Medical standard of care?

What is the name of your state? LA
I'm wondering if I have a legal complaint.
I have been treated for hypertension for over 20 years of which for the last 10 I have been under the care of a family physician. This doctor has always seen me for annual physicals and wrote me new prescriptions. The doctor always ordered blood work which was usually ok. My blood pressure was always high in the doctors office but lower when I took it at my home. The doctor said I had "White coat syndrome" and that my blood pressure was probably well controlled with the medications I was taking. I was never given an electro cardiograph from the family doctor. Recently I was diagnosed with cardiomyopathy and am now under the care of a Cardiologist. The cardioligist ran many tests such as echo and electrocardiographs, muga, and did a heart catheter. The doctor said my electrocardiograph was abnormal but he wished he had a baseline he could compare it to. The finding was that I did not have any blockages but have an enlarged heart with a reduced ejection fraction caused by poorly controlled blood pressure.
After doing some research, I found that had my family doctor given me routine electrocardiographs to monitor any damage that my high blood pressure could be causing to my heart then more aggressive treatment could have been given to prevent the condition I'm in today. My ability to work is shot now and I don't know what to do.

Ph128
Your question has been asked before on this forum but there is a difference between your scenario and the previous post's.

If your hypertension was controlled with diet, exercise, and medication and you had no symptoms of heart failure or dysrhythmias, 10-20 years ago it would not have been unusual for you not to receive routine ECGs. I would expect for you to have had an ECG at some time in your life, but the absence of having an ECG does not indicate that you suffered damages that you would not otherwise have suffered.

The cardiologist probably would like to have an ECG for baseline comparison to present status in order to know the progression rate. I don't know how he determined your hypertension was not properly managed if your BP measurements were within acceptable limits and your physical status was also within normal limits. Of course, I have no way of knowing your risk factors such as age, job, smoker, weight, level of exercise, heriditary factors, method of managing stress, etc. There are just too many factors that affect the management of hypertension and the prevention of complications.

There are some antihypertensive medications, some of the 'newer' ones, that can cause left ventricular hypertrophy and/or renal failure. These medications do require baseline ECG review and renal function testing in order to know whether or not to continue with the medication. These newer medications are in the category you described as 'more aggressive treatment' and they are not risk-free or without being known to cause some rather serious cardiac consequences.

Without knowing if you presented with symptoms of cardiomyopathy and were denied proper evaluation of your symptoms, including an ECG, then I have to determine that you suffered no damages that you would not otherwise have suffered (with regular ECG evaluation).

More likely than not, your family physician managed your care at or above the minimal standard of care and without negligence. It all comes down to whether or not you suffered significant damages that you would not have otherwise suffered. I don't think you would be able to prove that you did, not based on the lack of routine ECGs alone.

Best wishes,
EC

Ellencee
Thank you for your reply. I realize that with what little information I had given, it would be hard to come to much of a conclusion. After reading it I am a little confused.

In the first paragraph you said if my bp was under control that I would have still suffered damages? I thought that the purpose of controlling bp was to prevent damages. Apparently it was not under control.

Did I have ECGs in the past? Yes, from my previous physician whom I was with for about 9 years. He had me take one about every 1 ½ years. He said my condition was difficult to treat at his office due to White Coat Syndrome. He said he couldn’t get good bp readings and the ECGs would allow him to monitor if his treatment was adequate. He said my bp was labile. He prescribed beta blocker and ACE for control. My current family doctor continued with the same meds but later change them to CCB and ACE. I tried to find him (for my records) but his office is closed now. He is probably retired.

In your second paragraph, the cardiologist wanted to see past ECGs to see my progression. My question is now, why wouldn’t my current family physician want to see how I was progressing? After all I have had this condition a long time and was ripe for trouble if my treatment was not working. My office readings in the office had been as high as 165/110.
The cardiologist sent me through about 15 thousand dollars worth of tests (including Hospital for heart cath). I suspect he was trying to rule in or out just what was causing my problem. My bp was not good. He didn’t buy the White Coat Syndrome after seeing my condition. His diagnoses, after all the tests, poorly controlled hypertension. He does have it regulated now with 4 different medications. (coreg, ACE, CCB, ARB).

Third paragraph: No one has ever told me my LVH could be caused by the meds I was taking. Perhaps I was not taking them. What meds would do that? And then again you say an ECG would give valuable information to show if such were happening.

