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Heart Attacks: A Serial Killer

By Maria S. Diamond, J.D., and Judy I. Massong, J.D., RN

Heart disease is the nation’s No. 1 killer. Early diagnosis and treatment are critical factors in the mortality rate of heart attack victims. Misdiagnosed heart attacks are the most common form of medical malpractice and women are the most common victims.

The Scary Statistics

The statistics surrounding heart disease in the United States are quite shocking, particularly for women. More than 1.5 million people suffer a heart attack each year. About 400,000 to 500,000 of them die, half before they reach the hospital. More than 250,000 of those who die are women. [1, 2, 3, 4, 6] These numbers are likely to skyrocket as the population ages.

Heart disease accounts for approximately 23 percent of all deaths in women. Although the death rate from heart disease has declined since the 1980s, this decline has been far more dramatic for men than for women. Experts say the reason for this trend is multi-factorial. However, one big reason is that women and their health care practitioners often do not recognize heart attack symptoms. The delayed onset of coronary artery disease in women and the apparent protective effect of estrogen are partly to blame for the misconception that coronary artery disease primarily affects men. [5, 6, 7]

Underlying Gender Differences

Medicine is just catching up to the fact that women and men experience heart disease differently and require different treatments. Women share the same traditional risk factors (obesity, high blood pressure, familial history, diabetes, hyperlipidemia) for heart disease as men. However, there are significant gender differences in the epidemiology, diagnosis, treatment, and prognosis of heart disease that must be considered when caring for women. Unfortunately, data from clinical trials about the management of women with heart disease is limited since women are generally under represented in randomized controlled studies. [8]

Clinical Presentation

Women with heart disease are generally about 10 years older than men at the time of presentation and carry a greater burden of risk factors such as, age, diabetes, obesity, inflammation, and renal disease. [9, 10, 11]

Women are less likely than men to describe typical chest-pain symptoms, a fact that contributes to the underdiagnosis of heart disease. Women rate their chest pain as more intense; use different words to describe the pain; have more symptoms related to the pain; and more frequently have pain and other sensations in the neck and throat. Other reports identify weakness, unusual fatigue, and shortness of breath as the first symptoms of heart disease among women rather than the typical chest pain described by men. [12]

Also important when interpreting chest pain in women is the greater likelihood of it being induced by rest, sleep, and mental stress, in addition to or instead of physical exercise as often reported by men. Psychosocial factors are also important since women drastically underestimate or downplay their own risk of heart disease, and may attribute symptoms to “gallbladder attacks” and upset stomachs. [13, 14] Hence, fewer women than men receive pharmacological treatment for coronary artery disease on admission, but more women receive anxiolytics, antidepressants, and narcotics, suggesting they are being treated for psychiatric and psychosomatic complaints. [6, 7] Underestimating the risk of heart disease often results in delays seeking medical evaluation and treatment, which culminates in sicker women at initial presentation and worse mortality statistics. [6]

Disparities in Diagnostic Testing

Even when women are timely evaluated, there are gender disparities as to the validity of a number of noninvasive tests. As a screening tool for heart disease, treadmill- exercise stress tests are accurate for men but not necessarily for women. Comparing the accuracy of treadmill testing in men and women, one study found the test results to be misleading in 35 percent of the women studied. However, when the treadmill was combined with nuclear imaging using low-dose radioisotope (Thallium), the accuracy rate improved in women. [12, 15]

Nuclear imaging using thallium also improved the diagnostic accuracy of heart disease when combined with pharmacologically administered drugs such as adenosin and dobutamine since many women cannot endure the physical demands of a treadmill testing and produce suboptimal heart rates. Other explanations for the sex-related differences include the use of hormonal medications and the autonomic nervous system influences. [12, 15] However, the accuracy of stress echocardiography in men and women is similar.

Invasive coronary angiography remains the gold standard for diagnosing coronary artery disease. Even though the indications for diagnostic cardiac catheterization and coronary angiography are similar for men and women, the prevalence of significant coronary disease found at angiography is lower in women than men presenting with chest pain. The lack of angiographic disease in symptomatic women often leads to a search for noncardiac causes of their chest pain, rather than recognition of the higher incidence of nonocclusive coronary artery disease in women. [7, 16, 17, 18] Possible mechanisms for the absence of significant coronary disease in women include rapid clot lysis, vasospasm, and coronary microvascular disease. [19, 20]

A number of studies have documented gender-based differences in utilization rates of coronary angiography and revascularization, even among those women with heart attacks. [6, 21, 22, 23] These differences reflect physicians’ failure to refer women with positive exercise stress testing for subsequent testing, leading to poorer outcomes. [6, 21, 24]

Case Selection and Evaluation

Cases involving misdiagnosis of heart attacks in women are especially common because most doctors continue to consider chest pain as the most important heart attack symptom in both men and women. Attorneys handling these cases must understand the gender differences in clinical presentation and diagnostic evaluation.

