Reversibility of Cardiac Abnormalities in Adolescents With Anorexia Nervosa After Weight Recovery

doi:10.1097/01.CHI.0000046867.56865.EB

Journal of the American Academy of Child & Adolescent Psychiatry

Volume 42, Issue 7, July 2003, Pages 808-813

https://doi.org/10.1097/01.CHI.0000046867.56865.EB Get rights and content

ABSTRACT

Objective

Anorexia nervosa is a life-threatening condition, with significant risk for death due to cardiac complications. The objective of this study was to analyze the cardiac involvement in anorexia nervosa and to study the reversibility of cardiac abnormalities.

Method

Thirty-one consecutive adolescents (aged 12 to 17 years) with a diagnosis of anorexia nervosa were evaluated from January 1998 to January 1999 at the Hospital Clínic (University of Barcelona, Catalonia, Spain). An electrocardiogram, an echocardiogram, a 24-hour Holter recording with heart rate variability, an exercise test, and a tilt test were performed at initial examination and after refeeding (3 to 18 months later).

Results

The basal body mass index was 15.2 ± 2 kg/m2. Sinus bradycardia was found in 35% of patients, 93% showed a decreased left ventricular mass, and 70% had a diminished thickness of cardiac walls. The Holter recordings showed nocturnal bradycardia in 60% with an increased heart rate variability. After refeeding, a significant decrease in QT interval (p < .05) and QT dispersion (p < .01) was observed. Echocardiograms showed an increase in cardiac diameters (p < .01), left ventricular mass (p < .001), and cardiac output (p < .001). There was also an improvement in the exercise capacity (p < .05) and a normalization of the heart rate and heart rate variability (p < .05)

Conclusion

Cardiac structural and functional abnormalities provoked by anorexia nervosa are reversible in young adolescents after refeeding. J. Am. Acad. Child Adolesc. Psychiatry, 2003, 42(7):808-813.

Section snippets

Patients

From January 1998 to January 1999, thirty-one consecutive adolescent patients (aged 12 to 17 years) who fulfilled the DSM-IV diagnostic criteria for AN (American Psychiatric Association, 1994) were evaluated at the Department of Child and Adolescent Psychiatry and Psychology of the Hospital Clínic (University of Barcelona, Catalonia, Spain). Patients were admitted to the hospital or followed with an ambulatory program. Two patients with concomitant diseases were excluded from the study (one

General Characteristics

Thirty-one consecutive patients, beginning treatment 11.4 ± 6.8 months after the onset of dieting symptoms, were evaluated. There were 25 girls (80.6%) and 6 boys (19.6%). Mean percentage of weight loss was 24.3 ± 8.8%. The mean time of amenorrhea in postpubertal female patients was 6.9 ± 5.8 months. A total of 23 patients (74.2%) were restrictive and 8 (25.8%) were purging. At the second examination, performed 3 to 18 months later (mean: 7.9 ± 3.7 months), there was a 25% weight gain, all

DISCUSSION

Our work shows that even young adolescents with AN of short evolution suffer functional and structural cardiac abnormalities. On the other hand, data demonstrate that these abnormalities are reversible at the early stages of the disease. Whether or not cardiac alterations are reversible in patients with long-lasting anorexia is not known. It is important to recognize that cardiac involvement in AN presumably contributes to sudden death in some patients (Sullivan, 1995). Furthermore, it is one

