Found 27 Results Sorted by Case Date
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Florida – Cardiology – Patient With Serious Hemodynamic Compromise After Receiving A Cardiac Stent For Myocardial Infarction



On 4/5/2012, a patient arrived at a hospital after suffering a heart attack.  He received a stent to the left anterior descending artery and was transferred to the intensive care unit.

At 9:00 p.m., the patient began to experience chest pains and lowered blood oxygen.  A cardiologist did not report to the hospital to examine the patient at the time.

At 12:00 a.m., the patient began to have serious hemodynamic compromise.  The cardiologist did not report to the hospital to examine the patient at the time.

At 3:00 a.m., over three hours after the onset of the patient’s serious hemodynamic compromise, the cardiologist reported to the hospital to examine the patient.

Prior to reporting to the hospital, the cardiologist had been made aware of each of the patient’s clinical status changes.  The cardiologist planned to transfer the patient to another hospital where the patient was to undergo a pericardial window, performed by a cardiothoracic surgeon.

Prior to undergoing a pericardial window, the patient expired.

The Board judged the cardiologist’s conduct to be below the minimal standard of competence given that he failed to report to the hospital to attend to the patient’s clinical status changes, to properly recognize the need for an immediate pericardiocentesis, and to perform an immediate pericardiocentesis.  Upon arriving at the hospital, the cardiologist failed to recognize that the patient’s clinical deterioration was such that an immediate pericardiocentesis needed to be performed to improve the patient’s blood flow.

The Board issued a letter of concern against the cardiologist’s license.  The Board ordered the cardiologist pay a fine of $7,500 against his license and pay reimbursement costs for the case at a minimum of $5,239.98 and not to exceed $7,239.98.  The Board also ordered that the cardiologist complete five hours of continuing education in “risk management” and complete five hours of continuing medical education in cardiology.

State: Florida


Date: July 2017


Specialty: Cardiology, Hospitalist, Internal Medicine


Symptom: Chest Pain


Diagnosis: Acute Myocardial Infarction, Acute Myocardial Infarction


Medical Error: Improper treatment, Delay in proper treatment


Significant Outcome: Death


Case Rating: 3


Link to Original Case File: Download PDF



Florida – Internal Medicine – Patient Presents With Chest Pain That Started To Radiate To His Arms



From 2/22/2010 through 11/2/2011, a patient presented to an internist for medical assessment and/or treatment.

The patient presented to the internist with chest pain, unknown family medical history, several comorbid medical problems related to possible heart disease, and possible reflux esophagitis.

On 6/22/2011, during a medical evaluation, the internist noted that the chest pain changed in characteristic and began to radiate to his arms.

Despite the change in chest pain noted by the internist on 6/22/2011, he did not recommend a cardiologic evaluation and continued to treat the patient for possible reflux esophagitis.

On 10/4/2011, during a medical evaluation, the internist noted no complaints of heartburn but continued complaints of chest pain.

Between 6/22/2011 and 12/3/2011, the internist failed to refer the patient for cardiological evaluation.

On 12/3/2011, the patient died from a cardiac arrest.

The Medical Board of Florida issued a letter of concern against the internist’s license.  The Medical Board of Florida ordered that the internist pay a fine of $7,500 against his license and pay reimbursement costs for the case at a minimum of $3,458.14 and not to exceed $5,458.14.  The Medical Board of Florida ordered that the internist complete ten hours of continuing medical education in cardiovascular medicine and five hours of continuing medical education in “risk management.”

State: Florida


Date: April 2017


Specialty: Internal Medicine


Symptom: Chest Pain


Diagnosis: Acute Myocardial Infarction, Cardiac Arrhythmia


Medical Error: Referral failure to hospital or specialist


Significant Outcome: Death


Case Rating: 4


Link to Original Case File: Download PDF



Arizona – Cardiology – Multiple Complications During Cardiac Catheterization With Repeat Thrombosis Of The Right Coronary Artery



On 05/30/2014, a 56-year-old man presented with acute onset chest pain.  The cardiologist discovered that the left anterior descending (LAD) and right coronary artery (RCA) had significant stenosis.  The cardiologist first intervened up on the LAD with a stent, but found the proximal edge had “haziness” so he did not intervene further.  The cardiologist then focused on the RCA.  The first stent was deployed, but had a dissection for which the cardiologist deployed multiple other stents to correct.  Brisk flow in all coronaries was reported at the conclusion of these procedures.

