The heart of the problem
Mr P, a 56-year-old keen athlete, attended his GP, Dr M, with episodes of tight central chest pain while running. He was a non-smoker and had no family history of heart disease. He had a history of rectal carcinoma for which he had had a bowel resection four years previously.
Dr M arranged for bloods and an ECG and, in view of his previous cancer, a chest x-ray. The results of the bloods and chest x-ray were normal. The result of the ECG is not documented. Dr M arranged for Mr P to have an exercise ECG. The exercise ECG was reported as normal by Dr H at the hospital. It was stated that Mr P did not develop any chest pain during the exercise ECG test.
Mr P reported that his symptoms had almost settled. Dr M advised a trial of a proton pump inhibitor and documented that he felt Mr P had an element of anxiety about his cancer diagnosis and his stoma. However, Dr M stated that the patient would require cardiology referral if things did not settle.
Fourteen months later, Mr P presented to Dr M with right-sided chest pain on exertion and also at rest. Nothing else was documented about the nature of the pain, although it was so severe that Mr P had decided to stop exercising due to the pain. There was no dyspepsia, appetite was good and Mr P’s weight was stable. Dr M noted that Mr P’s chest was clear but did not document a cardiovascular examination. Dr M noted that the chest x-ray and ECG were satisfactory the previous year and advised a proton pump inhibitor.
Nine months later, Mr P attended Dr M to discuss the results of a recent colonoscopy for rectal bleeding. Dr M did not enquire about the chest pain. He documented that the patient was going to visit his family in Canada. Two months later, Mr P passed away in Canada. At postmortem the cause of death was found to be myocardial infarction. Mr P’s widow made a claim against Dr M.
Fourteen months later, Mr P presented to Dr M with right-sided chest pain on exertion and also at rest. Nothing else was documented about the nature of the pain
Expert opinion was critical of Dr M for not referring Mr P to cardiology at the first presentation, even in the presence of a negative exercise ECG, as the history was suggestive of classical angina pain (and particularly in light of the fact that the exercise ECG did not provoke any chest pain). It was also felt that Mr P should have been actively followed up to assess his response to the proton pump inhibitor and a cardiology referral made if the pain did not settle.
At the second presentation Dr M’s record-keeping was criticised as there was poor documentation of the nature of the pain and no assessment of how effective the proton pump inhibitor had been in the past. Dr M ignored his previous plan in the records to refer to cardiology if the pain did not settle.
An expert cardiology opinion concluded that, on the balance of probabilities, if Mr P had been referred to a cardiologist at either the first or the second presentation, he would have been diagnosed with coronary artery disease and would have had treatment, either medical or surgical, to reduce the incidence of angina and the risk of myocardial infarction. The claim was settled for a moderate sum.
- In any patient with chest pain, you should exclude a cardiac cause with a careful history, examination, investigation and ongoing referral to cardiology if there is any concern about the diagnosis.
- It is well-documented that exercise ECG tests may be unreliable. In this case Mr P did not experience chest pain during the test and it was therefore not possible to exclude angina on the basis of this test alone.
- Each time a patient presents with chest pain, you should make a note of the nature of the pain, its position, radiation and any relieving, precipitating or associated factors.
- Do not assume that the pain is the same pain as at the patient’s last presentation – pain should be reassessed at each presentation, especially if it is failing to settle.
- Be very cautious in attributing symptoms to anxiety and exclude all serious physical causes first.
- Follow up the patient after a trial of treatment, where the diagnosis is unclear, and consider referral to secondary care for advice or a second opinion if symptoms fail to settle.
- Consider putting reminders, such as “If symptoms do not settle refer cardiology” in bold in the records so they do not subsequently get missed.