Top Medical Malpractice Disasters in Evaluating Low-Risk Chest Pain

Educational Objectives

The goals of this program are to improve recognition of acute coronary syndrome (ACS). After hearing and assimilating this program, the clinician will be better able to:

1. Obtain and document a thorough history for patients presenting with chest pain.
2. Avoid common pitfalls in the diagnosis of ACS.

Summary

Background: missed acute coronary syndrome (ACS) in emergency medicine accounts for 20% of paid malpractice claims; medical malpractice cases — 60% to 70% focus on inadequate history; 25% to 50% focus on misdiagnosis with electrocardiography (ECG)

Failure to obtain and document adequate history: common reason for malpractice claim; history often overlooked in favor of highly sensitive troponins, sestamibi scans, and coronary computed tomography angiography; documentation — perform and record good history of present illness; use “OPQRST” mnemonic (ie, onset of symptoms, precipitating factors, quality and radiation of pain, severity, and timing); detailed thorough history of present illness results in broader differential diagnosis; speaker uses “OLD CARTS” mnemonic (onset, location/radiation, duration, character, aggravating factors, relieving factors, timing, and severity); document all information acquired while taking history; history rigorously dissected by attorneys during medical malpractice cases; defense response — adequate history taken but not recorded; history comprises only one component of any accelerated diagnostic protocol (ADP) (ie, history accounts for 20% of HEART [history, ECG, age, risk factors, troponin] score); performing and documenting complete history provides best defense against medical malpractice claims

Misdiagnosis: similar symptoms — reflux esophagitis or peptic ulcer disease most common misdiagnoses in missed cases of ACS; in cardiology literature, ≤50% of patients experiencing acute myocardial infarction (MI) or unstable angina report increase in belching during incident; check ECG to avoid overlooking ACS; symptoms classic for another diagnosis — 20% of patients with ACS described feeling burning or indigestion; avoid being misled by specific words patients use; response to therapy — studies indicate 15% of patients experience some relief from antacids (8% report complete relief); avoid using response to antacids as diagnostic tool; associated factors — in study of >10,000 patients with MI, 8% reported that, when pain began, they had been eating a meal; gastroesophageal reflux disease (GERD) and ACS often co-exist (ie, GERD more common in cardiac patients than in noncardiac patients); consider carefully before discharging patient with diagnosis of GERD; GERD most common misdiagnosis in patients with inferior wall ST elevation myocardial infarction (STEMI)

Failure to appreciate ACS in young patients: old rule about ACS occurring in women 55 to 65 yr of age or older and in men 45 to 55 yr of age or older no longer applies; ACS reported in preadolescent children; atherosclerosis — incidence increasing; pathologists identified significant atherosclerosis in soldiers killed in Korean and Vietnam Wars; Joseph et al (1993) reported on autopsy findings from 111 patients with average age 26 yr; significant atherosclerotic disease identified in 75% of individuals (20% with multivessel disease); hyperlipidemia — current generation of children expected to have shorter lives than their parents because of unhealthy diet and obesity; American Academy of Pediatrics actively debated routinely treating children with statin drugs; in 2009, 2.8 million prescriptions written for statins to treat hyperlipidemia in children; cardiologists predict increasing incidence of teenagers with STEMI over next decade

Failure to recognize ACS in atypical presentations

Women: two-thirds of cases in medical malpractice literature involve women in their 30s, 40s, and early 50s; young and premenopausal women do experience MI; painless presentations more common in women; ACS can present with isolated arm pain, radiation of pain to right side, or isolated pain in neck, jaw, or upper back; McSweeney et al (2003) — studied prodromal symptoms among women diagnosed with MI; only 30% reported chest pain; dyspnea, sleep disturbance, and fatigue (71%) reported most frequently; patient reports of feeling “wiped out” or tired for no apparent reason common among medical malpractice cases; check ECG in these patients

