Heart attack misdiagnosis in women

~ Carolyn Thomas

by Carolyn Thomas  ♥  @HeartSisters

A woman attending one of my heart health presentations told me of her recent trip to the Emergency Department of our local hospital, and an overheard conversation between the (male) doctor and the (male) patient in the bed next door beyond the curtain:

“Your blood tests came back fine, your EKG tests are fine – but we’re going to keep you for observation just to rule out a heart attack”.

A male patient is thus admitted to hospital for observation in spite of ‘normal’ cardiac test results – as current treatment guidelines require.  But I and countless other females in mid-heart attack are being sent home from Emergency following ‘normal’ test results like his, and with misdiagnoses ranging from indigestion to anxiety or menopause.  Why is this?      

Women (especially younger women) with heart disease are far more likely than men to be misdiagnosed.  Research on cardiac misdiagnoses reported in the New England Journal of Medicine looked at more than 10,000 patients (48% women) who went to their hospital Emergency Departments with chest pain or other heart attack symptoms. Investigators found that women younger than 55 were seven times more likely to be misdiagnosed than their male counterparts. The consequences of this were enormous: being sent away from the hospital doubled the risk of dying.(1)

UPDATE: The 2018 Heart and Stroke Foundation Report called Ms. Understood concluded that women’s hearts are victims of a broken system that is ill-equipped to diagnose, treat and support them. Other alarming findings:

  • early heart attack signs are missed in 78% of women
  • five times more women die from heart disease than from breast cancer
  • two-thirds of all heart disease clinical research focuses only on men
  • even the laboratory mice, rats and rabbits used in early studies are male animals

Dr. Jerome Groopman‘s book, How Doctors Think, helps to explain why misdiagnoses happen in the first place:

“Specialists in particular, are known to demonstrate unwarranted clinical certainty. They have trained for so long that they begin too easily to rely on their vast knowledge and overlook the variability in human biology.”

This so-called “disregard for uncertainty” was what I faced with that Emergency Department physician in 2008 who sent me home from hospital with a misdiagnosis of GERD (gastroesophageal reflux disease), despite the fact that I’d just presented with textbook heart attack symptoms like chest pain, nausea, sweating, and pain radiating down my left arm. His emphatic but unwarranted clinical certainty:

“You are in the right demographic to be having acid reflux!”

A PERSONAL ASIDE:  as if being misdiagnosed in mid-heart attack wasn’t bad enough, the ER nurse that fateful morning came up to my bedside at one point after the physician had moved on to the next patient, and warned me sternly that I’d have to stop asking questions of the doctor, adding:

“He is a very good doctor, and he does NOT like to be questioned.”

The question that I’d just had the temerity to ask him? 

“But doctor, what about this pain down my left arm?”

The medical error of a misdiagnosis like mine can include:

  • a complete failure to diagnose (totally missing the disease)
  • wrong diagnosis (for example, diagnosing acid reflux instead of a heart attack)
  • partial misdiagnosis (diagnosing the wrong subtype of heart disease or the wrong cause of the disease or its complications)
  • delayed diagnosis (when a doctor does not recognize a disease until long after it should have been identified)

There is also still, amazingly, a persistent myth that heart disease is a man’s disease. 

Even the name of the type of heart attack I survived (the so-called “widowmaker”) tells you that semantics reflect the medical profession’s historical assumption that this kind of myocardial infarction hits men, not women. It’s not, after all, called the “widowermaker”, is it?

Doctors may actually be reluctant to consider heart disease when a woman has cardiac symptoms, and instead will look for other causes. An American Heart Association study showed, in fact, that only 8% of family physicians and 17% of cardiologists were aware that heart disease kills more women than men each year.

UPDATE – June 22, 2016: A study published in the Journal of the American Heart Association reported: “Women presenting with cardiac arrest are less likely than male patients to undergo therapeutic procedures, including coronary angiography, percutaneous coronary interventions and targeted temperature management. Despite trends in improving survival after cardiac arrest over 10 years, women continue to have higher in‐hospital mortality when compared with men.”(2)

Women themselves are less likely than men to realize how vulnerable they are to heart disease.  

A number of studies report that women are more likely to delay seeking emergency treatment even when they experience serious cardiac symptoms. One survey, for example, suggests that only half of women indicated they would call 911 if they thought they were having a heart attack (and that’s down from 80% just five years earlier!). Few were even aware of women’s most common heart attack symptoms. 

