The majority of persons sustaining acute myocardial infarction are older, and in these older persons morbidity and mortality are high. Clinical presentations and characteristics are significantly different between older and younger infarction patients. Older infarction patients are more likely to be female and to have a history of heart failure, but they are less likely to have a family history of myocardial infarction, elevated cholesterol, or to smoke. Older patients will frequently have unrecognized or silent myocardial infarctions or, when present, symptoms will be atypical. Instead of chest pain, older patients may have shortness of breath or neurological symptoms, such as confusion. Also, older infarction patients will delay longer in seeking medical assistance after onset of symptoms, and often will not demonstrate ST elevation or Q waves on their electrocardiograms. Not infrequently, older infarction patients will demonstrate major complications such as heart failure or right ventricular infarction on hospital admission, and their presenting complaints will reflect these complications. Because of these atypical presentations and the wide variability of symptoms, physicians must be highly suspicious of the presence of an acute myocardial infarction in older patients who have an unexplained acute change in their physical condition.