Heartburn: Causes, Relief and Warning Signs

What heartburn feels like

Despite the name, heartburn has nothing to do with the heart. It is felt as:

• a burning pain behind the breastbone, often rising toward the neck
• worse after eating, especially in the first hour
• worse when lying down, bending over or straining
• often with a sour or bitter taste, or acid coming up into the throat or mouth (regurgitation)
• sometimes with burping, bloating, a feeling of fullness or nausea

Some people with reflux have little heartburn and instead notice a chronic cough, hoarseness, throat clearing, a lump-in-the-throat feeling or worsening asthma.

What causes heartburn

A ring of muscle at the bottom of the esophagus, the lower esophageal sphincter, normally acts as a one-way valve. Heartburn happens when it relaxes at the wrong time or is weak, letting acid back up.

Common triggers

• Large meals and eating within 2 to 3 hours of bedtime
• Fatty and fried foods, which slow stomach emptying and relax the valve
• Alcohol, coffee and fizzy drinks
• Chocolate, peppermint, onions and garlic
• Spicy, acidic and tomato-based foods (these irritate an already inflamed esophagus)
• Smoking, which weakens the valve
• Tight clothing and bending after meals

Conditions that make heartburn more likely

• Excess weight, especially around the waist, which pushes on the stomach
• Hiatal hernia: part of the stomach slides up through the diaphragm, weakening the valve
• Pregnancy: hormones relax the valve and the growing baby presses on the stomach. Heartburn affects many pregnant women, especially in the third trimester
• Slow stomach emptying, as in diabetes
• Medicines: NSAIDs and aspirin, some blood pressure medicines (calcium channel blockers, nitrates), some asthma medicines, sedatives, tricyclic antidepressants, bisphosphonates, iron and potassium tablets

Heartburn vs heart attack

The chest pain of a heart attack can feel like burning or indigestion, especially in women, older adults and people with diabetes. If in doubt, treat it as an emergency.

Other causes of burning chest pain include esophageal spasm, a stomach or duodenal ulcer, gallstones and inflammation of the esophagus from pills or infection.

When heartburn is GERD

Gastroesophageal reflux disease (GERD) is diagnosed when reflux happens often (typically twice a week or more) or causes complications. Long-term untreated GERD can lead to:

• Esophagitis: inflammation and ulcers in the esophagus
• Strictures: scarring that narrows the esophagus and makes food stick
• Barrett's esophagus: a change in the lining that slightly raises the risk of esophageal cancer
• Chronic cough, laryngitis, dental erosion and worsening asthma

How heartburn is diagnosed

Typical heartburn is diagnosed from symptoms, and doctors often start with a trial of acid-reducing medicine. Tests are used when symptoms are atypical, severe, not improving, or with red flags:

• Upper endoscopy: a camera examines the esophagus, stomach and duodenum and takes biopsies. Recommended for difficulty swallowing, bleeding, weight loss, anemia, or for screening for Barrett's esophagus in people with long-standing GERD and other risk factors
• pH or impedance monitoring: measures acid exposure over 24 to 96 hours
• Esophageal manometry: measures how the esophagus muscles work, before surgery or when spasm is suspected
• Tests for H. pylori if ulcer-type symptoms are present
• ECG and heart tests if heart pain is possible

How to get rid of heartburn

Fast relief

• Antacids (calcium carbonate, magnesium or aluminum compounds) neutralize acid within minutes but last only an hour or two
• Alginate preparations form a raft on top of stomach contents and are useful after meals and at bedtime
• Sit or stand upright and loosen tight clothing

Lifestyle changes that work

• Eat smaller meals and finish eating 3 hours before lying down
• Raise the head of your bed by 6 to 8 inches (15 to 20 cm) with blocks or a wedge, which works better than extra pillows
• Sleep on your left side
• Lose weight if you are overweight. Even 5 to 10 percent of body weight helps
• Stop smoking
• Identify and cut down your own trigger foods and drinks, rather than avoiding every food on a list

Medicines

• H2 blockers such as famotidine reduce acid for up to 12 hours. Take before a meal that usually triggers symptoms
• Proton pump inhibitors (PPIs) such as omeprazole, esomeprazole and lansoprazole are the most effective. Take 30 to 60 minutes before breakfast. Over-the-counter courses are for 14 days. See a doctor if you need them longer or repeatedly
• Follow the label dose for all over-the-counter medicines

Long-term PPI use is safe for most people who need it, but should be reviewed regularly to use the lowest effective dose.

Procedures

Surgery (fundoplication) or endoscopic procedures that reinforce the valve are options for people with confirmed GERD who do not respond to or do not want long-term medicine, especially with a large hiatal hernia.

Heartburn in pregnancy

Heartburn is very common in pregnancy and usually stops after delivery. Small meals, avoiding late eating and raising the head of the bed help. Calcium-based antacids and alginates are generally considered safe. Ask your doctor or pharmacist before taking other medicines, and avoid antacids containing sodium bicarbonate.

Frequently asked questions

What causes heartburn?

Heartburn happens when stomach acid flows back into the esophagus because the valve at its lower end relaxes or is weak. Large or late meals, fatty and spicy food, alcohol, coffee, smoking, extra weight, pregnancy, hiatal hernia and some medicines all make it more likely.

How can I get rid of heartburn fast?

An antacid or alginate gives relief within minutes. Sit upright, loosen tight clothing and avoid lying down for a few hours after eating. For frequent symptoms, an H2 blocker before meals or a short course of a proton pump inhibitor works longer.

How do I know if it is heartburn or a heart attack?

Heartburn is a burning feeling linked to meals and lying down, often with a sour taste, and eases with antacids. Heart pain is more often pressure or squeezing, may come with exertion, and comes with breathlessness, sweating or pain in the arm or jaw. If unsure, call 911.

Why do I get heartburn every night?

Lying flat lets acid flow back more easily, especially after a late or large meal. Finish eating 3 hours before bed, raise the head of the bed, sleep on your left side and limit alcohol in the evening. Nightly heartburn usually means GERD and is worth discussing with a doctor.

When should I see a doctor about heartburn?

See a doctor if you have heartburn twice a week or more, need antacids most days, have symptoms despite 2 weeks of treatment, or have trouble swallowing, weight loss, vomiting, black stools or anemia. New heartburn after age 60 should also be checked.