64-year-old male. Significant cardiovascular risk burden: advanced peripheral arterial disease, status post bilateral femorofemoral bypass (2018), hypertension (poorly controlled), hyperlipidemia, Type 2 diabetes (HbA1c 7.8%), active tobacco use (approximately 1 ppd, many years), significant daily alcohol use. Recent relocation — newly established with outpatient cardiologist.
Patient seen by cardiologist to establish as new patient. Vitals: BP 182/76 mmHg; HR 49 bpm. EKG obtained. Automated machine interpretation: Sinus brady; anteroseptal MI of indeterminate age; moderate T-wave abnormality; consider inferior ischemia. No documented interp by the cardiologist in his note.
Clinical decisions made at this visit:
Beta-blocker (bisoprolol/HCTZ) discontinued
Amlodipine discontinued
New antihypertensive regimen initiated: losartan, HCTZ, hydralazine
No aspirin ordered
No urgent or emergent cardiac workup initiated
No referral for urgent evaluation
No biomarkers ordered
Plan: return in 1–2 weeks with blood pressure diary
Patient presents to the ED two days later at 4:48pm with complaints of Band-like chest pain, Near-syncope / dizziness, dyspnea and diaphoresis. His BP was 162/63 mmHg. The patient disclosed he had recently seen a cardiologist who changed his cardiac medications.
ED workup:
EKG #1 (5:11 PM): Sinus rhythm; Q-waves in leads II and III
Aspirin 325 mg administered at 6:39 PM.
Troponin Draw 1 (5:36 PM): 33 ng/L
EKG #2 (6:41 PM): No STEMI criteria met
Troponin Draw 2 (7:27 PM collected / 8:06 PM resulted): 37 ng/L
On-call cardiologist contacted at 6:58 PM — between Draw 1 and Draw 2. Per the ED physician's note, the on-call cardiologist personally reviewed the EKG remotely by phone. Cardiologist was told the patient had one mildly elevated troponin, Q-waves, no STEMI, known PAD, and recent medication changes. Cardiologist recommended: Repeat troponin. If no significant delta — admit locally for further evaluation. If elevated — transfer for possible cardiac catheterization.
The on-call cardiologist:
Never came to the bedside
Generated no written note, no formal consultation document, and no written orders
Was not documented as being contacted again after Draw 2 resulted at 8:06 PM
The patient was transferred to observation/admission status under a hospitalist at 9:25 PM.
Patient's subsequent troponin course (under hospitalist care, after 9:25 PM) was as follows:
Draw 3 10:34 PM 11:13 PM 63 ng/L
Draw 4 1:23 AM 2:27 AM 69 ng/L
Draw 5 (STAT) 4:00 AM 4:44 AM 65 ng/L
At 4:19 AM a repeat EKG was generated reading:
"INFERIOR INFARCT, ACUTE + ANTERIOR INFARCT ACUTE (LAD) + >>> Acute MI <<< — ABNORMAL ECG — UNCONFIRMED"
Transfer was ordered at 4:49 AM. The patient arrived at a cath-capable facility at 5:34 AM. Catheterization began at 5:42 AM.
Catheterization findings:
Total calcific occlusion, proximal RCA (dominant vessel)
Total occlusion, LAD at ostium
90% distal Left Main stenosis
90% proximal Circumflex stenosis
Incessant ventricular fibrillation requiring 15 defibrillations
Emergency intubation, Impella CP placement
No revascularization achievable
The patient died seven days later. Cause of death listed on death certificate: NSTEMI → Cardiogenic Shock → Acute Kidney Injury.
Questions: Did the outpatient cardiologist on June 6th and the inpatient on call cardiologist on June 8th meet the standard of care?
Files:
No questions yet!
Do you believe there might have been medical error?
There should be close review of the EKGs. There was such incredible coronary disease with two being 100% occluded that it is hard to imagine there were not ST elevations or other criteria that would have suggested the need for emergent cath.
Do you believe there might have been causation (i.e. the medical error resulted in an injury)?
The extent of coronary disease here was very significant and peripheral arterial disease may have limited options even if taken to the cath lab sooner. However, "no revascularization achievable" is very strange and certainly needs to be better understood. A delay + no revascularization definitely contributes to causation.
What makes you a good expert for this case?
I am an interventional cardiologist with a specialty in STEMI and cardiogenic shock requiring mechanical circulatory support (ie Impella CP).
How often do you encounter cases similar to this one in your practice?
