Failure to Identify Blockage During Catheterization

A 37-year-old Virginia man experienced sudden-onset chest pain, dyspnea, diaphoresis, and jaw pain. He was transported to a community hospital, where he was admitted. The patient’s ECG was read as normal, and his troponin levels were mildly elevated. This took place in January.

The next day, he was seen by a cardiologist, who recommended a stress test. Instead, the patient requested a cardiac catheterization, based on his understanding that it was the definitive test to rule out heart disease. The cardiologist consented and had the patient transferred to a regional medical center. There, the patient was seen by Dr. A., an invasive cardiologist. Two days later, Dr. A. performed a cardiac catheterization and informed the patient that his coronary arteries were clean, normal, and free of disease. Dr. A. diagnosed the patient with pericarditis, recommended treatment with NSAIDs, and discharged him home.

Over the next two months, the patient’s chest pain and dyspnea returned. He saw a nurse practitioner at his family medicine practice four times. The NP had electronic access to Dr. A.’s catheterization report and to the patient’s discharge summary. The NP continued treatment for pericarditis.

In April, the patient experienced a massive MI. He was ultimately taken back to the regional medical center, where he received care from cardiologist Dr. B. (a partner of Dr. A.’s). Dr. B. performed an emergency cardiac catheterization and identified a complete blockage of the left anterior descending artery (LAD).

After several unsuccessful attempts, Dr. B. was able to dilate the artery and place two stents to improve blood flow. Further, Dr. B. reviewed the earlier catheterization performed by Dr. A. and noted a blockage of the LAD, which he characterized as an “eccentric 70% or so stenosis very proximally.”

Following the MI, the patient was hospitalized several times and underwent eight subsequent cardiac catheterizations. He had an internal cardiac defibrillator placed and eventually required coronary artery bypass surgery. His post-MI ejection fraction was 25% to 30%, compared with 55% to 60% noted by Dr. A. after the initial cardiac catheterization. The patient was determined to be in NYHA Class II or III heart failure and was expected to require a left ventricular assist device and ultimately a heart transplant within five to six years. The patient was assessed to have a 50% 10-year mortality.

The plaintiff claimed that Dr. A.’s interpretation of the cardiac catheterization as “normal” was negligent. The plaintiff contended that a stent should have been placed and that the plaintiff should have been told he had coronary artery disease (CAD).

The defendants admitted that Dr. A. had missed a partial blockage of the LAD but maintained that the blockage was only 20% to 30%; this, they argued, was clinically insignificant and did not warrant a stent. The defendants also claimed that the diagnosis of pericarditis was reasonable and that the plaintiff’s MI was the result of an unexpected plaque rupture.

Outcome
According to a published account, a $25 million verdict was returned. Posttrial motions regarding application of state caps were pending.

Comment
This $25 million dollar verdict is believed to be the largest medical malpractice verdict in Virginia history. For several reasons, this case warrants discussion.

Here, we have a 37-year-old patient presenting with symptoms suggestive of ischemic heart disease. His catheterization was initially read as “normal,” but a second look revealed a stenotic LAD. Dr. A. informed the patient that his coronary arteries were “clean, normal, and free of disease.” Yet during trial, Dr. A. changed his position—admitting disease but insisting that the blockage was clinically insignificant at only 25% to 30%.

The patient was diagnosed and treated for pericarditis and remained symptomatic during the next two months. The patient saw his NP four times with these symptoms and continued to be treated for pericarditis.

Three months after his first presentation, he experienced a massive MI with complete occlusion of the LAD. His left ventricular function is severely impaired, and he faces a 50% chance of mortality within 10 years, even with a successful heart transplant.

The jurors in this case seem to have found the plaintiff’s expert credible. They considered Dr. B.’s reassessment that the LAD was 70% occluded both alarming and vastly at odds with his partner’s first assessment of “normal” and second assessment of “only 25% to 30% occluded.” The jurors obviously dismissed the defense theory that a 25% to 30% “clinically insignificant” plaque suddenly and unexpectedly ruptured.

The patient’s four subsequent visits to the NP could have represented an opportunity to reconsider whether the source of his pain was related to coronary flow. Admittedly, it is tempting to view an essentially negative cath report as conclusive—and I submit many of us would. But the character, quality, and location of the pain (as well as the troponin bump during the initial presentation) could have raised suspicion that the source of the pain was related to coronary flow.

In counterargument, it would be difficult to fault the NP for relying on the faulty catheterization report if he or she had no reason to suspect that it was erroneous. Unless the patient’s presentation on those four visits had been suggestive of CAD or discordant with pericarditis, it is not likely the NP breached the standard of care.

