DEAR DR. ROACH: I am a 64-year-old woman with a family history of heart disease. Both of my parents had heart attacks and open-heart surgery. At ages 50, 55 and 60, I experienced what I thought were signs of a heart attack. With each experience, I ended up in the hospital and was given a nuclear stress test. None of the tests showed blockages, and it was concluded I had severe acid reflux/GERD. (An endoscopy at age 50 showed a hiatal hernia.)


Once again, I am experiencing symptoms that could be either heart- or acid-related. I take Protonix as needed. At present, the medication has not resolved my issues. There are days I feel more chest tightness and my heart seems to beat faster. This could be due to additional anxiety in my life. To rule out a heart issue, I made an appointment with my cardiologist. My EKG was normal and I had a strong heartbeat. But because of my symptoms, he wants me to have another nuclear stress test. This will be No. 4. How many of these tests are too many? I am very concerned about the amount of radioactive material that has been injected into my body. Is there a good indicator that can help me discern between GERD and heart issues? Would an exercise stress test alone give the cardiologist enough information to indicate a heart issue? I see my gastroenterologist this week and am scheduled for the nuclear stress test in two weeks. -- D.P.


ANSWER: Heart disease remains the leading cause of death in developed countries, so it is important to take symptoms seriously. Symptoms in women are more variable than in men, and some physicians are not as thorough as your cardiologist is.


A nuclear stress test is one of the most definitive ways to make the diagnosis of heart disease in both men and women. Regular exercise stress tests are not as accurate -- the nuclear test is both more sensitive and specific -- and too often, an exercise test comes back with an indeterminate result. For this reason, nuclear test remains a good option. The radiation dose is significant, but you seem to be getting these about every five years, which is not a huge total lifetime dose of radiation. Unfortunately, a good result five years ago does not mean that you are guaranteed free of artery blockages today.


Other options include a calcium score, a CT angiogram and a cardiac catheterization. None of these is perfect. The calcium score uses much less radiation and can help with predicting whether you have heart disease, but it does not give definitive results. The angiogram and cardiac catheterization are the most definitive tests, better than a nuclear stress test, but both use significant radiation, and the cardiac catheterization uses a large catheter in the artery, which can cause complications. Both procedures use dye, which can cause kidney problems, though rarely permanently.


The nuclear stress test remains an excellent option, with a dose of radiation that is low risk and outweighed by the benefits of getting believable results.


Finally, pantoprazole (Protonix), like other proton pump inhibitors, does not work well if taken as needed. It needs to be taken every day to be effective.