This case involves a female patient who presented to the emergency room complaining of chest pain and was admitted for a cardiovascular workup. The patient was found to have elevated troponin and uncontrolled hypertension, however her other cardiology tests came back relatively normal. She was discharged with instructions pertaining to the treatment and management of suspected bronchitis. In addition, she was not provided any prescriptions related to hypertension or put on anti-clotting medication. The patient was killed by a massive heart attack just two weeks after being discharged from the hospital.
Question(s) For Expert Witness
1. How often do you treat patients such as the one described?
2. What are the possible causes of an elevated troponin?
3. Should the patient have been discharged with prescriptions to address her cardiac issues and/or instructions to see a cardiologist?
Expert Witness Response E-007419
I treat many patients such as the one that you describe in this case. Patients with hypertension, chest pain and coronary artery disease comprise the majority of the patient's that I care for. An elevated troponin is highly suggestive of myocardial injury and a heart attack although there are situations which referred to as "troponin leak "which may occur during periods of hypertensive urgency, hypotension, or sepsis. I would not have discharged this patient from the emergency department particularly without having seen a cardiologist. If I were asked to consult on this particular case the standard of care would have been to admit the patient to the hospital for further monitoring, evaluation, and treatment. I have reviewed similar cases where individuals presented to the emergency department with chest pain and were discharged prematurely without appropriate evaluation.
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