Fourth: Showing signs of LVH? I was not showing major signs of LVH. It must have come on gradually. It was found when I had another condition (paracarditis) and was x-rayed. That’s when I was referred to the cardiologist. My family doctor was very surprised when viewing the x-ray.

Lastly, you say that I was probably being cared for at or above the minimal standard care. I can’t say. I’m not a doctor. I have not had years of college like a physician has and I just may not be understanding what procedures a physician should be taking when treating someone with a chronic condition like mine. No doctor has ever said just why I have it but said it can be controlled. They took the money.

Probably the ECGs taken between 10-20 years ago would not have shown much of any changes as I realize it takes a long time to develop damage from hbp. Old ECGS probably wouldn’t have made any difference today. But the last 10 years or even the last 5 years I feel should have been looked at closely considering the length of time I have had this disease. It wasn’t, why not?

Did I suffer damage that I wouldn’t have suffered anyway? Is it above the minimum standards to wait until a major crisis to take place to then realize a course of treatment was failing? Perhaps an ECG would not have been the tool of choice to see if the treatment was working. Which tool? That is probably what my question should be. Why wasn’t it used?
Would I have still suffered damage if my condition were adequately treated? It wasn’t, why not?

Please understand that I do appreciate you taking time away from what should be your own personal time to help the folks on this forum.
Thank You,

Ph128
You have given me a daunting task of condensing volumes of medical information into a brief and, hopefully, helpful response. I recognize your obvious intelligence and your genuine concern and, for a lack of a better word, 'grief', over your current health. I believe a broader understanding of hypertension and the treatment and sequelae will be helpful for you in understanding why I have answered as I did--that more likely than not, your care was rendered at or above the minimal acceptable standard of care (that is all that is required).

I'll start with your last two questions,

Would I have still suffered damage if my condition were adequately treated? It wasn’t, why not?

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Would you have? Who knows. Could you have? Yes; and, more than likely not, would have.
I can not assume (and neither should you or your cardiologist) that your hypertension was not managed properly (at or above the minimum standard of care). A cardiologist, obviously educated and skilled at a higher degree in cardiovascular systems than is a family physician, and especially a cardiologist much younger than your former family physician, can not be used as the measuring stick for evaluating the performance of your former family physician. The cardiologist may truly believe that if he had been managing your hypertension this would not have happened; but in reality, a cardiologist isn't going to provide routine management of essesntial (primary) hypertension and if he did, the cardiologist could only manage the BP and could not manage the unknown factor(s) producing hypertension.

Hypertension is the result of increased cardiac output (overworking of the heart muscle, which leads to enlargement of the cardiac muscle and to reduced ejection fractions) and increased peripheral vascular resistance. The mechanisms that control cardiac output and peripheral vascular resistance are the Central Nervous System, the renal (kidney) pressor system (renin-angiotensin-aldosterone system), and extracellular fluid volume (fluid outside of the cells, aka third-spacing, aka edema or swelling). Why these mechanisms fail is not known. The medications you received correct, or attempt to correct, the failed action(s) by the CNS, renal pressor system, and extracellular fluid volume.

Did I have ECGs in the past? Yes, from my previous physician whom I was with for about 9 years. He had me take one about every 1 ½ years. He said my condition was difficult to treat at his office due to White Coat Syndrome. He said he couldn’t get good bp readings and the ECGs would allow him to monitor if his treatment was adequate. He said my bp was labile. He prescribed beta blocker and ACE for control. My current family doctor continued with the same meds but later change them to CCB and ACE. I tried to find him (for my records) but his office is closed now. He is probably retired.

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Apparently, your ECG showed no problem during these nine years.
It is important to know that receiving an ECG with or without additional medical intervention, more likely than not, would not have prevented cardiac muscle enlargement and decreased ejection fraction.

Through medication, your heart muscle was given protection against overwork and enlargement. There is little difference in the medications prescribed by the two family physicians and your cardiologist. Beta-blockers reduce cardiac output by competitively blocking the number of impulses from the sympathetic nervous sytem to the heart muscle (blocking the beta-adrenergic receptors). Calcium-channel blockers inhibit the movement of calcium ions across the membranes of the cardiac and arterial muscle cells, which results in the depression of impulse formation in specialized cardiac pacemaker cells, which leads to decreased cardiac work (and decreased cardiac energy consumption, and increased delivery of oxygen to the heart's cells). ACE (angiotensin-converting enzyme) inhibitors work in the lungs to stop ACE from converting to angiotensin I, which is activated when renin is released from the kidneys. Simply put, ACE inhibitors reduce extracellular fluid levels.

