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Reconsidering chest pain

01 May 2008

Mr Y, a 46-year-old joiner, saw his GP, Dr S. He had a weeklong history of chest pain radiating to both arms, associated with shortness of breath on occasion. Mr Y was obese and smoked 10 cigarettes a day. The pain was not worse on exertion, and Mr Y was not pale, sweaty or dyspnoeic. Mr Y had been having a stressful time of late, putting in long hours at work, and having problems with his wayward teenage son.

Dr S documented that Mr Y had a normal blood pressure, heart rate and respiratory rate, and that his chest was clear. Dr S felt the pain represented costochondritis, exacerbated by Mr Y’s recent increase in physical work. Mr Y was advised to rest and take regular paracetamol, and to return if the pain persisted.

Two weeks later Mr Y returned to see Dr R. Although the shortness of breath had improved somewhat, he could still feel a dull ache in his chest, which was preventing him from carrying out heavy manual work.
After re-examining Mr Y and reassuring him regarding the likely diagnosis, Dr R requested an ECG to be performed in the surgery and the automated ECG report stated “non-specific changes.” Dr R interpreted this to support the initial diagnosis of a benign cause for Mr Y’s chest pain. He prescribed stronger analgesia and again advised Mr Y to return should his symptoms fail to settle or deteriorate.

The following week Mr Y returned to the practice, and saw a third GP, Dr T. He appeared to be very anxious and described an episode of severe chest pain that had occurred one hour previously, with no obvious trigger. This had been associated with breathlessness and lasted 10 minutes. Dr T reviewed the history, and re-examined the patient. Dr T noted the significant personal stress that Mr Y described and the result of the ECG performed at the second visit. Dr T concluded that, in the absence of any positive examination findings, the most likely diagnosis was a panic attack. A beta blocker was prescribed. One week later Mr Y was found dead by his wife.

The postmortem revealed severe coronary artery disease. Mr Y’s wife filed a claim against all the GPs involved in Mr Y’s care.

Expert opinion

A GP expert criticised all three GPs. In the first two consultations there was no documentation of chest wall tenderness or other findings consistent with costochondritis, and acute coronary syndrome was not ruled out. Dr R was falsely reassured by the “non-specific” changes on the computerised ECG report.

Although Dr T revisited the diagnosis he also failed to rule out acute coronary syndrome.

The case was settled for a substantial sum.

Learning points

  • Misdiagnosis of chest pain is often a feature in claims dealt with by the MPS. Be wary of ascribing chest pain to musculoskeletal causes until potentially more serious possibilities have been ruled out. A thorough documentation of cardiac risk factors is vital when assessing chest pain.
  • If an initial diagnosis is not responding to treatment, then it is good practice to think again, particularly if there are potentially serious alternatives. You should consider an alternative diagnosis that differs from that of a colleague or partner that had seen the patient previously.
  • ECG machines are increasingly used in general practice, but it is vital that the practice also has access to competent interpretation of the result. If this is a clinician with the practice they must have the necessary skills and clinical judgement.