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Where the heart is

01 January 2013

Fifty-five-year-old Mr R had a history of hypertension for which he was taking an ACE inhibitor.

He attended his GP, Dr S, with intermittent tightening of the chest and a sense of breathlessness. He did not have any symptoms of nausea or pins and needles. Mr R felt that he was suffering panic attacks, especially as he had recently been made redundant and was experiencing financial difficulties.

On examination, Mr R’s blood pressure was found to be high and Dr S attributed these symptoms to anxiety. However, he arranged an ECG and routine blood tests and asked Mr R to return to discuss the results.

When the results were available, Dr S considered the ECG for any abnormalities of rate, rhythm or appearance, and looked for changes suggestive of myocardial ischaemia or infarction. He felt that the ECG was essentially normal, aside from mild tachycardia, and did not see any gross abnormality requiring emergency admission.

Two days later, Mr R attended the surgery as an emergency, complaining of chest pain, shortness of breath and nausea over the weekend. Dr S saw him before surgery began in the morning and arranged for emergency admission to hospital. The ECG and blood test results were sent along with a handwritten referral letter.

Upon admission to hospital, Mr R clinically deteriorated and CPR was given; however, Mr R died within an hour of admission.The postmortem found that Mr R had a large saddle embolus in the pulmonary artery causing complete obstruction of the lumen. The left popliteal vein showed residual deep venous thrombosis and that this was the likely source of the fatal embolism.

Mr R’s widow made a claim against Dr S. Expert opinion criticised Dr S for his initial diagnosis of anxiety, his failure to consider that Mr R’s symptoms were potentially life-threatening and for failing to note that the ECG showed right bundle branch block and right axis deviation compatible with pulmonary embolism. Mr R should have been referred to hospital when he initially presented with chest discomfort, where a cardiologist would have diagnosed him and Mr R would have survived. The claim was settled for a moderate sum.

Learning points

  • Mr R had a number of risk factors for cardiovascular disease, including his age, high blood pressure and other symptoms that could possibly relate to circulatory problems. In any patient with chest discomfort you need to rule out serious cardiopulmonary causes with a careful history, examination and ongoing referral if warranted.
  • You should refer a patient for further assessment if an ECG is abnormal if they have risk factors for cardiovascular disease. Mr R should have been admitted to hospital to exclude an MI, even if Dr S was unsure of the diagnosis, because of his risk factors for cardiovascular disease.
  • Be aware of non-cardiac causes of chest pain. In this case, the history, in combination with tachycardia, pointed towards pulmonary embolism. However, the doctor only excluded a cardiac cause without considering embolism.
  • Anxiety symptoms can be very similar to symptoms of more sinister pathologies. When assessing someone with a history of or new presentation with anxiety symptoms, consider risk factors for cardiopulmonary disease when taking the history, examining and arranging follow-up tests.