Lack of “typical” symptoms cannot rule out acute coronary syndrome (ACS), and “atypical” symptoms should raise the EP’s index of suspicion, according to a recent review of the literature.1
“Traditional cardiac risk factors, such as hypertension, diabetes, hyperlipidemia, and a positive smoking history, are of limited diagnostic utility in evaluating these patients in the ED,” concludes Zachary Dezman, MD, one of the paper’s authors. Dezman is assistant professor in the department of emergency medicine at University of Maryland School of Medicine.
Researchers analyzed the literature on the ability of various components of the history and physical exam to identify which ED chest pain patients require further investigation for possible ACS.
“Clinician gestalt has very low predictive ability, even in patients with a non-diagnostic ECG. And gestalt does not seem to be enhanced appreciably by clinical experience,” Dezman says. The findings suggest that:
- history and physical alone can’t reduce a patient’s risk of ACS to a generally acceptable level of less than 1%;
- EPs should set a low threshold to perform some testing whenever there is not an obvious alternative cause;
- pain that is sharp in quality, reproducible on exam, or pleuritic points away from cardiac causes;
- pain that radiates, is worse with exertion, or is associated with diaphoresis or vomiting should raise the EP’s index of suspicion.
Documentation on whether these specific symptoms were or were not present at the time of the ED visit can help the defense to demonstrate why the EP believed ACS was unlikely. The same is true of a History, ECG, Age, Risk factors, and Troponin (HEART) score, which clinicians use to assess patients for risk of ACS.
“Emergency physicians should combine this information to appropriately disposition patients presenting with chest pain,” Dezman advises.
‘Incredibly Wide Net’
Vague chest pain and shortness of breath are common symptoms in missed ACS cases and for ED patients generally. “We all know these symptoms cast an incredibly wide net, as far as the differential,” says Jesse K. Broocker, JD, an attorney at Weathington McGrew in Atlanta.
Plaintiff attorneys typically begin their line of questioning by asking the EP, “What is the most dangerous thing in the differential? Why didn’t you rule it out?”
The next step is to ask about repeat cardiac troponins. “One is never enough,” Broocker cautions. “Plaintiff lawyers always look for a trend, which, in their book, means several over the course of a number of hours.”
One malpractice case involved a 40-year-old woman who was a current smoker, with a family history of coronary artery disease. She reported experiencing chest and jaw pain for two days. Two separate troponins drawn in the ED were normal. The ECG showed no ST elevations, but noted some other abnormalities. The patient was discharged with instructions to follow up with a cardiologist three days later, but died before she could do so. The family sued for wrongful death.
“What really helped in our defense of this case was the ED doctor using the HEART score algorithm,” Broocker recalls. “We got two experts to support the care, and when they saw the doctor used the HEART score, they immediately were reassured.”
A documented HEART score shows that the EP thought about ACS and made a reasonable decision, regardless of whether it turned out to be right or wrong with the benefit of hindsight.
Length of stay in the ED is another common area of focus in missed ACS cases. “Quick overturn can be used to spin an efficient evaluation and disposition as ‘punting’ on the patient,” Broocker notes. The plaintiff attorney can use electronic medical record time-stamping to show there was a short exam, a long wait to be brought back to a room, and a discharge shortly afterward. “This paints a picture of a patient who was put on the ‘fast track’ to support their position that something was missed,” Broocker adds.
The ED defense team is challenged to explain that just because something is in the differential does not mean it is reasonably indicated. “A fever has Ebola in the differential,” Broocker notes. “But this is the tack plaintiff lawyers take.”
Broocker says the HEART score is something of a “safety net” for EPs. “It’s commonly accepted in the community, and there is a lot of literature on it.” Appropriate use of the HEART score and pathway reliably risk stratifies patients, according to a recent review of the literature.2
“I have had docs use this to success in ACS cases,” Broocker says. By assigning a certain score for each criterion and coming up with a number, the EP can assign a likelihood for the patient experiencing an acute event. Juries probably will appreciate that the EP took this number into consideration when deciding whether to discharge or admit the patient.
“Laypeople tend to understand the thought process behind following a guideline, even if it turned out to be wrong,” Broocker adds.
- Dezman ZD, Mattu A, Body R. Utility of the history and physical examination in the detection of acute coronary syndromes in emergency department patients. West J Emerg Med 2017;18:752-760.
- Long B, Oliver J, Streitz M, Koyfman A. An end-user’s guide to the HEART score and pathway. Am J Emerg Med 2017;35:1350-1355.