Which patient is at risk for having an atypical presentation of an acute myocardial infarction?

• A. 21-year-old man with a history of asthma
• B. 37-year-old man with a history of obesity
• C. 72-year-old woman with a history of diabetes and hypertension
• D. 75-year-old man with a family history of coronary artery disease

Answer: (C)

Atypical MI presentations are more common in older adults, women, and people with diabetes because their symptoms can be less classic and more nonspecific. Diabetes, in particular, often causes autonomic neuropathy that dulls or alters chest pain, so myocardial ischemia may present as shortness of breath, fatigue, nausea, epigastric discomfort, or even confusion rather than the usual chest pressure. Age and female sex further increase the likelihood of nonclassic symptoms. The patient described—an older woman with diabetes and hypertension—has the combination of factors most strongly associated with an atypical presentation, making her the highest risk for not presenting with the typical chest pain.