And those symptoms can be more vague and atypical compared to men’s ‘Hollywood Heart Attack‘ symptoms. For many women in mid-heart attack, the words “chest pain” would not even be the ones they’d choose to describe their symptoms – instead, words like full, heavy, burning, pressure or aching might be more accurate descriptors.

And remember that 8-40% (depending on which of many studies you read) of women experience no chest symptoms at all during a heart attack.(3)  See also: How women can tell if they’re headed for a heart attack

It’s astonishing to me that even first-responders like ambulance paramedics are less likely to provide standard levels of care to women who call 911 with cardiac symptoms compared to their male counterparts, according to the disturbing results of a study at the University of Pennsylvania. See also: Fewer Lights/Sirens When a Woman Heart Patient is in the Ambulance

Researchers found significant differences in both aspirin and nitroglycerin therapy offered to women vs. men. In fact, this study showed that of the women transported to hospital by ambulance who were suffering from heart attacks, not one was given aspirin by paramedics en route. 

Once women do arrive at hospital, both nurses and physicians working in Emergency Departments report a bias towards looking for heart attack pain symptoms, even though a majority acknowledge that women often present with vague, non-chest pain symptoms during a cardiac event. Again, between 10-40% do not have ANY chest symptoms at all. See also: How  Can We Get Heart Patients Past the E.R. Gatekeepers?

Why don’t diagnostic tests pick these up?  Women are less likely than men to receive some cardiac diagnostic tests in the first place, and some tests don’t work as well in women. In fact, most tests for diagnosing heart disease have been fine-tuned in studies focused on (white, middle-aged) men.

The treadmill stress test, for example, has been found to be less accurate in women than in men, and particularly for identifying single vessel or non-obstructive heart disease – which are both more common in women.

Even the standard EKG (or ECG – electrocardiogram) can be problematic – especially when it’s not offered to female patients in a timely manner. A Montreal study, for example, found that women were significantly less likely than men to receive an electrocardiogram within the recommended 10 minutes of arriving in hospital with suspected cardiac symptoms.(4) And even when we do finally get hooked up to a 12-lead EKG in a hospital’s Emergency Department, the doctors there may not be able to correctly interpret the “significant EKG changes” that identify heart disease. Previous research has reported a disturbing reality about diagnostic EKGs, which is the likelihood that high-risk EKG abnormalities may NOT be detected by physicians working in Emergency Medicine.(5)  See also: When Your “Significant EKG Changes” are Missed

The gold standard test for diagnosing coronary artery disease in both men and women is the angiogram, but studies also show that women are less likely than men to be referred for angiography. And some types of non-obstructive heart disease like Coronary Microvascular Disease (small vessel disease) or Prinzmetal’s Angina (a spasm disorder), do not show up during angiography unless the spasm happens to occur during the procedure. See also: Misdiagnosed: Women’s Coronary Microvascular and Spasm Pain

UPDATE January 31, 2016:  We’ve been waiting 92 years for this announcement, ladies. The American Heart Association released its first ever scientific statement on women’s heart attacks, confirming that “compared to men, women tend to be under-treated”, and including this finding: “While the most common heart attack symptom is chest pain or discomfort for both sexes, women are more likely to have atypical symptoms such as shortness of breath, nausea or vomiting, and back or jaw pain.”

How to help yourself get an accurate diagnosis:

  • Know your symptoms
  • Know your facts
  • Ask clarifying questions if you don’t understand what you’re being told
  • Be specific
  • Be objective
  • Get results

What to do if you think you’ve been misdiagnosed:

  • Do not feel embarrassed to speak up/ask clarifying questions
  • Get more tests/ask for repeat tests
  • Get a second opinion
  • Keep going back until you are diagnosed accurately!

Dr. Jerome Groopman further recommends that you ask these critically important questions of your doctor:

  • “What else could it be?”  The cognitive mistakes that account for most misdiagnoses are not recognized by physicians; they largely reside below the level of conscious thinking. When you ask simply: “What else could it be?”, you help bring closer to the surface the reality of uncertainty in medicine.
  • “Is there anything that doesn’t fit?”  This follow-up should further prompt the physician to pause and let his/her mind roam more broadly.
  • “Is it possible I have more than one problem?”  Posing this question is another safeguard against one of the most common cognitive traps that all physicians fall into: search satisfaction. It should trigger the doctor to cast a wider net, to begin asking questions that have not yet been posed, to order more tests that might not have seemed necessary based on initial impressions.

