Jodi L. Nofsinger, trial lawyer and partner at Berman & Simmons

Management of Heart Attacks in Emergency Departments

About one in twenty people who seek help in Emergency Departments are there because they have chest pain. The vast majority of the time, the cause of the chest pain is a relatively benign process, not a heart attack. When chest pain is a warning symptom of a heart attack, however, proper diagnosis can mean the difference between life and death. Heart attacks can also lead to seriously disabling conditions. For that reason, when patients complain of chest pain, the medical care provider must consider and exclude imminently life-threatening causes first.

Medical standards of care for evaluating chest pain and other common signs and symptoms of heart attacks are well understood by medical care providers. Simple tests can reliably diagnose the problem at hand. Nevertheless, reported studies estimate that 2.2 percent of patients who are suffering from a heart attack (Acute Coronary Syndrome or Myocardial Infarction) are sent home without proper diagnosis and treatment. Sometimes, this failure is because patients present without the classic symptoms of a heart attack (chest pain radiating to the arm or jaw). Often it occurs as a result of failing to follow the clear rules that govern emergency medicine.

In 2004, the American College of Cardiology and the American Heart Association recommended that all hospitals implement written protocols for the management of patients who present with symptoms suggestive of heart attack. Those protocols dictate what steps must be taken by emergency department personnel to properly handle these patients. When Acute Coronary Syndrome (ACS) is the leading diagnosis, the initial assessment and intervention must be performed rapidly. Within the first ten minutes of arrival, the patient must be triaged, a focused history of the patient’s complaints must be taken, aspirin and nitroglycerin given, an intravenous line established, blood obtained for laboratory work, continuous electrocardiogram (ECG) monitoring started, and supplemental oxygen therapy provided. ECG and blood analysis to check for cardiac enzymes are crucial to making the diagnosis.

History and Physical Examination:

The interview of the patient should be focused on pain duration, character, provoking factors, and past history of heart disease risk factors. Chest pain from acute coronary syndrome has typical features. The pain is usually gradual in onset. Typically it starts, or is made worse, by activity. Patients often characterize it as discomfort, rather than pain, or squeezing, tightness, pressure, burning, aching or fullness in the chest. The pain often radiates to the upper abdomen, shoulders, arms, wrists/fingers, neck/throat, or lower jaw/teeth. The pain is usually not felt in one specific spot, rather it is a diffuse discomfort. The discomfort generally lasts more than 30 minutes. Some patients have a history that should alert the clinician of higher risk, such as a past history of ACS, other vascular disease, age, male gender, diabetes, high blood pressure, high cholesterol, and smoking. Patients often have pain associated with other symptoms, such as shortness of breath, nausea/indigestion, dizziness, clamminess, and fatigue.

Many patients present with atypical symptoms rather than chest pain. Compiled data shows that as many as one-third of patients undergoing ACS had no chest pain on presentation to the hospital. Instead, patients may present with only shortness of breath, weakness, nausea and/or vomiting, or heart palpitations. These atypical symptoms are more likely to occur in patients who are older, diabetic, and female. Unfortunately, studies show that the absence of chest pain greatly reduces the likelihood that the patient’s condition will be diagnosed in the emergency department even though a large percentage of patients do not have the classic symptom of chest pain with ACS.

The bedside physical examination includes listening to the heart and lungs and measuring the blood pressure in both arms. Physical examination is insufficient to make a diagnosis of ACS because it is usually normal in patients with ACS unless the patient has already progressed to a stage of heart/lung failure.

ECG

A 12-lead ECG should be performed on all patients with possible acute coronary syndrome, and the results should be immediately shown to an emergency physician for interpretation. The initial ECG, however, is often NOT diagnostic in patients who are in the midst of acute coronary syndrome. There can be a delay between the onset of the symptoms of ACS and the effects of ACS on heart function. The ECG records the damage to heart muscle from blockages in the coronary arteries, rather than the onset of the blockage. For that reason, if the initial ECG is not diagnostic and the patient still has symptoms, ECG should be repeated at 5 to 10 minute intervals until the symptoms resolve or a definitive diagnosis of what is ailing the patient is made. Some clinicians incorrectly assume that an ECG obtained while a patient is experiencing chest pain that fails to show an ongoing heart attack rules out that problem. Studies have shown, however, that the initial ECG was not diagnostic in 45% of patients and completely normal in 20% of patients who were subsequently determined to have been suffering from acute coronary syndrome.

Cardiac Enzymes:

Blood is drawn to look for the presence of cardiac enzymes, which are essential for confirming or ruling out ACS. Cardiac enzymes, most notably troponin, are released as a result of damage done to the heart muscle during ACS. As is the case with ECG, the initial test for cardiac enzymes may yield normal results in a patient who is in the midst of ACS. Troponin levels rise within a few hours of the damage occurring to cardiac muscle. A negative enzyme test at the time of presentation does not exclude ACS. In patients with concerning symptoms and a normal lab result, the test should be repeated at 2 to 3 hour intervals during the presentation in the emergency department. Typically, enzymes will be elevated within 6 hours of the onset of ACS.

Impact of a Missed Diagnosis of ACS:

Failing to diagnose and treat an unfolding heart attack can have significant, and often catastrophic, results. The longer the process is left untreated, the greater the likelihood that there will be permanent and greater damage to the heart, which can result in disability, a need for greater intervention, and possibly death. Medical literature demonstrates that patients with atypical presentations are most frequently missed, especially women who are less than 55 years of age, non-whites, patients with shortness of breath as the major presenting problem, and those who have an initial normal or non-diagnostic ECG. Because initial ECG and cardiac enzyme testing may not reveal ACS, and because the presenting symptoms may not include the classic symptom of chest pain, patients with an uncertain diagnosis after initial assessment may require further observation and evaluation, rather than simply being sent home.

Conclusion

Our firm has successfully handled many medical negligence cases where failure to diagnose acute coronary syndrome caused life-altering harm to patients. These cases require multiple experts to prove not only that the diagnosis should have been made or made earlier, but also that earlier treatment would have allowed the patient to obtain a significantly better recovery. Our attorneys are always available to evaluate potential medical negligence cases.

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Berman & Simmons is the leading personal injury and medical malpractice law firm in Maine. For more than 100 years, our trial attorneys have represented those who have been injured or harmed by the actions of others. These personal injury cases range from car and truck accidents to the most complex litigation involving defective products and malpractice by healthcare providers. We are known as the firm that will stand up and fight for injured Mainers in disputes against big corporations and powerful interests.