Heartburn vs. Cardiac Chest Pain: How to Tell the Difference

Burning Chest Pain: Is It Reflux or Your Heart?

Heartburn (pyrosis) is retrosternal burning from gastric acid reflux into the esophagus. However, cardiac ischemia can mimic it precisely. Distinguishing them is critical—missing a heart attack can be fatal.

Typical Heartburn / GERD Features

• Burning rising from epigastrium toward throat
• Worse after meals, lying down, bending over
• Sour/bitter taste (regurgitation)
• Relieved by antacids, PPIs, sitting upright
• No exertional pattern

Conditions Mimicking Heartburn

Condition	Distinguishing Features
GERD (chronic)	Frequent heartburn + regurgitation; may have dysphagia, cough, hoarseness, asthma
Eosinophilic esophagitis	Dysphagia > heartburn; food impaction; atopic history; eosinophils on biopsy
Esophagitis (pill, infectious, caustic)	Odynophagia (painful swallowing) prominent; medication history (bisphosphonates, doxycycline, KCl)
Hiatal hernia	Often asymptomatic; large hernias cause postprandial fullness, regurgitation, dyspnea
Peptic ulcer disease	Epigastric pain (relieved/worsened by food), night waking; H. pylori or NSAID link
Angina / MI (CRITICAL)	Pressure/squeezing/heaviness (not burning); radiates to arm/jaw/back; provoked by exertion/stress; relieved by rest/NTG; diaphoresis, dyspnea, nausea, sense of doom. Women/diabetics/elderly often atypical.
Pericarditis	Sharp, pleuritic, positional (better sitting forward); friction rub; diffuse ST elevation
Costochondritis	Reproducible tenderness at costochondral joints; no systemic symptoms
Pulmonary embolism	Sudden pleuritic pain, dyspnea, tachycardia; risk factors (immobility, OCP, cancer)

When to Seek Emergency Care

Call 911 / go to ER if:

• Chest pressure/squeezing lasting >5 min, not relieved by antacids/rest
• Radiating pain (arm, jaw, neck, back)
• Shortness of breath, cold sweat, nausea/vomiting, lightheadedness
• Known CAD, diabetes, smoking, hypertension, family history of premature CVD
• First episode >40 years old

Diagnostic Pathway

1. ECG + troponin (serial) → rule out ACS.
2. If negative, consider PPI trial (diagnostic/therapeutic) for GERD.
3. Persistent symptoms → EGD, esophageal manometry/pH-impedance, cardiac stress testing per risk.

Golden rule: When in doubt, rule out the heart first. A normal ECG doesn't exclude ACS—serial troponins and clinical judgment are key.