No appropriate diagnosis
14. Mr O says the Trust did not appropriately diagnose his heart problems when he presented with dizziness and breathing problems between April and May 2018. Specifically, he believes an angiogram should have been performed earlier and would have prevented him having to seek private care to get appropriate investigations. The Trust have not accepted any failings in the care and treatment provided to Mr O during that period. They explained that their investigations showed that he suffered moderate weakness of the heart and moderate narrowing of the aortic valve. In hindsight, we know that Mr O was suffering from Acute Aortic Stenosis (ACS). We have gone on to consider here whether the diagnosis the Trust made was appropriate based on Mr O’s clinical presentation at the time.
15. Mr O was understood to have heart issues from around August 2017. He had two echocardiograms (ECG) which showed Moderate Aortic Stenosis (MAS) with low left vertical (LV) functions. Mr O was then placed on medication. MAS occurs when the aortic valve is damaged. The aortic valve transfers blood from the left ventricle of the heart to the aorta which is the largest artery. Aortic stenosis can be classed as mild, moderate, or severe depending on how damaged the valve is. The more damaged the valve is the more that blood flow is reduced. The left ventricle is the heart’s main pumping chamber and pumps oxygen rich blood into the aorta and to the rest of the body. Ejection fraction refers to the percentage of blood that is pumped out of the left ventricle with each heartbeat. Mr O was noted to have a low function and in a consultation in February 2018 the Trust said the next step would be to look for the cause of his LV impairment.
16. In February 2018, Mr O’s LV ejection fraction rate was showing at 40-45%. Where there is no indication of heart problems this is usually between 55%-70%. The lower the percentage, the more risk of heart failure.
17. According to Sections 7.2 and 7.3 of the 2016 ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure and NICE NG106 1.4 it is appropriate to give beta blockers (medication to manage abnormal heart rhythm) and a diuretic (medication to reduce blood pressure). He was placed on Bisoprolol 1.25mg (a beta blocker), Furosemide (a diuretic) and Isosorbide Mononitrate. As such, the treatment Mr O received was in accordance with the guidance above. Our clinical adviser noted this was a conservative approach. We are satisfied that the actions of the Trust for this appointment were in line with the guidelines.
18. In early April 2018, Mr O continued to have symptoms of dizziness and was short of breath. He also had sensations which indicated he may faint. On 5 April 2018, he went to A&E where he was admitted to the Trust. The records show that his LV ejection had fallen to 35-40% which is significantly below the normal levels, and lower than his previous visit. The Trust took him off the beta blockers as there was a concern that they were the cause of his symptoms. The records note that his condition improved and was discharged on 9 April 2018, with a plan for an ECG follow up in three months (July 2018). Our understanding is that his diagnosis stayed the same (MAS).
19. Therefore, the actions of the Trust appear appropriate. They stopped beta blockers and monitored his clinical presentation. NICE Guideline 106 suggests introducing beta blockers in a 'start low, go slow' manner. They suggest that heart rate is assessed along with overall clinical status after each adjustment to the medication. We can see there that beta blockers had been started on the previous admission and stopped when there were concerns about the impact. From the records, we can see that when the medication was stopped, Mr O’s condition was improved and he was discharged. The Trust also arranged an ECG as per the guidelines. We are satisfied that there is no indication of failings for this admission.
20. However, Mr O’s symptoms of dizziness and feeling faint continued, and on 24 April 2018, he visited A&E again where he was admitted in the early hours of 25 April 2018. Our adviser explained that ACS should have been considered by this point, in line with NICE guidelines Acute Coronary Syndrome (ACS). They explained the troponin elevation on the background of his impaired LV function and aortic stenosis, would suggest coronary artery disease and ACS should have been considered.
21. However, the Trust placed him again on a heart monitoring device, which they say showed that he had possible Paroxysmal Atrial Fibrillation (PAF). PAF is a heart condition that causes an irregular and often abnormally fast heart rate. A normal heart rate should be between 60-100 beats a minute when resting. In PAF, the heart rate is irregular and can sometimes be very fast. Common symptoms are dizziness, shortness of breath and tiredness. These are the same symptoms that Mr O presented with.
