Missed heart attacks - how can it happen?

psu_213, BSN, RN · Jul 2, 2014

Absolutely they (trop, EKG, etc) can all be negative and an MI is in progress. I forget the exact time frame, but it takes a little while before there is a troponin "leak" 2/2 MI. Also, many MIs happen without EKG changes (an "NSTEMI"--Non-ST Elevation Myocardial Infarction).

It is pretty much impossible to answer "why did this happen?" without knowing his presentation to the first ED. Perhaps he signed in with "heart burn." The cardiac work up may have been done--and was negative--his pain was relived with a GI cocktail; this would significantly reduce the suspicion of a cardiac event. In addition, perhaps he was not having a cardiac event when he went to the first ED. Perhaps it was heartburn that got relived. After leaving the first ED, he then had a cardiac event and died prior to his arrival in the second ED.

It is certainly a possibility that the first ED "missed" something. In my hospital, a 40-something with chest pain is likely going to be admitted for a stress even if everything is negative; however, there is a whole lot about that first ED visit that we don't know making it impossible to pass judgement on them.

lisaghiggins66 · Jul 2, 2014

Cardiac enzymes can take 3-6 hours to become elevated during an MI. Typically, serial troponins will be collected at time of admission to the ER, followed by at least a 3 hour troponin (depending when the symptoms started).

emtb2rn, BSN, RN, EMT-B · Jul 2, 2014

Yep, had it happen just the other day. 1st ekg & set of enzymes were fine. Within an hour that all changed & we were off to the cath lab.

NP2BeNY · Jul 3, 2014

I'll second what everyone else said. It's relatively common...they're fine and then a serial ECG is done, new changes are seen and off to cath we go!

Enthused RN, BSN, RN · Jul 3, 2014

I'm familiar with the cardiac enzymes taking some time to show up on a test so in this case I'm guessing the first hospital didn't wait long enough. I mean, the guy coded mere hours after being released from the hospital.

zmansc, ASN, RN · Jul 3, 2014

From what has been presented here, there is no way to make any determination what so ever. 41 is extremely young to die of an MI irregardless of what happened at one hospital or the other unless there were other contributing factors in the history which we do not have. Congenital defects? Weight? Comorbidities? Drug use? Smoking?

Also, there is no information here about what he presented to the first ER for, what he was worked up for, why he left, etc. It could range from presenting for chest pain and not being worked up for it properly, leaving AMA, presenting for other conditions and having those worked up properly and never mentioning chest pain.

Finally, there is no indication here that he was having chest pain (or not having it), just an assumption that he presented to the first ER with chest pain as his CC. So, without knowing anything more about the first visit it is very difficult to discuss what "went wrong" at the first visit as we don't know enough about that first visit to know what did or didn't happen.

Having said all that, if someone presents with chest pain, discomfort, etc. in my ER, they get worked up for cardiac period. There is no judgement call in it. Full monitor, IV, EKG, chest xray, full labs, etc. Unless they are allergic they get ASA. Nitro unless ED med or R MI, etc. The only way this protocol is not implemented or is aborted is if the doc convinces the RN that it's not cardiac and we are not easily convinced.

One of my chronic pain pts came in and saw the full waiting room, decided she had chest pain as they got in faster than her usual headache. She got whisked away to a cardiac room, two IVs, EKG, full monitor, the whole works until she begged us to stop. We told her the only way it was going to stop was if she signed out AMA, which she finally did, then went back to triage 10 minutes later to complain of a headache! lol

My point is that we (and every ER I know of) take chest pain very, very seriously. As others have mentioned, if his presentation was one where the pain had just started, then the enzymes would not have been elevated. If it was a NSTEMI, then the EKG could have reported normal. Neg for cardiomegaly, than the chest xray would have appeared normal. If there were no other SxS of cardiac and the pt described the pain in such a way to be consistent with epigastric, or muscle pain and tx of those conditions relieved the pain, then it is possible that the pt could have been misdiagnosed. Likely? not really very high, in fact very, very minimal, but theoretically possible.

If you do know more, it would be an interesting case study for us all to see if there was anything that could have been done differently that would have changed the outcome. Please let us know if you find out autopsy results or the details of the first hospital visit. I seriously doubt that there was negligence at the root cause of this situation.

Enthused RN, BSN, RN · Jul 3, 2014

Wow, I wasn't looking for the absolute right or wrong answer for this specific case. Obviously we can't know that and will never know that. I'm asking about missed cases in your personal experience so I can learn from any mistakes before they happen on my watch.

Ultimately I'm looking to learn here, not for an answer regarding what happened.