So, each family physician gave you medication to prevent cardiac enlargement, which results in decreased ejection fractions, and gave you medication to reduce extracellular fluid levels.

The cardiologist sent me through about 15 thousand dollars worth of tests (including Hospital for heart cath). I suspect he was trying to rule in or out just what was causing my problem. My bp was not good. He didn’t buy the White Coat Syndrome after seeing my condition. His diagnoses, after all the tests, poorly controlled hypertension. He does have it regulated now with 4 different medications. (coreg, ACE, CCB, ARB).

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"Poorly controlled hypertension" is a medical term. In medical-speak, "poorly controlled" means even with (proper) medication, diet, exercise, the hypertension remained labile (unstable, ie. poorly controlled). It is not a statement of physician performance evaluation.

Coreg is an alpha- and beta-blocking agent to reduce cardiac output. The beta-blocking part assists in preventing reflux tachycardia assosciated with alpha-blockers and decreases plasma renin activity (extracellular fluid management). ARB (angiotensin II receptor blockers) work in the vascular smooth muscle and in the adrenal gland (both controlled by the CNS) to block the binding of angiotensin II. (Remember ACE inhibitors prevent the formation of angiotensin II from angiotensin I). So, these new meds work differently yet the same as the mediations you previously received.

Third paragraph: No one has ever told me my LVH could be caused by the meds I was taking. Perhaps I was not taking them. What meds would do that? And then again you say an ECG would give valuable information to show if such were happening.

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Don't worry; from the meds you listed, you did not receive any of the medications to which I referred.

Fourth: Showing signs of LVH? I was not showing major signs of LVH. It must have come on gradually. It was found when I had another condition (paracarditis) and was x-rayed. That’s when I was referred to the cardiologist. My family doctor was very surprised when viewing the x-ray.

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Pericarditis is not a minor player in this picture! Either the origin of the pericarditis, the pericarditis, or both, exacerbated the weakening of your heart muscle and decreasing ejection fraction.

Did I suffer damage that I wouldn’t have suffered anyway? Is it above the minimum standards to wait until a major crisis to take place to then realize a course of treatment was failing? Perhaps an ECG would not have been the tool of choice to see if the treatment was working. Which tool? That is probably what my question should be. Why wasn’t it used?

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It would be very difficult to reasonably prove that you suffered significant damage that you would not have otherwise suffered. Each year's standards of practice would have to reviewed and compared against the care you received in that year. Then, it would have to be determined when you knew or should have known that something was wrong. As your first indication that something was wrong occurred during a hospitalization for pericarditis, it will be even harder to prove that you had signs and symptoms of additional problems that were overlooked, undiagnosed, and untreated, which led to your developing cardiac enlargement and decreased/inadequate ejection fractions. (I'm determined to type 'injection fractions', so if I missed correcting any, please forgive me.)

Perhaps a different diagnostic test such as a cardiac cath would have given you a chance to receive additional treatment; but apparently, your physical findings did not indicate the need for such. Were you short of breath? easily fatigued? unable to enjoy your usual activities due to shortness of breath, chest pain, heart palpitations? Were your feet and legs (ankles) swelled and, or edematous? Could you push your thumb into any edema and leave a depressed (1/2-2"") impression of your thumb in the edema? If the answers are "no", then you most likely did not have clinical findings indicative of cardiac output deficit and therefore no indication for a cardiac catheterization.

There are many physical conditions that can not be and are not diagnosed until such time as the condition produces a crisis. I wish it were not so. Hopefully one day in the near future the general public will have available to them the 'body scan' that a select few have received (as seen and discussed on 'Oprah" a couple of years ago). That technology is truly preventative medicine. It detects subtle changes that would not have produced symptoms for decades.

I hope I have answered your questions satisfactorily. I urge you to meet with an medical malpractice attorney in your area. The consultation visits are usually free and certainly, the appointment will be beneficial to you. A statute of limitations applies to medmal claims and you must not let the statute expire or you are forever barred from bringing a medmal action against the physician. You also have the issue of the physician-in-question's being retired. I truly believe a consultation appointment will satisfactorily answer many of your questions.

