Atypical Symptoms, Atypical Patients: Both Increase the Odds of Missed STEMI
The “typical” heart attack patient presents with midline chest pain, sweating, and nausea. Certainly, this was not the case with a young man whose only complaint to ED providers was some dizziness.
“Fortunately, based on our triage system, every dizzy patient gets an ECG. The patient’s STEMI was recognized very rapidly,” says Andrew P. Pirotte, MD, an EP at University of Kansas Hospital and a clinical assistant professor at University of Kansas in Lawrence.
The patient experienced a good outcome. “But the dissimilarity between his complaint and his pathology was striking,” Pirotte notes. Other recent STEMI patients exhibited similarly atypical symptoms. “Many geriatric patients have presented with fatigue and weakness and were diagnosed with STEMI,” Pirotte adds.
The number of STEMI presentations at U.S. EDs declined approximately 30% between 2006 and 2011, according to the authors of a 2015 study.1 “Timely diagnosis of STEMI in the ED may be more challenging as a result of these changing demographics,” says lead author Michael Ward, MD, PhD, MBA, assistant professor in the department of emergency medicine at Vanderbilt University Medical Center. STEMI cases decreased from 300,466 in 2006 to 227,343 in 2011. The researchers suggested this could be because some STEMI patients bypass the ED and go directly to cardiac catheterization. Also, the decline could be attributed to the fact that medical management is reducing the number of STEMI cases seen in EDs.
Notably, the decrease was most pronounced in patients age 65 years and older. This suggests that younger patients, who tend to present with symptoms other than chest pain and shortness of breath, represent a larger proportion of cases seen by EDs. This carries important implications for liability risks, Ward says. Fewer cases mean EPs are less practiced at seeing STEMIs. “This may limit their ability to diagnose such cases in a timely manner,” Ward warns. “The cases that do present may be more unusual.”
Older STEMI patients also tend to present with atypical symptoms. One malpractice case involved a 75-year-old woman who complained of jaw pain and upper chest tightness.1 The primary care physician concluded the jaw pain was caused by temporomandibular disorder and prescribed a nonsteroidal anti-inflammatory drug. This case spotlights the importance of avoiding “locking in” on a particular diagnosis before the evaluation is complete, says Carla M. Ford, MD, a physician consultant at CRICO, a Boston-based patient safety and medical malpractice company.
Five days later, the woman presented to the ED with nausea and vomiting and was diagnosed with MI, which progressed into cardiogenic shock. The patient subsequently died. The patient’s cardiac risk factors and previous ECGs showing evidence of myocardial damage became issues in the malpractice lawsuit. So did the patient’s pain level, which was out of proportion to the physical findings. “Pain that seems excessive relative to findings is often due to a vascular problem,” Ford notes.
Researchers recently analyzed a risk scoring system built using five identified predictors of atypical AMI symptoms (age 75 years or older, diabetes mellitus, history of AMI, female gender, and absence of hyperlipidemia).2 Researchers concluded the scoring system can raise awareness of atypical AMI presentation and promote symptom recognition.
In another study, researchers identified missed diagnoses in 0.9% of all patients who came to EDs with chest pain or cardiac conditions, were discharged, and were subsequently admitted for AMI within a week.3 Younger patients and African-American patients had higher odds of missed diagnosis. “The younger population and the older population vary pretty dramatically in their presentation,” Pirotte says. “In many cases I’ve had, patients had no chest pain whatsoever.”
Pirotte says that ECGs, “as a noninvasive, low-cost, very rapid test, should be obtained very promptly.” That is especially true for patients with risk factors but nonspecific symptoms.
“We get ECGs on many patients now who don’t have chest pain. The risk/benefit ratio is very high when you need a time-sensitive diagnosis recognized,” Pirotte says. One obvious obstacle to prompt ECGs is that EPs cannot get into the room soon enough to order them. “Better from a risk management standpoint is a triage protocol,” Pirotte offers.
If a patient presents with specific symptoms, triage nurses obtain the ECG and show the results to the EP. For all patients who undergo ECG testing, should someone also measure the troponin levels in these patients? “My practice is essentially yes,” Pirotte says. “I think that combination of studies is a very safe and meaningful practice.” To reduce the risk of a lawsuit, or to make one more defensible, Pirotte recommends two charting practices:
• Give a clear picture of what the patient looks like right before discharge. Many ED charts are too sparse on this point. EPs simply state “no active distress; alert and oriented” when a chest pain patient goes home after a normal workup. This is not enough to defend a lawsuit once a bad outcome happens.
“It doesn’t speak to how a patient looks,” Pirotte explains. Much more defensible comments: “The patient looks excellent clinically, is cheerful and laughing with grandkids, ate lunch, and is asymptomatic at the time of the evaluation.”
“That paints a picture of a well person who’s not having active symptoms,” Pirotte says.
• Complete the chart within a few hours of the shift instead of several days later. If the patient does experience a cardiac event and the original ED chart is not yet completed, “that is very hard to defend,” Pirotte warns.
On the other hand, an ED chart showing the patient’s well-appearing status at the time of the first ED visit is helpful. This is because it supports the defense argument that the patient was not experiencing the cardiac event at that point.
“Whereas, if you are retrospectively charting after they’ve returned to the ED, that brings up a lot of questions,” Pirotte says.
- Ward MJ, Kripalani S, Zhu Y, et al. Incidence of emergency department visits for ST-elevation myocardial infarction in a recent six-year period in the United States. Am J Cardiol 2015;115:167-170.
- Li PWC, Yu DSF. Recognition of atypical symptoms of acute myocardial infarction: Development and validation of a risk scoring system. J Cardiovasc Nurs 2017;32:99-106.
- Moy E, Barrett M, Coffey R, et al. Missed diagnoses of acute myocardial infarction in the emergency department: Variation by patient and facility characteristics. Diagnosis (Berl) 2015;2:29-40.
The “typical” heart attack patient presents with midline chest pain, sweating, and nausea. Certainly, this was not the case for one young man. A physician noted "the dissimilarity between his complaint and his pathology was striking."
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