But for a bit more context, see article:

http://calcoastnews.com/2014/06/staff-sergeant-dies-following-training-exercise-camp-roberts/

From what has been presented here, there is no way to make any determination what so ever. 41 is extremely young to die of an MI irregardless of what happened at one hospital or the other unless there were other contributing factors in the history which we do not have. Congenital defects? Weight? Comorbidities? Drug use? Smoking?
Also, there is no information here about what he presented to the first ER for, what he was worked up for, why he left, etc. It could range from presenting for chest pain and not being worked up for it properly, leaving AMA, presenting for other conditions and having those worked up properly and never mentioning chest pain.
Finally, there is no indication here that he was having chest pain (or not having it), just an assumption that he presented to the first ER with chest pain as his CC. So, without knowing anything more about the first visit it is very difficult to discuss what "went wrong" at the first visit as we don't know enough about that first visit to know what did or didn't happen.
Having said all that, if someone presents with chest pain, discomfort, etc. in my ER, they get worked up for cardiac period. There is no judgement call in it. Full monitor, IV, EKG, chest xray, full labs, etc. Unless they are allergic they get ASA. Nitro unless ED med or R MI, etc. The only way this protocol is not implemented or is aborted is if the doc convinces the RN that it's not cardiac and we are not easily convinced.
One of my chronic pain pts came in and saw the full waiting room, decided she had chest pain as they got in faster than her usual headache. She got whisked away to a cardiac room, two IVs, EKG, full monitor, the whole works until she begged us to stop. We told her the only way it was going to stop was if she signed out AMA, which she finally did, then went back to triage 10 minutes later to complain of a headache! lol
My point is that we (and every ER I know of) take chest pain very, very seriously. As others have mentioned, if his presentation was one where the pain had just started, then the enzymes would not have been elevated. If it was a NSTEMI, then the EKG could have reported normal. Neg for cardiomegaly, than the chest xray would have appeared normal. If there were no other SxS of cardiac and the pt described the pain in such a way to be consistent with epigastric, or muscle pain and tx of those conditions relieved the pain, then it is possible that the pt could have been misdiagnosed. Likely? not really very high, in fact very, very minimal, but theoretically possible.
If you do know more, it would be an interesting case study for us all to see if there was anything that could have been done differently that would have changed the outcome. Please let us know if you find out autopsy results or the details of the first hospital visit. I seriously doubt that there was negligence at the root cause of this situation.

motherof3sons · Jul 3, 2014

Happened to my cousin, 43 yo. Went in to the ER with CP, complete work up done...nothing absolutely nothing was found. F/U apt made with primary MD. Two days later woke up in night with CP. His wife rushed him to hospital and ended up pulling him out of the car and did CPR on him on the side of the road. Someone went by and stopped, helped with CPR till ambulance arrived. He didn't make it. Found a cardiac defect on autopsy.

outlierrn · Jul 6, 2014

I had a 44 y/o guy come in full CPR in progress. We never got him back, but the story we got from the family was that he had started a new job about a week ago, and c/o of vague shoulder pain since he began (left, of course). If he had presented to me in triage and said 'I hurt my shoulder on my new job last week, I might have not taken it too seriously. Depending on which doc got him they might not have either.Enthused rn, this stuff happens, it will probably happen to you. You may want to spend some time thinking about how you're going to handle a child's death, a stupid accident, the patient you could save, not how I'm going to stop it from happening, but how I'm going to live with not having stopped it.

Enthused RN, BSN, RN · Jul 6, 2014

Thanks for the response. Your case sounds very different from the case I posted. I think a lot of people would miss that because the complaints were so vague and it was going on for a while.

Also, I'm not an articulate person and I don't know how to say this but I feel like people are starting to attack me on this thread. I already said I'm here to learn. I will be starting a new job soon and wanted to learn from other people's experiences, especially when it comes to missed diagnoses. I don't need people being condescending towards me when I'm trying to learn here. This is why I have become hesitant to post for help in understanding nursing-related things here on allnurses.com and will probably refrain from posting for help in the future. This site used to be a great resource when I was applying to nursing school and going through nursing school, but now as a RN I have found that people are not as nice here as when I was a student. The majority of you have been helpful but there's always a few that think it's ok to be rude and condescending towards the newer nurses who have questions.

I had a 44 y/o guy come in full CPR in progress. We never got him back, but the story we got from the family was that he had started a new job about a week ago, and c/o of vague shoulder pain since he began (left, of course). If he had presented to me in triage and said 'I hurt my shoulder on my new job last week, I might have not taken it too seriously. Depending on which doc got him they might not have either.Enthused rn, this stuff happens, it will probably happen to you. You may want to spend some time thinking about how you're going to handle a child's death, a stupid accident, the patient you could save, not how I'm going to stop it from happening, but how I'm going to live with not having stopped it.

Esme12, ASN, BSN, RN · Jul 6, 2014

I'm familiar with the cardiac enzymes taking some time to show up on a test so in this case I'm guessing the first hospital didn't wait long enough. I mean, the guy coded mere hours after being released from the hospital.

I know of patients that have dropped dead after a clean bill of health and a negative work up.

If this patient was having arrhythmia... the enzymes might not be elevated. He went on about his business and went into sustained VT. There is NO way to predict that.