A Woman’s Pain

by Ann S. Lofsky, M.D., Board of Governors

Many historic medical-scientific studies were performed primarily or solely on male subjects—often with the assumption that findings could then be generalized to the entire population. Evidence of gender differences in clinical incidences and presentations is now well described, and it is important that clinicians keep in mind the ways that female patients may differ in their presentation with common illnesses.

A 51-year-old woman was followed by a family practitioner for medical care and treatment over a 15-year period. She was noted to have high blood pressure, reflux esophagitis, and mild obesity. On multiple office visits, she listed complaints of occasional fatigue and mild persistent back and chest pains. The patient was advised to lose weight and was placed on a diuretic. Her blood pressure remained elevated with systolic pressures of 140–170 mm Hg and diastolic pressures ranging from 95–110. A beta-blocker was added as an antihypertensive. Electrocardiograms were obtained approximately every three years and were read as normal. The patient was last seen in the insured’s office for a blood pressure check. She had no complaints at the time. Her pressure was 156/98, and a routine EKG performed in the office was computer-read as “possible left ventricular hypertrophy.”

Does this Patient Require Additional Intervention?

Because the woman was without complaints, the family practitioner felt that no further testing was warranted. The woman was given a return appointment in three months for blood pressure evaluation. The insured received a phone call from the coroner two months after the last office visit stating that this patient had died suddenly at home. The cause of death was acute myocardial infarction, with extensive atherosclerotic cardiovascular disease noted at autopsy. The patient’s family filed suit alleging failure to diagnose and treat cardiac disease.

Did the Family Practitioner Deviate from the Standard of Care?

One family practitioner who was asked to review this case on behalf of the insured felt that with a history of chest pain and any abnormalities in the EKG, even in the face of a diagnosis of reflux, the patient should have been referred to a cardiologist for further evaluation. He also stated that the blood pressure should have been better controlled and rechecked sooner after the last elevated readings. Another defense family practitioner opined that the insured met the standard of care because none of the EKGs demonstrated evidence of ischemia, and the patient had minimal risk factors for coronary artery disease. A cardiologist agreed that the insured had acted appropriately since the patient was a nonsmoker, was only moderately overweight, and
had reasonably controlled blood pressure.

The plaintiff’s expert family practitioner described three areas where he believed the insured deviated from the standard of care. The first was in simply following the chronically high blood pressures for years without any documentation of new interventions. The second was the failure to follow up on one laboratory test showing elevated cholesterol and failing to educate the patient about the associations between elevated cholesterol, diet, and heart disease. Finally, it was alleged that the last few EKGs on this patient demonstrated left ventricular hypertrophy likely caused by the hypertension. This patient had listed shortness of breath, which may have been a symptom of left ventricular dysfunction, on a check-off sheet on at least two office visits. There was never any documentation of a differential diagnosis for this complaint. This expert felt that the patient should have been referred to a cardiologist for specific tests of her cardiac function.

The plaintiff’s expert cardiologist testified that the abnormal EKG warranted either a treadmill test or a cardiology referral. He felt that all of this patient’s EKGs had subtle abnormalities with nonspecific ST-T wave changes suggestive of left ventricular hypertrophy or ischemic heart disease. This cardiologist argued that with appropriate follow-up and testing, the underlying atherosclerotic disease would have been diagnosed and then treated with angioplasty, stent placement, or coronary artery bypass grafting.

All of the experts agreed that coronary disease in women may present atypically with complaints of shortness of breath and fatigue rather than with classic substernal chest pressure. These symptoms could have been further explored and the patient questioned about changes in her exercise tolerance, actions that were not evidenced in the medical records.

Should This Case Be Tried?

The defense’s expert cardiologist and family practitioner were supportive of the insured and willing to testify on his behalf, but other experts felt that the patient should have been sent for cardiology consultation in light of the EKG changes. The persistently elevated blood pressure readings were also an area of concern. The family practitioner consented to settle this case, but the plaintiff’s settlement demand remained near policy limits.

The decision was made, in conjunction with the insured, to proceed to trial. At the conclusion of testimony, the plaintiff’s attorney asked the jury to award a multimillion-dollar amount to the patient’s survivors. The jury deliberated for one hour before rendering a defense verdict in favor of the physician.

According to the American Heart Association, heart disease is the number-one killer of women in the United States. Cardiovascular disease, including strokes, causes more female deaths than the next six causes combined. Suggested contributing factors to the high death rate include the fact that both clinicians and patients often attribute chest pain in women to noncardiac causes such as pulmonary disease and gastro-esophageal reflux. Women have a greater tendency to describe atypical chest pains or to complain of abdominal pain, difficulty breathing, nausea, or unexplained fatigue. The possibility of ischemic heart disease should at least be considered in women presenting with these symptoms so that appropriate diagnostic and therapeutic measures may be undertaken when indicated.