Abstract Background Health literacy has been used to explain the social inequalities in ischemic heart disease that exists globally. However, most conceptualizations of health literacy employ an isolated focus on the patient's cognitive abilities without considering the social context. By using the cultural health capital framework, this paper aims at exploring how differences in social dispositions influence the interaction between doctors and ischemic heart patients with low health literacy and low socioeconomic status. Methods The paper is based on 30 qualitative interviews with Danish ischemic heart patients with low health literacy and low socioeconomic status and supplementary, contextual observations. The data collection was nationwide and carried out between October 2018 and August 2019. Results The findings showed that the patients and the doctors derived from different social spheres, which meant that they had developed dissimilar habitus and therefore used different explanatory models to understand and articulate the patient's problem. The doctors were primarily oriented towards the biomedical understanding of the malfunctioning of the body and therefore less aware of the patients' psychosocial illness experience. For the patients, these contradictions resulted in feelings of not being acknowledged, lack of trust in the healthcare system and disruption of treatment. Conclusions The findings suggest that to understand barriers for treatment of socially disadvantaged ischemic heart patients it is not only relevant to look at the patient's individual cognitive abilities but also to explore class-based contradictions in explanatory models between the patients and doctors. Key messages Health literacy should be understood as something embedded in the interplay between social structures and interpersonal dynamics. Contradictions in explanatory models may help explain barriers for treatment of socially disadvantaged ischemic heart patients.