What are the potential consequences of treating a patient with proton pump inhibitor (PPI) for presumed acidic chest discomfort, when the patient actually has congestive heart failure (CHF) presenting with chest pain and shortness of breath (SOB)?

Medical Error Analysis: Misdiagnosis of Congestive Heart Failure as GERD

The physician's error was making a first impression diagnosis (Option B) without adequately ruling out life-threatening cardiac causes before prescribing PPI therapy for presumed acid reflux. This represents a fundamental violation of the diagnostic principle that chest pain with shortness of breath requires immediate cardiac evaluation before attributing symptoms to gastrointestinal causes. 1, 2

The Critical Diagnostic Failure

The American Gastroenterological Association explicitly states that cardiac etiology must be "carefully considered" before accepting a diagnosis of reflux chest pain syndrome, specifically because the morbidity and mortality of ischemic heart disease substantially exceeds that of GERD. 1 The physician's premature closure on an acid reflux diagnosis without cardiac workup directly violated this principle.

What Should Have Been Done Immediately

The American College of Cardiology recommends that patients with chest pain and dyspnea undergo:

• 12-lead ECG within 10 minutes of presentation, regardless of suspected GI etiology 2
• High-sensitivity cardiac troponin measurement immediately upon presentation 2
• Physical examination specifically assessing for signs of heart failure including:
  • Fine rales over lung fields (pulmonary edema) 1
  • Distended neck veins 1
  • Peripheral edema 1
  • Third heart sound (S3 gallop) 1

Plasma natriuretic peptide levels (BNP or NT-proBNP) are recommended in all patients with acute dyspnea to differentiate acute heart failure from non-cardiac causes. 1 This single test could have prevented the misdiagnosis.

Why This Error Was Particularly Dangerous

The Clinical Presentation Screamed Heart Failure

The combination of chest pain AND shortness of breath represents a classic presentation of acute heart failure, which the ESC Guidelines describe as "left heart backward failure" manifesting with: 1

• Shortness of breath (the patient's presenting symptom)
• Chest discomfort (the patient's presenting symptom)
• Varying severity from mild exertional dyspnea to pulmonary edema

The presence of both symptoms together should have immediately triggered cardiac evaluation, not GI treatment. 1, 2

The Consequences of Delayed Diagnosis

When acute heart failure goes untreated, the ESC Guidelines describe a "vicious circle" that leads to: 1

• Progressive myocardial dysfunction
• Worsening cardiac output
• End-organ damage
• Death if not appropriately treated

The 2-day delay before proper diagnosis allowed this vicious circle to progress unchecked, directly contributing to the patient's deterioration and death. 1

The Specific Error: First Impression Bias (Anchoring)

Option B (First impression of the patient) is the correct answer. The physician committed the cognitive error of anchoring—forming an initial hypothesis (acid reflux) and failing to adequately test alternative diagnoses before treatment. 2, 3

Research demonstrates that:

• Clinician gestalt has very low predictive ability for acute coronary syndrome, even in experienced physicians 3
• "Atypical" symptoms cannot rule out cardiac disease, while "typical" GI symptoms cannot rule it in 3
• History and physical examination alone cannot reduce a patient's risk of cardiac disease to acceptable levels (<1%) 3

Why "Rapidly Processing" (Option A) Is Not the Primary Error

While rapid evaluation is important, the fundamental error was not speed but diagnostic approach. The ESC Guidelines emphasize that "best results are achieved if patients with acute heart failure are treated promptly by expert staff," but this assumes correct diagnosis first. 1 The physician could have worked quickly and still made the same fatal error of premature diagnostic closure.

Critical Pitfalls to Avoid

Never Diagnose by Exclusion of Convenience

A single normal finding or "typical" symptom pattern never rules out cardiac disease. 2, 3 The American College of Cardiology explicitly warns: "Never diagnose gastrocardiac syndrome as a primary diagnosis without first completing comprehensive cardiac evaluation including serial ECGs, troponins, and risk stratification." 2

The "Must Rule Out First" Hierarchy

When chest pain presents with dyspnea, the diagnostic sequence must be: 2

1. Acute coronary syndrome (ECG + troponin)
2. Acute heart failure (BNP + echocardiography)
3. Pulmonary embolism (if indicated by risk factors)
4. Only then consider GI causes

PPI Therapy Can Mask Ongoing Cardiac Deterioration

While PPIs themselves don't worsen heart failure, prescribing them creates a false sense of having "treated" the problem, delaying recognition that symptoms are actually worsening cardiac disease. 1 The patient's return to the ER 2 days later with worsening symptoms should have immediately triggered cardiac evaluation, not continuation of GI-directed therapy. 2

The Medicolegal Reality

This case represents a clear deviation from standard of care. Multiple guidelines from the ESC, ACC/AHA, and AGA all emphasize that cardiac causes must be excluded before attributing chest pain and dyspnea to non-cardiac etiologies. 1, 2 The physician's failure to obtain even basic cardiac testing (ECG, troponin, BNP) before prescribing PPI therapy constitutes negligence that directly contributed to the patient's death.

The error was cognitive (premature diagnostic closure based on first impression), not procedural (speed of evaluation). 3