© Carolyn Thomas  www.myheartsisters.org  

(1) Pope JH, Aufderheide TP, Ruthazer R, et al. Missed diagnoses of acute cardiac ischemia in the emergency department. N Engl J Med. 2000;342:1163-1170.
(2) L Kim et al. Sex‐Based Disparities in Incidence, Treatment, and Outcomes of Cardiac Arrest in the United States, 2003–2012. J Am Heart Assoc. 2016; 5: e003704 originally published June 22, 2016 doi: 10.1161/JAHA.116.003704
(3)  S. Dey et al, “GRACE: Acute coronary syndromes: Sex-related differences in the presentation, treatment and outcomes among patients with acute coronary syndromes: the Global Registry of Acute Coronary Events”, Heart  2009;95:1 20–26.
(4)  Roxanne Pelletier et al. Sex-related differences in access to care among patients with premature acute coronary syndrome. Canadian Medical Association Journal. March 17, 2014. cmaj.131450 10.1503/cmaj.131450 
(5)  Frederick A. Masoudi et al. Implications of the failure to identify high-risk electrocardiogram findings for the quality of care of patients with acute myocardial infarction: results of the emergency department quality in myocardial infarction (EDQMI) study. Circulation. 2006; 114: 1565-1571

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NOTE FROM CAROLYN:  I wrote much more about cardiac diagnosis and misdiagnosis in my book “A Woman’s Guide to Living with Heart Disease” . You can ask for it at your local bookshop, or order it online (paperback, hardcover or e-book) at Amazon, or order it directly from my publisher, Johns Hopkins University Press (use the code HTWN to save 20% off the list price).

 

See also:

 

ANOTHER NOTE from CAROLYN:   I am not a physician. Information on this site is not meant as a substitute for medical advice. If you are experiencing symptoms that are distressing enough to ask me about them, please see your doctor. Do NOT leave a comment here describing your symptoms.

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ANOTHER REALLY IMPORTANT NOTE: Comments in response to this post are now closed. If you believe your symptoms could be heart-related, please seek a medical opinion from a physician.

Published by Carolyn Thomas

64 thoughts on “Heart attack misdiagnosis in women”

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  4. Hi, I am 18 years old and I have been experiencing a high heart rate. I would go from around 75 to 100 bpm and I could literally feel that flip flop feeling in my chest all day. The feeling of racing heart would wake me up at night. I am very afraid because when I went to get blood work done, everything was normal aside from potassium being a little low. My EKG came back normal. I am still waiting on thyroid results. Considering things came back normal and I am still experiencing these symptoms, I am afraid of a misdiagnosis.

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    1. Hello Sara – I’m not a physician so cannot comment on your specific symptoms. I can tell you that generally this scenario is more common in women, and aggravated in those who smoke, drink large amounts of coffee or alcohol. Here’s a link to some basic info from the American Heart Association on fast heartbeat including some simple steps that might address it e.g. “pressing gently on the eyeballs with eyes closed” or “holding your nostrils closed while blowing air through your nose”. They also say: “Many people don’t need medical therapy for this.” See your family physician if it continues.

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  5. Hi,

    I have been having chest pain, left arm pain, back pain and pain in various parts of my body – mostly left side for over 7 months now. I even saw a cardiologist and he did holter test, echo test and stress test. All tests came normal which relieved me for some time but the discomfort continues. My left arm pain/tingling/discomfort is more than ever now. It comes and goes along with other symptoms I mentioned. In your opinion, what is the most accurate test for women for diagnosis of heart diseases? I fear it’s angina I have, but doctor has not disgnosed it correctly. I am 33 years old and of course that makes it difficult to be taken seriously by cardiologists.

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    1. Hi Stu – I am not a physician so of course cannot comment on your symptoms, other than to say that the tests the cardiologist ordered for you are the ones commonly done to identify heart disease. Other tests, like coronary reactivity testing, are sometimes used to diagnose specific types of heart disease like microvascular issues. You’re right – at your age, most physicians would consider heart disease to be a long shot. But something is causing these symptoms, and right now you just don’t know if they are heart-related or not. Try keeping a symptom journal for a few weeks to show to your GP, noting time of day, what you were doing/eating/feeling in the hours leading up to each episode. Pay special attention to pain in those “various parts” of the body you mentioned, too (i.e. not chest/back/arms) – depending on which body parts you mean, they may help to point your doctor towards a non-cardiac cause.