Many of the legal issues involved in misdiagnosed heart attacks are, of course, the same whether a man or woman is involved. Before accepting a case, make sure there has been profound injury–death, brain damage, or permanent heart damage resulting in a substantially reduced life expectancy or quality of life. Otherwise, the cost and risk of litigation will outweigh the benefit.

The analysis of liability and whether potential defenses have merit begins with a thorough investigation. Interview the client or her family and carefully examine the medical records to determine whether currently accepted procedures and tests for diagnosing heart disease were performed. Those include obtaining a history and physical with an assessment of heart disease risk factors; obtaining an electrocardiogram (EKG or ECG); establishing intravenous access; administering oxygen; providing aspirin; and examining laboratory values that may reveal myocardial injury, including serum troponin, creatine kinase (CK-MB), and other cardiac-specific enzymes. A patient with elevated serum troponin levels should be considered to have heart disease until proven otherwise–regardless of whether the chest pain symptoms are typical or the EKG is normal.

Depending on the risk assessment, the physician should administer nitroglycerine, beta-blockers, fibrinolytics, thrombolytics, or heparin. If a proper workup was not done, the patient may have lost the chance to fully recover through angioplasty or coronary artery bypass grafting (CABG).

Evaluation of the records may suggest multiple potential negligence theories. Although by no means an exhaustive list, those theories may include: failing to take an adequate medical history; failing to recognize and respond to the symptoms of a heart attack; failing to administer the proper tests, including an EKG and measurement of serum troponin levels; disregarding or misinterpreting test results; and failing to initiate appropriate follow-up tests or treatments.

The proximate cause defense is commonly raised in these as in other medical negligence cases. The defense will argue that even if a timely diagnosis had been made and all available treatment given, the patient would have had a similar outcome because of the nature and extent of the disease. No case should be taken until it has been reviewed by qualified medical experts who have confirmed that the patient’s injury or death was proximately caused by the defendant’s actions.

A defense often raised in mismanaged heart disease cases, particularly those involving women, is that the mistaken diagnosis is justified because the patient’s signs and symptoms were so unusual that they misled the doctor. Thus, the doctor’s error in judgment was not a deviation from the standard of care.

Comparative defense can be a particularly vexing issue in these cases and may be asserted in various ways. For example, the defense may claim that the patient failed to give an accurate history of risk factors, signs, or symptoms and that this failure misled the doctor, causing the misdiagnosis. Or the defense may claim that the patient’s failure to return to the hospital or doctor’s office after the symptoms worsened prevented a reevaluation, which would have allowed for a more accurate diagnosis. Or the defense may argue that the patient’s eating habits, smoking habits, or failure to exercise were really to blame for the heart attack. Given public awareness about the known risk factors for heart disease, the defense will almost certainly hammer the theme of personal responsibility.

The defense will often claim speculation in these cases, particularly those involving wrongful death. It is essential to obtain all scientific data available. An autopsy should always be recommended in a death case and the lack of one may well be a reason to decline the case. There are too many unknowns regarding the cause and mechanism of death that can only be answered by an autopsy. The lack of an autopsy can be a major defense theme from voir dire to closing argument.

If an autopsy was done, all tissue slides should be reviewed by an independent pathologist. These slides can be duplicated as photographs to be used as demonstrative evidence. A pathologist can often date an infarct with reasonable accuracy. If an autopsy was not done, consider advising the family to disinter the body. As the heart deteriorates at a slower rate than many other organs, it is possible to get valuable information about the heart even two to three years after death if the body has been adequately preserved by embalming and a tightly sealed casket.

Damages are another major battleground in heart-attack cases. Unless there is significant permanent damage such as an appreciable shortened life expectancy and/or a significant functional disability with an appreciable reduction in quality of life resulting from improper treatment, do not pursue the case. The defense may argue that the heart disease had progressed so far that even with proper diagnosis and treatment, life expectancy would have been substantially reduced or there would have been significant cardiac disability.

In refuting such arguments, it is necessary to determine the probable life expectancy, work-life expectancy, and quality of life that the patient would have had with the pre-existing disease. Although heart disease is progressive, medical management can substantially slow or even halt its progression. In order to assess what the patient’s cardiac function would have been with proper diagnosis and treatment, it is necessary to obtain all baseline data (including all EKGs), laboratory values (including heart-enzyme tests, angiograms, ultrasound, or echocardiogram studies), and all nuclear scans of the heart and all clinical records. The interpretation of that data and a prediction of life expectancy, survivability, and function are best done by a cardiologist.

Stereotypes based on gender affect the kind of medical treatment that women suffering from heart disease receive. Lawyers who understand these stereotypes will be more effective in screening and evaluating these cases and ultimately in developing strategies for addressing them.

