What error did the provider make in 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 diagnosed with congestive heart failure (CHF) in the emergency room (ER) after their condition worsened?

Cognitive Error: Premature Closure (Anchoring Bias)

The provider made the error of 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. This represents a failure to follow the fundamental principle that all patients presenting with chest pain and shortness of breath must be treated as high-priority triage cases requiring immediate cardiac evaluation. 1

The Critical Mistake: First Impression Bias (Answer B)

The provider's error was anchoring on the first impression of gastroesophageal reflux disease without completing the mandatory cardiac workup. This is the most dangerous cognitive error in chest pain evaluation because:

• Cardiac causes must be excluded first in any patient presenting with chest pain, as the morbidity and mortality of ischemic heart disease substantially exceeds that of GERD, and approximately 70% of non-cardiac chest pain has causes other than reflux. 2, 3

• CHF patients with chest pain have a 32% incidence of concurrent acute coronary syndrome (ACS), and these patients have significantly higher mortality rates (15 vs 7 deaths), longer hospital stays (5.2 vs 3.2 days), and higher ICU admission rates (44% vs 13%) compared to CHF patients without ACS. 4

• All patients with chest pain should be placed on cardiac monitoring immediately, with an ECG performed and evaluated within 10 minutes of presentation, following a predetermined institutional chest pain protocol. 1

Why This Was Not "Rapidly Processing" (Answer A)

The error was not about processing speed—it was about diagnostic sequence and thoroughness. The provider moved too quickly to treatment without completing the necessary diagnostic evaluation, but the fundamental problem was the wrong diagnostic pathway, not the pace of decision-making. 1, 2

The Proper Diagnostic Algorithm

Step 1: Immediate Cardiac Evaluation

• ECG within 10 minutes of presentation for any chest pain with shortness of breath 1
• Cardiac monitoring with emergency resuscitation equipment nearby 1
• Cardiac biomarkers as part of structured chest pain protocol 1

Step 2: Risk Stratification

• Patients with known coronary artery disease (67% of CHF patients with concurrent ACS have known CAD) and hypercholesterolemia are at particularly high risk 4
• If chest pain is unimproved or worsening after 5 minutes, activate emergency medical services immediately 2, 3

Step 3: Only After Cardiac Exclusion

• Once cardiac causes are definitively excluded through appropriate testing, proceed with gastrointestinal evaluation 1, 2, 3
• Consider empiric PPI therapy only after cardiac workup is complete 1

Critical Pitfalls in This Case

The Danger of Premature PPI Prescription

• Symptom improvement with PPI does not confirm GERD and may result from placebo effects or mechanisms other than acid suppression 1
• PPIs themselves can cause angina-like chest pain in patients with coronary artery disease, further confusing the clinical picture 5
• PPIs have negative inotropic effects on failing myocardium, potentially worsening CHF 6

The Misdiagnosis Trap

• CHF is frequently misdiagnosed, with rates ranging from 16.1% in hospital settings to 68.5% when general practitioners refer patients to specialists 7
• The most common misdiagnosis is COPD, but the reverse also occurs—cardiac disease misdiagnosed as gastrointestinal disease 7

The Correct Approach

Never attribute chest pain to a benign cause without cardiac evaluation, even in young patients or those with temporal associations suggesting non-cardiac etiology. 2, 3, 8 The provider should have:

1. Immediately performed ECG and cardiac biomarkers 1
2. Placed patient on cardiac monitoring 1
3. Considered CHF as a potential diagnosis given the presentation of chest pain with shortness of breath 4
4. Only after excluding cardiac causes, considered empiric PPI trial 1, 2

The error was anchoring on the first impression (Answer B) without completing the mandatory diagnostic sequence, resulting in a missed diagnosis of CHF and delayed appropriate treatment.