      I hope your symptoms are not due to your heart, and I hope you and your physician can solve the mystery. But I often say that whether we are diagnosed with heart disease or not, there is simply no downside to living life as if every single one of us knew for sure we were at high risk – meaning exercise every day, eat heart-smart foods, manage sleep and stress, don’t smoke, etc. That’s exactly what any doctor would advise you if you were to get a definitive cardiac diagnosis tomorrow.

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  6. Can someone give me advice? Two nights ago I worked out at the gym with 40 minutes of low intensity cardio (heart rate stayed around 130-140 while I was working out). About 2 hours later, sitting down, I got a terrible pain in my upper middle back on my spine. I thought maybe I had hurt something at the gym. I went to the bathroom, the pain spread from my middle back throughout my chest and became a 10 on a scale of pain from 1 to 10. It lasted about 10-15 minutes or so, and it hurt so terribly I couldn’t do anything except kneel on the floor crying. If I sat up straight the pain got worse, and if I sat with my chest to my knees it made the pain better.

    I’ve never experienced anything like this before. The pain just seemed to come out of nowhere and spread throughout my entire chest. I’m 28 and female and on the pill. My dad had his first heart attack around age 55…

    After the pain subsided a bit I felt incredibly weak and light headed. There were lingering pains in the left side of my chest, and a squeezing sensation on the left side too. I also started coughing a lot during this time (I don’t have a cold). It also was harder for me to speak at this time and I was stumbling over my words (I don’t have a stutter normally).

    I went to the ER. They did an EKG, chest x-ray, and a cat scan (they put iodine in my veins) to check for a blood clot in the lung. All the tests came back normal except for a blood test. I don’t remember the name of the blood test, but they said my results indicated that there could be a blood clot in the lung. My number from the blood test was 590 and they said a normal number is 500.

    Anyway, after staying there about 8 hours they released me at 7AM with no aftercare instructions or explanation for the pain. All they said was to follow up with my PCP. I don’t have a primary care physician…

    Two days later and I’m STILL experiencing chest pain and discomfort on the left side. I also feel like my heart is working harder whenever I walk up the stairs.

    What should I do???? They made me feel stupid for even going to the ER, but I feel like something is wrong since I’m still having chest pain and discomfort two days later.

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    1. Hi Rachel. What an awful experience! I’m not a physician so of course cannot comment on your symptoms or possible diagnosis. I can tell you however that if a health care provider in Emergency tells a patient “could be a blood clot in the lung”, it’s worth returning to that E.R. or an urgent care clinic for follow-up, especially if your symptoms return or worsen. Best of luck to you…

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  7. Now I suffer from anxiety. All these young and older woman who had Heart Attacks I’m sure they were not all 100% healthy there’s always something that’s going to cause it. High bp, high cholesterol etc. they never put on here what caused it.

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    1. Hi Barbara – it’s also important to remember that most heart disease is at least 20-30 years in the making. For some, this diagnosis is linked to a congenital heart condition they’ve had since birth; for others it could be a family history, for still others it’s high blood pressure, cholesterol, diabetes, smoking, pregnancy complications, etc. and for some women with absolutely no known risk factors at all, they have a heart attack caused by Spontaneous Coronary Artery Dissection (SCAD) and in fact, nobody actually knows for sure what has caused it. In general, heart disease is most likely the result of a combination of several risk factors over many years.

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      1. Yes thank you for clarifying that. I always think I’m having a heart attack because of the anxiety. I used to take medicine but I stopped it because it did mess with the rhythm of my heart and it gave me pvc’s and pac’s which I never had before. You get pros and cons with the meds.

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  8. OMG I don’t know what to think about the information and comments I am reading.

    I had been experiencing pressure on the top left side of my chest for about 2 weeks. One day at 3pm I went to pick my daughters up from school but started to feel almost out of myself a little sick, did I want to vomit? maybe?? That feeling passed but I felt light headed, then my attention was draw to my fingers on my left hand; they felt strange as I moved them, my whole left shoulder began to ache, then began burning, then my arm felt like it was burning.

