She walks into the emergency department with jaw pain and nausea. The triage nurse notes her vital signs, takes a brief history, and assigns her a moderate priority. She waits an hour before being taken back. The physician spends eight minutes with her, orders an antacid and an anti-nausea medication, and discharges her with a diagnosis of gastroesophageal reflux. She dies of a heart attack in her kitchen six hours later.
This scenario—or something like it—plays out in emergency departments across the country with disturbing regularity. Heart attacks are among the most commonly missed diagnoses in emergency medicine, and the misses disproportionately affect women and others whose symptoms don't match the textbook presentation.
The Presentation Problem
Everyone knows the classic heart attack: crushing chest pain radiating to the left arm, shortness of breath, diaphoresis. When patients present this way, emergency departments generally respond appropriately with immediate EKGs, cardiac enzymes, and cardiology consultation.
The problem is that many heart attacks don't look like this. Women, in particular, often present with symptoms that don't scream "cardiac"—fatigue, nausea, jaw or back pain, shortness of breath without chest discomfort, vague feelings that something is wrong. Diabetics may have "silent" heart attacks with minimal symptoms due to nerve damage that blunts pain perception. Younger patients aren't expected to have heart disease, so their symptoms get attributed to other causes.
These atypical presentations challenge emergency physicians to think beyond pattern recognition. The patient who doesn't fit the template requires more careful evaluation, not less—yet the opposite often happens. Atypical symptoms get attributed to non-cardiac causes, and patients are discharged without the workup that would have revealed their hearts were in danger.
The Testing Problem
Even when heart attack is considered, testing shortcuts can miss the diagnosis. EKGs can be normal or near-normal in early stages of some heart attacks. Relying on a single reassuring EKG may create false confidence that the heart isn't the problem.
Troponin testing—measuring proteins released when heart muscle is damaged—is essential for diagnosing heart attack, but troponin takes time to rise. A patient in the early stages of a heart attack may have normal troponin levels initially, with elevations appearing only hours later. Serial troponin testing, with measurements repeated over several hours, is standard practice for patients with possible cardiac symptoms. Discharging a patient based on a single normal troponin violates this standard.
The combination of a non-diagnostic EKG and a single negative troponin can create dangerous overconfidence. Neither test alone rules out heart attack in early stages, yet patients are frequently discharged on the basis of these incomplete results. When they return hours later in cardiac arrest, the missed opportunity is clear in retrospect.
The Cognitive Problem
Emergency physicians see hundreds of patients with chest pain, shortness of breath, and other symptoms that could represent heart disease. The vast majority of these patients don't have heart attacks. This base rate creates a cognitive challenge: it's easy to assume that any given patient is probably fine because most patients with similar symptoms have been fine.
This probabilistic thinking fails individual patients. The woman with jaw pain and nausea probably doesn't have a heart attack—but if she does, missing it could kill her. The appropriate response to cardiac risk factors and compatible symptoms isn't reassurance based on probability; it's systematic evaluation sufficient to actually exclude the diagnosis.
Gender bias compounds the cognitive challenge. Heart disease has historically been framed as a male condition, studied primarily in men, with diagnostic criteria developed from male presentations. Physicians trained on this male-centric model may not recognize female presentations as potentially cardiac. The emergency physician who would immediately work up crushing chest pain in a 55-year-old man may dismiss the same-age woman with nausea and fatigue as anxious or stressed.
The Time Problem
Heart attacks damage heart muscle progressively. Every minute that passes with a coronary artery blocked means more muscle death. Treatments that restore blood flow—clot-busting medication, angioplasty—work best when delivered quickly. Beyond a few hours, the window for meaningful intervention narrows or closes.
When emergency departments send heart attack patients home, they're not just delaying treatment—they're consuming the window in which treatment could help. The patient discharged with "reflux" who returns six hours later in cardiac arrest can't recover those lost hours. The damage that occurred while she was at home trusting the ER's reassurance is permanent.
Proving These Cases
Heart attack misdiagnosis cases require showing that the presentation should have prompted cardiac evaluation, that the workup performed was inadequate to exclude heart attack, and that earlier diagnosis would have enabled treatment that reduced harm. Medical records document vital signs, symptoms, tests ordered, and discharge diagnosis. Expert cardiologists and emergency physicians can evaluate whether this workup met standards and whether earlier intervention would have changed the outcome.
The stakes in these cases are high. Heart attack misdiagnosis often results in severe injury or death, with correspondingly significant damages. The pattern of missed cardiac cases—disproportionately affecting women and others with atypical presentations—also raises systemic questions about bias in emergency cardiac care that litigation can help address.