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A Patient With Chest Pain of Sudden Onset
Liability cases can be challenging. MD News uses an example of an actual case to show you how to handle the situation.
On March 9 at 2 p.m., a 42-year-old male with a history of
hypertension and cocaine abuse presented to the Emergency
Department (ED) with complaints of severe chest pain of sudden
onset. His blood pressure was 167/106; pulse rate, 86;
respirations, 18; and temperature, 98.7.
He was started on lisinopril and given nitroglycerin. A chest
X-ray showed an enlarged cardiac silhouette and prominent right
hilum. A CT scan with contrast was ordered, but the IV infiltrated,
so the CT was done without contrast. It showed diffuse infiltration
of the mediastinum, a moderate-sized high attenuation pericardial
effusion and dilation of the ascending aorta measuring 5 cm (normal
4 cm) at the level of the right pulmonary artery.
The radiologist discussed the findings with the emergency
physicians. He considered the results inconclusive and strongly
recommended a repeat CT with contrast. It was never done. At 11
p.m., the patient was admitted to ICU with a working diagnosis of
pulmonary embolism (PE) and poorly controlled hypertension. A
heparin drip was started. A subsequent ventilation/ perfusion lung
scan was normal, essentially ruling out PE. The consulting
pulmonologist's diagnosis was pericarditis, and he started the
patient on indomethacin.
The ICU resident reviewed the CT scan with the radiologist, who
expressed concern about possible hemopericardium. The resident
called our insured cardiologist on the morning of March 10, and
they agreed to discontinue heparin until hemopericardium was ruled
out. The insured said he would see the patient in consultation and
suggested a 2-D transthoracic echocardiogram (TTE) to assess the
potential hemopericardium. The resident ordered the TTE that night,
but did not write an order for a cardiology consultation. The TTE
was interpreted by the cardiologist, who described a 200 cc
pericardial effusion, stating there was no evidence of tamponade.
The aortic root was said to be normal in size; the size of the
ascending aorta was not mentioned.
The patient continued on indomethacin. His ongoing chest pain
was managed with Dilaudid. He seemed stable and was transferred
from the ICU to the medical floor on the afternoon of March 10,
under the care of a hospitalist. He was found dead in his room on
March 11 before being seen by the cardiologist. An autopsy revealed
pericardial tamponade secondary to an aortic dissection that began
3 cm above the aortic valve, just below the reflection of the
Three cardiologists opined the ED physicians should have
immediately performed a CT with contrast in accordance with the
radiologist's recommendation. Had that been done, the dissection
would have been diagnosed. They agreed that the TTE showed no
dissection, aortic regurgitation or tamponade, but they added that
a TTE will not usually show dissections of the distal ascending
aorta. They felt the insured's failure to mention the aortic root
enlargement and ascending aortic dilation was a breach in the
standard of care because these findings indicated the need for an
urgent follow-up test, such as an MRI or a transesophageal
echocardiogram (TEE) to rule out dissection.
A cardiothoracic surgeon believed the patient would have
survived surgery if the dissection had been diagnosed. He opined
that the CT scan was suggestive of dissection because it showed
blood in the mediastinum and that the patient's presenting symptoms
were consistent with dissection. He opined that diagnosing
pericarditis without ruling out aortic dissection was
A radiologist examined the CT films and found them suspicious
for dissection, even without contrast, because they revealed
infiltration of blood into the mediastinum. He believed that if the
CT had been repeated with contrast, the dissection would have been
The codefendant hospital's ED physicians faced the greatest
liability due to their failure to order a repeat CT scan with
contrast. The hospital claimed that the insured cardiologist was a
consultant with responsibility for managing the patient. The
defense counsel responded that the insured was not involved in
establishing the differential diagnosis and never saw the patient.
However, the TTE report stated that the patient was referred by the
pulmonologist for evaluation of chest pain and pericardial
effusion. The defense counsel pointed out that when the insured
cardiologist interpreted the TTE, he was unaware of the CT scan
suggestive of possible dissection. If he had seen that report, our
insured said he would have ordered a CT scan with contrast or an
MRI because of the known limitations of TTE in diagnosing aortic
The case was settled, with the hospital contributing 50% and the
pulmonologist and insured cardiologist each contributing 25%.
It is important to rapidly identify acute dissections involving
the ascending aorta, which are considered surgical emergencies.
Hemodynamically stable dissections confined to the descending aorta
are treated medically.
The Daily (Stanford) system classifies dissections that involve
the ascending aorta as type A and all other dissections as type B.
Ascending aortic dissections are almost twice as common as
descending dissections. Aortic arch involvement is seen in up to
30% of dissections.
