The failure of emergency department doctors to order serial troponin tests for a young woman with chest pain at a WA hospital has resulted in a $450,000 negligence payout.
Doctors discharged the 28-year-old woman from Sir Charles Gairdner Hospital on 6 January 2014 after her chest pain resolved and she had no abnormalities on ECG, in the belief that Acute Coronary Syndrome was extremely unlikely in a women her age.
However she was subsequently diagnosed as having spontaneous coronary artery dissection when she re-presented with a ST-elevation MI (STEMI) 72 hours later and underwent urgent coronary artery bypass graft surgery.
In a case heard at the District Court of Western Australia, a judge accepted the evidence of cardiologist expert witnesses who said that serial troponin testing would likely have detected a non-STEMI event on initial presentation, and the women could have avoided the subsequent transformation to STEMI.
Judge Alan Troy ruled that the ED doctor who assessed the woman had failed in his duty of care by not applying the ACS Pathway guideline in her case and not ordering troponin tests.
In his defence, the doctor said he had done what any reasonable doctor would to screen out non-cardiac chest pain based on clinical assessment and an ECG alone, and he had considered the woman was below a ‘threshold for test and treatment’.
He was backed up by expert witnesses who said it would not be reasonable or practical to order troponin tests for the thousands of people who presented to emergency departments with chest pain of unknown origin.
Associate Professor Roger Allan an interventionist cardiologist at the Prince of Wales Hospital, Sydney, said the likelihood of a 28-year-old female patient suffering myocardial ischaemia in the circumstances described was so low that a troponin test would not be warranted. The patient’s presentation with chest pain syndrome with atypical features, no evidence of MI on two ECGs and a history of anxiety requiring medication suggested the most likely diagnosis as GI reflux, he said.
However the judge was more persuaded by the testimony of other cardiologist witnesses – including Professor Richard Harper of Monash Heart and Associate Professor Neil Strathmore of the Royal Melbourne Hospital – who said that it was the role of an emergency physician to stratify the level of risk, which all guidelines stated would require biomarker assessment.
“He was sending home a 28 year old, otherwise healthy patient who had experienced, on any analysis, a fairly dramatic onset of chest pain, without any real idea what had caused it. Even if it was very unlikely that she had ACS, in the absence of an alternate, more likely, explanation, it is difficult to see how it was a reasonable balance to discharge her home without performing the troponin test,” the judge said.
A reasonable standard of care would require serial troponin testing and consideration of admission for assessment by the hospital’s cardiology service, the court heard.
“There is no support in the literature for the proposition that there is a level of risk below which a treating physician can avoid a troponin test,” the judge noted in his concluding remarks.
A judgement of $450,000 was made in favour of the woman against the North Metropolitan Health Service.