Embodiments include heart monitoring systems, apparatus, and methods adapted to detect myocardial ischemia. An apparatus includes at least one first-tier sensor/analyzer adapted to sense a first input related to cardiac function, and to produce a first-tier trigger signal when the first input indicates myocardial ischemia. In an embodiment, a first-tier sensor/analyzer includes an ECG sensor/analyzer. In another embodiment, a first-tier sensor/analyzer includes a patient activator. An apparatus further includes at least one second-tier sensor/analyzer adapted to sense a second input related to cardiac function, and to produce a second-tier trigger signal when the second input indicates myocardial ischemia. In an embodiment, a second-tier sensor-analyzer includes a heart sound sensor/analyzer. A triggering element is adapted to produce a response-invoking signal in response to the first-tier trigger signal and the second-tier trigger signal. The response-invoking signal may invoke a patient alert, a message to an external system, and/or a cardiac stimulus.