odds ratio, 2.2; 95% CI = 1.8 to 2.6), but there were no differences in the rates of cardiac catheterization and noninvasive stress cardiac imaging. Different clinical variables were associated with ACS in elder and nonelder patients. Chest pain as chief complaint, typical chest pain, and previous history of coronary artery disease were significantly associated with ACS in nonelder patients but were not associated with ACS in elder patients. Male gender and left arm pain were associated with ACS in both elder and nonelder patients.
  
  
  CONCLUSIONS
  Elder patients who present to the ED with suspected ACS represent a population at high risk for ACS and 30-day mortality. Elders are more likely to be admitted to the hospital, but despite an increased risk for adverse events, they have similar odds of receiving a diagnostic test, such as stress cardiac imaging or cardiac catheterization, compared with nonelder patients. Different clinical variables are associated with ACS, and clinical prediction rules utilizing presenting symptoms should consider the effect modification of age.
authors.affiliation: Department of Emergency Medicine, Vanderbilt University Medical Center, Nashville, TN, USA. jin.h.han@vanderbilt.edu
authors.forename: Jin H
authors.initials: JH
authors.lastname: Han
authors.forename: Christopher J
authors.initials: CJ
authors.lastname: Lindsell
authors.forename: Richard W
authors.initials: RW
authors.lastname: Hornung
authors.forename: Timothy
authors.initials: T
authors.lastname: Lewis
authors.forename: Alan B
authors.initials: AB
authors.lastname: Storrow
authors.forename: James W
authors.initials: JW
authors.lastname: Hoekstra
authors.forename: Judd E
authors.initials: JE
authors.lastname: Hollander
authors.forename: Chadwick D
authors.initials: CD
authors.lastname: Miller
authors.forename: W Frank
authors.initials: WF
authors.lastname: Peacock
authors.forename: Charles V
authors.initials: CV
authors.lastname: Pollack
authors.forename: W Brian
authors.initials: WB
authors.lastname: Gibler
mesh_terms: D000367:Age Factors; D000368:Aged; D000369:Aged, 80 and over; D006328:Cardiac Catheterization / Q000706:statistics & numerical data; D002423:Cause of Death; D003131:Combined Modality Therapy; D016001:Confidence Intervals; D017023:Coronary Angiography / Q000706:statistics & numerical data; D004562:Electrocardiography; D004636:Emergency Service, Hospital / Q000592:standards*; D005260:Female; D017052:Hospital Mortality / Q000639:trends*; D006801:Humans; D016015:Logistic Models; D008297:Male; D015999:Multivariate Analysis; D009203:Myocardial Infarction / Q000175:diagnosis* / Q000401:mortality* / Q000628:therapy; D016017:Odds Ratio; D011379:Prognosis; D012042:Registries; D018570:Risk Assessment; D012720:Severity of Illness Index; D018709:Statistics, Nonparametric