He was pitching hay to his horses when the pain struck — a heavy, dull pressure across his chest.
Within a few days, the pain hit again and again, when he was working out, during even minor exertion. Finally, it sent him to the emergency room. He knew what it might mean.
At the hospital, 46-year-old Stephen Coffey underwent one of the most common tests for heart disease — a treadmill stress test.
Used worldwide for half a century, the stress test is performed millions of times every year in this country, and now more than ever as huge numbers of aging baby boomers deal with the threat of our No. 1 killer.
But this time, something went terribly wrong. After exercising on the treadmill at Northwest Medical Center for more than 10 minutes, Coffey felt weak, dizzy and hot. He asked to lie down.
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Within an hour, he was dead — of a massive heart attack induced by the treadmill test.
What is perhaps shocking to the millions of Americans who will get on a treadmill to test their hearts this year is that one of every 2,500 will end up having a heart attack or even dying, the American College of Cardiology and the American Heart Association report.
"Although exercise testing is generally a safe procedure, both myocardial infarction (heart attack) and death have been reported … Good clinical judgment should therefore be used in deciding which patients should undergo exercise testing," state the guidelines for cardiac stress testing set by the heart associations.
In that straightforward statement lies the tricky nature of stress testing. Though considered a routine and generally safe test, only people suspected or known to have heart troubles get on these treadmills. Deciding who should be tested, and for how long and how hard, requires the careful, even exquisite judgment of highly trained cardiac professionals. Their judgment is a matter of life and death.
"You have to make these judgments on a case-by-case basis. Every patient is different, and there is a complex set of factors to weigh for each one," said Dr. Charles Katzenberg, a cardiologist with Pima Heart Associates who works at Tucson Heart Hospital.
"There are set protocols on how to run a stress test, but even these protocols are adjusted for each patient," he said.
"But the bottom line is, of all the things we do in medicine, stress tests are pretty darn safe. If there are definite indications for doing the test, the risks are reasonable."
Complaints of chest pain — a known symptom of heart and artery disease — are one of the most common reasons to conduct a treadmill stress test. Other reasons include a family history of heart disease, smoking, high cholesterol, high blood pressure and diabetes.
What doctors want to find out during the test is how the heart muscle responds to the need for extra oxygen. The patient starts out on the treadmill at a slow pace and slight incline, which are increased every three minutes until a peak target heart rate is achieved, signalling the heart is working hard enough. All the while, an electrocardiogram (ECG) machine records the heart's behavior, blood pressures are taken, the heart rate is tracked, and the patient's symptoms are watched.
"You have to pay very close attention to the patient on the treadmill," said Dr. Dietmar Gann, a longtime cardiologist with the Tucson Heart Group.
"At the first sign of a problem, you do not push them through the full protocol. You have to know who is at low, medium or high risk for taking this test. That's why judgment is so important. Routine standards, going 'by the book,' does not work for everyone.
"I would rather stop the test early than push a patient to get to the target heart rate. Doctors and therapists can get hooked on the targets, and that can get you in trouble."
That very problem — pushing the patient too hard to get to the target heart rate — turned out to be a critical issue in the death of Stephen Coffey.
Opinions mixed on man's death
It was one of a cascade of critical misjudgments made before, during and after the stress test primarily by the physician assistant who conducted it, Martina Frost, and to a lesser degree, by the Tucson cardiologist who ordered and supervised it, Dr. Tedd Goldfinger, according to the unanimous $2 million verdict awarded to the Coffey family after a jury trial this summer.
Experts testified that Coffey was a high-risk patient for the stress test, based on multiple risk factors — the recent onset of his chest pain, his high blood pressure, cholesterol and weight, and a suspicious ECG reading before the test.
During the test, experts testified, a combination of cardiac-affecting drugs in his system kept his heart rate artificially low, leading Frost to push him too hard for too long in an unsuccessful effort to reach his target heart rate. Also, there were abnormal, though subtle, changes in his ECG readings that should have stopped the test at six minutes, instead of pushing him almost twice that long, said Dr. Harold Marcus, cardiologist at Cedars-Sinai Medical Center in Los Angeles.
