Risk Management & Practice
Cardiology Malpractice: Recurring Failure Patterns and the Lessons They Teach
Closed-claims data and litigated cases point to three preventable failure modes — and a clear playbook for closing them.
Most cardiologists will face a malpractice allegation at some point in their career.
The costliest and most common allegation, by a wide margin, is a failure to diagnose.
A 2026 closed-claims analysis from The Doctors Company reviewed 321 cardiology malpractice cases closed between 2010 and 2025 and found that diagnosis-related and medical-treatment allegations each accounted for roughly a third of all claims.
Reading those cases side by side with a recently published American College of Cardiology case review reveals the same three failure points again and again.
None of them require a procedural complication or a rare disease — most involve an ordinary patient whose ordinary symptoms were filed under the wrong diagnosis for too long.
What Closed Cardiology Claims Allege
The Anatomy of a Closed Claim
Only a minority of filed claims ever result in a payment to the patient.
In the 321-case dataset, just 31% closed with an indemnity payment, and the average paid claim cost roughly $394,000 against a mean defense expense of about $79,000 regardless of outcome.
What separated the paid claims from the dismissed ones was rarely a single dramatic error.
It was almost always a contributing factor embedded somewhere in the workup, the procedure, or the chart.
| Contributing factor | Share of claims | Mean payment |
|---|---|---|
| Clinical judgment | 69.2% | $398,000 |
| Communication breakdown | 41.4% | $384,000 |
| Behavior-related factors | 28.4% | $429,000 |
| Documentation gaps | 22.4% | $387,000 |
| Technical skill deficits | 13.4% | $404,000 |
Data: The Doctors Company closed-claims review, reported via Becker's ASC, 2026.
Notice that behavior-related factors carry the highest average payment of any category, even though they appear less often than clinical-judgment lapses.
Juries and reviewers tend to punish dismissiveness toward a patient's concerns more harshly than a defensible clinical miss.
Pattern One — Anchoring on a Cardiac Masquerader
The most instructive case in the ACC's review involved a patient with hypertension, a smoking history, and chronic obstructive pulmonary disease who presented to a primary care office with neck, chest, and abdominal pain.
A same-day chest radiograph showed vascular congestion, yet the visit ended with a diagnosis of cervicalgia and the patient was sent home.
Two days later the same patient arrived at the emergency department with an ECG showing Q waves and was ultimately found to have an NSTEMI, but cardiac catheterization did not occur until roughly twelve hours after admission.
Expert reviewers agreed that the standard of care — consistent with the ACC/AHA/SCAI revascularization guideline — called for catheterization within two to four hours given the patient's ongoing symptoms and evidence of evolving heart failure, and the cardiologist named in the suit could not be defended on that point.
Timeline of a Litigated NSTEMI Delay
Closed-claims data from Maryland courts, compiled by a personal-injury firm that tracks cardiologist malpractice verdicts and settlements, shows the same anchoring pattern across very different presentations.
One settlement involved a patient with a known bicuspid aortic valve whose endocarditis was initially read as sinusitis, which allowed the infection to progress to sepsis and stroke before cardiology was consulted.
Another verdict involved a patient whose chest pain was attributed to non-cardiac panic attacks without further cardiac testing, and who collapsed from a fatal heart attack weeks later.
A third settlement followed a patient recovering from bypass surgery whose new symptoms were attributed to pneumonia and medication side effects rather than to an evolving aortic dissection, a recognized complication of the index operation.
In each case, the index symptom had a plausible benign explanation — and the chart shows no documented consideration of the cardiac alternative until it was too late.
The ACC review adds an important caveat worth repeating in any practice: women remain underdiagnosed and undertreated in acute coronary syndrome, and smoking, diabetes, depression, and anxiety can present as stronger or more confounding risk signals in women than in men.
Pattern Two — Procedural Vigilance Doesn't End When the Sheath Comes Out
A second cluster of claims involves patients who did fine during the index procedure and then deteriorated afterward.
One closed claim described a post-catheterization hematoma that progressed to uncontrolled internal bleeding, with allegations centered on a delay in ordering blood products and surgical intervention rather than on the index procedure itself.
The Doctors Company's risk-management guidance flags a related and very specific blind spot: postablation symptoms such as fever, fatigue, nausea, or vomiting need prompt in-person or telehealth evaluation, not a phone call or a portal message.
The same guidance calls out a cognitive trap clinicians should recognize in themselves — attributing fever and vomiting to "the flu" during flu season in a medically complex, recently instrumented patient is a textbook example of anchoring bias.
The lesson generalizes well beyond ablation: any new symptom in the days after a catheterization, device implant, or structural procedure deserves the same threshold for in-person evaluation that the index complaint did.
Pattern Three — The Result That Never Closed the Loop
Communication breakdowns are present in roughly four of every ten paid cardiology claims, and several closed cases show exactly why.
In more than one closed claim, an abnormal exercise stress test or imaging finding was generated, reported, and then never acted upon — sometimes because the result was relayed as reassuring when it was not, and sometimes because no one tracked that the recommended follow-up testing had not occurred.
