“I’ll give you a hint: the diagnosis is NOT heartburn or anxiety”

by Carolyn Thomas   ♥   @HeartSisters

This recent “What’s the diagnosis?”  ECG challenge on Twitter from Dr. Sam Ghali attracted many online guesses from his healthcare colleagues – including this from a critical care nurse practitioner who astutely wrote:

“In today’s healthcare system, she would probably be told ‘it’s all in your head’ or ‘maybe you should lose weight’.”

Dr. Ghali, an Emergency physician and associate professor at the University of Florida in Jacksonville, later explained the young patient’s heart attack to his colleagues:

“This is a very important case of a young woman with nausea, vomiting and severe ‘heartburn’ symptoms. The ECG was recorded in triage and should be very concerning. Classic, hyper-acute ischemic T-waves. I don’t care that this is a young patient. There’s injury in every single one of these ECG leads.”

“This young woman was found to have a 100% ‘wrap around’ mid-Left Anterior Descending coronary artery occlusion – that was opened up and stented in the cath lab.

“Remember this case and never ever write off people with chest pain – especially women who may present differently than men and are notoriously misdiagnosed or diagnosed late with worse outcomes. Please help spread awareness, and I promise you will make a difference in these people’s lives.”

Although most (but not all) Twitter responses correctly interpreted this ECG (also called EKG) in Dr. Ghali’s informal challenge, there was a range of incorrect guesses that came from people who have graduated from medical school.

Vasospasm received a number of votes – a non-obstructive coronary artery spasm disorder called Prinzmetal’s variant angina – including one vote for vasospasm caused by cocaine toxicity. This guess immediately struck a nerve with me because one of my longtime readers (age 33 at the time she first wrote to me; she now lives with an implanted defibrillator). She was shocked to be accused by an Emerg doc of being a cocaine user “because I was female, young and thin – barely 100 pounds soaking wet”).  He wrote on her medical chart that she had “denied” using the drugs – yet that wording itself suggests he suspected she was lying to him.

An electrophysiologist (a cardiologist who specializes in heart rhythm problems) guessed this was the ECG of a person with non-obstructive Takotsubo (“Broken Heart”) syndrome.

After a physician guessed SCAD (Spontaneous Coronary Artery Dissection, a heart condition that largely affects younger healthy women with few if any cardiac risk factors), one paramedic started his Tweet response with “I had to Google SCAD. . .”  which is just a tad disturbing, coming from a paramedic. I hope he was able to learn enough from Dr. Google before his next urgent call to the home of a real SCAD patient.

One physician questioned why an Emergency doc would order an ECG for such a young woman.

Another Twitter response came from Dr. Lea Merone, a public health physician in Australia who wrote: “The responses to this Tweet are why I did my PhD in women’s chronic disease.”  Her study, called “I Just Want to Feel Safe Going to a Doctor”, was published in the journal Women’s Health Reports.¹ 

A surprising response directly quoted the solution from ChatGTP (an artificial intelligence chatbot) for a virtual opinion.  The disembodied suggestion mirrored many of the human votes like this:

“Dr. Ghali should arrange for the patient to be transferred to a cardiac catheterization lab as soon as possible. Prompt treatment can help minimize the extent of heart muscle damage and improve the patient’s longterm outcomes.”

Although this was a Twitter exercise, and not a life-or-death real world test of diagnostic skill, the range of incorrect guesses was both surprising and disturbing if you’re a patient like me, who somehow managed to survive a misdiagnosed “widow maker” heart attack.  “You’re in the right demographic for acid reflux!” pronounced the very confident Emerg doc before sending me home just four hours after symptom onset, feeling terribly embarrassed for having made a fuss over nothing.

He too had graduated from med school.

Granted, ECG interpretation relies on unique critical thinking skills that improve with practice if accompanied by a keen enthusiasm for learning, but that practice typically arises from ongoing opportunities to practice – which are simply not applicable to all medical specialties – unless they’re the kind of doctor who enjoys playing Dr. Ghali’s educational “What’s the diagnosis?” challenges for fun.

