Patient Dies From Massive Heart Attack After Leaving ER

This case involves a sixty-five-year-old woman who presented to the emergency room with new-onset dyspnea. The patient reported that when she walked more than three blocks, she became short of breath and experienced severe pain in the abdomen. The patient had a history of type 2 diabetes, for which she was using Onglyza, hyperlipidemia, hypertension, and stage 2 chronic kidney disease. In the ER, the monitors showed her resting heart rate at 52bpm and her blood pressure was 148/88 mmHg. On ECG, the patient’s PR interval was 250 and she was found to have an incomplete left bundle branch block. The ER physician determined that the situation was not urgent enough to have the patient admitted to the hospital, and he suggested that she follow-up with an outpatient cardiology clinic. The patient was discharged and found dead from cardiac arrest in her home three days after her release from the emergency room.

Question(s) For Expert Witness

1. What other tests should have been done before discharging this patient?

Expert Witness Response E-001381

When a patient is suspected of having any form of cardiac disease, it is important to understand their overall functional capacity and the point at which they experience symptoms. I think it would have been appropriate to obtain further cardiovascular imaging before discharging this patient. If the patient is able to exercise, a stress test is preferred to a pharmacologic test, which should be used only in patients who cannot exercise. An exercise treadmill test without imaging would be fine if this patient had no ECG abnormalities. In this case, however, the patient had a left bundle branch block that would make the treadmill test less sensitive or less specific for ischemia. In any event, the patient should have been worked up further for an impending myocardial event, which could have prevented this fatality.