Ricardo Wang et al. José Carlos da Costa Zanon Fernando Carvalho Neuschwander
In Medical School, we learn the traditional way to conduct the investigative process in order to reach a diagnosis. This process is traditionally based on the collection of anamnesis and clinical exams, clinical reasoning, the generation of a hypothesis, and tests with complementary exams. In general, we follow the the Occam’s razor principle: “the simplest answer is usually the correct answer,” or as William Osler’s aphorism: “Where you hear hoofs, you don´t think of zebras”. However, in this investigative process, the clinical reasoning is challenged in an elderly population over 80 years of age, and not always is the simplest answer the most correct. In this age group, the presence of comorbidities is quite common and can interfere, changing the perception of cardiovascular symptoms (depression, dementia, medications that interfere in the central nervous system, diabetes, analgesics, etc.), or even modify the symptomatology. The presence of atypical symptoms, such as dyspnea, sudoresis, vomiting, diarrhea, epigastric pain, and mental confusion can all mask the cardiovascular pathology. ,
Many studies have shown the difficulty in diagnosing acute myocardial infarction (AMI) in this population, which clearly entails delays in or the lack of treatment. Even when the diagnosis and early treatment of AMI is established, the mortality rate remains high in this population. The under-treatment or lack of treatment contribute to the increase in mortality in this age group. – Understanding the factors that make the diagnosis difficult is of utmost importance in establishing protocols directed toward the older age elderly patient.
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