Heartburn or Heart Trouble? When Reflux Symptoms Warrant a Doctor's Visit

Almost everyone has felt it: a burning that climbs from the upper abdomen into the middle of the chest, sometimes reaching the throat, often with a sour or bitter taste in the mouth. Usually it follows a heavy meal, coffee, alcohol, or lying down too soon after eating, and then it fades. Two Israeli gastroenterologists explain why that familiar discomfort sometimes deserves a closer look.

Dr. Dan Livovsky, director of the neurogastroenterology and motility service at Shaare Zedek Medical Center in Jerusalem, separates heartburn from other stomach burning. Heartburn begins in the esophagus and is felt in the chest. In most cases it comes from gastroesophageal reflux disease, or GERD, in which acidic stomach contents pass through the lower esophageal sphincter, the valve meant to keep them down. But acid does not always cause burning. Some people feel chest pain instead, and that pain can closely resemble pain from the heart. Livovsky stresses that heart disease, lung disease or another dangerous cause must be ruled out first. Only then can chest pain be counted among the recognized symptoms of reflux.

Amir Klein, director of the Gastroenterology Institute at Rambam Health Care Campus in Haifa, adds that heartburn is a symptom, not a diagnosis. Reflux is the usual cause, but not the only one. Bile reflux is another, and it can be diagnosed too.

One common cause is a hiatal hernia. Normally the diaphragm, with muscle fibers called the crura around the esophagus, and the lower esophageal sphincter together form a barrier. In a hiatal hernia, the upper stomach and the sphincter move up through the diaphragm opening into the chest, cutting the sphincter off from its muscular support. In other people the sphincter is simply weak, or affected by medications or diseases. Sometimes the anatomy is normal but pressure in the abdomen, as in obesity or pregnancy, overwhelms it. A small group have functional heartburn, where burning persists though tests show no reflux disease. Livovsky describes it as a disorder of communication between the brain and esophagus that needs a different approach. Motility disorders of the esophageal muscles are another possible explanation.

GERD affects roughly 10% to 14% of people, Livovsky says, and Klein cites research that about 10% have heartburn at least weekly. A meta-analysis of 102 study populations and over 460,000 participants found an average prevalence of 13.3% when reflux was defined as weekly heartburn or regurgitation. Another international meta-analysis put global GERD prevalence near 14%. Livovsky says symptoms become troublesome when they hurt quality of life, impair function, cause complications or make eating hard. Even then, he notes, not every case needs a gastroenterologist, and certainly not surgery; only a small proportion need invasive treatment. Klein points out that the burden can still include long-term medication, frequent visits and unpleasant diagnostic procedures.

Obesity is the best-established risk factor, Livovsky says. The large meta-analysis also found higher rates among people 50 and older and among smokers. Klein says men tend to develop more aggressive forms. Smoking reduces saliva, which helps neutralize esophageal acid, and is a risk factor for complications and esophageal cancer. Evidence on alcohol is less consistent, though a meta-analysis of observational studies linked it to higher reflux risk, more strongly with heavier and more frequent drinking.

Medications matter too. Livovsky calls it paradoxical that weight-loss drugs can worsen heartburn even though weight loss usually helps reflux. A large 2025 study of people with type 2 diabetes found that those on GLP-1 drugs, a class that includes Ozempic and Wegovy, had a higher risk of developing GERD than those on another class of diabetes medication. One possible explanation is slower stomach emptying. But the study was observational, showing an association rather than proof of cause. Stress, meanwhile, can lower the threshold for sensing acid without necessarily increasing it.

For most people complications are rare, but they can occur, more often when reflux goes untreated and occasionally even with treatment. Klein lists esophagitis, with redness, erosions and ulcers that can hurt and bleed; scarring that narrows the esophagus near the stomach and makes swallowing difficult; and Barrett's esophagus, a precancerous change in the lining that is more common in men and in a small share of cases leads to esophageal adenocarcinoma. Diagnosis starts with a careful account of symptoms, including regurgitation, the upward movement of stomach contents toward the mouth.