What was the primary error made by the physician in a case where a patient presented with chest pain and shortness of breath (SOB), was initially diagnosed with acidic chest discomfort and treated with a Proton Pump Inhibitor (PPI), but later found to have congestive heart failure (CHF) after their condition worsened?

Cognitive Error in Misdiagnosis of Heart Failure

The primary error was premature closure based on the first impression of the patient (Answer B), where the physician anchored on gastroesophageal reflux disease without adequately ruling out life-threatening cardiac causes first.

Understanding the Cognitive Error

This case exemplifies a classic diagnostic pitfall where the physician committed anchoring bias by fixating on an initial diagnosis (GERD) without considering alternative, more serious diagnoses. The error specifically relates to:

• Premature closure: The physician stopped the diagnostic process too early after settling on GERD as the explanation for chest pain and shortness of breath 1
• Failure to rule out cardiac causes first: Guidelines explicitly state that cardiac causes must be excluded before attributing chest pain to esophageal origin, as the morbidity and mortality associated with ischemic heart disease is substantially greater than that of GERD 1, 2

Why This Was Not Rapid Processing

While rapid processing (Answer A) might seem plausible, the issue was not the speed of decision-making but rather the quality of the diagnostic reasoning. The physician failed to:

• Consider the differential diagnosis adequately, particularly given that chest pain with shortness of breath is a cardinal presentation of heart failure 3
• Recognize that heart failure misdiagnosis rates range from 16.1% to 68.5%, with respiratory symptoms frequently leading to misattribution to other conditions 4
• Appreciate that 32% of CHF patients presenting with chest pain have concurrent acute coronary syndrome, making cardiac evaluation mandatory 5

The Critical Diagnostic Sequence

The correct approach should have been:

1. Immediate cardiac evaluation for any patient presenting with chest pain and dyspnea, including ECG, cardiac biomarkers (troponin), and natriuretic peptides (BNP/NT-proBNP) 3, 1
2. Physical examination specifically looking for signs of heart failure: elevated jugular venous pressure, hepatojugular reflux, pulmonary rales, peripheral edema, and S3 gallop 3, 6
3. Only after excluding cardiac causes should GERD be considered as the primary diagnosis 1, 2

Why Enhanced Communication Was Not the Primary Error

Answer C (enhanced physician-patient communication) is not the fundamental error here. While better communication is always beneficial, the core problem was diagnostic reasoning failure, not communication breakdown. The physician made an incorrect clinical judgment regardless of how well they communicated with the patient 4.

Clinical Implications and Prevention

To avoid this error:

• Always maintain a broad differential for chest pain and dyspnea, with cardiac causes at the top of the list 3
• Use objective testing rather than clinical impression alone: BNP >100 pg/mL has 90% sensitivity for heart failure, while clinical judgment alone has only 49% sensitivity 3
• Recognize high-risk presentations: The combination of chest pain and shortness of breath should trigger immediate cardiac workup, not empiric PPI therapy 3, 1
• Understand that heart failure is frequently misdiagnosed as other conditions, particularly when respiratory symptoms predominate 4

The mortality risk is substantial: Patients with CHF complicated by acute coronary syndrome have significantly higher death rates compared to those without ACS (15 vs 7 deaths in one study), emphasizing the critical importance of not missing this diagnosis 5.