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 Discussion Data

• Altered Mental Status (AMS) is a fairly
common, if rarely understood or
appreciated, presentation of Acute
Myocardial Infarction (AMI), especially in
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.
• 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.
• She is treated with core measures for
NSTEMI, including enoxaparin, statin,
aspirin. Subsequently, she would regain
consciousness over the next few days.
• 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.
Data
• 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.
• 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%)
• Failure to recognize this presentation causes:
 Delays in diagnosis
 Delays in therapy.
• 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 References
patients.
• A retrospective review found that patients Conclusion
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more aggressive treatments, like PCI and
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