By Peter T. Crean and Michelle A. Frankel
Monday, February 6, 2017
Medical malpractice lawsuits may be brought against primary care physicians, emergency department physicians and cardiologists based on the failure to diagnose coronary artery disease (CAD), arrhythmia or other manifestations of heart disease. This risk may be diminished if there is an increased awareness and understanding by physicians and patients that men and women may demonstrate substantially different manifestations of heart disease.
This is important because studies have shown that women are significantly more likely to receive a misdiagnosis of ischemia or even myocardial infarction1, which may culminate in legal exposure.
A physician-owned medical malpractice insurer reviewed claims from 2011 to 2015 involving undiagnosed heart disease in women to assess for potential trends of increased exposure. The study found a significant sample died from an incorrectly diagnosed heart condition and 28 percent had heart muscle damage from myocardial infarction2.
Medical outcomes highlighted in malpractice lawsuits demonstrate occasional lack of appreciation about the extent to which women are plagued by heart disease but do not present with classic symptoms. Insufficient patient and physician awareness is further evident based on statistics and observations. Only one in five women believe that heart disease is their greatest health threat. Yet one in three women die of heart disease each year, while one in 31 die from breast cancer3. Many patients report that their physicians neither discuss coronary and arrhythmia risk nor recognize the symptoms, “mistaking [the symptoms] instead for signs of panic disorder, stress and even hypochondria4.”
The following clinical observations highlight similarities and differences in the presentation of cardiac symptoms in men and women that can be emphasized to improve diagnosis in all patients — but especially women. Both genders may be affected by risk factors such as obesity, smoking, diabetes, high blood pressure, family history, metabolic syndrome and high levels of c-reactive protein. Men and women may also experience classic symptoms, such as chest pain, but “…women are much more likely to [have] less common symptoms such as indigestion, shortness of breath and back pain, sometimes even in the absence of obvious chest discomfort5.”
Women are disproportionately affected by high testosterone levels prior to menopause and hypertension during menopause. Women can be more commonly affected by stress, depression or autoimmune diseases, such as rheumatoid arthritis, which can further impact cardiac risk6. Overall, women develop cardiovascular disease seven to 10 years later than men7, and clot-busting drugs and other medical procedures are not necessarily as effective for women8.
A greater awareness of the aforementioned risk factors may improve the diagnosis of heart disease. Physicians may further reduce associated medical malpractice risk by documenting all discussions regarding symptomology, testing and recommendations. More specifically, it can be beneficial to document whether recommendations made were followed and to what extent. Patients can also be counseled about addressing risk factors, such as smoking, diet, exercise and stress, that are more easily controlled. The development of written chest-pain protocols may also be advantageous. Physicians should offer same-day appointments or consider sending patients to an emergency department when they complain of continued symptoms.
All of these measures should always be documented in a patient’s medical record so they can be substantiated, and successfully defended, during a trial.