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Atypical presentation of heart disease

01 September 2006

Mrs F, a florist, had been diagnosed with hypertension while still in her twenties. She was a frequent attender at her GP practice, often seeing the practice principal, Dr W.

Mrs F had a number of significant visits to the practice. In 1992, now 41, she consulted Dr W, complaining of sweating and chest pain radiating to her arm. Dr W admitted Mrs F to hospital. She was diagnosed with non-specific chest pain and discharged with a prescription for hypertension medication. At the time Mrs F was smoking 15 cigarettes a day. In 1994, following a faint and a fall, a chest x-ray showed that Mrs F had fractured her ribs. No chest pain prior to the faint was recorded at the time.

Shortly afterwards Mrs F stopped taking her anti-hypertensives. Dr W counselled her as to the risks, and she started taking lisinopril. In 1996, Dr W’s partner, Dr R, saw Mrs F, and referred her to a cardiology specialist, Dr C. Mrs F was complaining of periodic chest pain. There was no chest tightness or radiation to jaw or neck, but on one occasion pressure along the arms was noted.

An exercise test was reported to be negative with no significant ST segment changes. Dr C’s opinion was that Mrs F had non-cardiac atypical chest pain. Her dyspnoea was attributed to iron-deficiency anaemia. It was clear that there were cardiovascular risk factors, including hypertension, smoking and cholesterol. Dr C stressed the importance that Mrs F stop smoking.

The following year, Mrs F died following a cardiac arrest.

The postmortem showed an enlarged ischaemic heart. Death was due to pulmonary oedema secondary to hypertension and ischaemic heart disease. A claim was made against Drs W and R for failing to recognise symptoms of myocardial ischaemia and to refer for investigation and treatment, and against Dr C for negligent misinterpretation of the exercise ECG.

Expert opinion

GP experts felt that the GPs, Dr W and Dr R, had provided competent care for Mrs F. Her voluminous records made it clear that she did have specific risk factors for ischaemic heart disease, but the presentation was by no means typical. The referral to the cardiologist was, they felt, to rule out ischaemic heart disease, rather than to confirm its presence.

A cardiology expert criticised Dr C’s interpretation of the exercise test. She argued that it should have been reported as inconclusive, and other investigations should have been performed. However, it was felt that this would have had little effect on the outcome for Mrs F.

The claim was successfully defended at trial.

Learning points

  • Good records were vital in this case. It might be tempting to skimp on the details for frequent attenders, but the consistently good-quality records provided by these GPs helped support their reputations as competent professionals.  
  • In the community setting, recording negative findings can often be as important as the positive ones. In this case, for example, notes often included “no chest or arm pain, no cough”, showing that the doctors had considered these possibilities.   
  • Consider the unusual presentation. If patients are attending with symptoms that do not improve, it is worth considering atypical presentations of alternative diagnoses and ruling these out.

Further information

Kavanagh, S. Assessing Chest Pain Casebook2003 (4) 11–16.
European Guidelines on CVD Prevention. Third Joint European Societies’ Task Force on Cardiovascular Disease Prevention in Clinical Practice www.escardio.org

Ayanian JZ, Epstein AM, Differences in the Use of Procedures Between Women and Men Hospitalized for Coronary Heart Disease N Engl J Med. 325:221–5 (1991)

Bickell NA, Pieper KS, Lee KL, Mark DB, Glower DD, Pryor DB, et al. Referral Patterns for Coronary Artery Disease Treatment: Gender Bias or Good Clinical Judgement Ann Intern Med 116:791–7 (1992)