Selecting the Right Cardiac Expert: Matching Sub-Specialty to the Disputed Issue in Missed Myocardial Infarction Claims

The Necessity of Sub-Specialty Alignment

In clinical negligence litigation involving allegations of a missed myocardial infarction (MI), the selection of an expert witness can influence whether a case meets the threshold of the Bolam and Bolitho tests. The expert’s sub-specialty should align with the clinical context of the alleged breach. For example, instructing an academic electrophysiologist to opine on the triage of an acute chest pain patient in an emergency department may not provide the most relevant evidence for the court.

Cardiac care is highly specialised. Consultant cardiologists typically focus on domains such as coronary intervention (PCI), electrophysiology, heart failure, or structural heart disease. Where a claim centres on an alleged failure to diagnose an MI, the disputed clinical decision-making often falls within the remit of general, acute, or interventional cardiology.

The court must determine whether the clinician acted in accordance with a practice accepted as proper by a responsible body of medical opinion. This requires an expert whose current clinical practice reflects the environment where the alleged breach occurred. For instance, an interventional cardiologist may provide insight into primary PCI pathways and angiographic findings, while a general cardiologist may be better placed to address failures in early risk stratification, such as the application of troponin pathways or the recognition of high-risk ECG patterns.

Navigating Clinical Complexity in Expert Instruction

The Fourth Universal Definition of Myocardial Infarction provides a framework for identifying myocardial injury and infarction. However, disputes often arise in the interpretation of its application in time-critical settings. Instructing solicitors should consider the following sub-specialty distinctions when selecting an expert:

• Acute General Cardiology: Relevant for claims involving the triage of chest pain, the application of risk stratification scores (e.g., HEART or GRACE), and the timeliness of clinical assessment in acute settings.
• Interventional Cardiology: Appropriate where the dispute concerns the threshold for emergency coronary angiography, the management of PCI complications, or the identification of culprit lesions in complex presentations.
• Inherited Cardiac Conditions: Essential in cases involving sudden cardiac death, where the focus is on whether warning signs of underlying cardiomyopathies or channelopathies were missed, potentially necessitating cascade screening or specific diagnostic investigation.

When preparing instructions, it is important to define the index event clearly. If the allegation concerns a failure to appreciate a subtle ECG change (such as a de Winter pattern or posterior MI), the expert should possess the specific interpretative skills consistent with contemporary acute cardiology standards.

Procedural Rigour under CPR Part 35

The expert’s overriding duty to the court is set out in CPR 35.3. This duty requires independence and impartiality. Selecting the right expert is not about finding one who supports a predetermined position but rather one whose clinical background provides robust evidence on whether the care provided was representative of a responsible body of professional opinion. Under CPR 35.10, the expert’s report must clearly identify the basis of their opinion, including the clinical standards and guidelines relied upon.

Where litigation involves multiple clinical issues—for example, an alleged failure in the emergency department combined with a subsequent failure in the cardiac catheterisation laboratory—the court may consider whether to order evidence from experts of different specialties or, in proportionate cases, to direct a single joint expert under CPR 35.7. Solicitors may need to argue for the necessity of specific expertise to assist the court, particularly if the standard of care in a niche area of cardiology is contested. Expert discussions under CPR 35.12 may be directed by the court or arranged where appropriate to narrow the issues in dispute.

Common Pitfalls in Expert Selection

A frequent error is relying on a ‘generalist’ cardiologist for highly technical procedures or sub-specialty decision-making. While many consultants maintain a broad knowledge base, the expert’s current clinical practice should align with the disputed issue. For example, an expert whose practice ended before the widespread adoption of contemporary clinical standards may struggle to provide an opinion that satisfies the court’s requirement for evidence-based reasoning.

Additionally, solicitors should ensure the expert’s experience is current. Standards for the management of ST-elevation myocardial infarction (STEMI) and non-ST-elevation myocardial infarction (NSTEMI) have evolved, and an expert should be familiar with the clinical environment relevant to the alleged breach.

Practical Guidance for Instructing Solicitors

To ensure effective expert witness instruction in cardiology claims, solicitors should:

• Identify the specific stage of the patient journey: Determine whether the dispute concerns initial triage, diagnostic interpretation, or the timing of intervention.
• Check the expert’s active clinical practice: Confirm the expert’s specialty profile matches the clinical decisions in question and that they remain actively engaged in the relevant setting.
• Clarify the scope of the report: Ensure the expert addresses the but-for test of causation in the context of the cardiac injury alleged, distinguishing between the natural history of the condition and the impact of the alleged clinical failure.
• Facilitate early discussion: Where breach and causation are highly technical, early engagement with an expert can help identify whether further documentation, such as complete imaging sets or ambulance records, is required to form a reliable opinion.

Specialist cardiology medico-legal assessment from an appropriately qualified expert can provide the necessary clinical clarity to resolve complex disputes regarding the standard of care.