Several times per week as this is my specific clinical specialty.
Do you believe there might have been medical error?
Tragic outcome in a patient with extraordinary cardiovascular risk burden and end-stage diffuse coronary disease at catheterization (total LAD ostial and proximal RCA occlusions, 90% left main, 90% proximal circumflex, incessant VF). Mortality in this anatomic scenario is extremely high regardless of timing. The outpatient visit has documentation concerns (no recorded EKG interpretation, beta-blocker discontinuation rather than dose reduction), but without primary records these are judgment questions rather than clear deviations. The on-call cardiologist's initial recommendation (serial troponins, transfer if rising) was reasonable for the information available. Time to catheterization (~12 hours) fell within the 24-hour window for early invasive NSTE-ACS management, though earlier transfer could be argued. Most importantly, causation is highly uncertain. Given the severity and distribution of disease, it is unclear that earlier intervention would have changed the outcome. I do not see a clear medical error from the information available.
Do you believe there might have been causation (i.e. the medical error resulted in an injury)?
Causation is highly unlikely given the catheterization findings. The patient was found to have total occlusion of the proximal RCA, total occlusion of the LAD at the ostium, 90% distal left main stenosis, and 90% proximal circumflex stenosis, with incessant ventricular fibrillation requiring 15 defibrillations. This represents severe, diffuse, multi-vessel coronary artery disease that the operator was ultimately unable to revascularize. The realistic alternatives at any earlier point in the timeline would have been emergency CABG in a hemodynamically unstable patient with severe LV dysfunction, or attempted high-risk PCI of disease that proved technically unrevascularizable. Mortality in this anatomic and clinical scenario is extraordinarily high regardless of the timing of recognition or transfer. Even granting the possibility that earlier workup at the outpatient visit or earlier transfer from the ED could have been pursued, it is not clear that the outcome would have been meaningfully different. The patient's underlying disease burden (advanced PAD, diabetes, long-standing tobacco use, and the coronary anatomy described above) reflects decades of progressive vascular disease that had reached a point where survival was unlikely with any intervention. For these reasons, I do not believe there is a likely causal connection between any potential lapse in care and the patient's death.
What makes you a good expert for this case?
I am a board-certified interventional cardiologist with 7 of clinical practice. This case sits squarely within my daily clinical practice. I routinely manage patients presenting with NSTE-ACS, evaluate the appropriateness and timing of invasive versus conservative strategies, perform catheterization and revascularization in patients with multi-vessel and left main disease, and consult on cases involving on-call cardiology decision-making, troponin interpretation, and transfer logistics. I also regularly care for patients with the comorbidity profile seen here, and am familiar with the secondary prevention standards relevant to the outpatient encounter.
How often do you encounter cases similar to this one in your practice?
The clinical scenarios in this case (NSTE-ACS workup, serial troponin interpretation, on-call decisions about timing of invasive management, and transfer decisions) are part of my routine practice. The patient comorbidity profile (advanced PAD, diabetes, tobacco use) is also common in my practice. The severity of coronary disease ultimately found at catheterization, however, is unusual; total LAD ostial and proximal RCA occlusions with severe left main and proximal circumflex disease and incessant VF represents an extreme end of the disease spectrum that I encounter only occasionally.
Do you believe there might have been medical error?
This patient has all the risk factors for severe CAD. Sometimes, in clinic setting, patients do not disclose their symptoms completely. They may not want to share. That is where clinical intuition comes into play. This patient has so many clinical findings and past medical history that further testing should have been ordered. An echocardiogram, nuclear stress test and/or a coronary CTA should have been discussed. If the patient refuses, then it should be documented. Second thing is that we have known PAD history, and bypass. This patient should have been placed on Aspirin and a statin.
Do you believe there might have been causation (i.e. the medical error resulted in an injury)?
In this case, further testing should be considered. There is definite indication for ASA. And a statin. These should have been handled during the initial visit. During ER visit, the consultant cardiologist should definitely place a note. Again, with these many risk factors, I would have started heparin infusion, cycle the troponin, and made sure that the nurse would call me with the 3rd set. EKG with the third set should be obtained.
What makes you a good expert for this case?
I have taken countless ER calls, and worked with thousands of patients like this. This is my typical patient portfolio. I make sure that these patients do not leave the office without testing scheduled. And documented. Also they need to have an antiplatelet in their list. During call, I go over all the EKGs, and get called for any change in clinical symptoms and troponins.
