Failure to Diagnose a Heart Attack: A Case-Screening Guide

Diagnostic error is the largest source of serious malpractice harm — the "Big Three" categories (vascular events, infections, cancers) account for roughly three-quarters of serious misdiagnosis harm, an estimated ~795,000 Americans a year suffering death or permanent disability (Newman-Toker et al., BMJ Quality & Safety, 2023–2024). The emergencies below are textbook "cannot-miss" diagnoses — narrow treatment windows where a delay maps directly to harm, which is exactly why a missed one so often becomes a viable case.

Why it's missed

The classic crushing chest pain is the easy case. Heart attacks are missed in the atypical presentations — women, diabetics, and younger patients who present with fatigue, nausea, jaw or back pain, or shortness of breath rather than textbook chest pain. A single normal ECG and one early troponin can falsely reassure, and the patient is discharged before the infarction declares itself.

What the standard of care generally expects

For a patient whose presentation raises cardiac risk, the defensible workup generally includes a careful risk assessment, an ECG read in the context of the symptoms, and serial troponins and serial ECGs over an appropriate window — not a single set — before discharge, with clear return precautions. Anchoring on "anxiety," "GERD," or "musculoskeletal" without ruling out ACS is where cases are made. [Confirm the standard with a qualified expert.]

What makes the case viable

• Breach: a presentation that should have triggered a full ACS rule-out, with a record showing it wasn't done (single troponin, no serial ECG, premature discharge).
• Causation: a window in which timely diagnosis (cath/reperfusion) would more likely than not have limited the damage — expert-dependent, time-sensitive.
• Damages: death, heart failure, or disabling cardiac injury.

The records angle

Pull triage, every ECG with its timestamp, each troponin value and time, the discharge instructions, and any documented reasoning for ruling cardiac out. The timing of the workup — and any note entered or amended after the bad outcome — is often where the case turns.

General information for attorneys, not legal or medical advice. Standard-of-care, causation, and damages rules vary by jurisdiction — verify every standard, statute, and deadline against current authority in your venue, and rely on a qualified medical expert for the clinical analysis.

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