What could be causing recurrent chest discomfort, dizziness, and anxiety in a 36‑year‑old relatively fit male with normal blood tests, echocardiogram, stress electrocardiogram, endoscopy (showing a small hiatal hernia), and CT scan?

Most Likely Diagnosis: Gastroesophageal Reflux Disease (GERD) with Anxiety Disorder

Given your comprehensive negative cardiac workup, your symptoms are most likely caused by a combination of gastroesophageal reflux disease (GERD) related to your hiatal hernia and an underlying anxiety disorder—both of which commonly present with chest pain, dizziness, and the exact symptom pattern you describe.

Primary Diagnostic Considerations

Your clinical picture fits a well-established pattern. According to the 2021 AHA/ACC guidelines, patients with recurrent chest pain despite negative cardiac evaluation should be systematically evaluated for noncardiac causes, with gastrointestinal and psychological etiologies being the most common 1.

Gastrointestinal Cause (Most Likely Primary)

Your documented small hiatal hernia is a significant finding that should not be dismissed. The guidelines specifically state that gastroesophageal reflux disease is the most likely cause for recurring unexplained chest pain of esophageal origin, affecting 10-20% of patients with chest pain 1.

Key points about your hiatal hernia:

• Even "small" hiatal hernias can cause significant symptoms 2
• GERD-related chest pain mimics cardiac ischemia—described as squeezing or burning, lasting minutes to hours, often worsening after meals or when lying down, and can worsen with stress 1
• The progression from alcohol-triggered to spontaneous symptoms suggests worsening reflux (alcohol relaxes the lower esophageal sphincter)
• Research shows that 63% of patients with non-cardiac chest pain have esophageal motor disorders on manometry 3

Psychological Component (Likely Co-existing)

The anxiety you describe is not just a reaction to your symptoms—it may be a primary contributor. Research demonstrates that 30-50% of patients with recurrent chest pain and normal coronary arteries meet criteria for panic disorder 4.

Critical distinguishing features that suggest anxiety disorder 5:

• Recurrent ED visits for chest pain (you've had multiple evaluations)
• Associated dizziness or lightheadedness (which you report)
• Fear and anxiety accompanying the chest pain
• Symptoms that occur unpredictably, not just with exertion

The combination of GERD and anxiety disorder is particularly common and creates a vicious cycle—anxiety worsens reflux through increased sympathetic activation, and reflux symptoms trigger more anxiety 6.

Recommended Diagnostic Algorithm

Step 1: Trial of Aggressive Acid Suppression

Start a high-dose proton pump inhibitor (PPI) twice daily for 8 weeks 1. This is the most cost-effective next step and provides both diagnostic and therapeutic value. If your symptoms improve significantly, this confirms GERD as a major contributor.

Step 2: Advanced Esophageal Testing (If PPI Trial Fails)

If symptoms persist despite adequate acid suppression, you need 1:

• Esophageal manometry to assess for motility disorders (nutcracker esophagus, diffuse esophageal spasm)
• 24-hour pH monitoring to quantify acid exposure
• These tests are essential because your endoscopy was normal—many patients with esophageal chest pain have normal endoscopy but abnormal function tests 3

Step 3: Formal Anxiety Assessment

Regardless of PPI response, you should be evaluated for anxiety disorder. The 2021 guidelines give a Class 2a recommendation for referral to cognitive-behavioral therapy in patients with your presentation 1.

The evidence is compelling:

• Cognitive-behavioral therapy reduces chest pain frequency by 32% in patients with non-cardiac chest pain and psychological factors 1
• Antidepressants and anxiolytics show mixed results, but CBT demonstrates consistent benefit 1
• 78% of patients with anxiety disorder and chest pain have recurrent ED visits—breaking this cycle requires addressing the anxiety 5

Critical Pitfalls to Avoid

1. Don't dismiss the hiatal hernia as "too small"—size doesn't correlate perfectly with symptoms 2, 7

2. Don't assume anxiety is "just stress"—panic disorder has specific neurophysiologic mechanisms involving anterior limbic circuits that generate real cardiovascular symptoms 4

3. Don't accept "normal endoscopy" as ruling out esophageal disease—most patients with esophageal chest pain have normal endoscopy but abnormal manometry 3

4. Don't continue repeating cardiac tests—your cardiac workup is complete and negative. Further cardiac testing increases anxiety and healthcare costs without benefit 1

Immediate Action Plan

Start now:

• High-dose PPI (e.g., omeprazole 40mg twice daily, 30 minutes before meals)
• Lifestyle modifications: elevate head of bed, avoid late meals, reduce alcohol, avoid trigger foods
• Request referral to gastroenterologist for esophageal function testing if no improvement in 8 weeks
• Request referral to psychologist/psychiatrist specializing in cognitive-behavioral therapy for anxiety

The combination of treating both GERD and anxiety disorder simultaneously will likely provide the most significant symptom relief 1. The guidelines emphasize that these conditions frequently coexist and both require treatment for optimal outcomes.

Your prognosis is excellent—patients with non-cardiac chest pain have minimal cardiac complications 1, and with appropriate treatment of GERD and anxiety, most patients achieve substantial symptom improvement.