'A typical' chest pain

Story:

Mr. FW was a 69-year-old man with a history of hypertension, hyperlipidemia, generalized anxiety, and chronic low back pain who presented to the emergency department (ED) from his primary care physician’s office with substernal burning chest pain that began earlier that morning while he was shopping with his wife.

The discomfort was mild (3 out of 10) and completely resolved by the time he arrived to the ED around 12:30 p.m. The day before, he had experienced the same substernal burning chest discomfort, but it had been more intense (7 out of 10). At that time, he was outside and observed his neighbor’s dog that appeared to have the patient’s cat in its mouth and apparently sprinted almost 100 yards to reach the animals. He developed the substernal chest discomfort while running.

The pain radiated to his neck and throat. He was short of breath from the exertion. The pain resolved after 30-40 minutes of rest after taking several antacid pills. The patient stated that he was not normally that active because of his back. Patient also noted that he had a pharmacologic stress test 3 years ago because of chest symptoms, and it was completely normal. His EKG in the ED showed normal sinus rhythm, voltage criteria for LVH and nonspecific ST segment and T-wave changes in the precordial leads but was otherwise normal. A CBC, basic metabolic profile, and cardiac biomarkers were all normal.

FW was seen by Dr. Hospitalist in the ED and documented that Mr. FW was pain free. Mr. FW was then admitted to the telemetry floor for atypical chest pain/rule out MI protocol. Dr. Hospitalist put Mr. FW on telemetry monitoring, a cardiac diet, aspirin 325mg daily, PRN nitroglycerin, PRN morphine, his baseline medications (amlodipine, atorvastatin, and lorazepam) and cycled cardiac biomarkers q8hrs x 2. Dr. Hospitalist also ordered a pharmacologic stress test for the morning.

At 10 p.m. that evening, as Mr. FW was up to go to the bathroom, he called out to the nurse complaining of a sharp pain in his neck and throat accompanied by lightheadedness. His blood pressure sitting was 70/30 mm Hg. Telemetry showed new left bundle branch block (LBBB). He was helped back to bed when he became unresponsive. Mr. FW underwent resuscitation efforts for the next 45 minutes. Telemetry strips demonstrated evolution of EKG waveforms with ST elevations in the anterior leads prior to the development of LBBB.

Mr. FW was unable to be revived and was pronounced dead at 10:55 p.m. No autopsy was performed

Complaint:

Shortly before Mr. FW became unresponsive, his wife had just left the hospital for the night after the nurse reassured her that Mr. FW would be fine.

Upon learning about the ST elevations during the code blue, Mr. FW’s widow met with an attorney and filed suit. The complaint alleged that Dr. Hospitalist failed to recognize unstable angina and failed to treat Mr. FW as acute coronary syndrome (ACS). She further alleged that Dr. Hospitalist breached the standard of care for not consulting a cardiologist and for not initiating beta-blockers and anticoagulation. As a result of Dr. Hospitalist failing to recognize ACS, Mr. FW died of ST-elevation MI, she asserted.

Scientific principles:

ACS comprises unstable angina (UA), non-ST elevation myocardial infarction, ST-elevation MI, and sudden cardiac death. By definition, ACS is an inflammatory reaction in the coronary vessels and is medically treated with antiplatelet agents and anticoagulation.

In a capable hospital, often ACS will be treated with a percutaneous coronary intervention.

UA is typical cardiac chest pain that is new in onset, increasing in frequency, duration, and intensity, and/or occurring with less exertion or at rest. UA is ultimately a clinical diagnosis based almost entirely on history, although it may be associated with EKG changes during chest pain episodes. Cardiac biomarkers are expected to be normal.

Typical cardiac chest pain is substernal or, in the anterior chest, with a character of burning or chest heaviness, is precipitated by exertion and relieved by rest or nitroglycerin. Typical cardiac chest pain radiates to the neck, left shoulder, or left arm, and is associated with shortness of breath and nausea.

Atypical chest pain is often fleeting (lasts seconds to a minute), is not in the anterior chest; the character is sharp, not reliably produced by exertion nor relieved with rest or nitroglycerin, and will occur in patients without known cardiac risk factors (male sex, hypertension, smoking, diabetes, hyperlipidemia, family history).

Complaint rebuttal and discussion:

Dr. Hospitalist was adamant that this patient did not have ACS. In fact, this hospital could not do PCI and if Dr. Hospitalist thought this was ACS, he wouldn’t have accepted the patient and the patient would have been transferred to an alternative hospital.

