A 57-year-old man went to the V.A. clinic due to left-sided chest pain. An internist evaluated him, noting two episodes of chest pain during the previous 48 hours. Both episodes resolved after 15 minutes of rest. The pain was described as dull. The patient had a history of stroke, hypertension, and other "heart problems." The echocardiogram (ECG) was read as showing an old inferior wall myocardial infarction and anterolateral ST and T wave changes consistent with "left ventricular strain." The internist concluded the patient had "chest wall pain" and sent him home. That evening the chest pain returned and the man was taken by ambulance to the hospital. Diagnosis was myocardial infarction with a Troponin elevation to 12 and a CPK elevation to 598. The patient was found to have multivessel coronary artery disease and he subsequently underwent bypass surgery. A medQuest internist reported the standard of care during the visit to the V.A. required routine blood tests, a serum CPK and Troponin measurement, in addition to the ECG that was performed. Cardiac enzymes might be abnormal when the ECG is not. Abnormal blood tests would have resulted in a swift transfer for a cardiac catheterization. A medQuest interventional cardiologist found the internist negligent in failing to diagnose the patient's acute coronary syndrome. The documented medical history was classic for unstable angina. The ECG showed a prior myocardial infarction as well as ST and T wave abnormalities. The patient should have been admitted to the hospital and treated with aspirin, heparin, nitrates and other medications as appropriate. With appropriate treatment, it is more likely than not the patient would not have had the myocardial infarction later that day.