How often do you encounter cases similar to this one in your practice?
Almost on a daily basis. In my clinic, at least 4-5 patients a week have almost identical histories. And in my ER calls, I have encountered many NSTEMIs that convert to STEMIs. You need to be vigilant, and extra careful, in patients like the one described, they are all vasculopaths, and anything can go south in a second.
Do you believe there might have been medical error?
There had to have been a good reason to stop the aspirin; that's the only thing that jumps out at me as odd.
Do you believe there might have been causation (i.e. the medical error resulted in an injury)?
Unless patient was on another anti platelet or DOAC
What makes you a good expert for this case?
Jimmy Kerrigan, MD, FSCAI, FACC, FASNC is an Assistant Professor of Medicine at the University of Tennessee Health Science Center and an interventional cardiologist at Saint Thomas Heart at Ascension Saint Thomas West in Nashville, Tennessee. He co-chairs the Interventional Cardiology Affinity Group for Ascension, chairs the Interventional Cardiology Chronic Total Occlusion Affinity Group for Ascension, and serves as co-director of complex coronary intervention for Ascension Saint Thomas. He is also co-director of the Pulmonary Embolism Response Team at Ascension Saint Thomas West and is involved in the leadership teams for interventional cardiology, inpatient pharmaceuticals and therapeutics, inpatient cardiovascular medicine, outpatient practices, clinical research in cardiovascular medicine, and quality improvement projects for Ascension Saint Thomas. He is interested in research in and the management of complex coronary disease, including chronic total occlusions, intracoronary imaging and physiology, cardiogenic shock, and the management of pulmonary embolism. He is board-certified in interventional cardiology, general cardiology, nuclear medicine, interpretation of vascular ultrasound, and internal medicine. He currently sees outpatients in Nashville, Gallatin, and Fayetteville, Tennessee. After finishing his undergraduate studies at Vanderbilt University in Nashville, he attended Washington University in St. Louis for medical school, where he continued his training as a resident in internal medicine. After working for a year as a hospitalist at Barnes Jewish Hospital, he joined the Cleveland Clinic for general cardiology fellowship, followed by a two-year fellowship in interventional cardiology, focusing on structural heart disease, peripheral vascular disease, and complex coronary intervention in his second year. He then joined Ascension Saint Thomas Heart in August 2019. He and his wife, Deborah, a stroke neurologist in Nashville, have two school-aged children and enjoy hiking, fishing, and attending local sporting events in their free time.
How often do you encounter cases similar to this one in your practice?
frequently isn't the right word, but it's not uncommon (i'm an interventional cardiologist, so i treat heart attack patients daily)
Do you believe there might have been medical error?
Both cardiologists met standard of care. Both initial and subsequent troponin are MINIMALLY elevated, with flat trajectory that is unconcerning. No immediate cardiology consult was needed. ECG indicates OLD myocardial infarction -- opinion further bolstered by the fact that he was "non-revascularizable" -- this points to chronic CAD, not acute. Outpatient, only medical therapy is indicated in the absence of symptoms, which the patient did not have.
Do you believe there might have been causation (i.e. the medical error resulted in an injury)?
Patient with chest pain/unstable angina presented to ER -- no high-risk markers, electrically and hemodynamically stable -- no indication for emergent cardiac consult or intervention.
What makes you a good expert for this case?
22 years of interventional cardiology practice, including 5 years of directorship at tertiary medical center/university setting. Multiple publications, including book chapters and international conferences, TV appearances. Previous experience in deposition and courtroom testimony.
How often do you encounter cases similar to this one in your practice?
All the time -- common presentation on almost every call day.
Do you believe there might have been medical error?
The man is in very poor overall health. The fact that the troponin, which if it is HS-troponin - is elevated, but not at the level of an NSTEMI and certainly not a stemi However - the cardiologist not consulting within 24 hours is not standard of care. The cardiologist who did the cath noted high grade stenosis of the LM. Catheter likely cause ischemia - and with cto of rca and lad - he likely had vt due to low flow and with all other co-morbidities - succumb eventually The interventionalist - is not at fault here
Do you believe there might have been causation (i.e. the medical error resulted in an injury)?
Patient is very poor protoplasm
What makes you a good expert for this case?
I’m an interventional cardiologist - seen this happen many times
How often do you encounter cases similar to this one in your practice?
Just had a similar case - but I put in impella due to a very high lvedp - patient ended up with surgery - he is still alive
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