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.

Story:

Mr. FW was a 69-year-old man with a history of hypertension, hyperlipidemia, generalized anxiety, and chronic low back pain who presented to the emergency department (ED) from his primary care physician’s office with substernal burning chest pain that began earlier that morning while he was shopping with his wife.

The discomfort was mild (3 out of 10) and completely resolved by the time he arrived to the ED around 12:30 p.m. The day before, he had experienced the same substernal burning chest discomfort, but it had been more intense (7 out of 10). At that time, he was outside and observed his neighbor’s dog that appeared to have the patient’s cat in its mouth and apparently sprinted almost 100 yards to reach the animals. He developed the substernal chest discomfort while running.

The pain radiated to his neck and throat. He was short of breath from the exertion. The pain resolved after 30-40 minutes of rest after taking several antacid pills. The patient stated that he was not normally that active because of his back. Patient also noted that he had a pharmacologic stress test 3 years ago because of chest symptoms, and it was completely normal. His EKG in the ED showed normal sinus rhythm, voltage criteria for LVH and nonspecific ST segment and T-wave changes in the precordial leads but was otherwise normal. A CBC, basic metabolic profile, and cardiac biomarkers were all normal.

FW was seen by Dr. Hospitalist in the ED and documented that Mr. FW was pain free. Mr. FW was then admitted to the telemetry floor for atypical chest pain/rule out MI protocol. Dr. Hospitalist put Mr. FW on telemetry monitoring, a cardiac diet, aspirin 325mg daily, PRN nitroglycerin, PRN morphine, his baseline medications (amlodipine, atorvastatin, and lorazepam) and cycled cardiac biomarkers q8hrs x 2. Dr. Hospitalist also ordered a pharmacologic stress test for the morning.

At 10 p.m. that evening, as Mr. FW was up to go to the bathroom, he called out to the nurse complaining of a sharp pain in his neck and throat accompanied by lightheadedness. His blood pressure sitting was 70/30 mm Hg. Telemetry showed new left bundle branch block (LBBB). He was helped back to bed when he became unresponsive. Mr. FW underwent resuscitation efforts for the next 45 minutes. Telemetry strips demonstrated evolution of EKG waveforms with ST elevations in the anterior leads prior to the development of LBBB.

Mr. FW was unable to be revived and was pronounced dead at 10:55 p.m. No autopsy was performed

Complaint:

Shortly before Mr. FW became unresponsive, his wife had just left the hospital for the night after the nurse reassured her that Mr. FW would be fine.

Upon learning about the ST elevations during the code blue, Mr. FW’s widow met with an attorney and filed suit. The complaint alleged that Dr. Hospitalist failed to recognize unstable angina and failed to treat Mr. FW as acute coronary syndrome (ACS). She further alleged that Dr. Hospitalist breached the standard of care for not consulting a cardiologist and for not initiating beta-blockers and anticoagulation. As a result of Dr. Hospitalist failing to recognize ACS, Mr. FW died of ST-elevation MI, she asserted.

Scientific principles:

ACS comprises unstable angina (UA), non-ST elevation myocardial infarction, ST-elevation MI, and sudden cardiac death. By definition, ACS is an inflammatory reaction in the coronary vessels and is medically treated with antiplatelet agents and anticoagulation.

In a capable hospital, often ACS will be treated with a percutaneous coronary intervention.

UA is typical cardiac chest pain that is new in onset, increasing in frequency, duration, and intensity, and/or occurring with less exertion or at rest. UA is ultimately a clinical diagnosis based almost entirely on history, although it may be associated with EKG changes during chest pain episodes. Cardiac biomarkers are expected to be normal.

Typical cardiac chest pain is substernal or, in the anterior chest, with a character of burning or chest heaviness, is precipitated by exertion and relieved by rest or nitroglycerin. Typical cardiac chest pain radiates to the neck, left shoulder, or left arm, and is associated with shortness of breath and nausea.

Atypical chest pain is often fleeting (lasts seconds to a minute), is not in the anterior chest; the character is sharp, not reliably produced by exertion nor relieved with rest or nitroglycerin, and will occur in patients without known cardiac risk factors (male sex, hypertension, smoking, diabetes, hyperlipidemia, family history).

Complaint rebuttal and discussion:

Dr. Hospitalist was adamant that this patient did not have ACS. In fact, this hospital could not do PCI and if Dr. Hospitalist thought this was ACS, he wouldn’t have accepted the patient and the patient would have been transferred to an alternative hospital.

