Patient Suffers Heart Attack After Delayed EMS Arrival

This case involves a 61-year-old female who was at a sporting event at a local field when she felt chest pain and shortness of breath. Because the event was small, there were no EMTs present on site. The woman’s husband called 911, and emergency responders reported they were on the way. There was a delay of several minutes for the EMS to arrive because the ambulance driver was unable to find the field. During this time, the patient became unresponsive. At the emergency room, the patient was found to have an anterior myocardial infarction. She was brought to the cath lab which showed occlusion of the LAD coronary artery treated with a stent. Despite the stent, the patient was found to have suffered an anoxic brain injury.

Question(s) For Expert Witness

1. How often do you treat patients with myocardial infarctions?

2. What is the treatment for a patient with an anterior STEMI?

3. How can a delay affect the outcome for a patient with an anterior STEMI?

Expert Witness Response E-318577

I treat patients with myocardial infarctions frequently. I am on the inpatient CCU service about 6 weeks a year and the consult service for 4 weeks a year. I spend 20% of my year involved in inpatient cardiovascular where I see at least 6 myocardial infractions a week, with at least 1-2 STEMIs per week on the CCU. The correct treatment for an anterior STEMI includes aspirin, P2Y12 inhibitor, beta blockers, heparin, high dose statin, and going immediately to the cath lab followed by cardiac rehab along with an echo. If there's LV dysfunction, then we add an ACE/ARB and if there is significant LV dysfunction in an older patient, eplerenone (though spironolactone) can be added. Warfarin can be considered as well if there's significant apical akinesis and stasis on the echo. If cardiac arrest occurs in a patient with an anterior STEMI then every minute is crucial. In that case, several minutes can be a sufficient delay that can result in brain injury if the bystanders cannot provide good CPR or immediate defibrillation. I have reviewed a case with a missed myocardial infarction by hospital staff. I have also managed cases where patients were found down or had an arrest en route to the emergency room where they had a consequent anoxic brain injury.