Taking the Risks to Heart: Misdiagnosis of Heart Disease

Heart disease is the leading killer of women, responsible for one in every four female deaths, and this danger was highlighted by the tragic death of actress Carrie Fisher in late 2016. But almost two-thirds of women who die suddenly from heart disease had no previous symptoms.1 Diagnosis of an impending heart attack in a woman may be more difficult, as women often show different early signs and symptoms than men.

In a study of closed medical malpractice claims involving undiagnosed heart disease in women from 2011 to 2015, The Doctors Company found that in 70 percent of claims the patient died when her heart condition was not correctly diagnosed and 28 percent had heart muscle damage from myocardial infarction.

Failure to diagnose heart disease in women is often thought of as a problem in the emergency department (ED). However, the study found that in 28 percent of these cases, it was a primary care physician (PCP) who allegedly failed to diagnose the patient’s heart disease. Cardiologists (28 percent) and emergency medicine physicians (13 percent) were also named in these claims.

In a study of 1,180 malpractice claims against internal medicine physicians that closed from 2007 to 2014,2 the most common patient allegation (39 percent of claims) was diagnosis-related—with a full 6 percent of cases involving undiagnosed or missed diagnosis of myocardial infarction in both sexes. In these cases, 22 percent of patients were in their 40s and had atypical pain and/or comorbid conditions that deflected attention away from possible cardiac-related diagnosis.

Consider these case examples:

Case 1

A 47-year-old obese woman presented to her PCP complaining of a burning sensation in her chest after eating. The patient reported a similar episode the prior day after eating lunch as well as increased heartburn over the last few weeks.

A review of the medical record reflected elevated blood pressures over the past six months and an elevated cholesterol level of 237 (mg/dl). On the day of the exam, her blood pressure was 160/90. She smoked, drank alcohol socially, and was unaware of a family history of coronary artery disease. A heart exam revealed normal rate and rhythm. The physician noted that the patient appeared diaphoretic; however, she wasn’t in acute distress and was pain-free throughout the examination. An ECG revealed a left bundle branch block. Prior ECGs were not available for comparison. Suspecting reflux esophagitis (heartburn), the PCP advised the patient to take an antacid and to return if the symptoms continued.

Two days later, the patient called her PCP’s office stating that her chest burning sensation continued. The nurse advised her to continue taking the antacid and scheduled an office appointment for the following day. She also advised the patient to go to the ED if she developed chest pain.

That night, the woman awoke with chest pain, nausea, and vomiting. She was taken to the ED for emergent coronary angiography, but died shortly after arrival.

Case 2

A 53-year-old male presented to the hospital with complaints of acute chest, epigastric, and back pain with nausea. No pain radiated to the arm or jaw. He gave a history of hypertension, diabetes mellitus, and being a smoker. A brother had died from an MI.

An EKG showed no evidence of ischemia and no significant ST segment changes. Lab test results included lipase of 1,455 U/L (normal range <95 U/L), CK of 78 U/L (total CK normal range for males <235 U/L), and elevated triglycerides of 388 mg/dL (normal range <250 mg/dL). He was admitted to the hospital by an internist and diagnosed with acute pancreatitis, probably due to alcohol abuse. The troponin was mildly elevated at 0.08 ng/mL (normal range <0.03 ng/mL).

The day after admission, the patient complained of pain in the lower chest but had decreased epigastric pain. The following day he had no epigastric pain and he was eating well. There was chest pain only on palpation, so the internist believed that it was not cardiac in origin. He was discharged with instructions to follow up with the internist in two to three days, but the patient did not schedule an appointment. Two weeks later, the patient presented to the ER with complaints of substernal chest pain radiating to his neck and jaw. The EKG indicated that he had suffered an MI. An emergent cardiac catheterization revealed 100 percent occlusion of the right coronary artery and 95 percent occlusion of the left anterior descending artery. An angioplasty was successful. A claim was filed alleging that the internist failed to diagnose and treat an impending MI. Physician reviewers opined that, even though the pain was atypical for angina and troponin levels were borderline, the patient’s risk factors should have prompted a cardiac workup.

To help avoid such risks:

  • Rule out myocardial infarction before arriving at a GI-related diagnosis such as gastric reflux as the cause of chest pain or discomfort.
  • Consider cardiac risk factors such as obesity, smoking, hypertension, and hyperlipidemia.
  • Offer patients same-day appointments when they complain of continued symptoms for which they were recently seen. If this is not possible, send them to the ED and document this in the medical record.
  • Develop a written chest pain protocol, determining what the nurse should advise the patient and when the physician should be notified.
  • Remember that differences in early signs and symptoms in women may make coronary heart disease more difficult to recognize.
  • Thoroughly evaluate patients of all ages who present with atypical chest pain.

References

  1. Women and heart disease fact sheet. Centers for Disease Control and Prevention. https://www.cdc.gov/dhdsp/data_statistics/fact_sheets/docs/fs_women_heart.pdf. Accessed January 11, 2017.
  2. Internal medicine closed claims study. The Doctors Company. http://www.thedoctors.com/KnowledgeCenter/PatientSafety/articles/Internal-Medicine-Closed-Claims-Study. Accessed January 11, 2017.

The guidelines suggested here are not rules, do not constitute legal advice, and do not ensure a successful outcome. The ultimate decision regarding the appropriateness of any treatment must be made by each healthcare provider in light of all circumstances prevailing in the individual situation and in accordance with the laws of the jurisdiction in which the care is rendered.

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