Best wishes,
EC

D'OH! I did not explain why an ECG would not have shown ejection fraction decreases. An ECG can only provide a picture of the electrical activity of the heart; thus, it can only show variances from the normal electrical conduction patterns (time it takes for the electrical wave to travel through the heart). To measure/evaluate the mechanical function of the heart, pulse and blood pressure are measured. Therefore, an ECG would not have shown myocardial mechanical cell inefficiency (decreased ejection fraction); a cardiac cath is needed.

Even though this addendum is tardy, this thread is still being read daily and I think the information may be of benefit to those who question why the absence of routine ECGs would most likely not have impacted the outcome for the poster.

Thanks...
EC

Ellencee
I have to agree about the ECG and ejection fraction. That was measured by using an echocardiogram which was less accurate than a heart cath. The cardiologist even thought (afer the echo) that heart damage was involved from a past heart attack but ruled that out with the heart cath. But the most accurate test was the MUGA test. They used a radio active substance injected into my blood with the MUGA. Not a cheap test. I would not expect a doctor to order any of the above tests as routine for regular montitoring of Hypertension. But wouldn't the electrocardiogram being least expensive be a good tool to show gradual changes in the heart and alert the physician into doing more investigation with the more accurate tests or at least get a specialist involved? A doctor would be treating blindly if he or she did not have a protocol in place of some sort to evaluate their treatment. The more I've thought about your saying damage would probably have occured anyway whether or not a patient was treated for hypertension gets me to thinking maybe too many hypertensive patients suffer damage anyway because they aren't being treated properly to start with and the stistics are showing that treatments are failing because standards of care are too low, not just because that happens to be the way things are. If treating hypertension is a lost cause then I am wondering if the cardiologist is going to do me any good. My bp is now under control but it took him 4 different meds to do it. My fatigue may be because of the meds. My EF could have went alot lower but luckly the cardiologist inetervened before that happened or lets hope it don't go lower. The paracarditis may have saved my life. If I had not had the x-ray when I did, I would have kept going on until the coughing, edema, etc. and probably 10 or 15% EF would have killed me. A general doctor should have a method better than waiting until that happens to figure out if he or she's doing their patients any good.
I hope your not getting tired of me going on and on.

Ph128
I'm not, at all, getting tired of your posts.

Most MDs do routine ECGs and I don't doubt that your family MD would have been prudent to have done routine ECGs. It's the legal part of it that is where it will be most difficult to prove that having routine ECGs would have made a difference. In order to have a valid claim of negligence, a medical expert would have to review your records and opine that 'but for' the absence of routine ECG monitoring, you would not have suffered an insufficient ejection fraction. Even if the medical expert opined that the family physician was negligent, or delivered care below the minimum standard by failing to do annual or routine ECGs, the expert would still have to state that the physician knew or should have known that by failing to routinely evaluate your ECG status, you would suffer ejection fraction deficit and significant damage, and your clinical status would have to show that the ejection fraction deficit occurred during the time you were not receiving routine ECGs.

Your MD wasn't treating blindly; he was measuring your BP, assessing quality of BP and pulse, assessing entire physical/health status through routine exams. You may not be aware of just how much about a person's BP can be evaluated simply by measuring BP with a stethescope and cuff or by counting, feeling, and assessing the pulse with one's fingers on the radial pulse. The same goes for what can be determined by listening to the chest for heart sounds and their qualities or by assessing the neck veins through looking and feeling of your neck or assessing lung sounds by listening with a stethescope or by touching/feeling of your lower back, legs, and feet. All of these methods that may seem simple to the patient are vital assessment tools for determining cardiac status.

I can't recall the exact number of millions of Americans who have hypertension or the number of millions who are diagnosed with hypertension each year; and, with the ever-lowering of systolic and diastolic measurements that define hypertension, the number of people diagnosed as hypertensive is dramatically increasing. In the millions of already diagnosed hypertensive patients and all of the newly diagnosed, most hypertensive patients are managed with medications identical to the ones you received from the family physicians and the cardiologist and they never develop any additional problem. Of course, each hypertensive person is at risk for stroke or MI. Why you developed loss of cardiac muscle strength and contractibility may always remain a mystery.

Left ventricular hypertrophy is sometimes an indicator of untreated hypertension, as in a person who has not received routine medical care. It occurs naturally with aging, too.

