Cognitive Bias: Premature Closure
The provider made the error of premature closure—accepting the first plausible diagnosis (gastroesophageal reflux disease) without adequately considering and excluding life-threatening cardiac causes in a patient presenting with chest pain and shortness of breath. 1
The Critical Diagnostic Failure
The provider's error represents Option B: First impression of the patient—a classic cognitive bias where the clinician latched onto an initial diagnosis without completing the necessary evaluation to rule out immediately life-threatening conditions. 2
Why This Was a Dangerous Error
Chest pain with shortness of breath demands immediate evaluation for acute coronary syndrome (ACS), heart failure, pulmonary embolism, and acute aortic syndromes before attributing symptoms to benign gastrointestinal causes. 1
The 2021 AHA/ACC Chest Pain Guidelines explicitly state that initial assessment must focus on "rapid identification of patients with immediately life-threatening conditions such that appropriate medical interventions can be initiated," including ACS and heart failure. 1
Dyspnea (shortness of breath) is NOT a typical symptom of gastroesophageal reflux disease—its presence should have immediately raised suspicion for cardiopulmonary pathology. 1
What Should Have Been Done
Mandatory Initial Evaluation
12-lead ECG within 10 minutes of presentation to assess for cardiac ischemia or injury. 3
Thorough history focusing on cardiac risk factors: hypertension, diabetes, atherosclerotic disease, obesity, metabolic syndrome, family history of cardiomyopathy. 1
Physical examination assessing volume status: jugular venous distension, peripheral edema, pulmonary rales, S3 gallop—all signs of heart failure that would be evident on examination. 1
Basic laboratory testing: complete blood count, basic metabolic panel, cardiac biomarkers (troponin), and BNP/NT-proBNP if heart failure suspected. 1, 3
Chest radiography to evaluate for pulmonary edema, cardiomegaly, or alternative pulmonary causes. 3
The PPI Trial Pitfall
While gastroenterology guidelines support a therapeutic PPI trial for typical GERD symptoms (heartburn, acid regurgitation), this approach is inappropriate when dyspnea is present. 1
The British Society of Gastroenterology states that PPI trials are cost-effective for chest pain only after cardiac causes have been excluded—not as a first-line diagnostic approach. 1
Extraesophageal manifestations of GERD do not include shortness of breath as a primary symptom, and clinicians should not assume GERD when cardiopulmonary symptoms dominate. 4
Common Patterns in Diagnostic Errors
Research on diagnostic errors shows that failure to order appropriate testing and clinician assessment errors (failure to consider competing diagnoses) account for 76% of diagnostic failures. 2
Heart Failure Misdiagnosis Rates
Heart failure misdiagnosis rates range from 16.1% in hospital settings to 68.5% in primary care, with COPD being the most common incorrect diagnosis. 5
However, misattribution to gastrointestinal causes also occurs when providers focus on a single symptom (chest discomfort) while ignoring red flags (dyspnea, clinical deterioration). 5
The Consequence of Premature Closure
Acute coronary syndrome and heart failure are among the most commonly missed diagnoses in emergency medicine, with potentially fatal consequences. 2
This patient's clinical deterioration over 2 days represents a missed opportunity for early intervention that could have prevented emergency department presentation and potential complications. 1
Key Takeaway
Never prescribe empiric PPI therapy for chest pain when dyspnea is present without first completing a cardiac evaluation. 1, 3 The combination of chest pain and shortness of breath mandates exclusion of life-threatening cardiopulmonary conditions through ECG, cardiac biomarkers, chest X-ray, and focused physical examination before considering benign gastrointestinal causes. 1, 3