Patients may get wrong message from media on ‘heart check’ fatality: cardiologist

Media coverage of the death of a woman after a CT coronary angiogram has cardiologists concerned that patients may be deterred from potentially vital treatment.

Victorian Coroner Simon McGregor found that Peta Hickey, 43, had an anaphylactic reaction to contrast dye during a CT coronary angiogram in 2019.

The inquest concluded she was a victim of substandard clinical judgment by two doctors and a diagnostic imaging industry that put “profits over patients”.

Ms Hickey should never have had the CTCA test, which was offered to senior executives as a “heart check” by the company where she worked as a general manager, and she was not informed of the risks involved, the coroner said.

The mother of two children had no history of heart trouble, was asymptomatic and exhibited none of the signs that would indicate or justify the CTCA procedure, the inquest was told.

“Peta died as a result of substandard clinical judgment from doctors at the beginning and the end of the [heart check] program, combined with the misalignment of incentives amongst the various business entities that facilitated the process,” Mr McGregor said.

The coroner recommended the Cardiac Society of Australia and New Zealand to work with the Royal Australian and New Zealand College of Radiologists on a joint position statement on when “screening” is an acceptable indicator for a CT angiogram or other invasive cardiac tests.

He also urged Federal Health Minister Greg Hunt to order an investigation of the private diagnostic imaging industry.

“The snapshot provided by the inquest has revealed an industry putting profits over patients,” he said.

Risks overstated

However Professor Tom Marwick, a cardiologist and director of the Baker Institute, said the tragedy of Ms Hickey’s case would be made even worse if the media spotlight left patients confused and reluctant about appropriate cardiac investigations.

Media reports had conflated CT and CTCA scans and lawyers had “overegged” the risks of the coronary angiogram, he said.

“I think, an un-nuanced message about balancing risk and benefit is harmful because it will inhibit people from getting a test which in the right situation is a very, very good test indeed,” he told the limbic.

“One of the benefits of doing a CT coronary angiogram in somebody with chest pain is that they may have moderate disease which indicates they may need to be on disease modifying treatment, like a statin, which you wouldn’t pick up if you were to do a stress test or a stress nuclear test  for their chest pain– because you will only identify an abnormality if it is severe enough to be limiting blood flow.”

The coroner referred two doctors to AHPRA:  Dr Doumit Saad, whose electronic signature appeared on Ms Hickey’s referral for the CTCA even though he had never seen or spoken to her; and Dr Gavin Tseng, a radiologist who performed the test at Future Medical Imaging Group (FMIG) at Moonee Ponds in May 2019.

The inquest heard that Ms Hickey’s employer, Programmed Skilled Workforce, consigned the heart check program, dubbed CHAP, to Priority Health Care Solution, a booking service. It engaged Jobfit, a provider of corporate medical assessments, which used another entity, MRI Now, to book the scan at FMIG.

Programmed launched CHAP in 2018, after a senior executive suffered a cardiac arrest during a business trip to Japan. It was “basically well-intentioned, though its CEO was mistaken in the impression he had formed as to why heart tests are not ordinarily referred by doctors for the asymptomatic”, the coroner said.

Ms Hickey thought the company might think she had “something to hide” if she declined the test, the inquest heard.

Questions over referral

In evidence, Dr Saad, who was working at the time for Jobfit, denied having known that his electronic signature appeared on automatically generated referrals for CHAP.  The coroner found that  explanation was implausible as he was receiving and reviewing patients’ reports as the referring doctor.

The doctor must have known that staff were undergoing CTCAs without any preliminary assessment by himself or any other medical practitioner and “was comfortable with that approach”, he said.

“He admitted he never came across any participant who met the criteria for a CTCA, that as a doctor he would have had an obligation to notify Programmed of this and that he didn’t actually know of any other doctor involved in the CHAP.”

Dr Saad had further admitted that he should have known who the referring doctor was and should have looked at the papers in front of him for that information.

“Dr Saad was at least wilfully blind to the medical risks that he ought to have known his ‘candidates’ (patients) were experiencing,” Mr McGregor said.

The coroner was critical of Dr Tseng for accepting an invalid referral with no supporting clinical information, failing to contact the referring doctor and not discussing the source of the test and the risks involved with Ms Hickey.

“The overwhelming weight of the expert evidence was that it was not appropriate for Tseng to proceed with the CTCA in this case,” he said.

“While he was ultimately responsible for patient care at the clinic that day, I note the experts’ view that a radiologist in the position of Tseng was under significant pressure to perform the procedure where response to an invalid referral is left to the day of the procedure itself and not vetted beforehand.”

However, the radiologist testified that he had satisfied himself that the procedure was appropriate and even in hindsight he did not indicate he would form a different view.

“This surprising but admirably candid response, given the expert consensus that Peta’s screen should NOT have proceeded in this way on this day, is evidence of a powerful throughput pressure within private radiology clinics where workplace screening is being performed,” the coroner said.

Dr Tseng’s failure to quickly recognise Ms Hickey’s contrast reaction and order IM adrenaline which might have saved her life was “likely due to a lack of training and experience as well as shock”, he found.

Ms Hickey, who recorded a coronary calcium score of zero in her ultimately fatal test, died nine days later without regaining consciousness in Royal Melbourne Hospital.

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