The patient experienced a sudden thrombosis of the RCA two days later.  The cardiologist placed 3.5 diameter stents and used 2.0 and 2.5 mm balloons to reopen the RCA.  The patient also developed cardiogenic shock and acute respiratory failure from probably aspiration and required emergency intubation, which was described as traumatic.  The patient was on pressors and an intra-aortic balloon pump (IABP) was placed.

On 06/02/2014, the patient was noted to be improving with decreased dependence on pressors.  The IABP was removed the following day, but the patient became progressively agitated and experienced increased ST changes.

On 06/05/2014, the patient became hypoxic with ST elevation and was taken back to the catheterization lab where it was determined that the RCA was thrombosed.  The cardiologist performed balloon angioplasty on the RCA during which a perforation of the posterior descending (PDA) branch occurred.  The cardiologist made several attempts to stop the bleeding, including prolonged balloon inflations, which failed, and an attempt to completely occlude the PDA branch by placing a covered stent.  The stent could not be placed or withdrawn in the location of concern and was deployed more proximally.  A wire was left in the mid-RCA, which was ultimately coiled by an interventional radiologist due to ongoing bleeding.  The cardiologist noted a pericardial effusion, which did not demonstrate tamponade and did not require pericardiocentesis.

Over the next several days, the patient continued to experience worsening abdominal distention, right heart failure, episodes of bradycardia (which the Board deemed was not adequately addressed by the cardiologist), mottling of the lower extremities, liver congestion, and acute renal failure.  On 06/08/2014, the IABP was removed.

On 06/10/2014, the patient went into multi-organ system failure.  The decision was made to make the patient comfortable.  The patient had runs of ventricular arrhythmias and passed away that evening.

The Board judged that while there was no single defined even in the cardiologist’s treatment of the patient that would be considered a deviation of a standard of care, there were several areas of concern regarding his treatment of the patient.

The Board ordered the cardiologist to be placed on probation given complications among several patients he had managed.  He was prohibited from performing interventional cardiology until the Board granted him permission.  The cardiologist must provide evidence that he is able to safely perform interventional cardiology before the Board would consider lifting the prohibition.

State: Arizona


Date: April 2017


Specialty: Cardiology


Symptom: Chest Pain


Diagnosis: Acute Myocardial Infarction


Medical Error: Procedural error


Significant Outcome: Death


Case Rating: 3


Link to Original Case File: Download PDF



California – Cardiology – Inferior Wall Myocardial Infarction With Wire Placed In Small Side Branch And Balloon Dilated



On 7/5/2013, a 67-year-old female was brought by ambulance to a medical center for severe chest pains.  An electrocardiogram (EKG) was obtained and was consistent with inferior wall myocardial infarction.  The patient was immediately brought to the cardiac catheterization lab for angiography and angioplasty.

A cardiologist was noted to by the Board to have placed a wire in a small side branch and not in the distal right posterior descending artery, where the culprit lesion was located.  He inflated the balloon in the small side branch leading to a small perforation.  He then moved his wire and made another inflation, which resulted in a larger perforation.  After causing these four perforations and a large pericardial effusion, the cardiologist proceeded to inflate the balloon an additional four times.

At 7:47 p.m., the pericardial effusion was documented.  However, pericardiocentesis was not performed until 8:21 p.m.  The delay occurred even though the patient’s blood pressure continued to decline.

The Medical Board of California judged the cardiologist’s conduct as having fallen below the standard of care given failure to perform a pericardiocentesis in a timely manner, failure to identify the pericardial effusion in a timely manner, failure to place the wire in the correct location, and failure to address the culprit lesion.

The Medical Board of California placed the cardiologist on probation with stipulations to complete 40 hours annually while on probation of continuing medical education in the areas of deficiency, complete a clinical competence assessment program, and complete a professional enhancement program.  The professional enhancement program would include a quarterly chart review, semi-annual practice assessment, and semi-annual review of professional growth and education.

State: California


Date: April 2017


Specialty: Cardiology


Symptom: Chest Pain


Diagnosis: Acute Myocardial Infarction, Post-operative/Operative Complication


Medical Error: Wrong site procedure, Delay in proper treatment, Diagnostic error, Procedural error


Significant Outcome: N/A


Case Rating: 2


Link to Original Case File: Download PDF



California – Emergency Medicine – Chest Pain, Shortness Of Breath, Left Bundle Branch Block On EKG



On 1/19/2014 at 4:40 a.m., a patient arrived at the emergency department complaining of shortness of breath and weeks of intermittent chest pain.

