Failure to diagnose and treat cardiovascular disease

by Laura Hale Brockway, ELS, Vice President, Marketing, and
Emma Louise, Risk Management Representative

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Presentation‍

A 61-year-old woman came to the emergency department (ED) at 11:10 p.m. on August 7. She reported chest tightness, shortness of breath, and fingertip tingling and numbness.
 
The patient attributed these symptoms to anxiety due to her husband’s recent illness and her daughter’s cancer diagnosis. The patient also reported a history of anxiety attacks that were untreated. She did not have a primary care physician (PCP).

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Physician action

‍The patient was treated by Emergency Medicine (EM) Physician A. The patient denied chest pain, dyspnea upon exertion, edema, palpitations, and syncope. She was described as being in “no acute distress.”
 
The patient’s blood pressure was 191/86 mmHg, and a chest x-ray was read as showing no cardiopulmonary acute process. EM Physician A read the electrocardiogram (ECG) as “normal rate, normal sinus rhythm, no acute ischemic changes, no STEMI, normal QRS, normal ST waves, normal T waves, normal axis, normal intervals, and adequate tracing.” The patient’s troponin level was drawn once and the result was reported as normal.
 
The patient was given 1 mg of lorazepam at 11:35 p.m. An hour later, she reported feeling much better. After a re-evaluation, the patient was discharged with instructions to follow up with her primary care physician. Her discharge papers said she was treated for “Anxiety, Panic.”
 
The patient’s ECG was overread by a cardiologist at 8:33 a.m. as “normal sinus rhythm, nonspecific ST abnormality and abnormal ECG.” The patient was not told of this finding.
 
The patient went to an urgent-care clinic on August 10 reporting symptoms of “anxiety, panic attacks, arms get numb and tingling, not sleeping well and after anxiety attacks pass, I get cold.” Family Physician A documented that the patient had panic attacks over the last month and that they came in waves. She was noted to have gone to the hospital three days earlier and had an ECG, chest x-ray, and labs and was told of no abnormalities. Family Physician A diagnosed anxiety and prescribed hydroxyzine for insomnia. The patient was instructed to “follow up with PCP this week/next week.”
 
On August 14, the patient came to a primary care clinic, where she was last seen four years earlier. (Her previous visits to this clinic were for treatment of GERD, sciatica, bronchitis, and seasonal allergic rhinitis.) The patient completed a new patient form and noted a history of acid reflux, asthma, and high cholesterol. Her current symptoms were fatigue, cough, shortness of breath, chest tightness, heart palpitations, and anxiety.
 
Family Physician B noted that the patient was being seen for “ED follow up where she was diagnosed with panic attacks.” There were no records at this clinic of the ED visit. The patient reported increased anxiety and shortness of breath.
 
Family Physician B documented that the patient had “no chest pain, no syncope, no neuro change, no vision change, positive mild depression, no suicidal ideations.” The exam revealed that that patient’s heart and lungs were normal. Family Physician B prescribed sertraline, alprazolam, and an albuterol inhaler. The patient was also counseled about her high BMI. She was told to follow up in six weeks and to go to the ED if she felt worse.
 
The patient died at home on August 16. The autopsy report stated that she died “as a result of ruptured myocardial infarct due to atherosclerotic cardiovascular disease with coronary thrombosis.” She had 70 percent stenosis of her right coronary artery.
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Allegations‍

A lawsuit was filed against Family Physicians A and B and their clinics. The allegations were failure to properly evaluate the patient, failure to administer proper treatment, and failure to administer routine tests (ECG or lab studies) to diagnose the patient’s condition.
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Legal implications

‍According to the plaintiff’s family practice expert, Family Physician A did not properly re-assess the patient’s symptoms from the ED visit or properly evaluate the symptoms the patient listed on her medical intake form. This expert stated that the standard of care required a referral for a full cardiac evaluation with stress testing.
 
Regarding the actions of Family Physician B, the plaintiff’s expert claimed that she breached the standard of care for assuming the ED visit was adequate to rule out cardiac disease, when she did not have the hospital records to verify this information. The standard of care would have been to order a further cardiac work up.
 
A cardiologist who reviewed this case for the plaintiffs stated that the patient’s reports of chest discomfort, tightness, heartburn, back pain, numbness, and shortness of breath should have been considered cardiac in nature until otherwise ruled out.
 
Family physicians who reviewed this case for the defense stated that the defendants’ actions were reasonable. The patient was seen by three different physicians in the nine days before she died. With each of these physicians, she reported a similar set of symptoms and had similar physical examinations (according to the medical records). Each of these physicians reached the same conclusion and found that the patient had an anxiety disorder.
 
Additionally, there was the question of the patient’s troponin level, which had been reported as normal. Patients who are experiencing cardiovascular disease for several days would show an elevated troponin level. “The troponin test is very sensitive, especially when ischemia has been occurring over days. This test will generally turn positive within three hours and remain positive for up to a week when the heart muscle is suffering from diminished blood flow,” said one of the defense experts.

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Disposition

‍This case was settled on behalf of Family Physicians A and B.

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‍More on diagnostic errors.

Risk management for adult primary care physicians.

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