    I managed to take my daughter home and then with a friend proceed to the ER; in transit my left shoulder blade began to ache/pain. I forgot to mention I was sweating also. When I arrived I was asked questions about my symptoms and then admitted to ER; I received an ECG and blood tests were taken. I was feeling very calm, not stressed but very tired. My blood pressure was 138/89 instead of my normal 110/70; the nurse said that was fine.

    Long story short, after 4 hours tests were repeated; I was told I was anaemic but nothing else and sent home. That was 3 days ago. I still don’t feel 100%, very tired, a little short of breath and a continued feeling of pressure on my chest. The local doctor said I had a panic attack and I am awaiting further blood results. I just can’t believe I had a panic attack, I was so calm & then at the hospital, I was falling asleep. I’m 46.

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    1. Raewyn, I’m not a physician so cannot comment specifically on your symptoms. They may or may not be heart-related – do not hesitate to seek further medical help if they continue or get worse.

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  9. I love this article. It is probably because I was a 42 y/o female that was originally misdiagnosed and went through several of the events in your article. I was sent home from my first ER with a muscle relaxer and an explanation that I must have pulled a chest muscle while exercising that week. Thank goodness my husband fed me aspirin and took me to another ER the next day. I was in the waiting room with two men who had chest pain. I sat in the ER waiting room for 7 1/2 hours, watching as the two men went back and were released.

    When I was finally seen, I spent about 45 minutes in the back and then the fun started. I went from the occasional nurse visit… two in 45 minutes… to being surrounded. When I asked what was going on, they said I was headed to cardiac ICU. I honestly felt fine at the moment.

    When they took me back for an angiography a couple of hours later, the cardiologist told me he did not think he was going to find anything, but he was going to look. A 95% blockage and 1 stent later, I was good to go. I had no idea I was about to have a heart attack, but thank goodness for my over protective and persistent husband. If it weren’t for him, I would probably have been very relaxed (the muscle relaxers from the first ER) and very dead.

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    1. Hi Elizabeth! Have you thought about cloning that wonderful hubby of yours? He’s a keeper! And also very smart of you to listen to his insistence to keep seeking help.

      Your 7 1/2 hour wait in the ER waiting room is appalling for any patient, male or female, who presents with frickety-frackin’ CHEST PAIN! Your age likely worked against you (which should be irrelevant, but still too often seems to result in diagnostic delays for women).

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  10. I think it’s horrible that the people you trust to be experts, and that you assume are doing everything possible to make sure you don’t lose your life, don’t really know what they are doing.

    As I read this article I could see all the wrong things happening to me in my visits (visits with an “s”) to the ER. I was even admitted once and kicked out the next day with no idea as to what happened to me. I still don’t know. There was a problem but they didn’t tell me what it was. I went recently and was told I had a heart murmur, anxiety, palpitations and unidentified chest pains. I was told to follow up with my doctor.

    I hesitated to go back because it felt like a waste of time. But because of this article and encouragement from a female friend who has heart problems, I will go back.

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    1. Hello Teria – I sure hope you did follow up with your doctor. Not knowing what’s wrong is frustrating, but when you say “there was a problem but they didn’t tell me what it was”, it’s important to remember that requesting a clear explanation of “what’s wrong” is up to you. If there were indeed something “wrong” that the hospital staff identified, it wouldn’t be kept secret from the patient. If/when you do go back to hospital again, please don’t leave without clear answers about what’s going on. Best of luck to you…

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  11. Maybe someone out there can help me. I’m 47 years old and have had diabetes for 35 years, experienced chest pains off and on for several years but nothing ever shows. The other night I helped my mother pick my father up off the floor as he had fallen. While picking him up I did not experience any symptoms but right after I became very weak, very very lightheaded, broke out in a cold clammy sweat, could not breathe, and had a lot of pressure in the chest. It felt like I was going to pass out but I didn’t. I called my doctor’s office the next morning and was advised to go to the ER, but I did not go. I have gone in before with chest pain and they told me to have a seat in the waiting area, waited 45 minutes and got up and went to an ER out of town. But of course, nothing showed.

    Back to my current problems: I had waited it out this time because I had an upcoming appt with my doctor in 2 days. He did an EKG, supposedly was normal after a lot of puzzled looks and moving wires around and several questions as to if I was in pain and are you ok? Are you sure you’re ok? And getting another person to help, and them asking if I w,s ok? And are you nervous etc. My doctor was ok with the test and ordered blood test which came back ok as well.