References
  1. W. Rosamond, et al., Heart Disease and Stroke Statistics–2008 Update: A report from the American Heart Association Statistics Committee and Stroke Statistics Committee, 117 CIRCULATION 25 (2008).
  2. D. Lloyd-Jones, et al., Executive Summary: Heart Disease and Stroke Statistics–2010 Update: A Report from the American Heart Association, 121 CIRCULATION 948 (2010).
  3. D.M. Lloyd-Jones, et al., Lifetime Risk of Developing Coronary Heart Disease, 363 LANCET 89 (1999).
  4. E.D. Eaker, et al., Cardiovascular Disease in Women, 88 CIRCULATION 1999 (1993).
  5. L. Mosca, et al., Cardiovascular Disease in Women: A Statement for Health Care Professionals from the American Heart Association, 96 CIRCULATION 2468 (1997).
  6. B. Bozkurt, Where Do We Currently Stand with Advice on Hormone Replacement Therapy for Women?, 6(4) METHODIST DEBAKEY CARDIOVASC. J. 21 (2010).
  7. P. Gopalakrish, et al., Gender Differences in Coronary Artery Disease: Review of Diagnostic Challenges and Current Treatment, 121(2) POSTGRAD. MED. 60 (2009).
  8. P.Y. Lee, et al., Representation of Elderly Persons and Women in Published Randomized Trials of Acute Coronary Syndrome, 286 JAMA 708 (2001).
  9. A. Orencia, et al., Effect of Gender on Long-Term Outcome of Angina Pectoris and Myocardial Infarction/Sudden Unexpected Death, 269 JAMA 2392 (1993).
  10. W.B. Kannel, et al,, Demographics of the Prevalence, Incidence, and Management of Coronary Heart Disease in the Elderly and in Women, 2 ANN. EPIDEMIOL. 5 (1992).
  11. D.J. Lerner, et al., Patterns of Coronary Heart Disease Morbidity and Mortality in the Sexes: 26-Year Follow-Up of the Framingham Population, 111 AM. HEART J. 383 (1986).
  12. V. Stangl, et al., Current Diagnostic Concepts to Detect Coronary Artery Disease in Women, 29 EUR. HEART J. 707 (2008).
  13. C.J. Pepine, et al,, Characteristics of a Contemporary Population with Angina Pectoris, 74 AM. J. CARDIOLOGY 226 (1994).
  14. B.G. Birdwell, et al., Evaluating Chest Pain, 153(17) ARCH. INTERN. MED. 1991 (1993).
  15. R.F. Gibbons, Exercise ECG Testing with and without Radionuclide Studies, in N.K. Wenger, et al., Cardiovascular Health and Disease in Women, 329(4) New Eng. J. Med. 247 (1993).
  16. O. Gurevitz, et al., Clinical Profile and Long-Term Prognosis of Women < 50 Years of Age Referred for Coronary Angiography for Evaluation of Chest Pain, 85 AM. J. CARDIOL. 806 (2000).
  17. A.K. Sullivan, et al., Chest Pain in Women: Clinical, Investigative, and Prognostic Features, 308 BMJ 883 (1994).
  18. C.N. Merz, et al., The Women’s Ischemia Syndrome Evaluation (WISE) Study: Protocol, Design, Methodology and Feasibility Report, 33 J. AM. COLL. CARDIOL. 1453 (1999).
  19. R. Glaser, et al., Benefit of an Early Invasive Management Strategy in Women with Acute Coronary Syndromes, 288 JAMA 3124 (2002).
  20. M.T. Roe, et al., Clinical and Therapeutic Profile of Patients Presenting with Acute Coronary Syndromes Who Do Not Have Significant Coronary Artery Disease. The Platelet Blycoprotein IIb/IIIa in Unstable Angina: Receptor Suppression Using Integrilin Therapy (PURSUIT) Trial Investigators, 102 CIRCULATION 1101 (2000).
  21. L.J. Shaw, et al., Gender Differences in the Noninvasive Evaluation and Management of Patients with Suspected Coronary Artery Disease, 120 ANN. INTERN. MED. 559 (1994).
  22. V.L. Roger, et al., Sex Differences in Evaluation and Outcome of Unstable Angina, 283 JAMA 646 (2000).
  23. J.Z. Ayanian, et al., Differences in the Use of Procedures Between Women and Men Hospitalized for Coronary Heart Disease, 325 NEW ENG. J. MED. 221 (1991).
  24. J.N. Tobin, et al., Sex Bias in Considering Coronary Bypass Surgery, 107 ANN. INTERN. MED. 19 (1987).

Maria S. Diamond and Judy I. Massong, R.N., are partners at DiamondMassong, PLLC in Seattle, WA, where their practice focuses on medical negligence, pharmaceutical and medical-device products liability, and other personal injury cases. They are both past presidents of the Washington State Trial Lawyers Association.

This article was first published in Trial News, January 2012

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