Always consider the possibility that a study could have been misinterpreted or that it could have mistakenly described the wrong patient. Additionally, even a reassuring cath report can’t account for all clinically important coronary events, such as vasospastic causes or plaque disruption. If the patient’s story is compelling, be willing to revisit the possibility of CAD.

Further, the plaintiff’s expert likely testified that the first cath report demonstrated a significant stenosis which required stenting and that the standard of care required aspirin, b-blockers, and lipid-lowering agents. Whether or not stent placement and medical optimization would have ultimately made a difference for this patient in the next three months, we don’t know. We do know the plaintiff’s attorney was able to persuade the jury that these efforts would have spared the patient and that the missed diagnosis was causally related to the plaintiff’s subsequent severe MI and unfortunate sequelae—justifying the monumental $25 million verdict.

Virginia state law places a $2 million cap on medical malpractice damages. However, as of the date of this writing, the plaintiff’s attorney is challenging the validity of Virginia’s cap.

The defendant’s theory brings up an important issue: the adherent plaque that does not by itself cause clinically important flow disruption—but causes mayhem if ruptured. The rupture of a “vulnerable plaque” was the unfortunate case with Tim Russert, the late, great host of Meet the Press. Mr. Russert was known to have CAD and by all accounts was well optimized, but suffered an unexpected and unpredictable rupture of a “vulnerable plaque,” which proved fatal.

Consider traditional fixed stenotic lesions that cause the usual flow limitations, but also remember that a modest lesion could represent a “vulnerable plaque” capable of rupture. —DML

Cases reprinted with permission from Medical Malpractice Verdicts, Settlements and Experts, Lewis Laska, Editor, (800) 298-6288.

A 37-year-old Virginia man experienced sudden-onset chest pain, dyspnea, diaphoresis, and jaw pain. He was transported to a community hospital, where he was admitted. The patient’s ECG was read as normal, and his troponin levels were mildly elevated. This took place in January.

The next day, he was seen by a cardiologist, who recommended a stress test. Instead, the patient requested a cardiac catheterization, based on his understanding that it was the definitive test to rule out heart disease. The cardiologist consented and had the patient transferred to a regional medical center. There, the patient was seen by Dr. A., an invasive cardiologist. Two days later, Dr. A. performed a cardiac catheterization and informed the patient that his coronary arteries were clean, normal, and free of disease. Dr. A. diagnosed the patient with pericarditis, recommended treatment with NSAIDs, and discharged him home.

Over the next two months, the patient’s chest pain and dyspnea returned. He saw a nurse practitioner at his family medicine practice four times. The NP had electronic access to Dr. A.’s catheterization report and to the patient’s discharge summary. The NP continued treatment for pericarditis.

In April, the patient experienced a massive MI. He was ultimately taken back to the regional medical center, where he received care from cardiologist Dr. B. (a partner of Dr. A.’s). Dr. B. performed an emergency cardiac catheterization and identified a complete blockage of the left anterior descending artery (LAD).

After several unsuccessful attempts, Dr. B. was able to dilate the artery and place two stents to improve blood flow. Further, Dr. B. reviewed the earlier catheterization performed by Dr. A. and noted a blockage of the LAD, which he characterized as an “eccentric 70% or so stenosis very proximally.”

Following the MI, the patient was hospitalized several times and underwent eight subsequent cardiac catheterizations. He had an internal cardiac defibrillator placed and eventually required coronary artery bypass surgery. His post-MI ejection fraction was 25% to 30%, compared with 55% to 60% noted by Dr. A. after the initial cardiac catheterization. The patient was determined to be in NYHA Class II or III heart failure and was expected to require a left ventricular assist device and ultimately a heart transplant within five to six years. The patient was assessed to have a 50% 10-year mortality.

The plaintiff claimed that Dr. A.’s interpretation of the cardiac catheterization as “normal” was negligent. The plaintiff contended that a stent should have been placed and that the plaintiff should have been told he had coronary artery disease (CAD).

The defendants admitted that Dr. A. had missed a partial blockage of the LAD but maintained that the blockage was only 20% to 30%; this, they argued, was clinically insignificant and did not warrant a stent. The defendants also claimed that the diagnosis of pericarditis was reasonable and that the plaintiff’s MI was the result of an unexpected plaque rupture.

Outcome
According to a published account, a $25 million verdict was returned. Posttrial motions regarding application of state caps were pending.

Comment
This $25 million dollar verdict is believed to be the largest medical malpractice verdict in Virginia history. For several reasons, this case warrants discussion.

Here, we have a 37-year-old patient presenting with symptoms suggestive of ischemic heart disease. His catheterization was initially read as “normal,” but a second look revealed a stenotic LAD. Dr. A. informed the patient that his coronary arteries were “clean, normal, and free of disease.” Yet during trial, Dr. A. changed his position—admitting disease but insisting that the blockage was clinically insignificant at only 25% to 30%.