    So why all those horrible symptoms, can it possibly be nothing at all? Any help would be greatly appreciated.

    Thank you in advance,
    Carla

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    1. Hello Carla,
      I’m not a physician so can’t comment specifically on your symptoms. I can tell you generally that the next time you have ANY kind of diagnostic test at which you notice the kind of staff response you describe here, SPEAK UP! Ask questions of your doctor to help you understand what’s going on. Right now, something is causing these symptoms, and you just don’t know if they are heart-related or not. Best of luck to you, and meanwhile check out this post on the many causes of chest pain.

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      1. Thank you Carolyn for responding. You’re right, ask questions. I should have asked my doctor when he came back in after the EKG what his MA and nurse were seeing to make them keep asking me if I was ok. I agree, something is going on and I strongly feel it is something with my heart – it may not have been a heart attack or so that’s what they are saying, but I do believe it’s something with my heart. Today, my heart started beating faster and I broke out in sweats just doing dishes – I rested and it got better. I vacuumed later and the same thing happened and went away with rest.

        Do you or any out there know of anything natural that would help my symptoms since I don’t seem to be getting any help from the doctors in our area? Any help would be greatly appreciated.

        Thank you,
        Carla

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        1. Hi Carla – again, I’m not a physician so cannot comment (except to say that if there were some “natural” product that actually could address symptoms that may or may not be heart-related, I’m not aware of it – and realistically, if such a product did exist, Big Pharma would have patented it in a big hurry by now!) Generally, what you’re describing (racing heart rate) could be palpitations – considered very common and usually not serious, as cardiologist Dr. David Sabgir once described:

          “We see more patients for palpitations than any other concern. In almost all situations, there is nothing to worry about.”

          Read Dr. Sabgir’s list of other factors that can cause palpitations, ranging from stress to low potassium levels, thyroid problems or caffeine consumption! Do some homework, and most of all, try to proactively manage your current stress levels (which can ironically worsen the very symptoms you’re describing). Many people find it useful to keep a symptom journal (record what you were doing/eating/feeling in the few hours leading up to each episode – sometimes interesting patterns can emerge to help solve the mystery). Good luck to you…

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  13. This is happening to me. I am 41, became suddenly ill 3 years ago. Was taken from work with chest pains, sweating, pasted out. I was sent home 2 hrs later with GERD (acid reflux). I was diagnosed with everything from gout to mental illness. Nobody did an EKG or anything heart-related. I haven’t been able to walk without losing breath for 3 years. The chest pains and not being able to breathe worsened recently. ER visit found I’ve had a heart attack and the bottom of my heart is so damaged it can not pump the blood out now – EF 48%. My primary care doctor informed me I am having congestive heart failure, prescribed me potassium and directives (ER found my electrolytes were off and potassium was very low) and sent me home. My last ER visit, the nurse told the transport guy I was only there wanting attention. I am waiting on referral to a cardiologist and urologist. They even put me on psych meds because it is all in my head. I can’t lay down without very sharp pains starting under my left breast, can’t take a deep breath.
    Advice?

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    1. Wendy, this sounds like quite an ordeal you’ve been through for three years. I’m glad you finally have some answers, and I hope you get your cardiologist’s referral very very soon. Meanwhile, your only job while you’re waiting is to learn as much as you can about heart disease so you’ll be as informed as possible (and know what kinds of questions to ask your cardiologist). For example, a “normal” ejection fraction (EF) typically ranges from 55-70%; an EF of less than 40% may confirm a diagnosis of heart failure. Yours is not under 40%. Here’s a good resource (Cleveland Clinic, widely considered the top cardiac institute in North America) with lots more information for you. Go back to your GP and request a second opinion for your breathing and sharp pain issues, which may or may not be related to heart problems. Good luck to you…

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  14. I went to the local ER (Sheffield, All) holding my chest and crying in pain yet was left to sit in waiting room for my turn. Then was called to the desk and asked what makes me think it’s my heart?
    Was treated somewhat like a patient with mild problem.

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    1. I can’t explain why that happened, Starr. Surprising that any ER, no matter where it’s located, wouldn’t treat chest pain as heart-related until proven otherwise – and not before.

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