ACS as upper abdominal pain: problems in chest can produce upper abdominal pain; problems in abdomen can produce chest pain; check ECG in patients with upper abdominal pain without localized tenderness; 12% of elderly patients with ACS present with upper abdominal pain rather than chest pain

Overreliance on troponin levels: avoid overlooking history and ECG in favor of troponin levels; ≈50% of medical malpractice cases document normal troponin level and ignore history or diagnostic ECG; biomarker-negative ACS does exist; abnormal ECGs often ignored because troponin level documented as normal; no validated ADPs support solely relying on troponin to rule out ACS

Conclusion: use externally validated ADPs (eg, HEART, ADAPT); use ADPs properly (avoid “going rogue”); medical malpractice attorneys use ADPs (especially HEART score); calculate actual score and document in chart; perform and document thorough history; avoid exclusion of ACS solely based on reflux symptoms (most common misdiagnosis); no age too young to consider ACS; increase suspicion for ACS in young women; check ECG in patients with upper abdominal pain and no significant tenderness

Readings

Dezman ZD et al: Utility of the history and physical examination in the detection of acute coronary syndromes in emergency department patients. West J Emerg Med, 2017 Jun;18(4):752-60; Fanaroff AC et al: Does this patient with chest pain have acute coronary syndrome?: The rational clinical examination systematic review. JAMA, 2015 Nov 10;314(18):1955-65; Graham G: Acute coronary syndromes in women: recent treatment trends and outcomes. Clin Med Insights Cardiol, 2016 Feb;10:1-10; Joseph A et al: Manifestations of coronary atherosclerosis in young trauma victims--an autopsy study. J Am Coll Cardiol, 1993 Aug;22(2):459-67; Long B et al: An end-user’s guide to the HEART score and pathway. Am J Emerg Med, 2017 Sep;35(9):1350-5; Mahler SA et al: Safely identifying emergency department patients with acute chest pain for early discharge. Circulation, 2018 Nov;138(22):2456-68; McSweeney JC et al: Women’s early warning symptoms of acute myocardial infarction. Circulation, 2003 Nov;108(21):2619-2; Quinn GR et al: Missed diagnosis of cardiovascular disease in outpatient general medicine: Insights from malpractice claims data. Jt Comm J Qual Patient Saf, 2017 Oct;43(10):508-16; Smaardijk VR et al: Sex- and Gender-Stratified Risks of Psychological Factors for Incident Ischemic Heart Disease: Systematic Review and Meta-Analysis. J Am Heart Assoc, 2019 May;8(9):e010859.

Disclosures

For this program, members of the faculty and planning committee reported nothing to disclose.

Acknowledgements

Dr. Mattu was recorded at Rocky Mountain Winter Conference on Emergency Medicine, held February 23-27, 2019, in Steamboat Springs, CO, and presented by SCP Health. For information about upcoming CME activities sponsored by SCP Health, please visit SCP-Health.com. The Audio Digest Foundation thanks Dr. Mattu and SCP Health for their cooperation in the production of this program.

CME/CE INFO

Accreditation:

The Audio- Digest Foundation is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians.

The Audio- Digest Foundation designates this enduring material for a maximum of 0 AMA PRA Category 1 Credits™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Audio Digest Foundation is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center's (ANCC's) Commission on Accreditation. Audio Digest Foundation designates this activity for 0 CE contact hours.

Lecture ID:

EM370301

Expiration:

This CME course qualifies for AMA PRA Category 1 Credits™ for 3 years from the date of publication.

Instructions:

To earn CME/CE credit for this course, you must complete all the following components in the order recommended: (1) Review introductory course content, including Educational Objectives and Faculty/Planner Disclosures; (2) Listen to the audio program and review accompanying learning materials; (3) Complete posttest (only after completing Step 2) and earn a passing score of at least 80%. Taking the course Pretest and completing the Evaluation Survey are strongly recommended (but not mandatory) components of completing this CME/CE course.

Estimated time to complete this CME/CE course:

Approximately 2x the length of the recorded lecture to account for time spent studying accompanying learning materials and completing tests.

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