High-Risk Emergency Medicine: Legal Disasters in ACS - Notes

High-Risk Emergency Medicine: Legal Disasters in ACS

Objectives

  • Discussing subtleties to better protect patients.
  • Understanding what's needed to better protect oneself.

Non-STE ACS

  • ACC/AHA 2007 Guidelines for the Management of Patients with Unstable Angina/Non-STEMI
    • Summary of literature and recommendations for non-STE ACS management (Anderson JL, Circulation and JACC 2006).

Rules of Cardiology

  • Rule #1: You cannot diagnose every case of acute coronary syndrome.
  • Rule #2: You can't change rule #1.

Why is this important?

  • ACS is high-risk but high payoff:

    • Very good outcome vs. very bad outcome.
    • Bad outcomes can lead to malpractice.

  • Missed ACS accounts for 20% of malpractice dollars paid out in EM.

  • The majority of cases involve failure to recognize concerning features in the history.

  • 25-50% of cases involve ECG misreads.

Pitfalls in the Diagnosis of ACS: The History

  • Failure to do (and document) a good history (especially the HPI).

  • Importance of a good history:

    • Asking about the onset.
    • Considering precipitating factors.
    • Assessing the quality of pain.
    • Identifying radiation.
    • Determining severity.
    • Noting the timing.

  • OLDCAAAR HPI for patients with CP:

    • Onset
    • Location
    • Duration
    • Character
    • Alleviating/aggravating factors
    • Activity at onset
    • Associated Symptoms
    • Radiation

  • Caveats:

    • Understanding that not everything asked/done is documented.
    • HPI is only one component of any Assessment and Plan (ADP).
    • It constitutes only 20% of the HEART score.

  • Good documentation of a good history might keep you out of trouble.

Common Misdiagnosis

  • Misdiagnosis as reflux.

  • Up to 50% of MI patients have an increase in belching.

  • 20% describe their ACS pain as "burning" or "indigestion."

  • 15% of ACS patients get improvement with antacids.

  • 8% of patients report their ACS pain began during a meal.

  • GERD and ACS frequently co-exist.

Failure to Appreciate ACS in Young Patients

  • ACS is typically reported > 55yo.

  • Young patients:

    • 123,000 AMIs per year in patients 29-44yo.
    • 5-10% of AMIs occur in patients < 45yo.
    • Minority are related to cocaine use

  • Autopsy studies — Korean/Vietnam wars

    • Joseph, et al (J Am Coll Cardiol, 1993)
    • Autopsy study of 111 patients (< 35yo., avg. age 26yo.), victims of non-cardiac trauma
      • evidence of atherosclerosis in 78%
      • 20% had LAD or “significant” 2- and 3- vessel involvement
      • 9% had > 75% narrowing in at least one vessel

  • Marsan, et al (Acad Emerg Med, 2005)

    • 1023 patients 24-39yo. presenting with CP
    • Cocaine users excluded
    • 98% available for 30-day follow-up
      • 5.4% ruled in for ACS
      • 2.2% had an adverse cardiac event (death, MI, need for PCI or CABG)

  • “…in 2009, pediatricians wrote children in the U.S. at least 2.8 million prescriptions for drugs to lower cholesterol; nearly 2.3 million of them were for statins.” (ConsumerReports.org, June 2010)

  • Key point! – Don’t discount the risk of ACS purely because of a patient’s age!

Failure to Appreciate ACS and Atypical Presentations in Women

  • Painless presentations are more common.
  • Atypical locations of pain and radiation.
  • Unexplained dyspnea, flu-like symptoms, indigestion, malaise, fatigue, weakness.
  • More symptoms than men lead to misdiagnosis!
  • These points apply to younger women as well as older.
  • McSweeney, Circulation 2003
    • Unusual prodromal Symptoms
      • Chest discomfort 30% (only!)
      • Dyspnea 42%
      • Sleep disturbance 48%
      • Fatigue 71%

Upper Abdominal Pain

  • If there’s no significant tenderness, consider the possibility of ACS (or another thoracic problem).

Over-reliance on Troponin Negatives (TNs)

  • Diagnosis of ACS requires 3 components:

    • A good history
    • Scrutiny of the ECG
    • Troponins (TNs)

  • EVERY validated ADP incorporates all 3.

Pitfalls in the Diagnosis of ACS: The ECG

  • 25-50% of cases involve ECG misreads.
  • Experience suggests > 50% involve ECG misreads that are not “arguable”.

Over-Reliance on the Computer Interpretation

  • Especially “normal” and “nonspecific”.

Ignoring the ECG because of negative Troponins

Failure to Repeat the ECG

  • If the first ECG is poor quality.
  • If ongoing concerning Symptoms.
  • ACC/AHA guidelines recommend serial ECGs every 15-30 min for the first hour if there are concerning Symptoms and initial ECG is non-diagnostic.
  • 15-20% of STEMIs are diagnosed on the repeat ECG!

Take-Home Points: The History

  • Do and document a good history.
  • Do not exclude ACS purely based on:
    • Reflux Symptoms
    • Age
    • Female gender
    • Abdominal pain
    • Negative Troponins

Take-Home Points: The ECG

  • Scrutinize the ECG.
  • Don’t trust the computer interpretation.
  • Get serial ECGs when the history is concerning but the first ECG is non-diagnostic.