Evaluate Chest Pain with Caution

Each year there are five hundred thousand sudden deaths in the United States from cardiac disease. Problems related to diagnosis or treatment of ischemic heart disease are among the leading causes of medical malpractice claims in emergency rooms today.

According to closed-claim data, problems arising from diagnosis or treatment of chest pain account for 20 percent or more of the total dollar losses incurred in emergency medicine claims.

Many patients with chest pain or related symptoms have conditions unrelated to myocardial infarction. The presence of chest pain in any patients, however, should alert you to consider them high risk and should remind you that improper evaluation and management of such cases are frequent sources of malpractice claims. This article offers some suggestions for evaluating chest pain cases and avoiding pitfalls that can result in liability for physicians and hospitals.

Case History

Consider this typical scenario: A 49-year-old corporate executive was out of town on a business trip. Late one night, he was taken to a hospital emergency department by an associate. He had been experiencing a “funny feeling” in his chest and slight shortness of breath. Earlier that evening, he had tried to dismiss the symptoms as indigestion.

The man’s vital signs were taken and revealed: blood pressure 145/100; pulse 90; and respiration 25. He was warm and dry and no longer complained of discomfort in his chest. The following notations were made in his record: Past medical history includes slight hypertension attributed to stress. Family history of diabetes/maturity onset. Father died suddenly at age 63. No siblings. No current medications.

A review of the man’s symptoms proved essentially negative, except for previous occurrences of discomfort in his chest after heavy meals. A physical exam showed a slightly obese male who appeared anxious and felt dry and warm to the touch. His breath smelled of alcohol, but he was oriented. A cardiac exam showed no rubs, murmurs, clicks, or gallop. An emergency physician ordered an electrocardiogram (EKG) and a chest x-ray, which were interpreted as being within normal limits. Based on a review of the history, physical examination, and discussion with the patient, the physician discharged the man with instructions to see his personal doctor for a possible gastrointestinal disorder when he returned home.

Within two hours after leaving the hospital, the patient started feeling nauseated. He became unconscious and stopped breathing. The emergency physician received a call from the paramedic squad saying that the man had suffered a cardiac arrest and they were bringing him in. Resuscitation efforts at the scene were complicated by aspiration. When the ambulance arrived at the emergency department, the monitor showed asystole. The physician’s efforts to resuscitate the man were unsuccessful.

Two weeks later, a medical records clerk mentioned to the physician that an attorney had sent for a copy of the decedent’s medical records.

High-risk Conditions

The decision to discharge a patient who presents with chest pain as the primary complaint should be made only after careful consideration of potential consequences. Patients with myocardial ischemia (MI), angina, pulmonary embolism, dissecting aortic aneurysm, or pneumothorax all can present with chest pain. Your evaluation and documentation should take into consideration all of these high-risk conditions.

Remember these key points for patients with chest pain:

• Patients’ emotion-laden and subjective complaints can distort the history and obscure the significance of findings from a physical exam.
• The risk of error in emergency departments is increased by the constraints of time, limited resources, and difficulty obtaining timely consultation and referral.

Recommendations

The guidelines offered here focus specifically on ischemic heart disease. Published studies of postmortem evaluation and routine annual EKG show a high rate of missed MIs—more than 25 percent and as high as 40 percent.

Appropriate history concentrates on pain history and risk factors such as diabetes, high blood pressure, previous coronary artery disease, previous MI, age (over 30), sex (still male dominated, although the gap is closing). Additional risk factors include abnormal lipids in the blood, high levels of cholesterol, and habits such as excessive alcohol consumption, smoking, or sedentary lifestyle.

Most important are a history of angina or previous MI, and the use of nitrates or other cardiac medications.

The acute history should concentrate on the location, radiation, and duration of the pain.

MI pain is usually central or left arm pain, but occasionally it can be in the neck, right arm, back or jaw. The pain usually lasts one minute and is often associated with exertion or excitement.

Inquire about associated symptoms, including diaphoresis, excessive anxiety, a sense of doom, nausea, lightheadedness, dizziness, or shortness of breath.

Myocardial ischemic pain is frequently associated with sweating, shortness of breath, cool and clammy skin, nausea, vomiting, and lightheadedness.

