Issue 1 – Heart conditions
19. Before we decide if we should conduct a detailed investigation of a complaint, we look at whether there are signs the organisation has got something wrong. We do this by comparing what should have happened with what did happen. We have done this and have not found any indications that something has gone wrong.
20. In the section, ‘Recommendations for screening for coronary artery disease in asymptomatic subject’ the above ESC guideline says, ‘Assessment of coronary artery calcium score with computed tomography may be considered as a risk modifier in the cardiovascular risk assessment of asymptomatic subjects.’
21. This means that doctors can use a CT scan to measure the amount of calcium in the arteries which supply the heart. This ‘coronary artery calcium score’ (CAC score) can help clinicians understand a person’s cardiovascular risk. A higher CAC score means patients have a higher chance of both the presence and risk of coronary artery disease.
22. Section 3.1.5.1 in the above ECS guidelines say, ‘However lower grade coronary atherosclerosis not linked to ischaemia remains undetected by functional testing and, in the presence of a negative functional test, patients should receive risk-factor modification based on commonly applied risk charts and recommendations.’
23. This means that in the presence of atherosclerosis (where a person’s arteries become narrowed making it difficult for blood to flow through them) which is not linked to reduced blood flow (ischaemia) to other parts of the body, patients should receive preventative treatment.
24. Section 7 of the above GMC guidelines says, ‘In providing clinical care, you must:
• adequately assess the patient's conditions, taking account of their history including: • symptoms • promptly provide (or arrange) suitable advice, investigation, or treatment where necessary’.
25. The above BioMed article also says, ‘Late gadolinium enhancement (LGE) imaging has become one of the cornerstones of the core cardiovascular magnetic resonance (CMR) examination. Also known as delayed enhancement imaging, LGE enables the differentiation of viable from non-viable myocardium in a wide range of patients with ischemic and non-ischemic myocardial disease and is now considered the imaging reference standard for the diagnosis of myocardial infarction and scarring.’
26. This means that LGE imaging is highly specific in the diagnosis of a myocardial infarction (MI or heart attack). LGE imaging works by using a contrast agent called gadolinium. Damaged or scarred heart tissues holds onto gadolinium differently to healthy tissue.
27. Miss O says the Trust told her she has a heart condition which she says is not correct. She also says a clinician at the Trust told her she had a ‘silent heart attack’.
28. In its response, the Trust said Miss O has significant disease in her heart and she needs preventative treatment.
29. It also said she had a previous cardiac MRI which had shown the likelihood of a previous heart attack. It explained that ‘Patients can sometimes suffer heart attacks but not be aware they have happened. The evidence of a previous, unnoticed heart attack is the thinning and late gadolinium enhancement in the apical inferior wall, and reduced blood supply to other parts of the heart (Inducible perfusion defect in the apical septum/inferior wall). This is exactly what was observed in your heart’.
30. From our review of Miss O’s medical records, we can see the Trust performed a CT coronary angiography at the end of April 2024. It showed Miss O had a calcium score of 1847.
31. In addition, the coronary angiogram the Trust completed at the end of May 2024 also showed mild to moderate atheroma (build-up of fatty material inside the arteries) in all but one artery.
32. Our adviser said evidence of both of a high calcium result and mild to moderate atheroma show evidence of a heart condition. They said that a CAC score above 400 is high and Miss O’s calcium score was 1847. Our adviser said both show Miss O has a heart condition known as coronary artery disease (CAD). CAD is a specific form of atherosclerosis. Atherosclerosis is where a person’s arteries become narrowed making it difficult for blood to flow through them.
33. Based on the available evidence, we find the Trust acted in line with the above guidelines in diagnosing Miss O’s heart condition. We know this information will be distressing for Miss O to hear once more and we are sorry she has this heart condition.
34. A clinician wrote in Miss O’s medical records at the end of May 2024, ‘Earlier CMR had shown thinning of the inferior wall and limited apical perfusion defect. I have advised coronary angiography with a view to intervention if needed.’ We have not seen the earlier CMR report in Miss O’s records only the above summary.
35. The above BioMed article says LGE (late gadolinium) imaging is highly specific in diagnosing an MI. The summary in Miss O’s medical records also says imaging had shown the thinning of the inferior wall of her heart.
36. The thinning of the inferior wall and the apical perfusion defect (an area of the heart muscle which is receiving a reduced blood supply) would indicate a scar is present in part of the heart muscle. Our adviser said the reference to both of these in Miss O’s medical record indicates she had a previous silent heart attack.
37. The British Heart Foundation describes a silent heart attack as, ‘a heart attack that has no symptoms. They are often only diagnosed weeks, months or years afterwards, during a routine check-up, or because of ongoing symptoms, like chest pain (angina) or breathlessness.
38. Silent heart attacks are common. They are estimated to make up around a third of all heart attacks’.
39. We can see that based on the previous CMR imaging, clinicians referred Miss O for further assessments (a coronary angiography). The above GMC guidelines say clinicians should take account of a patient’s condition and arrange suitable investigations. Our adviser said this showed the Trust acted in line with this.
40. As we have seen clinicians acted in line with the above guidelines in their diagnosis of Miss O’s heart condition and silent MI, we will take no further action on this aspect of her complaint.
41. We know finding out about conditions such as these can be very worrying. We acknowledge this has negatively impacted her mental health and caused upset to her family.
Issue 2 – Beta blockers
42. NICE NG185 states: • ‘Section 1.4.27: • Offer people a beta-blocker as soon as possible after an MI, when the person is haemodynamically stable’ • ‘Section 1.4.29: • ‘Consider continuing a beta-blocker for 12 months after an MI for people without reduced left ventricular ejection fraction (LVEF)’ • ‘Section 1.4.30: • Discuss the potential benefits and risks of stopping or continuing beta-blockers beyond 12 months after an MI for people without reduced LVEF.’
43. Miss O says she should not have been prescribed medication (beta blockers, a medication primary used to manage heart related illnesses) for a condition she did not have. She says she took these for six months but believes they were not needed.
44. The Trust said her GP must have prescribed the beta blockers Miss O mentioned. The clinician at the Trust does not agree her heart conditions ‘do not exist’.
45. We can see the results of the coronary angiography performed in June 2024 showed Miss O had non obstructive coronary disease. Clinicians noted at this time her heart did not require stenting.
46. From our review of Miss O’s records, we cannot see evidence that the Trust prescribed beta blockers for her.
47. Our adviser said that with evidence seen above that Miss O had a previous heart attack, clinicians should prescribe beta blockers and to do so is in line with the above sections of the NICE guidelines.
48. While it is not clear to us who prescribed Miss O this medication, the decision to do so was in line with NICE guidance. We will therefore take no further action on this aspect of Miss O’s complaint.
49. We understand that through bringing her complaint to us, she has relived the events which have happened since April 2024. We know that hearing she had a heart condition and had a silent heart attack would be very distressing for her. We know this news has impacted her life and caused her much concern.