Correspondence from the world of cardiology
Dear Sirs,
I recently, at the age of 49, survived an out-of-hospital cardiac arrest. It helped that I am a GP and was on a ward round in a local care home. The nurse sitting next to me started cardiopulmonary resuscitation (CPR) immediately and I was defibrillated within a few minutes by a team of paramedics. It was strange to wake up somewhere else and told to “keep the oxygen on”. I thought I was in a dream.
It is hard to thank sufficiently the teams in the acute cardiac unit, the ITU and CCU. Usually only 5% survive such an event. Often survivors suffer cognitive deficit that, hopefully, for me is minimal. I did not really have any major risk factors except a strong family history: four generations of heart disease presenting at a young age. My mother and uncle are still alive after their heart attacks at ages 46 and 36 years, respectively. The emergency angiography showed my coronary arteries were 100%, 95% and 90% blocked. I now have three stents, hopefully doing a grand job.
Because of my family history and some atypical sensations at the age of 48 years, I thought it would be a good idea to get screened for heart disease. So within the year before my event, I had an exercise tolerance test. This result was equivocal to the cardiologist, although I thought I could see some ST depression, so he recommended I have a thallium scan. This showed no evidence of significant risk for ischaemic heart disease.
I was seen in an outpatient clinic four months later by the registrar, who counselled me on lifestyle modification and then she discharged me from the clinic. It was an odd consultation. I did not think she knew I was a doctor. I left the room feeling unhappy with how our encounter went but I know this can happen sometimes for all of us and shows how important the consultation is.
In one sense, I have been lucky and I am doing well. If I had not, my family would have been left asking how and why, especially as nothing had been found before. As for me, I keep trying to make sense of it all. I was unaware, for example, that the sensitivity of thallium scanning locally is 93%, i.e. a false negative rate of 7%. I wonder if this had been discussed with me whether I would have requested further tests.
It has left me thinking about patients I knew with negative investigations and subsequent drastic events – often advanced cancer. I have had difficult consultations when they have asked why nothing was found before. From the cardiologist’s point of view, it has made me see how difficult their jobs are, especially when National Institute of Health and Care Excellence (NICE) guidelines are based on risk scores. For lower risk cases, minimally invasive tests are recommended. For atypical presentations, it is also less likely to recommend invasive tests. Since angiography comes with a risk of complications, it is only performed for higher risk cases. The atypical pain meant I had a thallium scan. If it had been based on family history, I would have had a CT angiogram.
This leaves me wondering about the use of our sixth senses and the importance of medical acumen. This has to be balanced against the risk of over investigating a population and the harm that this could cause. I usually avoid going to see a doctor but in this case it was my strong family history that made me seek help. If I had been offered further invasive tests and I knew the risks involved, would I have declined them? I found that, even as a doctor, I reverted to the patient role and relied on specialist advice.
Three months post-event, I went to see my first consultant to try and understand what had happened. Being human, I was stern and somewhat angry. It must have been hard for him to sit and listen to me. Although nothing could be changed, I hope he realised that I thought communication could be changed for future throughout the process and that it might protect him more.
The lessons I have drawn from this are:
- the use of a good consultation
- that screening tests have pitfalls and
- patients may need to be more aware.
In the future for my patients’ sake, I will endeavour to be better informed on the sensitivity or specificity of each test. Finally I have learned when to use your acumen and sixth sense.
Anonymous
