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Medical Articles »Roger Nacouzi, M.D.
From the Heart: Evaluating Cardiovascular Injuries
Roger Nacouzi, M.D.
Internal Medicine & Cardiology
Symptoms caused by heart disease and cardiovascular illnesses include high blood pressure, chest pain, heart attacks, stroke, irregular heartbeat, palpitation, loss of consciousness, shortness of breath and heart murmur. The heart anatomy includes the muscle that pumps the blood, the valves that allow the blood to move only in one direction and the coronary arteries that feed the heart muscle. Diseases of the heart and circulation are so common and the population at large is so well acquainted with the major symptoms resulting from these disorders that patients, and occasionally physicians, erroneously attribute many complaints to organic and physiologic cardiovascular disease.
The establishment of a correct diagnosis starts with a thorough and complete history and physical examination. Indeed, the clinical examination remains the basis for the diagnosis of a wide variety of cardiovascular disorders. The exam may then be supplemented by the cardiac tests: electrocardiogram, chest X-ray, noninvasive exercise treadmill test and echocardiogram, and occasionally invasive procedures such as cardiac catheterization. In making a diagnosis, the results obtained from each of these tests should be analyzed together with the history and physical exam. It is only then that a physician can avoid an erroneous diagnosis. For example, different images of the same heart can be obtained by an echocardiogram through the application of different techniques. The same image can be interpreted differently by different physicians. Thus, the correct diagnosis can only be made when one test is combined intelligently with the results of other tests on one side and with the history and physical exam on the other side. Because medical records contain the results of the cardiac tests, they are valuable tools to confirm the clinical impression made from the history and physical examination.
The arduous task of addressing the issue of causation requires not only a history, a physical exam, the review of records, information obtained from other medical specialties, investigative reports, depositions and other medical-legal evaluations, but also relies on new scientific discovery in the medical literature. Over the last decade, physicians have been increasingly recognizing the importance of physical and / or emotional stress in triggering the rupture of a so-called atherosclerotic plaque, the pathology within the coronary arteries that leads to obliteration of the blood flow and an acute cardiac event. Live images of the heart and open-heart surgeries have provided valuable information on the mechanism of cardiovascular disease. Examples include muscle contusion and ruptured valve in a chest trauma that required surgery, or the differentiation of the damage to the heart put under high blood pressure or tension from the natural progression of illness obtained through live images of the heart.
The issue of causation is made more complex in certain categories of employment that fall under law presumption. Certain law enforcement and fire fighting personnel are entitled to statutory presumption that the heart disease or trouble arose out of, and in the course of employment which developed or manifested itself during the employment period. Although the burden of proof is shifted onto the employing department, the employee must show that the condition exists. Hence, the importance of a correct diagnosis, as discussed above. The presumption is disputable and may be controverted by sound medical evidence reasoning that absent the subject employment, the employee would have developed the heart disease or trouble. Examples include a deputy sheriff getting a heart attack while hunting with friends in the Rocky Mountains or a highway patrol officer getting a stroke when his wife left him. The mechanism of disease would be the rupture of a non-symptomatic plaque within the artery leading to the formation of a tiny clot that would occlude the blood flow to the noble organ. It remains true, however, that the presumption for heart trouble is a reflection of a public policy implemented to protect our law enforcement and fire fighters who provide vital and hazardous services to our society. If in doubt, an evaluating physician would err in favor of the employee.
The assessment of functional impairment and residual capacity relies on the results of the exercise treadmill test in combination with the history from the patient. The exercise test monitors blood pressure, heart rate, electrocardiogram and the symptoms while the patient is running on a treadmill. The speed and grade are increased according to standard protocols that establish workload, measured in METs, at each level of the treadmill exercise. One MET unit is equivalent to the level of energy expenditure required by the body at rest sitting quietly. For example, a person who can reach a level of 3-4 METs on the treadmill can assemble a machine, clean windows, lay bricks, walk three miles an hour, bike six miles an hour, play golf or play energetic music.
There are different therapeutic options available to patients with cardiovascular illnesses. In the absence of evidence for heart disease, the patient should be reassured with a definitive statement to that effect. Otherwise, continued attention to non-existing heart trouble may lead to the patient developing an abnormal fixation on the heart. If there is no evidence for cardiovascular disease, but the patient has one or more risk factors for development of such a disease, a plan for risk reduction should be developed. Non-symptomatic or mildly symptomatic patients with established heart disease should be evaluated periodically.
In this manner, early signs of deterioration of the ventricular function can be detected and may signify the need for further treatment despite the absence of disabling symptoms. For the treating physician, it is important to establish clear criteria for deciding on the form of treatment modality, that is, medical, angioplasty or surgery in patients with heart disease.
In summary, the evaluation of a cardiovascular claim is not an easy task. its complexity stems from the need to gather and analyze detailed information from multiple sources and determine that such information is internally consistent before rendering an opinion on the medical-legal issues involved. In this manner, correct diagnosis, causation, level of impairment and treatment option can be presented in a medically reasonable and convincing way.
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