Case Presentation: A 68 year-old Spanish-speaking female with PMH of type 2 diabetes mellitus, GERD, and tobacco use presented to the Emergency Department (ED) with one day of acute-onset substernal chest pain associated with nausea/vomiting and bilateral arm numbness L>R. Initial workup revealed CXR with mass-like opacity in the right upper lobe, high sensitivity troponin of 28.7 ng/L, and EKG with T-wave inversions in lead III and T-wave flattening in aVF. Non-contrast chest CT revealed a RUL mass like-lesion concerning for malignancy with invasion into the chest wall, and repeat troponin was 48.8 ng/L. Cardiology was consulted and felt troponin elevation most likely represented non-MI troponin elevation vs type 2 myocardial infarction in the setting of likely malignancy and recommended trending troponin/EKGs. Overnight, troponin increased to a peak of 206 ng/L. EKGs were notable for new T-wave inversions in AVF. Cardiology again felt that findings were due to new lung mass and did not recommend additional workup or change in medical management. Plan was made for outpatient biopsy and discharge home. Shortly prior to discharge, pt developed acute substernal chest pain, diaphoresis, nausea and vomiting. Repeat EKG showed ST-elevation in inferior leads. Coronary angiography revealed subtotal thrombus occlusion of the mid right coronary artery, and two drug-eluding stents were placed via percutaneous coronary intervention. Pt was discharged on DAPT, statin, beta-blocker, and ARB. Subsequent biopsy of lung mass revealed squamous cell carcinoma, and the patient was started on chemoradiation.
Discussion: This ‘near-miss’ case highlights the potential impact of cognitive biases to cloud clinical reasoning and lead to diagnostic error. Anchoring and availability bias led providers to attribute patient’s symptoms to newly identified lung mass, in spite of having ‘classic’ ACS symptoms. While it is difficult to ascertain the degree to which patient’s race, gender, language barrier or medical literacy contributed to our patient’s delayed diagnosis, studies have shown that the greatest positive predictor for being incorrectly discharged from the ED while having acute myocardial ischemia is being female. Moreover, Hispanic women with MI are less likely to be hospitalized or undergo cardiac procedure and have higher mortality than white men. One means to combat cognitive biases is through utilization of clinical pathways, such as a chest pain pathway. HS troponin assays are now used in many institutions, familiarity with and standardization of their use is limited. In our patient’s case, had the clinical pathway been properly utilized, the patient would have been initiated on goal-directed medical treatment for type 1 MI based on: 1. Classic symptoms of cardiac ischemia 2. Elevated hs-troponin, and 3. Troponin increase of >20%. While many disparate cognitive errors likely converged in this case, special care should be given to potential biases. Guidelines and clinical tools become especially important in these settings and represent some of the systemic and personal steps that must be taken to begin to narrow these disparities.
Conclusions: There is a higher prevalence of missed and undertreated myocardial infarction in young Hispanic women and in females. It is imperative to be cognizant of implicit biases and potential for cognitive error, especially in historically underserved and high-risk populations. Clinical pathways can be a helpful tool in combating cognitive biases and aide in medical decision making.