What error did the provider make in diagnosing a patient with chest pain and shortness of breath (SOB) who was initially prescribed a proton pump inhibitor (PPI) for suspected acidic chest discomfort, but was later found to have congestive heart failure (CHF)?

Cognitive Error: Premature Closure (Anchoring Bias)

The provider committed premature closure by anchoring on the initial impression of "acidic chest discomfort" and failing to adequately rule out life-threatening cardiac causes before prescribing a PPI, which directly led to a dangerous delay in diagnosing congestive heart failure.

The Specific Error Made

The error corresponds most closely to Option B: First impression of the patient. This represents a classic cognitive bias where the provider:

• Anchored on a benign diagnosis (GERD) without systematically excluding cardiac pathology 1, 2
• Failed to recognize that chest pain with shortness of breath is a cardinal presentation of both acute coronary syndrome and heart failure 1
• Violated the fundamental principle that cardiac causes must be ruled out first, as the morbidity and mortality of cardiac disease substantially exceeds that of GERD 2

Why This Was a Critical Failure

The Diagnostic Imperative in Chest Pain with Dyspnea

• The combination of chest pain and shortness of breath demands immediate consideration of life-threatening diagnoses including acute coronary syndrome, heart failure, pulmonary embolism, and aortic dissection 3, 1
• The American College of Cardiology explicitly recommends considering ACS in patients with chest pain and shortness of breath, even when accompanied by other symptoms 1
• The European Heart Journal identifies the triad of dyspnea, leg edema, and chest pain as strongly suggestive of acute decompensated heart failure 1

The Danger of Empiric PPI Therapy Without Cardiac Workup

• While empiric PPI therapy is appropriate for suspected reflux chest pain, this recommendation applies ONLY after cardiac causes have been excluded 2
• The American College of Gastroenterology's recommendation for empiric PPI therapy explicitly requires that cardiac causes be ruled out first 2
• Prescribing PPIs without cardiac evaluation creates a false sense of reassurance and delays critical diagnosis 4

The Correct Diagnostic Approach That Was Missed

Immediate Evaluation Required

The provider should have performed or ordered:

• ECG to evaluate for acute ischemia, arrhythmia, or signs of heart failure 1
• Chest X-ray to assess for pulmonary edema, cardiomegaly, or pleural effusions 1
• Cardiac biomarkers (troponin, BNP/NT-proBNP) to evaluate for ACS and heart failure 1
• Oxygen saturation assessment given the presence of shortness of breath 1

Recognition of High-Risk Features

• Shortness of breath is NOT a typical feature of GERD-related chest pain and should have raised immediate concern for cardiopulmonary pathology 1
• The presence of dyspnea with chest pain significantly increases the probability of cardiac disease 3
• Patients presenting with reduced exercise tolerance due to dyspnea and/or fatigue require evaluation for heart failure 3

Common Pitfalls in This Scenario

Anchoring on Benign Diagnoses

• Atypical presentations of cardiac disease are common, particularly in women and elderly patients, and should never be dismissed based on the presence of "GI-sounding" symptoms 1, 4
• More than 30% of dyspnea cases are multifactorial, and attributing all symptoms to a single benign diagnosis prematurely is a documented source of error 1
• The presence of symptoms that "could be" GERD does not exclude cardiac disease—these conditions frequently coexist 4

Misunderstanding the Role of Empiric PPI Therapy

• The PPI test has a role in diagnosing GERD-related chest pain, but ONLY after cardiac evaluation 2, 5
• Studies showing PPI efficacy for non-cardiac chest pain specifically enrolled patients who had already undergone cardiac evaluation 5
• Using PPIs as a first-line diagnostic test without cardiac workup is never appropriate 2

Failure to Recognize Red Flags

• Shortness of breath accompanying chest pain is a red flag that demands urgent cardiac evaluation 3, 1
• Worsening symptoms over 2 days indicates progressive pathology inconsistent with simple GERD 3
• The need for emergency department presentation after initial treatment failure should have triggered immediate reassessment 3

The Broader Context of Diagnostic Error

• Diagnostic errors in primary care commonly involve atypical presentations, non-specific presentations, and the presence of co-morbidity—all potentially present in this case 4
• Myocardial infarction and heart failure are among the most commonly misdiagnosed conditions in primary care 4
• Premature closure (jumping to a diagnosis before adequate evaluation) is one of the most frequent cognitive errors leading to misdiagnosis 4

Answer to the Multiple Choice Question

The error is B: First impression of the patient (anchoring bias/premature closure). The provider locked onto an initial benign diagnosis without systematic evaluation, failed to consider life-threatening alternatives, and prescribed treatment that delayed appropriate care. This is distinct from "rapidly processing the patient" (Option A), which would imply rushing through an otherwise appropriate evaluation—the problem here was not speed but rather the failure to perform any cardiac evaluation whatsoever before assuming a GI etiology.