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.

Story:

Mr. FW was a 69-year-old man with a history of hypertension, hyperlipidemia, generalized anxiety, and chronic low back pain who presented to the emergency department (ED) from his primary care physician’s office with substernal burning chest pain that began earlier that morning while he was shopping with his wife.

The discomfort was mild (3 out of 10) and completely resolved by the time he arrived to the ED around 12:30 p.m. The day before, he had experienced the same substernal burning chest discomfort, but it had been more intense (7 out of 10). At that time, he was outside and observed his neighbor’s dog that appeared to have the patient’s cat in its mouth and apparently sprinted almost 100 yards to reach the animals. He developed the substernal chest discomfort while running.

The pain radiated to his neck and throat. He was short of breath from the exertion. The pain resolved after 30-40 minutes of rest after taking several antacid pills. The patient stated that he was not normally that active because of his back. Patient also noted that he had a pharmacologic stress test 3 years ago because of chest symptoms, and it was completely normal. His EKG in the ED showed normal sinus rhythm, voltage criteria for LVH and nonspecific ST segment and T-wave changes in the precordial leads but was otherwise normal. A CBC, basic metabolic profile, and cardiac biomarkers were all normal.

FW was seen by Dr. Hospitalist in the ED and documented that Mr. FW was pain free. Mr. FW was then admitted to the telemetry floor for atypical chest pain/rule out MI protocol. Dr. Hospitalist put Mr. FW on telemetry monitoring, a cardiac diet, aspirin 325mg daily, PRN nitroglycerin, PRN morphine, his baseline medications (amlodipine, atorvastatin, and lorazepam) and cycled cardiac biomarkers q8hrs x 2. Dr. Hospitalist also ordered a pharmacologic stress test for the morning.

At 10 p.m. that evening, as Mr. FW was up to go to the bathroom, he called out to the nurse complaining of a sharp pain in his neck and throat accompanied by lightheadedness. His blood pressure sitting was 70/30 mm Hg. Telemetry showed new left bundle branch block (LBBB). He was helped back to bed when he became unresponsive. Mr. FW underwent resuscitation efforts for the next 45 minutes. Telemetry strips demonstrated evolution of EKG waveforms with ST elevations in the anterior leads prior to the development of LBBB.

Mr. FW was unable to be revived and was pronounced dead at 10:55 p.m. No autopsy was performed

Complaint:

Shortly before Mr. FW became unresponsive, his wife had just left the hospital for the night after the nurse reassured her that Mr. FW would be fine.

Upon learning about the ST elevations during the code blue, Mr. FW’s widow met with an attorney and filed suit. The complaint alleged that Dr. Hospitalist failed to recognize unstable angina and failed to treat Mr. FW as acute coronary syndrome (ACS). She further alleged that Dr. Hospitalist breached the standard of care for not consulting a cardiologist and for not initiating beta-blockers and anticoagulation. As a result of Dr. Hospitalist failing to recognize ACS, Mr. FW died of ST-elevation MI, she asserted.

Scientific principles:

ACS comprises unstable angina (UA), non-ST elevation myocardial infarction, ST-elevation MI, and sudden cardiac death. By definition, ACS is an inflammatory reaction in the coronary vessels and is medically treated with antiplatelet agents and anticoagulation.

In a capable hospital, often ACS will be treated with a percutaneous coronary intervention.

UA is typical cardiac chest pain that is new in onset, increasing in frequency, duration, and intensity, and/or occurring with less exertion or at rest. UA is ultimately a clinical diagnosis based almost entirely on history, although it may be associated with EKG changes during chest pain episodes. Cardiac biomarkers are expected to be normal.

Typical cardiac chest pain is substernal or, in the anterior chest, with a character of burning or chest heaviness, is precipitated by exertion and relieved by rest or nitroglycerin. Typical cardiac chest pain radiates to the neck, left shoulder, or left arm, and is associated with shortness of breath and nausea.

Atypical chest pain is often fleeting (lasts seconds to a minute), is not in the anterior chest; the character is sharp, not reliably produced by exertion nor relieved with rest or nitroglycerin, and will occur in patients without known cardiac risk factors (male sex, hypertension, smoking, diabetes, hyperlipidemia, family history).

Complaint rebuttal and discussion:

Dr. Hospitalist was adamant that this patient did not have ACS. In fact, this hospital could not do PCI and if Dr. Hospitalist thought this was ACS, he wouldn’t have accepted the patient and the patient would have been transferred to an alternative hospital.

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.