Finally, at the end of the test, after Coffey lay down, struggling to breathe, with severe chest pain, plummeting blood pressure and signs of a heart attack, he was given two doses of nitroglycerin — a fast-acting drug that dilates blood vessels — sending his blood pressure into fatal decline, Marcus said.
"It is contraindicated to give nitroglycerin when undergoing an evolving (heart attack) and the blood pressure is low," Marcus testified, according to Pima County Superior Court records.
"The addition of these two nitroglycerins made things so difficult they couldn't dig their way out of the hole they had put the patient in."
Summing up the case, Ronald Mercaldo, attorney for the Coffey family, said: "The decision to put someone on a stress test should merit a lot more consideration than Steve was given. This is an example of what can happen if the doctor is not paying the proper amount of attention to you and is not following vital guidelines."
Coffey's family declined to comment.
The cardiologist who ordered the stress test, Goldfinger, was not present when Coffey was on the treadmill, and arrived only after he began to suffer the heart attack. In court records, he testified that Coffey was a "low risk" patient for the stress test, though the ER physician described him as "very suspicious for coronary artery disease."
Goldfinger also testified that the drugs Coffey was on did not interfere with the test, and that the ECG changes during the test were not abnormal enough to stop it, though they did suggest there was some drop in blood flow to the heart.
"This patient wasn't high risk at all, he was a low-risk candidate — the exact type of person the stress test was designed for," said Dan Cavett, the attorney for Goldfinger and Frost. He declined to allow either to comment due to plans to appeal, he said.
"It was only after the test was over with that the ECG showed signs of a heart attack, and the first thing to do in that situation is to give nitroglycerin. His blood pressure was not too low for that — it did not fall out.
"Nothing at all went wrong with the test. A heart attack is one of the risks of this procedure, and bad things happen to good people without it being anyone's fault."
Coffey's autopsy showed a severely enlarged heart and severe atherosclerotic disease, with two badly blocked arteries.
"It was only afterward that we learned his heart was nearly twice the normal size," Cavett said. "So this was an unfortunate, tragic result in a very complex, sophisticated medical situation, but not because of any substandard care."
Some of the top cardiologists in Tucson disagree completely about how this patient was treated — indicating once again how difficult some of the decisions and judgments about this very common test truly are.
"Given his risk factors, I would not have stress-tested this patient. There was enough evidence of disease — it made no sense to do a stress test, especially for as long as 11 minutes," Gann said. "This was a very high-risk patient, and in that situation, the test must always be done by the physician."
But Dr. Gordon Ewy, director of the University of Arizona Sarver Heart Center, said he was familiar with the case and no malpractice was committed.
"The real disservice here would be to scare people off of treadmill tests. You don't want to do that," he said.
"You do this test to discover potential problems, fix them and save a person's life. It's a disservice to say it is too risky.
"The treadmill is one of the most critically important tests we have."
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● The test is designed to unmask the signs and symptoms of heart disease under the stress of exercise. These symptoms may not be evident when a patient is at rest.
l Heart rate and blood pressure are recorded before the test, when a patient is at rest.
l Sticky electrodes are attached to the patient's chest, shoulders and hips, to take electrocardiogram readings.
l The treadmill is started at a fairly low warm-up speed.
l Every three minutes, the treadmill speed and incline are increased.
l Blood pressure is measured during the second minute of each three-minute "stage" of the test, or more frequently if it's is too high or too low.
l The physician or physician's assistant conducting the test studies the patient's heart rate, blood pressure, changes in the electrocardiogram and heart rhythm, and the patient's appearance and symptoms.
l The treadmill is stopped when a patient achieves the target heart rate, or before if a patient develops chest pain, shortness of breath, dizziness, unsteady gait or serious ECG or blood pressure changes.
Source: HeartSite.com