Dr. David Cook, lead author of a 2020 study on accuracy in interpreting ECGs, concluded that, on average, only half of all ECGs are accurately interpreted, with medical students having the lowest accuracy and – not surprisingly – cardiologists having the highest at 75 per cent² . Yet when Yale cardiologist Dr. Harlan Krumholz reviewed this report for the New England Journal of Medicine’s Journal Watch, he wrote:

“This sobering study reports low accuracy in the interpretation of electrocardiograms across a wide range of groups. Cardiologists did best, but still had a high prevalence of errors. And training had only a modest effect in the studies.”

I wrote here about a horrific example of dueling hospital physicians who seemed unable to agree on the interpretation of a patient’s ECG.

That case involved the preventable death of a 70-year old woman who had arrived at her local Emergency Department with textbook cardiac symptoms she’d been experiencing for five days. She died there after waiting 2 1/2 hours for care while Emergency physicians argued with cardiologists about whether she was sick enough to move to the cath lab. This tragic example is a case study described by Emergency physician Dr. Pendell Myers of Charlotte, NC,  published on Dr. Stephen Smith’s ECG blog (including expert ‘what went wrong?’ analyses of this kind of tragedy).

Diagnostic errors are a serious problem in women, writes Dr. Alyson McGregor, among many others. She’s an Emergency physician at Brown University who wrote the book: “Sex Matters:  How Male-Centric Medicine Endangers Women’s Health and What We Can Do About It“.   Dr. McGregor defines male-centric medicine like this: medical research and medical practice based on models historically designed to work in men, while ignoring the unique biological/emotional differences between men and women. In fact, she writes that “the male-centric model of medicine is now so pervasive in health care that many of us don’t even realize it exists”.

Meanwhile, I’d love to have physicians like Dr. Ghali in every Emergency Department, and even more importantly, teaching every medical school class. I’d love to believe that all physicians could become as skilled as Dr. Ghali in correctly interpreting ECGs – and as willing to teach colleagues how to practice their own ECG interpreting skills.  And of course I’d love to have physicians who know what Dr. Ghali already understands about women with heart disease who “may present differently than men and are notoriously misdiagnosed or diagnosed late, with worse outcomes.” 

I often tell my Heart-Smart Women presentation audiences that I wish the Emerg doc who told me my ECG was “normal” and misdiagnosed my heart attack as acid reflux had bothered to Google my symptoms (central chest pain, nausea, sweating and pain down my left arm). I’m pretty sure that Dr. Google would have come up with only one search result: myocardial infarction.

And if I can’t get somebody like Dr. Ghali to interpret my next ECG, maybe my second choice just may end up to be (gasp!)  ChatGTP.

For younger women, accurate cardiac diagnoses still remain significantly more elusive than those our male counterparts will receive. As one wise med student observed in response to Dr. Ghali’s quiz:

“The ECG contains two parts that make doctors ignore the patient: ‘young’ and ‘female.’ ”

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1. Lea Merone et al. “I Just Want to Feel Safe Going to a Doctor”: Experiences of Female Patients with Chronic Conditions in Australia.”Women’s Health Reports.Dec 2022.1016-1028.

2. Cook DA et al. “Accuracy of Physicians’ Electrocardiogram Interpretations: A Systematic Review and Meta-analysis.” JAMA Intern Med. 2020 Nov 1;180(11):1461-1471.

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NOTE FROM CAROLYN:   I wrote much more about cardiac diagnosis and misdiagnosis in my book, A Woman’s Guide to Living with Heart Disease (Johns Hopkins University Press). You can ask for it at your local library or favourite bookshop (please support your local independent booksellers) or order it online (paperback, hardcover or e-book) at Amazon – or order it directly from Johns Hopkins University Press (use their code HTWN to save 30% off the list price).

Q:  Have you ever been told your ECG was “normal” – when it wasn’t?

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See also: 

Almost any page on Dr. Stephen Smith’s ECG blog. This is where many ECG hobbyists (as they describe themselves) who love interpreting challenging electrocardiograms come to hang out with other experts for fun. I can only hope to have an ECG hobbyist interpreting my next hospital ECG. . .