At 4:50 a.m., an ED physician evaluated the patient.  The patient was hypotensive, mildly tachycardic, tachypneic, and hypothermic.  He had rales, rhonchi, and a few wheezes.  The ED physician documented “Today, his pain is less,” but otherwise did not document any further description of the patient’s pain.

In his dictated note, the ED physician explained that he was concerned with the patient suffering septic shock.  In a subsequently written narrative, the differential diagnosis was expanded to include cardiac causes.

Laboratory studies were ordered along with an EKG, a troponin level, and a brain natriuretic peptide level.  The EKG was performed timely and was abnormal.  While the ED physician identified a left bundle block pattern (“LBBP”) in his dictated notes, he neither offered further interpretation of the EKG nor referenced criteria known to be helpful in identifying myocardial infarction in those with an LBBP on EKG.  The ED physician wrote that the EKG showed an LBBP “consistent with a myocardial infarction…”

The small community hospital where the patient presented had an ST-elevated myocardial infarction (“STEMI”) protocol in collaboration with a larger regional hospital better equipped to handle patients with cardiac emergencies.  Once activated, the protocol provides for rapid transportation of the patient to the larger hospital by ambulance.  The ED physician did not activate this protocol.

45 minutes after the EKG was performed, the troponin and BNP results indicated myocardial infarction and congestive heart failure.  A subsequent chest x-ray revealed pulmonary edema.  At this point, the ED physician called the on-call cardiologist to discuss transfer of the patient for treatment at a larger regional hospital.

The Board issued a reprimand and expressed concern that the ED physician departed from the standard of care by failing to obtain and document a more robust history and failing to more promptly consult cardiology regarding the patient’s abnormal EKG.

The Board ordered 40 hours of continuing medical education.

State: California


Date: October 2016


Specialty: Emergency Medicine, Cardiology, Internal Medicine


Symptom: Chest Pain, Shortness of Breath


Diagnosis: Acute Myocardial Infarction, Heart Failure


Medical Error: Delay in proper treatment, Failure to examine or evaluate patient properly, Lack of proper documentation


Significant Outcome: N/A


Case Rating: 3


Link to Original Case File: Download PDF



Washington – Family Medicine – Reproducible Chest Pain Diagnosed As Atypical Musculoskeletal Pain



On 5/11/2016, a patient presented to a family practitioner’s clinic complaining of three previous episodes of sharp chest pain, just left of the sternum.  The patient was an athletic 60-year-old male with a family history of coronary artery disease and myocardial infarction, and a medical history of hyperlipidemia.  The family practitioner performed a physical examination that revealed tenderness upon palpation of the chest wall and when the patient took a deep breath.  The family practitioner diagnosed atypical musculoskeletal pain and ordered blood work.  The family practitioner did not pursue further cardiac workup.

On 5/24/2015, the patient died from hemopericardium following a ruptured myocardial infarction.

The Commission stipulated the family practitioner reimburse costs to the Commission, complete an Advanced Cardiovascular Life Support (ACLS) course, allow the Commission to conduct annual announced practice reviews, and write and submit a paper of at least 1000 words, with annotations, on how to properly respond to a 60 year old male presenting with chest pain with a medical history including hyperlipidemia and a family history of coronary artery disease.

State: Washington


Date: September 2016


Specialty: Family Medicine, Internal Medicine


Symptom: Chest Pain


Diagnosis: Acute Myocardial Infarction


Medical Error: Underestimation of likelihood or severity


Significant Outcome: Death


Case Rating: 4


Link to Original Case File: Download PDF



Arizona – Emergency Medicine – Gastroenteritis Diagnosed For A Patient With Shortness Of Breath, Palpitations, Chest Pain, Nausea And Vomiting, And Numbness Of The Arms Or Legs



The Board received notice of a malpractice settlement.

On 12/03/2012, a 63-year-old female presented to urgent care.  The patient’s boyfriend completed her health history document and provided the urgent care physician (UC physician) with information on the patient’s current medications and her history of a motor vehicle accident a year prior to the appointment.  She was noted to have a history of frequent and severe headaches.

The patient’s current symptoms included shortness of breath, “palpitations or pounding heart…chest pain or pressure,” “nausea and vomiting,” and “numbness of the arms or legs.”  The patient reportedly had neck or back pain with “numbness of the arms or legs.”