Have you heard or read about the clinical trials for a net/mesh 'glove' or 'stocking' in which the heart is placed and that provides the lacking 'strength' to the cardiac muscle? Since you are basically a healthy person, you may be an ideal candidate for this procedure. From what I have read on this procedure, it looks very, very promising and it's for patients just like you.

If I can answer any more questions, or clarify anything for you, or research anything for you, please let me know.

Best wishes,
EC

Ph128
Your situation has, for sure, captured my interest and I can not seem to stop looking for definitive answers. What I've come up with are some questions for you and a few facts that suggest your physician's diagnosis of white-coat syndrome should have been ruled-in or ruled-out during this nine to ten year period. (I'm not finding any treatments that would have been different, though...and, I'm not able to access diagnostic/hypertensive managment information prior to the year 2000.)

If you have previously answered these questions, I apologize for being repetitious. I am having difficulty establishing a chronological order of events that led to the diagnosis of ventricular hypertrophy and decreased ejection fraction.

Was it your first family physician who retired or the second (most recent) family physician that you are unable to locate and suspect has retired? Do you know the findings of the ECG done on admission when you had pericarditis? Did you have a chest x-ray for any reason during the time you were under the care of the second family physician? Have you obtained ECG results from the first family physician, or from the facility that performed the ECGs or from the cardiologist who interpreted the ECGs (if not interpreted by the family physician)? If you filed insurance claims for these ECGs, have you inquired of the insurance company to see if they have copies of the notes from the ECGs?

Side note: For clarification, I edited my last post by adding to the last sentence in the first paragraph.

Thanks,
EC

Ellencee
I’ll try to retrace my history as well as I can recall.
I was in my late 20s when I found about my hypertension. I had the usual blood chemistry tests but can’t remember if I had an ECG at that time. He was my family doctor from birth. He couldn’t determine what was causing it and told me that it looked like I was going to be taking medication for life.

After a couple of years I moved to another state and lived there for about 9-10 years. I found a doctor there and was with him until I moved to LA. He operated a clinic but it is gone now. He looked old enough then for me to assume that he is retired today. He would not let me go more than six months between office visits. My bp readings were high in his office and he suspected or said he thought I may just be feeling stress and said he didn’t think he could control it in his office, he used the term “White Coat Syndrome”, but had me take ECGs every other or third visit. I asked why he did them (more cost for me) and he said to see, by comparing them to a baseline, if my heart was getting enlarged or changing. This would allow him to determine if my bp was under control outside the office and change treatment if necessary. I asked him about my cholesterol and he said that I was fine and would probably not be a candidate for clogged arteries. That may explain why my cardiologist today said he saw no blockages with the heart cath. I do not have any medical records from this doctor. The clinic is closed.

After moving to this state where I live now (I’ve been here for about 10 yrs) I started seeing the family physician (my current one) who is the one who never gave me an ECG until the paracarditis attack I had. That is one of the most painful things I have ever suffered.
I didn’t even realize it was my heart that was hurting. It was hurting under my left rib and up my back. The doctor suspected my heart and ordered a x-ray, urine, ECG, gave me an aspirin and nitro pill. The office is also a clinic so they had all the equipment at hand. After seeing the x-ray the doctor said my heart was enlarged. After the ECG the doctor said it was abnormal. A cardiologist was consulted which also is in a group (clinic) and rather than send me to the hospital he had me go there(it's like a hospital). I assume they thought I was stable enough to do that.
My family physician seemed pretty nervous or concerned about my condition and had another doctor come in and double check me. The second family physician had me change several positions to see which worsened or reduced the pain and listened to my heart. He said something about a rub or a third sound. He said my heart’s lining might be rubbing against my diaphragm or something like that creating a third sound. They both determined it was probably paracarditis.
The doctor gave me a copy of the x-rays and ECG and had me go to the Cardiologist.

When I arrived at the cardiologist’s office, I gave him the x-rays and ecg but he wanted his own ecg. They had a staff there, which seemed like a trauma team. They gave me another nitro pill. They took blood, did an ecg, did an echo and determined that my crisis was paracarditis and not a heart attack. He gave me celebrex for it and the pain went away. He said my ecg was not normal and wanted to do a stress test that next week. The next day they called and said the echo was showing some heart damage and rather than a stress test, wanted to do a heart cath the next day. They asked me how I was doing and I said just fine until I heard that bit of too much information. They had me start Toprol and quit the Cardizem.

