Coronary Prevention

Failure to diagnose Coronary Heart Disease (CHD) is a common cause of action in medical malpractice litigation. Though breach of Standard of Care may be proven, Causation is often difficult to establish.

Both recreational drugs and (particularly in over-dosage) prescription medications that stimulate the sympathetic nervous system - cocaine[1], norepinephrine, thyroxine[1a], phenylephrine[1b] - may trigger Myocardial Infarction in people with Coronary Heart Disease and even in otherwise normal individuals. There is some evidence[1c] [full-text] that the dihydropyridine calcium antagonists such as Adalat (nifedipine), rather than protecting the heart, may actually increase the probability of Myocardial Infarction in patients with Coronary Heart Disease.

Long-term prevention of a first heart-attack consists mainly of addressing well-publicised life-style risk factors - obesity, sedentary habits, smoking - and detecting and treating high blood pressure and high cholesterol. Estrogen replacement for postmenopausal women, modest alcohol consumption and Vitamin E supplements may contribute. These health risks and benefits need to be, and usually are, addressed to some extent whether or not CHD is present or is likely to be present[1d].

PRACTICE POINT

Standard medical care requires identification and treatment of the major causes, whether or not Coronary Heart Disease is diagnosed

Only in exceptional circumstances is it possible to show on the balance of probability that failure to detect or treat one remediable risk factor - blood pressure or cholesterol, for example - would have made a material difference to the subsequent development of a first heart-attack.

In the short-term, however, the situation has changed during the last few years. A recent review article[2] on the efficacy of drug therapy in suspected Acute Myocardial Infarction summarised the evidence from the many very large clinical studies on Aspirin, Heparin (blood-thinner) and Fibrinolytic (clot-dissolving) Therapy.

Misdiagnosis of unstable angina and Acute Myocardial Infarction is one of the top 5 causes of successful malpractice litigation following discharge from the Emergency Room[2a]. Inadequate history-taking[2b] and failure to undertake or correctly interpret an ECG and cardiac enzymes[2c] account for the majority of cases.

The bottom-line is that prescribing half a regular adult aspirin on suspicion of a developing heart-attack is the most important therapy.

PRACTICE POINT

Critical actions on suspecting a heart-attack are:

1 half an aspirin
2 ECG
3 cardiac enzymes

For certain ElectroCardioGraphic (ECG) findings confirming Acute Myocardial Infarction, Fibrinolytic Therapy materially reduces the risk of death, particularly if given within 12 hours of the onset of symptoms.

PRACTICE POINT

If ECG and cardiac enzymes are nondiagnostic, failure to hospitalise will likely be shown to have a material effect only if remediable complications developed