The medical assistant (MA) completed the Urgent Care “Abdomen/Groin GI/GU” encounter form.  On the form, the MA noted the patient’s blood pressure to be 106/68 with respirations of 18, “O2 99%,” and a temperature of 95.5.  The UC physician wrote on the same encounter form that the patient had been experiencing symptoms, which included four hours of vomiting and myalgia.  The UC physician noted that the patient felt like she had impending diarrhea.

The encounter documentation stated that she had a history of a cholecystectomy and an appendectomy.  The UC physician checked off current patient symptoms of nausea, vomiting, and chills.  He checked boxes indicating a “no” to constipation, fever, black stools, diarrhea, flank pain, heartburn, jaundice, dysuria, hematemesis, hematuria, dyspepsia, fatty food intolerance, and post-prandial pain.

In his objective notations, the UC physician noted only a single finding of abdominal tenderness by checking “yes.”  He checked “no” to 18 other exam findings which included the cardiac, pulmonary, skin, neurologic, gastrointestinal, and genitourinary systems along with mental status.

The UC physician’s diagnosis was listed as gastroenteritis and “viral syndrome” was checked as “no.”  The UC physician concluded the written record by indicating “medications” and giving prescriptions for prochlorperazine 25 mg, OTC Imodium, and Pepcid AC.  He also noted that he had counseled the patient on her diet.

At 10:00 a.m. on 12/04/2015, there was a final entry in the patient’s record, a handwritten note, that the Scottsdale Police had contacted the UC physician informing him that the patient was found unresponsive on that morning and that the paramedics could not revive her.

An autopsy on the patient revealed a 95% atherosclerotic occlusion of the major coronary arteries, ventricular hypertrophy, acute coronary artery thrombosis, pericarditis, chronic pulmonary and renal disease, and an adrenal mass.  The cause of death was acute myocardial infarction.

The Board judged the UC physician’s conduct to be below the minimum standard of competence given failure to diagnose acute myocardial infarction.

The Board ordered the UC physician to be reprimanded.

State: Arizona


Date: June 2016


Specialty: Emergency Medicine, Internal Medicine


Symptom: Chest Pain, Constipation, Nausea Or Vomiting, Numbness, Back Pain, Head/Neck Pain, Palpitations, Shortness of Breath


Diagnosis: Acute Myocardial Infarction


Medical Error: Diagnostic error


Significant Outcome: Death


Case Rating: 2


Link to Original Case File: Download PDF



California – Internal Medicine – 55-Year-Old Female Who Recently Started An Exercise Program Presents Develops Chest Pain Worsened By Raising Her Arms



On 9/17/2009, a 55-year-old female presented to an internist’s office at 8:45 a.m. for an outpatient visit.  The patient had not previously been seen in that clinic’s affiliated hospital system, so no prior medical records were available.  The patient reported that she had been experiencing a breathing problem for the last three days that was characterized by pain, usually during the evening and at night.  The patient characterized the pain as intermittent sharp, non-radiating pain around the sternum, which became worse when she took a deep breath or pressed on the sternum area.  The internist noted that the patient’s pain was not associated with shortness of breath, fever, chills, cough, nausea, vomiting, or diaphoresis.  The patient reported that the pain was exacerbated when she moved her arms into certain positions, such as raising them.  The patient indicated that she had started an exercise program the previous week that included push-ups.

The patient gave a family history that included the facts that her mother had hypertension and that her sister had heart disease.  No further information concerning this family history of heart disease was in the record. The patient stated that she seldom consulted physicians, and she reported no personal history of heart problems.  The internist described the patient as a “self-professed health care avoider.”  No further social or medical history was obtained.  The internist indicated taking some further family history during her examination, but it was not indicated what additional information was added.  The patient’s vital signs were recorded as blood pressure 130/90, pulse rate 135 bpm, with no notation about rhythm, and temperature 98.3 F.  The patient’s height was 5’5”, and her weight was 172.5 lbs. (overweight).  The internist’s examination consisted of an ear, nose, and throat examination, respiratory auscultation, cardiac findings without mention of jugular venous distention or point of maximal impulse, and notations concerning normal extremity pulses and the absence of edema, clubbing, and cyanosis.  There was no mention of any attempt to reproduce the pain with anterior chest palpation or deep inspiration.  Although the internist noted that the patient’s heart rate was measured at 135 bpm, her electronic progress notes indicated that the heart rate was normal, and the rhythm regular, with no further information.

