What is the likely cause of intermittent chest discomfort, dizziness, and anxiety in a patient with normal stress ECG, echocardiogram, MRI, CT scan, and endoscopy showing only a small hiatal hernia?

Your symptoms most likely represent noncardiac chest pain related to anxiety disorder and/or gastroesophageal reflux disease (GERD) from your hiatal hernia, given your comprehensive negative cardiac workup.

Primary Diagnosis and Management

Given your extensive negative cardiac testing (stress ECG, echocardiogram, MRI, CT scan), you should be referred to a cognitive-behavioral therapist for evaluation and treatment of anxiety disorder, which is the most common cause of recurrent chest pain with normal cardiac studies 1. The 2021 AHA/ACC Chest Pain Guidelines specifically recommend this approach for patients like you with recurrent chest pain and no physiological cardiac cause found on prior testing.

Why This Is Your Most Likely Diagnosis

Your symptom pattern strongly suggests a psychological etiology:

• Anxiety disorders are present in 30-50% of patients with recurrent chest pain and normal coronary arteries 2
• Generalized anxiety disorder specifically causes chest pain in 48% of cases, often associated with episodes of excessive worry 3
• The temporal relationship you describe (initially after alcohol, now occurring frequently even without alcohol) suggests a progression of anxiety symptoms
• Your triad of chest discomfort, dizziness, and anxiety occurring together is classic for panic disorder or generalized anxiety disorder
• The timing pattern (late mornings into afternoon) may correlate with stress or worry episodes rather than cardiac ischemia

The Role of Your Hiatal Hernia

Your small hiatal hernia is a secondary contributor:

• Gastroesophageal reflux disease is the most likely gastrointestinal cause of recurring unexplained chest pain 1
• GERD-related chest pain can mimic cardiac ischemia, presenting as squeezing or burning that lasts minutes to hours, often worsens after meals or at night, and can be stress-related 1
• Small hiatal hernias (≤2 cm) have been associated with atrial fibrillation risk 4, though your cardiac testing was normal
• However, hiatal hernias alone rarely cause the symptom pattern you describe without prominent reflux symptoms

Evidence-Based Treatment Approach

1. Cognitive-Behavioral Therapy (First-Line)

Psychotherapy using cognitive-behavioral methods showed a 32% reduction in chest pain frequency over 3 months in patients with chest pain and no cardiac disease 1. This is more effective than medications alone.

2. Consider Pharmacologic Treatment

• Antidepressants and anxiolytics have mixed evidence but may be helpful as adjuncts 1
• Your physician should evaluate you for panic disorder or generalized anxiety disorder specifically

3. Trial of Acid Suppression

• Given your hiatal hernia, a trial of proton pump inhibitor (PPI) therapy is reasonable
• GERD symptoms often worsen with stress, which may explain why your symptoms persist even without alcohol 1
• If chest pain improves with PPI therapy, this supports a gastrointestinal contribution

Critical Clinical Pitfalls to Avoid

The most common error in managing patients like you is continuing to pursue repetitive cardiac testing rather than addressing the actual underlying anxiety disorder 1. Studies show:

• Less than 10% of physicians inquire about or document psychological factors in chest pain patients with self-reported anxiety 1
• These patients undergo extensive, repetitive, costly cardiac testing with avoidable radiation exposure 1
• Depression, anxiety, and gastroesophageal syndromes each exceed coronary artery disease by almost 10-fold in low-risk chest pain patients 1

Reassurance About Prognosis

The prognosis of patients with noncardiac chest pain is largely devoid of cardiac complications 1. Your comprehensive negative cardiac workup provides strong reassurance that you do not have life-threatening cardiac disease.

Specific Next Steps

1. Request referral to a cognitive-behavioral therapist who specializes in anxiety disorders and somatic symptoms
2. Start a PPI (e.g., omeprazole 20-40 mg daily) for 8 weeks to address potential GERD from your hiatal hernia
3. Avoid alcohol completely, as it worsens both anxiety and reflux
4. Keep a symptom diary tracking chest pain episodes, associated anxiety/worry, meals, and timing to identify patterns
5. Do not pursue additional cardiac testing unless new symptoms develop that are distinctly different from your current pattern

The connection between your initial alcohol-related symptoms and current symptoms likely reflects alcohol's role as both an anxiety trigger and GERD exacerbator, with anxiety symptoms now persisting independently.