When dyspnea replaces chest pain: Age-dependent symptom profiles in ACS and non-ACS patients undergoing coronary angiography

BACKGROUND Advancing age fundamentally alters the clinical presentation of suspected coronary artery disease. Although chest pain remains the hallmark symptom of acute coronary syndrome (ACS), older adults increasingly present with dyspnea or heart failure (HF)-related symptoms, creating substantial diagnostic uncertainty during emergency department (ED) evaluation. Whether this age-dependent shift is specific to ACS or represents a broader change in the clinical phenotype of patients undergoing coronary angiography remains incompletely understood. We therefore investigated age-related changes in symptom presentation and determined whether these patterns differed between patients with and without ACS. METHODS We performed a retrospective patient-level analysis of a single-center coronary angiography registry comprising 3198 procedures consolidated into 2560 unique patients. Patients aged ≥50 years presenting with documented chest pain and/or dyspnea/HF symptoms were stratified into four age groups (50-59, 60-69, 70-79, and ≥ 80 years). Presentations were categorized as isolated chest pain, isolated dyspnea/HF, or combined symptoms. ACS status was determined using clinical presentation and biomarker data. Multivariable logistic regression identified independent predictors of dyspnea-containing presentations after adjustment for demographic and cardiovascular comorbidities, and interaction analyses assessed whether the association between age and symptom presentation differed by ACS status. RESULTS Among 1530 eligible patients, isolated chest pain declined progressively with age, whereas dyspnea-containing presentations more than doubled, increasing from 18.8% in patients aged 50-59 years to 47.2% in those aged ≥80 years (P < 0.001). This transition occurred in both ACS (n = 602) and non-ACS (n = 928) patients. After adjustment, patients aged ≥80 years had more than twofold higher odds of dyspnea presentation than those aged 50-59 years (adjusted OR 2.64, 95% CI 1.64-4.29; P < 0.001). Despite the age-related transition toward dyspnea, both significant and multivessel coronary artery disease increased progressively with advancing age. No significant age-by-ACS interaction was observed (Pinteraction = 0.993). CONCLUSIONS Advancing age is associated with a marked and independent transition from isolated chest pain toward dyspnea-containing presentations regardless of ACS status, suggesting that older patients with suspected coronary disease increasingly present with dyspnea rather than isolated chest pain. These findings support considering dyspnea a high-risk presenting symptom that should prompt careful evaluation for ACS and other cardiovascular disorders in older adults. Equivalent rather than merely an atypical symptom in older adults, even in the absence of typical chest pain.