Heart disease is the leading killer of women, responsible for one in every four female deaths, and this danger was highlighted by the tragic death of actress Carrie Fisher in late 2016. But almost two-thirds of women who die suddenly from heart disease had no previous symptoms.*
In a study of closed medical malpractice claims involving undiagnosed heart disease in women from 2011 to 2015, The Doctors Company found that in 70 percent of claims the patient died when her heart condition was not correctly diagnosed and 28 percent had heart muscle damage from myocardial infarction.
Failure to diagnose heart disease in women is often thought of as a problem in the emergency department (ED). However, the study found that in 28 percent of these cases, it was a primary care physician (PCP) who allegedly failed to diagnose the patient's heart disease. Cardiologists (28 percent) and emergency medicine physicians (13 percent) were also named in these claims.
Consider this case example:
A 47-year-old obese woman presented to her PCP complaining of a burning sensation in her chest after eating. The patient reported a similar episode the prior day after eating lunch as well as increased heartburn over the last few weeks.
A review of the medical record reflected elevated blood pressures over the past six months and an elevated cholesterol level of 237 (mg/dl). On the day of the exam, her blood pressure was 160/90. She smoked, drank alcohol socially, and was unaware of a family history of coronary artery disease. A heart exam revealed normal rate and rhythm. The physician noted that the patient appeared diaphoretic; however, she wasn't in acute distress and was pain-free throughout the examination. An ECG revealed a left bundle branch block. Prior ECGs were not available for comparison. Suspecting reflux esophagitis (heartburn), the PCP advised the patient to take an antacid and to return if the symptoms continued.
Two days later, the patient called her PCP's office stating that her chest burning sensation continued. The nurse advised her to continue taking the antacid and scheduled an office appointment for the following day. She also advised the patient to go to the ED if she developed chest pain.
That night, the woman awoke with chest pain, nausea, and vomiting. She was taken to the ED for emergent coronary angiography, but died shortly after arrival.
To help avoid such risks:
- Rule out myocardial infarction before arriving at a GI-related diagnosis such as gastric reflux as the cause of chest pain or discomfort.
- Consider cardiac risk factors such as obesity, smoking, hypertension, and hyperlipidemia.
- Offer patients same-day appointments when they complain of continued symptoms for which they were recently seen. If this is not possible, send them to the ED and document this in the medical record.
- Develop a written chest pain protocol, determining what the nurse should advise the patient and when the physician should be notified.
- Remember that differences in early signs and symptoms in women may make coronary heart disease more difficult to recognize.
- Thoroughly evaluate patients of all ages who present with atypical chest pain.
*Women and heart disease fact sheet. Centers for Disease Control and Prevention. https://www.cdc.gov/dhdsp/data_statistics/fact_sheets/docs/fs_women_heart.pdf. Accessed January 11, 2017.
Contributed by The Doctors Company. For more patient safety articles and practice tips, visit www.thedoctors.com/patientsafety.