Chest pain is a common reason people go to the emergency room. It accounts for one in twenty emergency room visits. But it’s estimated that as many as 60,000 patients a year – two to four percent of the 1.5 million who come to the emergency department with what’s called “acute coronary syndrome” – are inappropriately sent home instead of being given lifesaving heart treatment.
Chest pain often comes from the heart. (The pain comes from the heart not getting enough oxygen for the muscle to do its work.) But chest and abdomen pain and discomfort also can have other causes. And especially if the chest pain isn’t evaluated seriously and carefully, a misdiagnosis can occur that can be fatal to the patient.
There are two main issues in medical malpractice related to heart attacks:
- First, was there a failure to diagnose the patient’s heart disease in time to provide life-saving treatment? The time for effective intervention could be hours or days before the heart attack, or even in the middle of a heart attack that was not properly recognized.
- Second, was the heart attack care, once started, carried out effectively and timely?
In the emergency room, malpractice can occur when the doctor mistakenly decides the patient is just having stomach upset, or some other benign problem. This is particularly a problem if the patient doesn’t fit the doctor’s preconception of who is at high risk for heart attack. Surprisingly often, young adults and women turn out to have serious heart disease.
Malpractice can also happen from simple neglect. This killed the brother of actor James Woods in Rhode Island. He died in an emergency room hallway from an unnoticed heart attack. Out of the family’s medical malpractice lawsuit there came one positive good: the new Michael J. Woods Institute, which the hospital funded to help teach hospital staff how to pay better attention to patients and develop a more “human-centered” standard of care.
Once diagnosed, the hospital’s job is to get the patient into fast treatment — usually a balloon angioplasty to see if blocked arteries in the heart can be reopened before permanent death of the heart muscle occurs. Failure to move quickly enough if the patient is in the middle of a heart attack can be malpractice. The standard is that angioplasty should start within 60 to 90 minutes of the patient’s arrival at the emergency room. Longer times risk permanent damage to the heart.
Standards of Care for Quality Heart Attack Care in the Hospital
For diagnosis of anyone with chest pain, the standard evaluation includes:
- A careful history from the patient of the type of pain and how it came on. This can be the best tipoff to heart-related chest pain. For example, sharp pain that gets worse with breathing isn’t related to the heart. But lots of different descriptions of chest pain CAN be from the heart. It doesn’t even have to be “pain” per se – patients describe pressure, tightness, heaviness, a burning sensation. And it can radiate to the neck, arms, jaw, back or shoulders. Other classic warning signs include nausea or vomiting associated with the chest discomfort, persistent shortness of breath, and dizziness or lightheadedness. But frequently patients can get heart attack with some of these associated symptoms yet NO report of chest pain.
- Electrocardiogram (EKG). In some patients, this can point to the specific area of the heart muscle that is affected. However, a single EKG does NOT rule out heart attack. One well-known study found that the EKG was normal or non-diagnostic in HALF of patients who later went on to have a proven myocardial infarction (heart attack). So doing more than one EKG over a period of hours can be important if the diagnosis isn’t obvious immediately.
- Cardiac enzymes. These are proteins released by dying cells in the heart. The typical ones tested for are troponin, creatinine phosphokinase (CK) and myoglobin. The most specific to the heart – and so the best – is troponin. But a normal level of cardiac enzymes does NOT rule out heart attack. The testing could just be too early in the process, because these enzymes don’t start to rise in the blood until three or more hours after the injury. So the standard is to run the cardiac enzyme at least twice, six hours apart, before being satisfied that a “normal” result on the first test was truly normal.
Besides moving quickly to diagnose any patient coming into the ER with chest pain, here are the accepted standards for minimum acceptable care for heart attack patients. (Most of these come from the Rand Corporation’s compilation of standard treatments put together by medical specialty societies, as described in Patrick Malone’s book, The Life You Save: Nine Steps to Finding the Best Medical Care — and Avoiding the Worst. (Da Capo Lifelong 2009.)
- Angioplasty within 60 minutes, if possible, from the patient’s arrival at the emergency room. This is even more effective than clot-busting drugs (see below). This requires that the hospital be staffed with an interventional cardiologist 24/7, which not all hospitals have.
- (If angioplasty is not available) Clot-busting drugs (thrombolytics) as soon as possible, within 30 to 60 minutes of arrival to the ER. These drugs can chew up a clot that already exists, unlike aspirin, which just helps keep the clot from getting bigger. The problem is they do no good unless given within twelve hours of the onset of symptoms of a heart attack.
- Aspirin coming into the hospital and aspirin going home. Aspirin is a lifesaver for the heart (and the brain, as we’ll discuss later) because it blocks the stickiness of platelets, the particles that form the first layer of blood clots. If you think of a platelet as a piece of Velcro, aspirin knocks out one section of the Velcro, and Plavix, also an antiplatelet drug, knocks out another, so they’re often used together for maximum antistickiness. But the absolute minimum standard, unless you’re allergic to aspirin or have problems taking it, is to take an aspirin within two hours of arriving at the emergency room, and then receive instructions to continue taking it every day when you go home.
- A beta-blocker drug coming in and going out. Beta-blockers smooth out the heart rhythm and slow the heartbeat and thus help protect the heart after a heart attack. This is another minimum standard unless there’s a very good reason not to give it.
- ACE inhibitor drug on discharge if heart pumping is impaired. Of the four chambers of the heart, the one whose pumping you will see measured most is the left ventricle, the workhorse that pushes freshly oxygenated blood into the aorta and from there to the entire body. The volume of blood ejected with each beat divided by the volume of blood in the ventricle just before the contraction is called the ejection fraction, and in a normal person is above 55 percent; that means that with each beat, the heart should pump 55 percent or more of the blood in the left ventricle out to the body If it’s under 40 percent at any time during a heart attack hospitalization, an ACE inhibitor drug should be prescribed at discharge. These drugs help compensate for the reduced pumping efficiency of the heart by increasing the volume of blood ejected by each contraction and lowering the resistance of the tiny arteries in muscles, making it easier to feed blood to the body.
Here is another important source for standard of care statements on diagnosing and managing chest pain and acute coronary syndrome, from the Institute for Clinical Systems Improvement (ICSI).
If you know you’re at risk for a heart attack, it pays to find out ahead of time which hospitals in your area are fully equipped for emergency angioplasty.
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