Finding into death of H I
Deceased
HI
Demographics
49y, female
Date of death
2017-11-28
Finding date
2022-01-20
Cause of death
Acute myocardial infarction secondary to giant-cell arteritis and atherosclerosis of the coronary arteries
AI-generated summary
49-year-old woman died from acute myocardial infarction secondary to giant-cell arteritis of coronary arteries. On 26 November, she presented to her GP with left-sided chest pain described as atypical and unlikely ischaemic, given absent traditional cardiac risk factors. No ECG or troponin testing was performed; an exercise stress echocardiogram was ordered for investigation days to weeks later. Two days later she presented unwell with hypotension and was referred to ED where she arrested and died. The coroner found that whilst an onsite ECG would have been reasonable, the GP's clinical decision-making was consistent with peer practice and RACGP standards at the time. Giant-cell arteritis affecting coronary arteries is exceptionally rare and would be difficult to encapsulate in guidelines. The case highlights absence of RACGP-endorsed chest pain assessment guidelines.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Error types
Drugs involved
Contributing factors
- Failure to perform ECG at initial GP presentation on 26 November 2017
- Failure to perform cardiac biomarker testing (troponin) at initial presentation
- Ordering of non-invasive stress testing instead of immediate definitive risk stratification
- Absence of RACGP-endorsed guidelines for management of suspected acute coronary syndrome in primary care
- Giant-cell arteritis affecting coronary arteries (exceptionally rare condition)
Coroner's recommendations
- The RACGP consider either endorsing the National Heart Foundation of Australia & Cardiac Society of Australia and New Zealand Guidelines (and future revisions) for management of Acute Coronary Syndromes or produce their own guidelines for assessment and management of potential ischaemic chest pain in primary care
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