This case involves a forty-two-year-old male patient with a past medical history of hyperlipidemia, hypertension and a long history of cigarette smoking. The patient also had an extensive family history of cardiovascular disease with both parents suffering myocardial infarctions in their forties and thus, he was using multiple medications, including Lipitor and Benicar. While at work, the patient experienced an episode of acute chest pain and became extremely diaphoretic when he got up from his desk. A colleague called for an ambulance and the patient was taken to the emergency room. The patient was admitted for overnight observation due to the suspicion that he may have been suffering from angina. He was worked up by a cardiologist who ordered a stress test and EKG which were all interpreted to be normal. The patient was scheduled to undergo diagnostic cardiac catheterization however the procedure was cancelled without explanation and the patient was discharged shortly thereafter. Two weeks later the man suffered a massive ST-elevation myocardial infraction and died as a result. An autopsy was performed which revealed that the patient suffered from severe coronary artery disease with 100% occlusion in the left anterior descending coronary artery and 80% occlusion in the diagonal branch.
Question(s) For Expert Witness
- 1. Would the catheterization procedure have made a difference in this patient's outcome?
- 2. Given his autopsy results, should this person have been discharged from hospital without further evaluation?
Expert Witness Response E-004780
It is likely that diagnosis and treatment of the patient’s coronary artery disease would have averted his cardiac event. The autopsy indicated severe coronary artery disease and patients with chest pain and severe coronary artery disease should not be discharged until appropriate treatment is instituted. This patient should have been started on anticoagulant therapy and advised to make lifestyle changes at the very least prior to discharge. Given this patient’s past medical history, family history and social history of smoking coronary artery disease should have been a primary concern when he initially presented with chest pain. The patient should not have been discharged without establishing the underlying cause of his symptoms. The rationale behind cancelling the scheduled catheterization should be investigated. If the treating physicians did not have compelling evidence as to why the procedure did not go ahead then this may constitute a departure from the standard of care. The negative EKG and stress test would not have been enough to dismiss this patient’s symptoms in the context of his medical history.