Either I’m missing something, or I slept through the lecture where they talked about using thrombolytics for non-ST elevation MI. Consider this case:
At 58 years old, Dr. F is a careful and experienced physician who has been practicing in rural Florida for more than 20 years. Given the reduced reimbursement rates of the past few years (and the fact that he had just put three children through college), his retirement savings plan has fallen behind schedule. As a leader in the medical community and an influential figure in his local hospital, he had never been required to carry malpractice insurance and had never been sued. However, recent development of surrounding communities has brought an influx of older and savvier patients who are more likely to sue. It was not long before Dr. F’Â’s perfect record became tarnished.
The patient was a 63-year-old woman who came to the ER with chest pain. Dr. F ordered an ECG, which showed no ischemia. Troponin was also negative, but the patient continued to have mild pain, which was treated with sublingual nitroglycerin. Dr. F had her admitted overnight for observation. That night, she experienced minor T-wave changes accompanied by mild enzyme elevation. The cardiologist who examined her the next day diagnosed a small MI. The patient made a routine recovery and was discharged after several days of monitoring. One week later, she consulted a plaintiff lawyer, who filed a malpractice suit against Dr. F for failing to diagnose the infarct earlier and treat it with “clot busters.”
Let’s go over the case in more detail.
We have a patient who comes into the ER for chest pain. ECG was negative (ruling out ST-elevation MI) and initial troponin was negative. The chest pain responded to nitroglycerin – perhaps suggesting a cardiac etiology.
There is absolutely no indication for thrombolytics (“clot busters”) at this time. From UptoDate:
The results of a number of smaller trials and the comprehensive TIMI III trial strongly argue against the use of intravenous thrombolytic therapy in unstable angina or NSTEMI (non-ST elevation MI).
An initial negative troponin is misleading, since it may take 3-12 hours after onset of an MI before you see any elevation. That is why the patient was admitted for observation. Before admission, a chest x-ray and basic labs would be routinely ordered. I cannot think of any other tests at this time that would have “diagnosed the MI earlier”.
During that night, she had a repeat EKG, showing T-wave changes. A repeat troponin was positive – confirming the diagnosis of a non-ST elevation MI. A cardiac catheterization would then be done to define the coronary anatomy. Depending on what was found, angioplasty or bypass surgery are options for treatment.
It is unfortunate that such a meritless lawsuit was allowed to get this far. Cases like these are why malpractice screening panels are needed. Anyone with a 2nd year medical school education would have enough sense to stop this case dead in its tracks.
As an aside, imagine if Dr. F had given lytics to this patient in the ER. If she had an intracranial hemorrhage from this, his ass would have been fried for giving it in this very inappropriate situation.
