Ischaemic heart disease

Doctor’s failure to act on troponin result highlighted in MI death: inquest

A doctor’s failure to act on troponin results and follow a chest pain protocol were contributory factors in the death of a 49-year old man from a heart attack, a South Australian inquest has concluded.

The patient had experienced chest and jaw pain while working a shift as a packer in a warehouse, but an ECG obtained by paramedics while he was being transported to a clinic in Murray Bridge appeared normal, the inquest was told.

The GP who treated the man did not do a repeat ECG and told a coronial hearing that he now recognised he had misinterpreted the results of troponin tests he ordered.

Dr Jose Valerio, who qualified as a GP in the US and started working at the Bridge Clinic, Murray Bridge in 2014, told the inquest that when the patient presented he looked well and was not in pain. As the ECG obtained by the paramedics was in normal sinus rhythm, he believed the patient was not having a cardiac event, and advised him to rest and return for a follow up consultation for lifestyle advice on his drinking and smoking.

He ordered blood tests, which included troponins “for completeness”. When the pathology lab phoned to advise him that the troponin result was 45ng/L, Dr Valerio said he misinterpreted the lab’s standard notation for troponin T levels of 30-100ng/L which state that this may indicate myocardial damage. Dr Valerio said he believed the advice only recommended action be taken if the troponin result was over 100ng/L.

The patient was released home where his body was discovered a few days later. An autopsy concluded he died from ischaemic heart disease with coronary artery thrombosis.

An expert report from cardiologist Dr William Heddle said a chest pain protocol should always be applied whether or not chest pain has resolved.

His report also stated that referral to hospital would have been the most appropriate move in light of the troponin results.

“Unequivocally a repeat ECG should have been done and the patient should have had at minimum repeat ECG and troponins within six hours after referral to the local hospital or if there had been any ECG changes,” the report said.

“And if the elevated troponin on the first test had been noted, referral to the ICCNet would have been the next appropriate move, as the deceased almost certainly would have required urgent if not emergency retrieval to a major hospital where emergency or urgent coronary angiography could be undertaken depending upon whether an ST elevation or non ST elevation myocardial infarction. “

At the inquest Dr Valerio apologised to the man’s family and told the coroner that his management of the man was not at the standard that he would expect of a medical practitioner and ‘undoubtedly a better management would have most likely resulted in Mr Mitchell’s survival’.

Following the incident the doctor was required by AHPRA to work under supervision and undertake remedial one-on-one education sessions.

“In view of the actions taken by AHPRA and Dr Valerio’s compliance with that agency’s requirements, I make no recommendations in this matter,” the coroner concluded..

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