The most important predisposing factor is hypertension (72%
overall and more common in type B). Under age 40, only 34% have
hypertension. Marfan syndrome is present in 50% of those under age
40. Most patients with Marfan syndrome and aortic dissection have a
family history of dissection.
Other predisposing factors, especially in younger patients,
include aortic aneurysm (13%), bicuspid aortic valve (9%), previous
aortic valve replacement (5%), cardiac catheterization (2%), weight
lifting or other strenuous resistance training, and crack cocaine
Patients with acute aortic dissection typically present with
abrupt onset of severe, sharp or "tearing" posterior chest or back
pain (in dissection distal to the left subclavian) or anterior
chest pain (in ascending aortic dissection). The pain can radiate
anywhere in the thorax or abdomen. Other symptoms relate to
impaired blood flow to an organ or limb induced by the dissection
or its propagation. Impaired or absent blood flow to peripheral
vessels is manifested as a weak or absent carotid, brachial or
Descending aortic dissection can lead to splanchnic ischemia,
renal insufficiency, lower extremity ischemia or focal neurologic
deficits due to spinal artery involvement. Ascending aortic
dissection can induce one or more of the following:
- Acute aortic insufficiency leading to a diastolic decrescendo
murmur, hypotension or heart failure. The murmur is most commonly
heard along the right sternal border, as compared with the left
sternal border when insufficiency is due to primary aortic valve
- Acute myocardial ischemia or MI due to coronary occlusion, most
commonly involving the right coronary artery.
- Cardiac tamponade and sudden death due to rupture into the
- Hemothorax if the dissection extends into the pleural
- Variation (>20 mm Hg) in systolic blood pressure between the
- Syncope, stroke or decreased consciousness due to direct
extension of the dissection into the carotid arteries.
Aortic dissection is suspected from the history and physical
examination. An analysis of 250 patients with acute chest and/or
back pain found that 96% of acute aortic dissections could be
identified based upon some combination of three clinical
- Abrupt onset of thoracic or abdominal pain with a sharp,
tearing and/or ripping character
- Mediastinal and/or aortic widening on chest radiograph
- A variation in pulse (absence of a proximal extremity or
carotid pulse) and/or blood pressure (>20 mm Hg difference)
between right and left arms Because conventional chest radiographs
show mediastinal widening in only 63% of type A dissections and 56%
of type B dissections, additional imaging studies are usually
The nature and location of the chest pain and the absence of ECG
changes characteristic of ischemia usually allow aortic dissection
to be distinguished from angina pectoris or an MI. In a review of
464 patients, the ECG was normal in 31%, showed nonspecific ST and
T wave changes in 42%, ischemic changes in 15%, and, among patients
with an ascending aortic dissection, evidence of an acute MI in
Aortography has been largely replaced by noninvasive testing. It
has a reported sensitivity of 88% and a specificity of 94%. The
positive and negative predictive values are 96% and 84%,
respectively. CT scan (with contrast) is often the initial
screening study, especially in the ED setting where TEE and MRI are
less available, especially after hours. In two reports of 162 and
110 patients, the sensitivity of standard CT for the diagnosis of
aortic dissection was 83% and 98%, and the specificity was 87% and
100%. Accuracy is improved with spiral (helical) CT.
MRI is highly accurate for evaluating the thoracic aorta in
suspected dissection. In a prospective trial of 110 patients with
suspected aortic dissection, the sensitivity and specificity of MRI
were each 98%.
TTE has limited utility for evaluation of aortic dissection
because of its inability to adequately visualize the distal
ascending, transverse and descending aorta in most patients. TTE is
most useful for assessing cardiac complications of dissection,
including aortic insufficiency and pericardial
Multiplane TEE can be performed in the ED, although it requires
esophageal intubation. The following may be seen: intimal
dissection flaps, true and false lumens, pericardial effusion,
concomitant aortic regurgitation and visualization of the proximal
coronary arteries. In three large series, the sensitivity of TEE
for the diagnosis of aortic dissection was 97% to 99%. However, the
specificity of TEE alone has been as low as 77% to 85%.
The guidelines suggested in this article are not rules, do
not constitute legal advice and do not ensure a successful outcome.
They attempt to define principles of practice for providing
appropriate care. The principles are not inclusive of all proper
methods of care nor exclusive of other methods reasonably directed
at obtaining the same results.
The ultimate decision regarding the appropriateness of any
treatment must be made by each health care provider in light of all
circumstances prevailing in the individual situation and in
accordance with the laws of the jurisdiction in which the care is
The following reference is from UpToDate, Rose BD (Ed), UpToDate,
Waltham, MA 2008. Copyright 2008 UpToDate, Inc. Accessed on June
10, 2009. For more information, visit www.uptodate.com.
Manning WJ. Clinical manifestations and diagnosis of aortic
dissection. Last literature review completed through May 2009.
MD News February 2010