After the heart cath, the cardiologist said he could not find any blockages or damage but my EF was 30%. The echo showed 20 to 25% EF. He wanted to start me on Coreg, which takes several weeks to titrate to full dose. He changed the ACE to a different one and max dose. He said my bp was not under control and said he was going to get it under control. After a couple weeks my bp was still too high and he added Norvasc (a CCB) after a week or so he doubled the dose and still not controlled after another week or so he added Avapro and that did it.

The summary on the heart cath says:
“Nonischemic dilated cardiomyopathy with normal coronary anatomy, but marked reduction in left ventricular function with estimated ejection fraction of 30%. This is most likely due to chronic hypertension.”



I have the ECGs but am not sure what they mean but here is what I see at the top. I have had three different ECGs so far. (After the paracarditis)
The first ECG says Sinus tachycardia, rate 109. Under that is Left bundle branch block. Nothing is on third line.

The next ECKG was taken a month later and is different. It says normal sinus rate 80. Next line Left bundle branch block.
Third line, Consider left atrial enlargement

The latest one is the same as the last except the rate is 68 rather than 80.

There are other things on the ECGs but they are letters and numbers. I do not understand what they mean. Right above the graph area it says –ABNORMAL ECG-.
Let me know which ones you need.

You asked about the White coat syndrome? That is what I have been told from the start but I think doctors should consider it multi-coat syndrome. Just because a patient is feeling stress in the docs office does not mean the patient does not feel stress under many other situations. The least likely place a patient will suffer stress is while in comfortable surroundings like their homes. My bp was good when taken at home. Maybe mild Agoraphobia (probably misspelled) to some extent plays a part. If you can watch a group of children candidly, you will notice some are shy and some are bold. When they become adults, the shy ones should have grown out of being apprehensive. Maybe they just learned how to cope but their nervous systems haven’t. I believe there are way too many people with hypertension that have no definable cause for this to not have some merit.
My very first doctor told me that some people deal with stress by developing an ulcer, others, high blood pressure.

That’s why I believe a doctor should pay closer attention to patients with so called White coat syndrome and not just think it’s just a doctor office thing going on. I'm not talking about just a couple of points S/D bp. They never see good bp readings in the office.

My situation is not like an aging patient with cholesterol and other problems. I was pretty young when it started. I’m not all that old now. At least too young to be feeling this tired. That probably puts me in another category of hypertensives.
I have read that as many as 50% of hypertensive patients are not properly under control. That will be good job security for the cardiologists of the future. The bad thing, these folk think they are in good hands. The cardiologist never gets to see them until they are too far gone.

I don’t believe that doctors set out to mistreat or under-treat anyone. My family doctor is a fine individual and very likable. I just think that the ball was dropped in my situation. It could be that even if it were caught before now it wouldn’t have helped but maybe it would have. It’s at least better than one day hearing,“WOW", You Have an Enlarged Heart”

Let me know if I’ve left anything out.

Ph128
Thank you for the information; it helped me to be able to research your individual course of hypertension and the management thereof. I found the documentation that I had hoped to find and wouldn't you know it, the US resources wanted $65 for access to the information--but the United Kingdom provided free access to the information! So, now I have the information from the World Health Organization and all its participants (US) on the issues of hypertension diagnosis, management (including drug therapy), and on White-Coat Syndrome.

White-Coat Syndrome is a hot topic. There are three suggested methods of evaluating a BP before diagnosing a White-Coat Syndrome. One is in-office BP measurements by an MD, an RN, and by a less 'threatening' healthcare worker such as an aide or lab tech, not all done on the same visit. If the nurse and/or the less threatening healthcare worker obtain lower BP measurements, then it's a positive indicator for White Coat Syndrome. Next, the patient measures his or her BP at home and those values are compared to the in-office measurements. Lastly, a 24-hour ambulatory BP monitoring is obtained. This would provide the evaluation of 'other coats syndromes' as you suggested. Sadly, 24-hour BP monitoring isn't recognized as being generally or easily available and is affected by too many variances in compliance.

Preferred diagnosis of hypertension vs. White Coat Syndrome reverts back to successive BP measurements above the norm for at least three elevated readings. This must be done before drug management is begun.