Record family history of diabetes, high blood pressure, and especially coronary artery disease or sudden death of unknown etiology.

The physical examination should focus on:

• Signs of diaphoresis
• Presence of vascular disease
• Signs of heart failure
• Valvular disease
• New murmurs or extra heart sounds
• Cardiac irregularity, irritability, or dysfunction

EKG Evaluation

While the physical exam, chest x-ray, and other laboratory tests are important to consider in evaluating patients with chest pain, the history and the EKG are the most important factors in the diagnosis of ischemic heart disease.

Proper evaluation of the EKG is essential, concentrating on comparisons with previous EKGs and changes such as s-t segment elevations, new bundle branch block, s-t segment depressions, Q-waves, and hyperacute T-waves.

A normal EKG does not exclude the diagnosis of acute MI. The sine qua non to evaluation of the patient with chest pain is clinical judgment. EKG and chest x-ray results can be misleading.

Patients with Chest Pain Are at Risk—Use Both Liberal Consultation and Liberal Admission Policies

The decision not to admit a patient with chest pain centers on whether MI, crescendo angina, and unstable angina can be ruled out. Also remember that there are other reasons to consider admitting patients who have chest pain.

Cardiac arrythmias or cardiac failure can arise from a variety of conditions within the continuum of diseases resulting from coronary insufficiency.

Although positive enzyme studies are diagnostic of MI, normal enzymes do not exclude the diagnosis of ischemia or acute MI. It takes some time (two hours or more) for CPK-MB enzymes or other marker enzymes to appear in levels sufficient to be measurable in acute myocardial infarction. Clinical judgment also must guide the physician in the decision to admit a patient; since normal enzyme studies are not helpful when considering the possibility of coronary insufficiency without infarction, which may cause sudden death.

Remember that diabetics and elderly patients are prone to silent ischemia with minimal symptoms. However, changes in clinical condition—including confusion, pulmonary edema, and heart failure—do appear.

Discharging a patient with a potentially life-threatening condition must always be considered in light of the risk. The applicable legal principle here is that the degree of caution should be proportionate to the magnitude and forseeability of the risk. Actions and documentation related to the decision to discharge should verify that the physician applied the appropriate degree of caution.

Use the following guidelines to establish consistent documentation habits.

• Remember the chief complaint. Given the presenting symptom, document pertinent negatives that rule out high-risk possibilities.
• Document pertinent positives that support your diagnosis, treatment, and disposition of the case.
• Double-check your documentation to see whether the chief complaint, history, and your findings support the diagnosis.
• Directly address any suspicion of MI, pneumothorax, dissecting aneurysm, or pulmonary embolus. Verbalize your suspicions, and note them in writing.

Finally, remember that a review of the medical chart—weeks, months, or years later—should demonstrate that high-risk conditions were considered and effectively ruled out, that you made an orderly, intelligent evaluation of the patient, and that the appropriate treatment and disposition were accomplished, given the risks.

New Trends In Litigation

Delayed treatment and negligent care management are at the center of a new trend in claims involving cardiac cases. To help avoid these claims, the treatment of chestpain patients might include:

• Using CPK subforms, myoglobin and troponin, for more sensitive and specific indicators of cardiac damage
• Expanding the number of EKG leads beyond 12 to pick up right and posterior injuries
• Establishing chest pain observation units with protocol
• Repeating EKG and enzyme tests at closer intervals
• Administering heparin and nitroglycerin for suspected unstable angina
• Using thrombolytics early in cases where MI injury pattern is present
• Consider radionuclide studies as highly sensitive and specific for ischemia heart disease

Conclusion

Litigation in cases involving MI and sudden death usually occurs when a patient suffers cardiac arrest or failure soon after being examined for chest pain and discharged. The prudent physician should:

• Take a complete history, concentrating on the high-risk entities that present with chest pain.
• Do a physical exam, concentrating on signs of heart dysfunction or failure.
• Carefully interpret the EKG.
• Maintain a high index of suspicion.

Admission for cardiac monitoring is suggested when MI or unstable angina is suspected. Cardiac failure and rhythm disturbances can then be picked up and treated with intravenous drugs. Early aggressive management of cardiac injury and failure reduce the risk of litigation.

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