Differences in the early symptoms and signs of an impending heart attack in women may make diagnosis more difficult compared to men. In a study of closed medical malpractice claims involving undiagnosed heart disease in women, The Doctors Company found that in 61 percent of claims the patient died when her heart condition was not correctly diagnosed and 33 percent had heart muscle damage from myocardial infarction. In the following case, failure to diagnose acute myocardial infarction resulted in death: A 47-year-old obese woman presented to her PCP complaining of a burning sensation in her chest after eating. The patient reported a similar episode the prior day after eating lunch as well as increased heartburn over the last few weeks. A review of the medical record reflected elevated blood pressures over the past six months and an elevated cholesterol level of 237 (mg/dl). On the day of the exam, her blood pressure was 160/90. She smoked, drank alcohol socially, and was unaware of a family history of coronary artery disease. A heart exam revealed normal rate and rhythm. The physician noted that the patient appeared diaphoretic; however, she wasn’t in acute distress and was pain-free throughout the examination. An ECG revealed a left bundle branch block. Prior ECGs were not available for comparison. Suspecting reflux esophagitis (heartburn), the PCP advised the patient to take an antacid and to return if the symptoms continued. Two days later, the patient called her PCP’s office stating that her chest burning sensation continued. The nurse advised her to continue taking the antacid and scheduled an office appointment for the following day. The nurse advised the patient to go to the ED if she developed chest pain. That night, the woman awoke with chest pain, nausea, and vomiting. She was taken to the ED for emergeny coronary angiography, but died shortly after arrival. To avoid such risks: Rule out myocardial infarction before arriving at a GI-related diagnosis such as gastric reflux as the cause of chest pain or discomfort. Consider cardiac risk factors such as obesity, smoking, hypertension, and hyperlipidemia. Offer patients same-day appointments when they complain of continued symptoms for which they were recently seen. If this is not possible, send them to the ED and document this in the medical record. Develop a written chest pain protocol. Contributed by The Doctors Company. For more patient safety articles and practice tips, visit www.thedoctors.com/patientsafety .