The internist diagnosed the patient with costochondritis and prescribed ibuprofen (600 mg. t.i.d. for 7 to 10 days, then prn), GI precautions, and push-up cessation, and the patient was sent home.  The tachycardia (135 bpm) was not addressed.  The patient declined immunizations and mammography.  The internist ordered the following tests for the patient: fecal globin, fasting glucose, lipid panel, and alanine transferase.  There is no indication in the record that these tests were taken or completed.  The internist encouraged the patient to make an appointment for a full physical examination and blood work, especially given her family history.  There was no immediate order or plan for further cardiac examination or for an electrocardiogram.

On 9/22/2009, the internist returned a telephone call from the patient.  The patient indicated that her research convinced her that costochondritis was a reasonable diagnosis, but that the ibuprofen prescribed brought only short-duration relief from her chest pain.  The internist then prescribed Relafen (nabumetone, 500 mg 1-2 tablets b.i.d. prn), a long-acting NSAID, and again advised limited activity.

On 9/26/2009, the patient experienced severe shortness of breath and chest pain, and an ambulance was summoned.  The patient was taken to the hospital. While at the hospital’s emergency department, the patient suffered a cardiac arrest and had to be resuscitated.  The patient was admitted to the hospital, and the admitting physician noted that the patient had had continued chest pain and mild shortness of breath for the week before admission.  Diagnosis was a probable ischemic event approximately a week ago, most likely an anterior myocardial infarction, persistent chest pain, and a likely inferior myocardial infarction on arrival at the emergency department as well as development of mitral regurgitation and pulmonary edema.  The patient eventually was diagnosed as having suffered a STEMI.

The admission history taken at the hospital confirmed a negative past medical history, but the family medical history taken included that fact that the patient’s father died of prostate cancer at the age of 77, the patient’s mother died of a myocardial infarction at age 75, and that the patient’s sister had suddenly died of a presume myocardial infarction at age 55.  The social history taken included the facts that the patient did no exercise, had not seen a doctor in 15 years, and drank 4 to 6 beers each night.

On the day of admission to the hospital, the patient underwent a full heart catheterization, including a coronary angiogram.  The results showed diffuse, severe coronary disease of the left anterior descending artery and circumflex and lesser disease of the right coronary artery and multiple smaller vessels.  Collateral flow from the distal right coronary artery supplied at least some of the left circulation.  Pressures were pulmonary artery pressure 45/28, mean 36; pulmonary artery wedge pressure 30/37, mean 30; cardiac output 3.75; and cardiac index 1.96.  A transesophageal echocardiogram revealed an ejection fraction of 30%, several mitral regurgitation, thrombus of the left atrial appendage, and probable ruptured tertiary chordae to the posterior leaflet.

Stenting of the left anterior descending artery and insertion of an intra-aortic balloon pump was done at the hospital, but the patient developed anoxic encephalopathy, so further treatment was curtailed in favor of transferring the patient to another hospital on 10/6/2009 for management of a small right occipital cerebral hematoma.  No surgery was done because the hemorrhage was small and stable.  The patient was transferred to a third hospital on 10/9/2009 for possible cardiac surgery, including mitral valve repair and coronary bypass, but upon arrival, the patient was in heart failure, ventilator-dependent, and agitated, so surgery was not performed.  The patient subsequently developed a fever and cardio-respiratory failure and expired at the third hospital on 10/15/2009. On 10/7/2009, after the internist had been informed of the patient’s admission to the second hospital, cardiac condition, and myocardial infarction, the internist placed an addendum note in her progress notes of 9/17/2009 indicating that the right sternal edge was tender to palpation.

