'A typical' chest pain
The admission history and physical by Dr. Hospitalist noted prior episodes of chest pain with dancing and suggested that Mr. FW’s history was consistent with chronic angina and that his pain after racing across his lawn to rescue his cat was a demand ischemia phenomenon (not ACS) in a man who was usually sedentary. Dr. Hospitalist further argued that the pain could easily have been GI related because of its burning character, radiation to the throat, and relief with antacids. The patient was pain free at admission without acute changes on his EKG and had had two sets of normal biomarkers before Dr. Hospitalist left for the day. Dr. Hospitalist also argued that a cardiologist wasn’t necessary unless Mr. FW had a positive stress test the following morning.
Unfortunately, Dr. Hospitalist did not take a thorough and comprehensive history regarding Mr. FW’s chest discomfort on the day of admission. Dr. Hospitalist appeared to pay far more attention to Mr. FW’s symptoms on the previous day when he was trying to rescue his cat. On the day of admission, Mr. FW developed chest discomfort while simply walking in the grocery store with his wife. They immediately went to see their primary care physician, who obtained an EKG in the office while Mr. FW was having symptoms.
The EKG showed deeper ST depression with new T-wave inversions in the precordial leads, compared with the EKG performed at the ED several hours later. In addition, the pain lasted for almost 50 minutes, including the time during which he was driving (almost at rest) on the way to the ED. The widow’s deposition also confirmed that Mr. FW’s occasional chest discomfort while dancing the polka was not typical cardiac chest pain. The widow further confirmed that Mr. FW, despite a history of low back pain, was quite active and did not routinely experience exertional chest symptoms.
Conclusion:
Hospitalists are frequently called upon to "rule out MI." It is important, however, to distinguish patients with atypical, noncardiac chest pain from those with typical cardiac chest pain.
Patients with atypical chest pain are being admitted for observation and to rule in or rule out whether their symptoms are cardiac or not. Patients admitted with a history of typical cardiac chest pain, regardless of whether they are pain free at the time of admission, should be treated for ACS until they can receive a diagnostic cardiac catheterization or further risk stratification by a cardiologist. The jury recognized the failure of Dr. Hospitalist to perform a thorough and adequate history in this case.
The case in question occurred in a non–tort reform state. As such, there were no limits on noneconomic damages (in other words, pain and suffering). A judgment was rendered for the widow in this case with damages in the amount of $1 million.
Dr. Michota is director of academic affairs in the hospital medicine department at the Cleveland Clinic and medical editor of Hospitalist News. He reported having no relevant financial conflicts.