Before drug management is begun, the patient must be evaluated for organ involvement or impairment. Your first family physician met this standard and began appropriate treatment. Your second family physician appears to have been within the standard by accepting the most recent ECG and other clinical findings by your first family physician. If he did not get your prior records, then it may be considered negligent--but, before we say "aha! he should have foreseen the risks of significant damages!", we have to look at what the WHO determined after years of research, record keeping, drug studies, clinical practice studies, etc. and we have to look at the "rule of halves".

The latter, the rule of halves, is shorter, so I'll start there. 'Half of all persons with hypertension will be diagnosed with hypertension; half of those diagnosed will receive treatment; half of those treated will achieve proper controlmanagement of their hypertension, which yields a net 10-15% of all hypertensive patients achieve proper management/control of hypertension.' This rule is accepted world-wide as a truth, a beginning point in studies, and finding a way of changing of the rule is a goal/spring-board in continuing study of the management of hypertension.

The World Health Organization information on hypertension that meets your personal history, essentially says that despite ECGs, echocardiograms, x-rays, etc., clinical observation of the patient is the best/preferred method of detecting/diagnosing left ventricular hypertrophy. (Even though you had one diastolic BP >100, your average diastolic BP was <100; therefore, the information below correlates to your hypertensive status.)

An electrocardiogram is an insensitive way of detecting LVH. Electrocardiographic LVH did not predict risk in one study. The best way of detecting LVH is by echocardiography. Echocardiographic LVH has been shown to be prognostically significant. However, the availability of echocardiography is limited and at least one guideline has come out against its routine use in hypertension. Blood pressure treatment can in some cases regress LVH but there is no end point evidence to show a difference in deaths or strokes or myocardial infarcts. In patients with diastolic BP (DBP) 90-99mmHg the presence of target organ damage or additional risk factors indicates the need for treatment. In such patients echocardiography may be indicated but there are no prospective controlled studies to show the merit of this approach. Indeed, when the blood pressure is in this borderline range, the likelihood of finding LVH is small. Therefore in the absence of readily available and accurate, standardised investigations it is recommended that evidence of LVH be sought clinically only

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Based on the history that you provided and the information from the WHO, I'm of the opinion that the second family physician more likely than not met the standards of care for monitoring, treating, and diagnosing your hypertension, including evaluation of organ involvement. Of course, I don't have your medical records and have no way of evaluating the actual documented treatment.

I still suggest that you contact a local attorney and verify the statute of limitations that would apply should you decide to pursue a medmal claim investigation. If your cardiologist states that he believes that the damages to your heart are a direct result negligence, then hasten to a medmal attorney and get the investigation started.

Professionally, I recommend that you locate a wellness center (not a place to exercise such as a gym) and with the advice and involvement of your cardiologist, that you begin to attain overall wellness. Achieving your optimal level of wellness will do as much or more to improve your health, reduce risks, and protect your future than any form of medication. You live in the 'perfect' area to find a wellness program that meets your individual lifestyle and personality and you appear to possess the ability to achieve wellness.

Best wishes,
EC

Ellencee
Thank you for your reply,

In reference to the White coat syndrome, my bp would be high no matter who took it. Usually the nurse or who ever weighed me in was the one who took my bp. I would also on some visits take my own bp machine and would have it compared to their reading. It would always be very close. My bp would be high even though I always took my medication. I’m willing to bet that if I went to the post office and had the janitor take my bp it would have been high. I don’t think the doc’s office was my problem but apparently the doctor believed so. At home it would be normal. I never wore a monitor for bp.

After looking at the ECGs which were recent, I don’t have the old ones taken 10-20 years ago, I looked up the Left bundle branch block (LBBB) and wondered when that happened. My old physician never mentioned anything about his ECGs being abnormal or LBBB. I could not find anything on how fast that appears. Only that the electrical timing is off. It had to show up sometime in the last 10 years but will never know since no ECG was ever taken during that period.

Perhaps my family doctor followed the proper protocols for treating HBP but it failed to reveal LVH. The x-ray did that (enlarged heart). Clinical signs of LVH must not show up (mine didn’t) until the very end when the heart can’t pump blood fast enough to keep the fluid from accumulating in the lungs, joints & abdomen. Doing an Echo at that time would be like the pilot flying at night who just lost his engine, turning on his landing lights and if not liking what he sees, just turning them off. Waiting for clinical signs of LVH seems to me to be a poor way of measuring success or failure. The crash is imminent.

The medical community must rely too much on studies. Common sense should also be used. No physician should ever say “Hey I followed the minimum standards of WHO so Oh Well”. I realize it will work in the courts though.