None of these failures required a missed diagnosis at the moment of testing; they required a system that let a flagged result sit unresolved.
A documented, closed-loop process for abnormal results is one of the few risk-reduction strategies that is entirely within a practice's control, independent of how busy or complex any single day becomes.
| Failure pattern | Where it hides | Risk-reduction strategy |
|---|---|---|
| Anchoring on a benign diagnosis | Atypical chest, neck, or abdominal pain attributed to musculoskeletal, infectious, or anxiety-related causes | Document the cardiac differential explicitly, even when ruling it out, especially in women and atypical presenters |
| Post-procedural symptom drift | Fever, bleeding, or hypotension after catheterization or ablation managed remotely | Default to in-person or telehealth evaluation for any new post-procedural symptom — never phone or message alone |
| Unclosed result loop | Abnormal stress test, imaging, or lab result generated but not tracked to action | Build a hard-stop tracking system so every abnormal result is acknowledged and documented before the chart closes |
Inside the Claim: How a Malpractice Case Actually Unfolds
Knowing the failure patterns matters less if the litigation process itself feels like a black box.
A practical overview of the medical malpractice litigation process from Cardiology Magazine walks through exactly how a claim moves from a first letter to a final resolution, and the sequence is worth internalizing before it is ever needed.
The Path of a Malpractice Claim
1 & 2 — The First Signals and the Clock
The earliest hint of a possible suit is often nothing more than a routine-looking records request from a patient or an attorney, and not every request signals litigation.
A more definite signal is a formal notice of claim, and a number of states require either a pre-suit notice of intent or a review by a screening panel before a case can proceed to court.
The clock on all of this is the statute of limitations, generally one to three years from the date of the alleged injury, though the exact window varies by state and can differ for minors or patients who lack legal capacity.
3 — Protecting the Record
Once a clinician has any reason to suspect a claim, the medical record must be treated as frozen exactly as it stands.
Defense attorneys routinely retain forensic document experts, and for electronic records, an EHR metadata audit can reconstruct every keystroke, deletion, and timestamp after the fact.
A record shown to have been altered after the fact does more than weaken a defense — it can expose a clinician to punitive damages and a separate licensing board inquiry.
4 — Discovery, Depositions, and Experts
Most of the substantive work in a malpractice case happens during pre-trial discovery, where both sides exchange written interrogatories and take oral depositions.
A deposition is frequently the single most consequential event before trial, and the best-prepared physicians answer only the question asked, resist the urge to fill silence with extra detail, and say "I don't recall" rather than guess.
Expert witnesses retained by each side ultimately do the real work of defining what the standard of care required and whether it was met.
5 — How Claims Actually End
The headline figures bear repeating because they run counter to most physicians' intuition about their own risk: roughly 80% to 90% of defensible claims are dismissed with no payment at all, and of the claims that do result in payment, about 97% are resolved by settlement rather than a jury verdict.
The entire process, start to finish, commonly takes two to five years, with long stretches of inactivity between bursts of legal work.
None of this changes the clinical lessons above, but it does mean that a well-documented, well-defended case is statistically very likely to end in dismissal — which is one more reason the chart, written in real time, is worth protecting.
Case Vignette
A 56-year-old with hypertension, type 2 diabetes, and a 30-pack-year smoking history presents to an urgent care clinic with two days of intermittent neck tightness, mild nausea, and fatigue.
Vital signs are normal, a screening ECG is not performed, and the visit closes with a diagnosis of musculoskeletal strain and a recommendation to follow up if symptoms worsen.
The patient returns 36 hours later in the emergency department with frank substernal pressure, and an ECG now shows new T-wave inversions with a mildly elevated troponin.
Applying the patterns above, the most defensible version of the first visit would have documented the cardiac risk factors, obtained a same-visit ECG given the multiple risk factors present, and given explicit, written return precautions rather than a general "follow up if worse" instruction.
The clinical outcome may not always change, but the documentation of a reasoned cardiac differential — and a low threshold for objective testing in a high-risk patient — is precisely what separates a defensible miss from a successful claim.
Bottom Line
The cardiology claims most likely to result in payment rarely involve rare diseases or technical failures; they involve atypical ACS presentations anchored to a benign diagnosis, post-procedural symptoms managed remotely instead of in person, and abnormal results that were generated but never closed out.
All three are addressable with documentation habits and triage thresholds that cost nothing to implement and have nothing to do with diagnostic difficulty.
This article is intended for physician education and reflects publicly reported litigation outcomes and aggregate closed-claims data; it is not legal advice, does not establish a standard of care for any individual patient, and case outcomes vary by jurisdiction and specific facts. Clinicians with questions about an active or potential claim should consult their professional liability carrier and defense counsel directly.
References
- American College of Cardiology, Cardiology Magazine — Misdiagnosis: Lessons Learned From a Cardiology Malpractice Case
- American College of Cardiology, Cardiology Magazine — Understanding the Medical Malpractice Litigation Process
- Becker's ASC — Cardiology Malpractice Cases by the Numbers
- Miller & Zois — Cardiologist Medical Malpractice Lawsuits in Maryland: Verdicts and Settlements