22. According to NICE Guidance on Atrial Fibrillation, it is appropriate to offer an ECG to people who are suspected of PAF. The Trust did this during his admission and noted no indications of abnormalities in the rhythms. They also arranged for a three day monitor to be in place to get a longer understanding of his heart rhythms. The records also note that blood tests were done.
23. Mr O’s investigation results showed a first degree AVB (atrioventricular block). This is a delay in the sending of electrical impulses. At the lower end of this presentation, treatment is not considered necessary. Where findings are more significant (PR interval over 0.3) further action may be taken. They also gave Mr O anticoagulant medication which is also advised by Section 1.7.7. of the guideline, to manage the risk of stroke. The Stroke Association explain where people have AF, they are five times more likely to be at risk of stroke.
24. Overall, we are satisfied it was appropriate to explore PAF on 25 April 2018, but the investigation results did not support this as a diagnosis. We can see by 26 April 2018, the Trust dismissed this and believed that his dizziness was more postural than cardiac as Mr O’s heart had shown no sign of arrythmia. This means that it was more likely due to vertigo rather than heart related. The Trust accepted he should have another ECG test (R test) and then have been referred to cardiology.
25. However, we know that Mr O had an existing diagnosis of MAS. Our adviser said that Mr O’s second admission within four weeks should have raised the alarm for a diagnosis of ACS. Particularly given his troponin elevation paired with his LV impairment and existing diagnosis of AS. Troponin is a type of protein found in the heart muscles. When heart muscles become damaged, troponin is sent into the bloodstream. As heart damage increases, greater amounts of troponin are released in the blood.
26. The records show that on the second admission (25 to 26 April 2018), Mr O’s blood tests showed his troponin level to be 32 (pre-admission) and 35 after his admission. This is significantly elevated level as any reading over 30 is considered to be high risk and suggestive of ACS. Given of his existing diagnosis of AS and his high level of troponin, ACS should have been considered as a diagnosis. We have not seen any basis to suggest this was the case. Therefore, this was a missed opportunity for an earlier diagnosis of ACS.
27. Nine days after his second admission, Mr O presented to the Trust again with the same symptoms. The Trust placed him on an ECG which showed a narrow complex tachycardia at 150rpm and diagnosed him with Paroxysmal Atrial Fibrillation (PAF). Again, according to our adviser, ACS should have been considered at this time considering the repeated presentations, and investigation results. Overall, we decided that on the second and third presentation, Mr O should have been considered for a possible diagnosis of ACS and this does not appear to have happened.
Impact
28. Mr O says his symptoms were deteriorating and he had genuine concerns about his life, and the lack of diagnosis could have been disastrous for his health. Moreover, he felt that the Trust did not understand what was wrong with him and by the third admission, he lost faith in the Trust. Mr O decided to go to a private cardiologist who confirmed his ACS and advised that he would need a coronary intervention. Mr O decided to undergo the coronary intervention privately at a cost of £2000.
29. We appreciate that Mr O was admitted to the Trust three times between April and May 2018. We have not taken account his first visit as we have seen no failings in that. We have found there was a missed opportunity for an earlier diagnosis at the second and third visit. If this had happened Mr O would have avoided both the need to return for the third period, and his frustration when he was turned away again on the third visit. Moreover, according to the advice we received, had ACS been considered then, the management of his care would also have been different. We have also seen a further missed opportunity on the third presentation.
30. We note that the focus of investigation was on his heart. Given that he already had some positive tests (i.e., LV ejection, high Troponin (35)) and considering the continuation of his symptoms, it’s understandable that Mr O would be worried about his life, and that his ability to live a relatively normal life was affected. We can appreciate that after the third admission (with no definite diagnosis) Mr O lost his faith in the Trust providing him diagnosis and treatment.
31. We accept that as he felt his symptoms and underlying heart condition were being dismissed, Mr O saw a private cardiologist in late May who diagnosed him with ACS and advised for either bypass surgery or coronary intervention (stent). Mr O chose to do a stent around four months later. We think this was not unreasonable after two failed opportunities to get a diagnosis, and his significant concerns about his health.