Heartburn natural history, complications and prognosis

the natural history of heartburn depends on its cause. The most common cause is gastroesophageal reflux disease (GERD) which, if left untreated, 20% of patients with GERD may progress to develop esophageal stricture due to excessive acid in the lower esophagus. Complications of GERD include:

• Barrett’s esophagus;
• Erosive esophagitis;
• Esophageal ulcer;
• Esophageal adenocarcinoma.

Prognosis of GERD is good with the appropriate treatment.

• The natural history of heartburn depends on the cause. The most common cause of heartburn is GERD but there are many other causes with different progressions.
• The symptoms of GERD include heart burn, regurgitation, and dysphagia. Other causes such as acute coronary syndromes may have a type of chest pain that is described similarly to heartburn but radiates to the left shoulder or neck and that is worsened by exercise.
• If left untreated, GERD will develop to esophageal stricture which occurs in around 20% of the patients with GERD.^[1]
• Esophageal stricture occur due to excessive acid in the lower of the esophagus which lead to scar formation. This scar causes narrowing of the esophagus and may lead to difficulties in swallowing.
• Acute coronary syndromes are life-threatening conditions due to acute coronary blood flow obstruction that may present with unstable angina, NSTEMI or STEMI.
• Scleroderma is a slowly progressing disease without a disease-modifying treatment that may present with progressive heartburn, dysphagia and symptoms present in the CREST syndrome.
• Esophageal cancer is usually of adenocarcinoma type that presents very aggressively and with a poor prognosis in most cases.

Complications that can develop as a result of GERD include the following:^[2]

• Barrett’s esophagus:
  • A type of dysplasia, is a precursor high-grade dysplasia, which is in turn a precursor condition for carcinoma. The risk of progression from Barrett’s to dysplasia is uncertain but is estimated to include 0.1% to 0.5% of cases, and has probably been exaggerated in the past.
  • Due to the risk of chronic heart burn progressing to Barrett’s esophagus, EGD every 5 years is recommended for patients with chronic heartburn, or who take drugs for chronic GERD.
• Erosive esophagitis
• Esophageal ulcer:
  • The excess acid secretion in the esophagus can lead to ulcer formation which increases pain in GERD patients.
• Esophageal adenocarcinoma
• Acute coronary syndromes may lead to death, heart failure, arrhythmias or mechanical complications.

• The majority of patients with GERD respond to nonsurgical measures, with lifestyle changes and medications. However, many patients need to continue to take drugs to control their symptoms.
• Prognosis of heartburn as a symptom of other diseases is more variable.
• Scleroderma is a progressive disease with poor prognosis.^[3]
• Acute coronary syndromes are life-threatening conditions that can present with variable prognosis when properly treated. Prognosis tend to be poor and may lead to death or severe heart failure if not treated.Harjola, Veli‐Pekka, et al. “Acute coronary syndromes and acute heart failure: a diagnostic dilemma and high‐risk combination. A statement from the Acute Heart Failure Committee of the Heart Failure Association of the European Society of Cardiology.” European Journal of Heart Failure (2020).