The Medical Board of California judged that the internist’s conduct to be below the minimum standard of competence given that she failed to consider and rule out a cardiac origin for the patient’s pain, garner a detailed history on all cardiac risk factors, including family history, weight, blood pressure, lipids, alcohol consumption, amount of exercise, and diabetes, and perform a complete cardiovascular examination, paying particular attention to vital signs, including jugular venous distention, lung and cardio auscultation, PMI palpation, assessment of vascular bruits, and peripheral pulses.  After learning of coronary artery disease in the patient’s female family members, the internist also failed to take details concerning this familial heart disease, such as type of heart disease, age of onset, type of treatment, outcome, and age of death, if any.  The cardiology failed to do an EKG, take cardiac enzymes, or order a chest x-ray in light of the patient’s symptoms and her family history as well as not ruling out and examining for possible etiologies for the patient’s chest pain other than costochondritis.  The internist failed to explore the pain’s time of day, severity, duration, location, or possible association with activity, stress, food, or other precipitation factors and focused instead on the patient’s report of doing push-ups.  The internist did not pay attention to the patient’s tachycardia (135 bpm) and order an immediate EKG.  The internist ordered some testing for cardiac risk factors and a possible gastrointestinal cause for the patient’s symptoms, but only those useful for risk stratification purposes (ALT, blood sugar, fecal globin, and lipids).  The internist failed to order cardiac enzymes, an EKG, or chest x-ray, or other tests necessary to rule out a cardiac or other more serious cause for the patient’s immediate symptoms, specifically chest pain.  During the internist’s telephone call with the patient on 9/22/2009, the patient reported that ibuprofen provided only short-term relief from her chest pain.  The internist failed to recognize that the temporary efficacy of the ibuprofen could have indicated an etiology for the patient’s chest pain other than costochondritis.  The internist failed to inquire about the patient’s general condition and her chest pain, whether it had changed in character or duration.  The internist assumed costochondritis was the correct diagnosis, noting that the patient corroborated the diagnosis, and the internist missed the opportunity to ask questions about her general condition and her pain or to arrange for further examination or testing.

The Medical Board of California issued a public reprimand and ordered that the internist complete 8 hours of continuing medical education course in the diagnosis and treatment of heart disease.

State: California


Date: November 2015


Specialty: Internal Medicine, Cardiology, Emergency Medicine


Symptom: Chest Pain, Shortness of Breath


Diagnosis: Acute Myocardial Infarction, Intracranial Hemorrhage


Medical Error: Diagnostic error, Failure to examine or evaluate patient properly, Failure to order appropriate diagnostic test, Ethics violation, Lack of proper documentation


Significant Outcome: Death


Case Rating: 4


Link to Original Case File: Download PDF



Virginia – Cardiology – Failed Wire Guide Into Left Anterior Descending Artery Leads To Complication



On 4/4/2012, a 44-year-old female was admitted complaining of chest pain radiating to her left shoulder and to her back.  She was diagnosed with acute coronary syndrome.  Cardiac catheterization revealed a 99% exceptionally long stenosis of the proximal left anterior descending artery (“LAD”).  The cardiologist attempted to advance a guide wire in the LAD, but concluded that the LAD was too small for coronary stenting and abandoned the effort after a number of attempts.

Seven hours after the procedure, the patient’s blood pressure suddenly dropped and an echocardiogram indicated pericardial effusion, which was due to a micro-puncture of the patient’s coronary artery during angioplasty.  The patient required emergent pericardiocentesis.

The Board issued a reprimand.

State: Virginia


Date: October 2015


Specialty: Cardiology


Symptom: Chest Pain, Back Pain


Diagnosis: Post-operative/Operative Complication, Acute Myocardial Infarction


Medical Error: Procedural error


Significant Outcome: N/A


Case Rating: 1


Link to Original Case File: Download PDF



Virginia – Cardiology – Nitroprusside And Furosemide For Shortness Of Breath, Tachycardia, Diaphoresis, Hypertension, And 5-7 mm Of ST Elevation



On 10/16/2012, a 51-year-old male presented to the emergency department with shortness of breath, tachycardia, diaphoresis, a blood pressure of 240/193, and a pulse of 151.  The patient denied chest pain on admission, but he had experienced brief chest pain when his shortness of breath began, and his EKG showed 5-7 mm of ST elevation in the precordial leads.

Cardiologist A treated the patient with nitroprusside and furosemide that evening and admitted the patient to the intensive care unit.  Over the next several hours, the Cardiologist A neither re-examined the patient nor re-evaluated him for cardiac catheterization.  The following morning, the patient’s troponin was 185.66 versus 0.87 the prior evening.  He underwent emergency stenting of his left anterior descending artery by Cardiologist B.

Cardiologist A testified that he believed the patient’s hypertension, pulmonary edema, and inability to lie flat for the procedure increased the risk of performing cardiac catheterization and angioplasty.  He stated that the patient had not met criteria for emergency catheterization given that the patient had not experienced 30 minutes of constant chest pain.

The Board issued a reprimand.

State: Virginia


Date: October 2015


Specialty: Cardiology


Symptom: Shortness of Breath


Diagnosis: Acute Myocardial Infarction, Hypertensive Emergency


Medical Error: Delay in proper treatment, Failure to properly monitor patient


Significant Outcome: N/A


Case Rating: 2


Link to Original Case File: Download PDF



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