Missed Cardiac Diagnoses and Contributing Factors

Diagnostic Challenges in Cardiac Conditions

• The American College of Cardiology recommends consideration of acute aortic dissection in patients with abrupt/instantaneous onset pain, severe intensity, ripping/tearing quality, pulse deficit, blood pressure differential between arms, and new aortic regurgitation murmur, with approximately 40% of chest films lacking widened mediastinum 2
• The American Heart Association suggests that patients without any high-risk features still require consideration of aortic imaging, particularly those over 70 years, with syncope, focal neurologic deficit, or recent aortic manipulation 2
• The European Society of Cardiology notes that arrhythmogenic right ventricular cardiomyopathy represents a major source of diagnostic error when imaging is interpreted by non-specialists, requiring expert-level interpretation of cardiac MRI findings 1
• The American College of Cardiology recommends comprehensive annual assessment including family history, echocardiography, 24-48 hour Holter monitoring, and exercise blood pressure response for patients with hypertrophic cardiomyopathy, the most common cause of sudden cardiac death in young people and competitive athletes 5

High-Risk Conditions and Demographics

• The American Heart Association warns that cardiac amyloidosis is frequently missed in older adults presenting with heart failure symptoms and should be suspected in patients with heart failure and preserved ejection fraction, particularly with increased wall thickness 6
• The European Society of Cardiology notes that up to 30% of idiopathic dilated cardiomyopathy cases are familial, yet family screening is often not performed, and recommends three-generation family history to identify relatives with cardiomyopathy, sudden unexplained death, conduction system disease, and skeletal myopathies 6, 7, 8
• The American College of Cardiology recommends consideration of cardiac channelopathies in patients with family history of sudden cardiac death, sudden infant death syndrome, or unexplained drowning in first-degree relatives, and detailed medication history including over-the-counter medications and supplements 9, 10

Systematic and Technical Factors Contributing to Missed Diagnoses

• The European Society of Cardiology notes that faulty cognition accounts for 34-37% of diagnostic errors in cardiovascular imaging, representing the major cause rather than knowledge deficiency, and recommends analytical "System 2" thinking to reduce errors 1
• The American Heart Association suggests that diagnostic errors are more common with rare diseases and suboptimal image quality, and that non-specialist interpretation shows 44% error rate versus 3% for experts in pediatric echocardiography 1