Chest pain with no heartburn

I'm a 42 year woman, overweight, hypertension, migraines (with auras), and a long family history of heart disease.  I take Toprol XL 50 mg, daily aspirin, and nitro when needed. Started Prilosec this morning.

On 10/31/07 I experienced a frightening event where, when simply leaving for the morning to go to work, I had a crushing pressure in my mid-chest (crushing like an elephant on my chest - no burning), broke out in a sweat, nauseous, dizzy, pain radiated quickly into my left neck and jaw, pounding pain in my left armpit and down the inner part of my left arm, severe pounding in both my femoral arteries (in both upper thighs), and was having trouble breathing.  Pain lasted about 20 minutes or so and then started to abate.  Pain level was a 10.  Since that event I've had at 6 or so similar events, although none were as severe, ranging from a 4-9 in pain.

11/10/07 I went to ER.  They performed a cath and found no problems, but did note small vessels (?). Blood tests were all good.

12/7/07 I had an Upper GI done with found that I have a slight hiatal hernia and some reflux (happened twice when standing and twice when lying).  I have NO heartburn, stomach pain, or reguritation.  I'm a low sodium, organic diet, with very limited caffenine, non-smoker, limited alcohol.

My GP believes the chest pains are esophagus spasms caused from the reflux, since my cath showed no problems.

Questions:
1.  Is it normal to have reflux but not feel the heartburn or have regurgitation? Should I go to GI doctor to seek additional tests for why I don't feel the heartburn?
2. Everything I've read says that Esophagus spasms feel like "burning" and not crushing.  Is this correct? (I wonder if I have multiple problems.)
3. Can Esophagus spasms cause the "pounding" feeling I have in my arteries (neck, left armpit/arm, and in both groin femoral arteries?

P.S. Nitro relieves the chest pain. Mylanta does not.

Thank you so much for your help! Tonya

[Kevin Pho, MD]

To answer your questions:
1) I agree with the workup thus far.  Further evaluation of the upper digestive tract can be done with an upper endoscopy.  The negative cath would rule out coronary artery disease.

2) Typically esophageal spasms would not present as crushing pain.  That being said, there are cases of atypical presentations.  If a motility disorder is a concern, motility testing should be done.

3) Again, the pounding can be an atypical presentation.  The only way to know for sure would be to perform motility studies.  Nitrates can help with esophageal spasm.  Other options would be calcium channel blockers or an injection of botulinum toxin.

These options can be discussed with your personal physician or GI physician.

Followup with your personal physician is essential.

This answer is not intended as and does not substitute for medical advice - the information presented is for patients education only. Please see your personal physician for further evaluation of your individual case.

Kevin, M.D.
www.kevinmd.com