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Business of Medicine | Lessons Learned From a Cardiology Malpractice Case

Lessons Learned From a Cardiology Malpractice Case

An adult patient under the age of 40 presented to their family physician's office with complaints of syncope experienced three days before. The patient's history included hypertension and diabetes and they were taking lisinopril and metformin. The physician completed an EKG which reflected sinus rhythm with QRS (R) contour abnormality consistent with an old inferior infarct. The patient was referred to a cardiologist for follow-up of the abnormal EKG and syncope.

Two days later the patient saw the cardiologist for an initial evaluation and underwent an exercise stress test (EST). The EKG leads were not properly placed, causing a poor connection. No attempts were made to reset the EKG leads and restart the EST or consider additional imaging. The patient was able to reach the target heart rate of 156 bpm and the test was reported as normal.

Five days later the patient returned to the family physician's office and saw both the family physician and the group's PA-C. The patient reported complaints of lightheadedness, shortness of breath, teeth clenching and jaw pain, and stated the EST performed at the cardiologist's office was reported as normal.

The PA-C documented that the patient was diagnosed with angina symptoms and an abscess. It was documented that the patient was instructed to follow-up with the cardiologist or go to the nearest emergency department (ED) if symptoms persisted.

More on Professional Liability

Visit to read a recent Leadership Page by Richard A. Chazal, MD, MACC, and B. Hadley Wilson, MD, FACC, who look at current trends in medical malpractice and work by the ACC to address the issue.

The next morning at 6:15 a.m. the patient was taken to the hospital in cardiac arrest and died minutes later after arrival to the ED. An autopsy reflected cardiomegaly with mild atherosclerotic disease of the coronary arteries, two ostia over the left aortic cusp and atrial septal defect.

Six months after the patient's death, the family physician received a request for medical records from an attorney representing the family of the deceased patient. At that time, the PA-C made a late entry into the EMR that on the last date of care it was "recommended pt go to ED – pt refused. Refused EMS transport."

The family filed a lawsuit against the cardiologist, family physician and the PA-C alleging the patient's multiple episodes of lightheadedness, an episode of loss of consciousness and other symptoms in the days preceding death were all consistent with coronary artery anomalies and there was a failure to diagnose an acute coronary syndrome (ACS) leading to sudden cardiac arrest and death. The case was difficult to defend with no supportive experts for any of the clinicians and was settled on behalf of all parties.

"Three P" Analysis
The "Three P's" refer to the three key elements to reduce practitioner risk related to malpractice litigation.1


Prevent Adverse Events

An analysis of the closed lawsuit, including a review of medical records and the opinions of both plaintiff and defense experts, revealed several factors that contributed to this patient's cardiac event and subsequent death.

  1. Failure to timely appreciate signs and symptoms of acute coronary distress resulting in death.
  2. Improper conduct and interpretation of an EST resulting in questionable results.
  3. Altered medical record entry. While this did not impact medical care, it raised suspicion and was a contributing factor to the filing of the medical malpractice lawsuit.

Preclude a Malpractice Case Despite an Adverse Event

  1. Widen your focus. The plaintiff experts opined that both the family physician and PA-C failed to appreciate an ACS in a high-risk cardiac patient at the last clinic visit and should have immediately sent him to the ED. This case is a reminder that heart disease continues to be the number #1 killer for both men and women.2
  2. Don't dismiss younger patients. The degree to which the patient's age affected the thought process and follow-up recommendations of the family physician and PA-C are unknown. However, it's important to recognize the rise in the diagnosis of cardiovascular risk factors in young adults, such as hypertension, diabetes and obesity.3
  3. Ensure equipment is functioning correctly. The plaintiff expert opined the EST was conducted and interpreted improperly due to the improperly placed EKG leads. Furthermore, if it was completed correctly, the results may have shown ischemia and prompted a quick intervention, such as cardiac catheterization.

Prevail in Lawsuits When a Claim is Made

  1. A well-documented medical record is essential to demonstrating quality care and can support a clinician if litigation occurs. Documentation should include the thought process for the treatment plan and decisions including clinically relevant patient discussions.
  2. Ensure that late clinically relevant medical record entry corrections or additions are completed properly. Upon receiving notice that a malpractice suit may be, or has already been filed, clinicians must ensure the safety and integrity of the patient's record. Any changes made to the record after learning of a possible lawsuit raise questions about the provider's truthfulness, motives and the quality of the care.


  1. Feldman DL. Prevent, Communicate, Document: Medical Malpractice Data Help Us Manage Risk. The Doctor's Advocate. Available here.
  2. Centers for Disease Control and Prevention. Heart Disease Facts. Available here.
  3. An J, Zhang Y, Zhou H, et al. Incidence of atherosclerotic cardiovascular disease in young adults at low short-term but high long-term risk. J Am Coll Cardiol 2023;81:623-32.

This article was authored by Debra Davidson, MJ, CPHRM, CPPS, senior patient safety risk manager for The Doctor's Company and TDC Group in Napa, CA. It was reviewed by Sunny Jhamnani, MD, FACC, partner, TriCity Cardiology, Chandler, AZ, and Amy Brownell, MSN, FNP-C, AACC, systems director of heart failure, Ascension Health, Chicago, IL.

The guidelines suggested here are not rules, do not constitute legal advice, and do not ensure a successful outcome. The ultimate decision regarding the appropriateness of any treatment must be made by each health care provider considering the circumstances of the individual situation and in accordance with the laws of the jurisdiction in which the care is rendered.

Clinical Topics: Acute Coronary Syndromes

Keywords: Cardiology Magazine, ACC Publications, Malpractice, Syncope, Acute Coronary Syndrome, Medical Records, Cardiac Catheterization

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