Chest Pain or Acidity? How to Tell Heartburn from a Heart Problem

Almost everyone has had chest discomfort at some time. In most cases the cause is harmless, such as acidity, muscle strain or anxiety. But because the heart can cause very similar symptoms, it is difficult, even for doctors, to tell the difference without an examination and tests. This guide explains the typical differences, but if you are unsure, treat it as urgent.

Why acidity and heart pain feel alike

The oesophagus (food pipe) and the heart sit next to each other, and they share nerve pathways. When acid flows back from the stomach (gastro-oesophageal reflux, GERD), it irritates the lower oesophagus and can cause burning pain behind the breastbone. A heart attack or angina may cause pressure in the same place, along with nausea or belching, which is why it is often mistaken for indigestion.

Typical features of acidity (heartburn)

• Burning feeling behind the breastbone, rising towards the throat
• Sour or bitter taste in the mouth, belching or bloating
• Starts after a large, spicy or fatty meal, or when lying down or bending forward
• Worse at night or after tea, coffee, alcohol or chewing betel
• Often eased by antacids, sitting upright or drinking water
• Lasts minutes to hours, may recur

Typical features of heart-related chest pain

• Pressure, squeezing, tightness, heaviness, or a band around the chest
• Spreads to the left arm, both arms, jaw, neck, back or shoulders
• Brought on by effort, stairs, hurrying or emotional stress, and eased by rest within minutes (angina)
• With a heart attack: lasting more than 10-15 minutes, not relieved by rest, with sweating, nausea, breathlessness, dizziness or a sense of doom
• Not clearly related to meals, and not relieved by antacids

Other causes of chest pain

• Muscle or rib strain: sharp, worse with movement, deep breathing or pressing on the chest wall
• Costochondritis: inflammation of the rib cartilage, tender to touch
• Anxiety or panic attack: rapid breathing, tingling, palpitations, fear, usually in younger people
• Pericarditis: sharp pain that eases when leaning forward, often after a viral illness
• Pulmonary embolism: sudden sharp chest pain with breathlessness, often after long immobility or surgery (emergency)
• Pneumonia or pleurisy: pain on breathing with fever or cough
• Aortic dissection: sudden tearing pain spreading to the back, with very high blood pressure (emergency)
• Shingles: burning pain and rash on one side of the chest

Red flags: go to emergency immediately

• Chest pain lasting more than 10-15 minutes
• Pain with sweating, nausea, vomiting, breathlessness or fainting
• Pain spreading to the arm, jaw or back
• Sudden severe or tearing pain
• Chest pain in someone with diabetes, high blood pressure, smoking or a family history of early heart disease
• New chest pain in anyone over about 40
• Pain after a long flight or surgery, or with swelling in a leg

Call 1990 in Sri Lanka or go to the nearest hospital. See our heart attack symptoms guide for first-aid steps.

What doctors do

• Examination and ECG (electrocardiogram), repeated if needed
• Blood tests such as troponin, which rises after heart muscle injury
• Chest X-ray, and sometimes CT, echocardiogram or stress testing
• If a heart cause is excluded and the picture fits reflux, an endoscopy or acid-suppressing trial may follow

A normal first ECG does not always exclude a heart attack, which is why doctors observe and repeat tests.

Managing acidity and reflux

If your doctor has confirmed reflux:

• Eat smaller meals and avoid lying down for 2-3 hours after eating.
• Limit spicy, fatty and fried foods, chocolate, coffee, strong tea, fizzy drinks and alcohol.
• Raise the head of the bed and avoid tight clothes.
• Lose weight if overweight and stop smoking.
• Use antacids for occasional symptoms; proton-pump inhibitors for frequent symptoms, as prescribed.
• See a doctor if you have difficulty swallowing, weight loss, vomiting blood, black stools or symptoms that last more than a few weeks.

Reduce your heart risk

Control blood pressure, diabetes and cholesterol, keep a healthy weight (use our BMI calculator), exercise regularly, avoid smoking, and eat more vegetables, pulses and fish. Read how to lower high blood pressure.

When to see a doctor

See a doctor soon for chest discomfort that recurs, especially with exertion, or if you have heartburn more than twice a week. Go to the hospital immediately for any of the red flags above. It is always better to be checked and told it is only acidity.

References

• American Heart Association / American College of Cardiology: guideline for the evaluation and diagnosis of chest pain
• NICE guideline CG95: recent-onset chest pain of suspected cardiac origin
• American College of Gastroenterology: guidelines for the diagnosis and management of gastroesophageal reflux disease