Question: A 60-year-old obese patient experiences episodic substernal discomfort over the past several months. He is a type 2 diabetic with associated hypertension and hypercholesterolemia, none treated to target. Recently, a sibling was diagnosed with coronary artery disease and underwent successful stenting. The physician is aware of his patient’s high coronary risk. The patient subsequently develops crushing chest pain, rapidly complicated by fatal cardiogenic shock. An autopsy was performed by the coroner. Which of the following best supports the plaintiff’s allegation of medical malpractice?

A. Failure to refer to a cardiologist for evaluation of ischemic heart disease.

B. Failure to achieve strict control of his blood glucose and cholesterol.

C. Failure to control hypertension.

D. Failure to document that an exercise stress test was recommended, but declined by the patient.

E. Failure to obtain a chest CT to rule out a dissecting aortic aneurysm if that’s the cause of death.

Answer: E. All choices are plausible, but E is best. Misdiagnosis of an underlying cardiac condition such as a dissecting aneurysm in the setting of chest pain is a recurring malpractice allegation. Not treating risk factors where primary prevention is effective may constitute negligence, especially where there are national guidelines. An obvious example is in the diagnosis and treatment of hypertension. Not prescribing a low cholesterol diet in a hyperlipidemic patient has also been litigated as a negligent omission. Essentially, the plaintiff is asserting that the doctor deprived him or her of a chance of preventing the eventual injury ("loss of a chance" doctrine). Finally, whether and when to refer is to be judged by what a reasonably prudent doctor ought to do under the circumstances, and this requires expert testimony. For example, in Evanston Hospital v. Crane an Illinois court rejected the claim that it was common knowledge that someone should be referred to a cardiologist for a heart condition.

Failure to diagnose and treat myocardial infarction forms the basis of many lawsuits, including delay in or forgoing emergency heart catheterization in patients with acute chest pain. Another area of diagnosis-related liability is in exercise-induced sudden death, especially in professional athletes. Although many of the causes of sudden death in this young, healthy population (cardiomyopathy, valvular heart disease, coronary artery disease, and Marfan syndrome) may not be detectable by the usual screening tests, the physician should nonetheless heed the American Heart Association guidelines on what practices are customary in this setting.

Treatment negligence has been alleged over medications, invasive procedures, devices – and informed consent. Cardiac drugs like digitalis, anticoagulants, and antiarrhythmics are common examples of medication-related lawsuits. Prescription legibility may be at issue. In a highly publicized case of dispensing error, a cardiologist’s written prescription for Isordil was mistaken for Plendil, allegedly causing the patient to die from a heart attack. The family filed and won a lawsuit, with the jury awarding $450,000, equally apportioned between the cardiologist and pharmacist (State of Vasquez v. Albertsons). The invasive cardiologist or surgeon additionally faces lawsuits related to post-procedural or surgical complications such as perforation following angioplasty, postop strokes, hemorrhage, paralysis, and infection. Devices such as pacemakers can be defective and cause injuries. Improper indications, failure to warn of material risks, and post-procedure complications are the key issues when dealing with medical devices.

Remember, the plaintiff carries the burden of proving causation. Roskin v. Rosow is illustrative. The patient was being treated for hypercholesterolemia, and developed constipation and abdominal pain after taking cholestyramine and codeine. Her perforated colon was found to be distended with feces the size of tennis balls. The defendant-doctor contended that the plaintiff reported only mild constipation, and that the bowel was perforated during a barium enema study rather than from the use of medications. The case went to trial, and the jury found for the doctor. Reason: plaintiff failed to satisfy the causation element.

An emerging area of malpractice litigation affects patients who drive. Suppose a patient loses control of his or her car because of a cardiac arrhythmia or a drug reaction, and hits a pedestrian. The driver’s doctor may face a liability claim by the injured pedestrian. In a 2002 Hawaii case, such liability was held to attach "... where the physician has negligently failed to warn the patient that the medication may impair driving ability and where the circumstances are such that the reasonable patient could not have been expected to be aware of the risk without the physician’s warning."

According to MIEC, a medical professional liability insurance carrier, the quarterly premiums ($1 million/$3 million coverage) for an invasive and noninvasive cardiologist were $4,273 and $2,808 respectively, compared to $2,442 for a general internist (Hawaii, 2011). Of 230,624 closed claims from 1985 through 2007, 4,248 (1.8%) involved cardiologists. In all, 18% of these cardiovascular claims resulted in indemnity payments, averaging close to $250,000. The most common allegation was diagnostic error, especially regarding coronary artery disease. Coronary catheterization and angioplasty cases accounted for 12% and 7% respectively. Claims against cardiovascular and thoracic surgeons outnumber those against cardiologists, whose claims, in turn, outnumber other internists. These figures represent paid claims to the Physician Insurers Association of America, which collectively covers 60% of physicians in private practice.

Dr. Tan is an emeritus professor at the University of Hawaii, Honolulu. This article is meant to be educational and does not constitute medical, ethical, or legal advice. It is adapted from the author’s book, "Medical Malpractice: Understanding the Law, Managing the Risk." For additional information, readers may contact the author at siang@hawaii.edu.

Cardiovascular Malpractice