Missed MI in the Emergency Department: What the Standard of Care Requires
A board-certified emergency physician explains how heart attacks get missed in the ED, what an adequate chest-pain workup looks like, and how the medical record reveals whether the standard of care was met.
By Jason Koob, MD — board-certified emergency physician and emergency medicine expert witness
When a missed-MI case reaches my desk, I start where I always start: the patient’s age.
Age is the lens through which the entire presentation must be viewed. An 80-year-old who tells the triage nurse he has heartburn commands a very different level of attention than a 30-year-old with the same complaint. Both patients can be harmed — the older patient by a clinician who accepts the benign explanation at face value, the younger by a clinician who assumes youth is protective and explains classic symptoms away. But the calibration starts with who is sitting on the gurney. Before I read a single vital sign or lab value, I want to know whether the physician saw the patient’s risk the way the patient’s age demanded.
Most dangerous, not most likely
Emergency medicine runs on a principle that inverts ordinary diagnostic thinking: the emergency physician must consider and address the most dangerous diagnoses on the differential, not merely the most likely one. That does not mean every patient receives every test — the principle carries its own limiting discipline, and it is called risk stratification. What it does mean is that the dangerous diagnosis must be genuinely engaged: weighed against the presentation, pursued to the depth the clinical picture warrants, and set aside only for articulable reasons. Statistically, most burning chest discomfort really is reflux. That is precisely why the discipline exists — because the emergency department is where the exceptions arrive, and the cost of missing one is measured in heart muscle and lives.
This is the first place a diagnosis goes wrong, and it is usually visible in the chart. A note that records an 80-year-old’s presentation as “burning in the chest, most consistent with gastric reflux” — and stops there — is a conclusion in place of an evaluation. To be clear, the note and the care are not the same thing: a physician may think carefully and chart thinly, and the analysis is always of the care itself. But the record is the primary evidence of what was actually considered, and reasoning that appears nowhere in it is difficult to credit after the fact. The benign diagnosis is allowed to win only after the dangerous one has been genuinely considered and addressed — and the chart should show it.
The workup that earns a discharge
Considering the dangerous diagnosis is not an abstraction; it has a shape, and it starts earlier than most people expect — in the history itself. The history of present illness is not a formality to be transcribed. It is where the physician should be deliberately collecting everything needed to risk-stratify the patient: the character and timing of the symptoms, what provokes and relieves them, the cardiac risk factors, the prior history. A well-taken history is the first diagnostic instrument used on a chest-pain patient, and a thin one shows.
Then comes the data: the ECG, the laboratory studies, the chest x-ray. Each piece matters, but none of them is the answer by itself. The standard of care asks the physician to combine the history and the data and measure the whole against validated risk-stratification tools — the HEART Score being one familiar example — which translate the clinical picture into a disciplined estimate of risk. No single tool is mandatory, and every tool has limitations; what matters is that a genuine risk assessment is performed. Layered onto that is the clinician’s own experience and practice history, which legitimately inform the ultimate disposition — alongside the objective data, not in place of it; a disposition that departs from what the risk assessment suggests deserves documented reasoning. The tools do not replace judgment; they structure it — and, just as importantly for a later reader of the chart, they document it.
Where these cases turn
When I review a missed-MI chart, the question is rarely whether a test was technically performed. It is whether the record shows the dangerous diagnosis being taken seriously: a history that gathered the risk factors rather than skipping past them, data obtained and actually integrated, a risk score that supports the disposition, reasoning a reader can follow from presentation to discharge. A chart like that can be defensible even when the outcome was tragic — medicine deals in probabilities, and a rigorous negative workup is exactly what the standard of care asks for.
The indefensible chart looks different, and the difference is usually apparent within a page: the benign label applied at the door and never re-examined, the risk factors unrecorded, the disposition resting on “most consistent with” rather than on evidence that the alternative was excluded. The analysis runs both directions — the same review that exposes a physician who never truly considered the heart can vindicate one who considered it carefully and reasonably concluded the patient was safe to go home. Reading the record honestly, in whichever direction it points, is the entire value of an independent expert.
Dr. Jason Koob is a board-certified emergency physician in full-time community emergency department practice since 2014, and accepts emergency medicine engagements nationwide from both plaintiff and defense counsel. This article is general information, not legal or medical advice, and does not reference any specific case or patient.