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Delayed appearance of refeeding syndrome in a patient with anorexia nervosa: A case report
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Refeeding syndrome (RFS) can be a severe and life-threatening complication of anorexia nervosa (AN) associated with electrolyte abnormalities and organ damage, and occurs with the transition from a prolonged catabolic to anabolic state, particularly with an overzealous nutrient supply. There is no unequivocal definition of RFS, although hypophosphatemia is recognized as a crucial factor in its pathogenesis. RFS can be responsible for cardiovascular complications, such as heart failure, left ventricular damage, and arrhythmias, because of different potential mechanisms: electrolyte imbalances, increased retention of sodium and liquids secondary to insulin secretion, and excessive fat emulsion supplementation. We report on the case of a 13-y-old male patient with severe AN in whom a delayed and reversible myocardial dysfunction was documented during cautious nutritional replenishment, even in the absence of serum electrolyte imbalances. Seven days after the inception of integrative enteral nutrition, heart failure was unexpectedly documented as follows: reduction in fraction ejection, presence of mild bilateral perimalleolar edema, and increased n-terminal prohormone of brain natriuretic peptide. A more pronounced water restriction protocol and delayed achievement of goal feeding rate, resulting also in lower sodium intake, were implemented to reduce cardiac overload with a full resolution of the complication in approximately 2 mo. Refeeding patients with AN could be complicated by heart failure despite cautious nutritional replenishment and regardless of electrolyte imbalance, even in a later phase of recovery. Therefore, strict adherence to recommendations for nutritional replenishment and close monitoring of cardiac function should always be considered when refeeding patients with AN.
Heart rate variability as a biobehavioral marker of diverse psychopathologies: A review and argument for an “ideal range”
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Heart rate variability (HRV), a measure of the variability in intervals between subsequent heart beats, is now widely considered an index of emotion regulatory capacity and the ability to adapt flexibly to changing environmental demands. Abnormalities in HRV are implicated in a host of psychopathologies, making it a potentially powerful transdiagnostic biobehavioral change mechanism in treatment interventions. While most mental illnesses are associated with low HRV, eating disorders have been linked to elevated HRV. We examined 62 research articles on HRV in psychopathology to test the hypothesis that there is an “ideal range” of HRV that predicts optimal functioning. Relationships between symptom severity and parameters that quantify HRV were examined graphically. More extreme time-domain HRV measures, both high and low, were associated with psychopathology, whereas healthy controls displayed mid-range values. Findings preliminarily support the hypothesis that there is an “ideal range” of HRV that could be targeted in biofeedback interventions.
The Brugada Type 1 Electrocardiogram and Ventricular Tachycardia With High-Dose Amitriptyline
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This is corroborated based on an animal study demonstrating that dose-dependent Brugada-like changes are not present at normal therapeutic doses of amitriptyline (8). Cardiac abnormalities, such as sinus bradycardia, reduced cardiac mass, and QT prolongation, in anorexia can recover following successful refeeding (9). Anorexia nervosa and BrS has been previously reported once, with the ECG pattern persisting after successful refeeding (10).
A 32-year-old woman with anorexia nervosa experienced ventricular tachycardia while on therapeutic-dose amitriptyline despite normal blood tests, imaging, and intracardiac recordings. Electrocardiograms over several years featured the Type 1 Brugada pattern. Careful electrocardiogram monitoring should be made if using high doses of amitriptyline, especially in those with low body weight. (Level of Difficulty: Intermediate.)
A case series of profound bradycardia in patients with severe anorexia nervosa: Thou shall not pace?
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Medical Complications of Eating Disorders in Youth
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These findings highlight the importance of checking an electrocardiogram on all patients with EDs, regardless of weight, because patients with BN tend to be in a normal weight range. Nearly one-third of hospitalized patients with AN have mitral valve prolapse and pericardial effusions.33,40–43 Several small studies have demonstrated almost complete reversibility of both structural and functional derangement,42,43 although ipecac abuse in patients who purge can lead to an irreversible cardiomyopathy.44–48
Enhanced cortical processing of cardio-afferent signals in anorexia nervosa
2019, Clinical Neurophysiology
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Systematic reviews of the literature confirm that although bradycardia and parasympathetic dominance are often found in AN, results of sympathetic dominance or no alterations as compared to HC are also common (Mazurak et al., 2011; Sachs et al., 2016). Alterations of cardiac autonomic function generally return to normal after refeeding (Rechlin et al., 1998; Mont et al., 2003). While the patients participating in our study were still underweight (BMI < 18.5), their treatment program required them to consume five meals per day, thus excluding effects of acute fasting.
To assess cardiac interoception in anorexia nervosa (AN) using a multidimensional approach.
We assessed the physiological dimensions of cardioception, i.e. the peripheral signal itself (heart rate, HR, and heart rate variability, HRV) and its cortical representation (heartbeat evoked potentials, HEPs), and the psychological dimensions of interoceptive accuracy (heartbeat perception) and interoceptive sensibility (confidence ratings). Electroencephalogram (EEG) and electrocardiogram (ECG) were recorded concurrently during rest and while performing a heartbeat perception task in a sample of 19 female in-patients with AN (DSM-5) and 19 healthy control women (HC).
HEPs, defined as mean EEG amplitude in a time window of 455–595 ms after the R-peak of the ECG, were significantly larger in the AN than in the HC group across conditions (p = .002, d = 1.06). There was a trend toward better heartbeat perception in AN, but no group differences in HR, HRV, and confidence ratings.
Individuals with AN showed an interoceptive profile of heightened cortical processing, a trend toward heightened interoceptive accuracy, and unaltered cardiac autonomic activation and interoceptive sensibility.
In terms of neurobiological models of AN, enhanced cortical representations of interoceptive signals might reflect a mechanism, which promotes fasting by alleviating negative body states.

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: Dr. Herreros was supported by a grant from the Fundació Clínic per a la Recerca Biomèdica.

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SPECIAL COMMUNICATIONReversibility of Cardiac Abnormalities in Adolescents With Anorexia Nervosa After Weight Recovery

ABSTRACT

Objective

Method

Results

Conclusion

Section snippets

Patients

General Characteristics

DISCUSSION

Am J Cardiol

Int J Cardiol

J Adolesc Health Care

J Adolesc Health Care

Diagnostic and Statistical Manual of Mental Disorders

QT interval in anorexia nervosa

Br Heart J

Cardiovascular findings in adolescent inpatients with anorexia nervosa

Psychosom Med

Effects of self-induced starvation on cardiac size and function in anorexia nervosa

Circulation

Echocardiographic measurements in normal subjects: growth-related changes that occur between infancy and early adulthood