The patient was diagnosed and treated for pericarditis and remained symptomatic during the next two months. The patient saw his NP four times with these symptoms and continued to be treated for pericarditis.

Three months after his first presentation, he experienced a massive MI with complete occlusion of the LAD. His left ventricular function is severely impaired, and he faces a 50% chance of mortality within 10 years, even with a successful heart transplant.

The jurors in this case seem to have found the plaintiff’s expert credible. They considered Dr. B.’s reassessment that the LAD was 70% occluded both alarming and vastly at odds with his partner’s first assessment of “normal” and second assessment of “only 25% to 30% occluded.” The jurors obviously dismissed the defense theory that a 25% to 30% “clinically insignificant” plaque suddenly and unexpectedly ruptured.

The patient’s four subsequent visits to the NP could have represented an opportunity to reconsider whether the source of his pain was related to coronary flow. Admittedly, it is tempting to view an essentially negative cath report as conclusive—and I submit many of us would. But the character, quality, and location of the pain (as well as the troponin bump during the initial presentation) could have raised suspicion that the source of the pain was related to coronary flow.

In counterargument, it would be difficult to fault the NP for relying on the faulty catheterization report if he or she had no reason to suspect that it was erroneous. Unless the patient’s presentation on those four visits had been suggestive of CAD or discordant with pericarditis, it is not likely the NP breached the standard of care.

Always consider the possibility that a study could have been misinterpreted or that it could have mistakenly described the wrong patient. Additionally, even a reassuring cath report can’t account for all clinically important coronary events, such as vasospastic causes or plaque disruption. If the patient’s story is compelling, be willing to revisit the possibility of CAD.

Further, the plaintiff’s expert likely testified that the first cath report demonstrated a significant stenosis which required stenting and that the standard of care required aspirin, b-blockers, and lipid-lowering agents. Whether or not stent placement and medical optimization would have ultimately made a difference for this patient in the next three months, we don’t know. We do know the plaintiff’s attorney was able to persuade the jury that these efforts would have spared the patient and that the missed diagnosis was causally related to the plaintiff’s subsequent severe MI and unfortunate sequelae—justifying the monumental $25 million verdict.

Virginia state law places a $2 million cap on medical malpractice damages. However, as of the date of this writing, the plaintiff’s attorney is challenging the validity of Virginia’s cap.

The defendant’s theory brings up an important issue: the adherent plaque that does not by itself cause clinically important flow disruption—but causes mayhem if ruptured. The rupture of a “vulnerable plaque” was the unfortunate case with Tim Russert, the late, great host of Meet the Press. Mr. Russert was known to have CAD and by all accounts was well optimized, but suffered an unexpected and unpredictable rupture of a “vulnerable plaque,” which proved fatal.

Consider traditional fixed stenotic lesions that cause the usual flow limitations, but also remember that a modest lesion could represent a “vulnerable plaque” capable of rupture. —DML

Cases reprinted with permission from Medical Malpractice Verdicts, Settlements and Experts, Lewis Laska, Editor, (800) 298-6288.

A 37-year-old Virginia man experienced sudden-onset chest pain, dyspnea, diaphoresis, and jaw pain. He was transported to a community hospital, where he was admitted. The patient’s ECG was read as normal, and his troponin levels were mildly elevated. This took place in January.

The next day, he was seen by a cardiologist, who recommended a stress test. Instead, the patient requested a cardiac catheterization, based on his understanding that it was the definitive test to rule out heart disease. The cardiologist consented and had the patient transferred to a regional medical center. There, the patient was seen by Dr. A., an invasive cardiologist. Two days later, Dr. A. performed a cardiac catheterization and informed the patient that his coronary arteries were clean, normal, and free of disease. Dr. A. diagnosed the patient with pericarditis, recommended treatment with NSAIDs, and discharged him home.

Over the next two months, the patient’s chest pain and dyspnea returned. He saw a nurse practitioner at his family medicine practice four times. The NP had electronic access to Dr. A.’s catheterization report and to the patient’s discharge summary. The NP continued treatment for pericarditis.

In April, the patient experienced a massive MI. He was ultimately taken back to the regional medical center, where he received care from cardiologist Dr. B. (a partner of Dr. A.’s). Dr. B. performed an emergency cardiac catheterization and identified a complete blockage of the left anterior descending artery (LAD).

After several unsuccessful attempts, Dr. B. was able to dilate the artery and place two stents to improve blood flow. Further, Dr. B. reviewed the earlier catheterization performed by Dr. A. and noted a blockage of the LAD, which he characterized as an “eccentric 70% or so stenosis very proximally.”

