New Hampshire Bar Association
About the Bar
For Members
For the Public
Legal Links
Online Store
Vendor Directory
NH Bar Foundation
Judicial Branch

A confidential, independent resource for NH lawyers, judges and law students.

NH Bar's Litigation Guidelines
New Hampshire Bar Association
Lawyer Referral Service Law Related Education NHBA CLE NHBA Insurance Agency
Member Login
Member Portal

Bar News - October 6, 2006

Medical Malpractice Law Evaluating Heart Attack Cases Requires Familiarity with Diagnosis


We all know someone who has died of a heart attack. Heart disease is the leading cause of death in this country. Twenty-three million Americans, 11 percent of all adults, have been diagnosed with heart disease. Not surprisingly, medical malpractice claims for failure to diagnose an impending coronary arrest are somewhat common. Counsel evaluating these cases must be familiar with the general principles of medicine governing the diagnosis and treatment of coronary artery disease.

        In my experience, these cases usually involve a patient coming to the emergency room or to a primary care physician with complaints of pain of recent onset, which by the time I am consulted, appear in retrospect to have been signs of a cardiac arrest in progress or one on the way.

        Angina, which is the pain or discomfort a patient can experience when the heart gets insufficient blood due to the obstruction of blood vessels, can present in a variety of ways, including: feeling of pressure in the chest; radiating pain in the arm, jaw, or back; or a feeling of chronic heart burn. Angina can be triggered by the stress of physical exertion or emotion or, more ominously, can occur at rest. The clinicianís suspicion should rise with the number and quality of the coronary artery disease risk factors present: increased age (83 percent of patients who die from heart attacks are 65 years old or older); being male (although after age 80 men and women have the same risk of heart disease); a family history of heart disease; smoking (increases risk of disease two to four times); high cholesterol; high blood pressure; sedentary lifestyle; obesity; and diabetes.

        A metabolic disease which can interfere with a patientís sensory systems, diabetes not only increases the risk of heart disease, it can make detection of an impending heart attack more difficult for the patient and physician. Fifteen to 20 percent of heart attacks are painless and this type is most likely to occur among diabetics. As a result, a physician must be especially vigilant with a diabetic patient.

        The physician can administer a variety of tests to evaluate for the presence of heart disease, including: resting electrocardiogram (ECG) (which carries a risk of false negative results); treadmill ECG; thallium imaging study; and cardiac enzyme tests. Depending on the results, due care may require the performance of further tests and ultimately surgical or other treatment.

        In a death case, an autopsy may be critical to whether a case can be pursued. In my experience, the autopsy will define the extent to which each of the major vessels of the heart were occluded, which is important in assessing the extent to which the patientís condition was operable, the lost life expectancy, and the extent of impairment the patient would have experienced had he survived.

 Ralph Holmes
Ralph Holmes

        I will usually request records for any recent hospital admissions, even if unrelated to cardiac care. The records sometimes contain a resting ECG taken to get baseline health data or for preoperative screening. If the ECG is viewed as abnormal by my cardiology expert and was interpreted by the hospital clinicians as normal, then a case might be built against hospital clinicians. In any medical case, it is important for plaintiffís counsel and his experts to identify the earliest time the medical condition at issue should have been diagnosed because, the greater the opportunity lost, the better the case.

        As mentioned above, age is a risk factor for coronary artery disease. New Hampshire has the seventh oldest population in the country. The incidence of this disease and other age-related diseases is likely to increase. Counsel handling medical cases need to be familiar with the medical principles governing the diagnosis of this disease.


Ralph F. Holmes is a partner at the McLane Law Firm. He handles medical malpractice, probate, and commercial litigation, and can be reached at



Supreme Court Rule 42(9) requires all NH admitted attorneys to notify the Bar Association of any address change, home or office.

Home | About the Bar | For Members | For the Public | Legal Links | Publications | Online Store
Lawyer Referral Service | Law-Related Education | NHBA•CLE | NHBA Insurance Agency | NHMCLE
Search | Calendar

New Hampshire Bar Association
2 Pillsbury Street, Suite 300, Concord NH 03301
phone: (603) 224-6942 fax: (603) 224-2910
© NH Bar Association Disclaimer