Imagine if the government used the rule of halves to defend us from terrorists. Saying not to worry, they can’t kill maybe more than 10 or 15% of us. Statistically you won’t be one of the deaths. Sounds like doctors do though.

According to the WHO, I was in the half who were discovered, in the half who were treated and then in the half whose treatment failed. It’s seems odd to me that the Cardiologist has my diastolic out of the 90s and 100s and into the 60s and 70s but my family physician did not, even though I was receiving proper treatment (the minimum standard of care). Why can the Cardiologist achieve control and a family doctor cannot or did not? Each case should be individually assessed. A one-rule fits all protocol would probably work 50% of the time. That may work at the craps table but it’s frightening to think our medical professionals can practice that way. I have always thought of the physicians as almost gods.

Statistics aren’t always reliable though. How about the man who drowns in a river that was statistically impossible to drown in. The river only averaged 6 inches deep.

I imagine that a medical malpractice suit would be a big investment for an attorney and they would have to look at this statistically also and probably come to the same conclusion as you have. It’s a long shot even at 50%. Too much risk. They’d rather have a case where the wrong foot was amputated or a tool was left inside the patient.

I have never sued anyone before and don’t think much of those who do so frivolously. This just drives up medical costs. I would probably find that I have Attorney Coat syndrome anyway along with the rest of the closet syndromes.

I usually try to avoid most confrontations and let thing go and just walk away.

The only reason I have comptemplated such a thing is that I don’t have anywhere to walk to. I am on my spouses insurance plan. I read an article the other day that stated that only 3% of the covered employees consume 90% of the medical claims. It wouldn’t take a rocket scientist to figure out that ridding the company of these employees would reduce the company’s insurance premiums for everyone. A company would have to weigh just how much it is worth to keep them. Of course they couldn’t fire them for something like that but could find something none-the-less. I had to sign a release to them (for medical records) not too long ago so I’m worried. Life will get real bad if something like that happens.

I would rather be able to get through the day without having to take a nap. I can’t participate or enjoy the things I once did because I’d rather just sleep. Life is just not the same with half-mast eyelids in the middle of the day. I have another appointment with the cardiologist coming up and maybe he will be able to help me with the fatigue.

All of this because the doctor only has to statistically give me the minimal standard of care.

Thank you for all the attention that you have given to me.

ph128
I have enjoyed assisting you. I don't want you to think that the WHO's information and resulting standards are based on incompetent MDs. Their findings, decisions, and resulting standards are based on the best medical science has been able to provide, not just in the US but worldwide.

From what I read, the best that can be offerred is ACE and you have been on those meds from the start. Although ACE and related meds are considered to be beneficial, the percentage of success in preventing ventricular hypertrophy and loss of ejection fraction is way below 50%.

I did read that sometimes pericarditis is the result of a heart attack and each is diagnosed when the symptoms of pericarditis are evaluated. You are right; without a recent ECG prior to the pericarditis, you have no way of making such a determination in your situation.

The LBBB is included in LVH. Not all patients with a Left Bundle Branch Block develop left venrticular hypertrophy to a degree that causes significant loss of ejection fraction.

A medmal suit will be expensive, aggravating, frustrating, and lengthy. The last average length of time I read is five years from the time of the first appointment with the attorney until conclusion. If you believe it is something you must do in order to determine what happened and if it could have been prevented, for what it's worth, you have my support. Maybe there is a possibility that you were denied the last, best chance at preventing the damages you suffered.

From my own personal experience, I can tell you that one can achieve a state of wellness that allows one to function at maxium potential and allows a full, productive, and happy life. It takes time and effort, success and failure, but it can be done and it's worth it--at least it has been for me.

EC

Bravo EC, nursing education at its best.

I am a classic case of white coat bp or even pharmacy bp. I have been on meds for the past 8 yrs and while I don't consider the meds to cure me, I do consider them to stablelize me.

I am a smoker and just a basically high strung person.
When I go to see my PA my bp is always down (because I go in the mornings and am a PM smoker).

Do you smoke or drink or anything that can cause you to have high bp? I can cover up mine but some can't.

Good luck and hopefully neither one of us will stroke out as my Mom did 3 yrs ago

And as far as EC, SHE ROCLS IN MED KNOWLEDGE!!!!!

lkc15507 and tammy8
Many thanks!

EC