Following the MI, the patient was hospitalized several times and underwent eight subsequent cardiac catheterizations. He had an internal cardiac defibrillator placed and eventually required coronary artery bypass surgery. His post-MI ejection fraction was 25% to 30%, compared with 55% to 60% noted by Dr. A. after the initial cardiac catheterization. The patient was determined to be in NYHA Class II or III heart failure and was expected to require a left ventricular assist device and ultimately a heart transplant within five to six years. The patient was assessed to have a 50% 10-year mortality.

The plaintiff claimed that Dr. A.’s interpretation of the cardiac catheterization as “normal” was negligent. The plaintiff contended that a stent should have been placed and that the plaintiff should have been told he had coronary artery disease (CAD).

The defendants admitted that Dr. A. had missed a partial blockage of the LAD but maintained that the blockage was only 20% to 30%; this, they argued, was clinically insignificant and did not warrant a stent. The defendants also claimed that the diagnosis of pericarditis was reasonable and that the plaintiff’s MI was the result of an unexpected plaque rupture.

Outcome
According to a published account, a $25 million verdict was returned. Posttrial motions regarding application of state caps were pending.

Comment
This $25 million dollar verdict is believed to be the largest medical malpractice verdict in Virginia history. For several reasons, this case warrants discussion.

Here, we have a 37-year-old patient presenting with symptoms suggestive of ischemic heart disease. His catheterization was initially read as “normal,” but a second look revealed a stenotic LAD. Dr. A. informed the patient that his coronary arteries were “clean, normal, and free of disease.” Yet during trial, Dr. A. changed his position—admitting disease but insisting that the blockage was clinically insignificant at only 25% to 30%.

The patient was diagnosed and treated for pericarditis and remained symptomatic during the next two months. The patient saw his NP four times with these symptoms and continued to be treated for pericarditis.

Three months after his first presentation, he experienced a massive MI with complete occlusion of the LAD. His left ventricular function is severely impaired, and he faces a 50% chance of mortality within 10 years, even with a successful heart transplant.

The jurors in this case seem to have found the plaintiff’s expert credible. They considered Dr. B.’s reassessment that the LAD was 70% occluded both alarming and vastly at odds with his partner’s first assessment of “normal” and second assessment of “only 25% to 30% occluded.” The jurors obviously dismissed the defense theory that a 25% to 30% “clinically insignificant” plaque suddenly and unexpectedly ruptured.

The patient’s four subsequent visits to the NP could have represented an opportunity to reconsider whether the source of his pain was related to coronary flow. Admittedly, it is tempting to view an essentially negative cath report as conclusive—and I submit many of us would. But the character, quality, and location of the pain (as well as the troponin bump during the initial presentation) could have raised suspicion that the source of the pain was related to coronary flow.

In counterargument, it would be difficult to fault the NP for relying on the faulty catheterization report if he or she had no reason to suspect that it was erroneous. Unless the patient’s presentation on those four visits had been suggestive of CAD or discordant with pericarditis, it is not likely the NP breached the standard of care.

Always consider the possibility that a study could have been misinterpreted or that it could have mistakenly described the wrong patient. Additionally, even a reassuring cath report can’t account for all clinically important coronary events, such as vasospastic causes or plaque disruption. If the patient’s story is compelling, be willing to revisit the possibility of CAD.

Further, the plaintiff’s expert likely testified that the first cath report demonstrated a significant stenosis which required stenting and that the standard of care required aspirin, b-blockers, and lipid-lowering agents. Whether or not stent placement and medical optimization would have ultimately made a difference for this patient in the next three months, we don’t know. We do know the plaintiff’s attorney was able to persuade the jury that these efforts would have spared the patient and that the missed diagnosis was causally related to the plaintiff’s subsequent severe MI and unfortunate sequelae—justifying the monumental $25 million verdict.

Virginia state law places a $2 million cap on medical malpractice damages. However, as of the date of this writing, the plaintiff’s attorney is challenging the validity of Virginia’s cap.

The defendant’s theory brings up an important issue: the adherent plaque that does not by itself cause clinically important flow disruption—but causes mayhem if ruptured. The rupture of a “vulnerable plaque” was the unfortunate case with Tim Russert, the late, great host of Meet the Press. Mr. Russert was known to have CAD and by all accounts was well optimized, but suffered an unexpected and unpredictable rupture of a “vulnerable plaque,” which proved fatal.

Consider traditional fixed stenotic lesions that cause the usual flow limitations, but also remember that a modest lesion could represent a “vulnerable plaque” capable of rupture. —DML

Cases reprinted with permission from Medical Malpractice Verdicts, Settlements and Experts, Lewis Laska, Editor, (800) 298-6288.