The Significance of Bradycardia in Anorexia Nervosa

Abstract

One Friday evening, during routine work, I was called to the Children and Psychiatry Department to check a 17-year-old girl, with the diagnosis of anorexia nervosa (AN), because of bradycardia (heart rate (HR) of 38/min). A month later, a friend of mine asked me to check her 16-year-old daughter who has lost weight and has HR of 47/min. At that time, I realized that not all physicians (in hospitals, the community, or in the military service) are acquainted with the simple, easy to check physical sign of bradycardia in AN, and thus I became involved and decided to collect data concerning this issue.Eating disorders, and particularly AN, confer a long-lasting increase in morbidity and mortality especially among young adults. It is a life-threatening disorder, with a significant risk for sudden death (5 to 20%) due to severe cardiovascular complications. It is a generalized disorder that affects multiple organ systems, such as skeletal bones, linear growth, brain development, and fertility functions. Previous reports pointed out conflicting evidence concerning its reversibility upon treatment. 1-8AN carries the highest mortality rate of all psychiatric disorders, mostly due to sudden unexpected cardiac arrhythmic death.9,10 Studies have disclosed a mortality rate of up to 20%. 11 Cardiac arrest secondary to electrolytic disturbances, and QT c (QT corrected to HR) interval prolongation (secondary/primary) were recorded among AN patients. 12,13The mechanism of sudden death in AN is obscure and is attributed to sudden arrhythmic death. AbstractAnorexia nervosa (AN) is a life-threatening condition, with a significant risk for death, due to cardiovascular complications. It is characterized by abnormal eating behavior and has the highest mortality rate of all psychiatric disorders. It has been associated with bradycardia (a heart rate [HR] of less than 60 beats per minute) (up to 95%), hypotension, mitral valve prolapse, and heart failure. The diagnosis of AN can be elusive, and more than half of all cases are undetected. The purpose of this study was to raise and improve awareness to the possible diagnosis of AN in adolescent and young adult patients with weight loss displaying bradycardia and new cardiac disorders. Clinical characteristics, HR, and electrocardiographic data of 23 consecutive patients (20 females) with AN and of 10 young adults (8 females) without AN, between the years 2006 and 2009, were recorded and summarized. At presentation 16/23 (69.6%) showed HR < 50 bpm. The mean lowest HR of all patients was 44 AE 6 (range 26 to 68) bpm. No patient needed pacemaker therapy. Bradycardia in young adults, especially females with weight loss, should raise the possible diagnosis of AN, so it can be treated early in-time, and thus prevent premature death.

Cardiovascular complications of anorexia nervosa: A systematic review

“…In a 2013 study by Yaholom et al 22 out of the 23 patients with anorexia nervosa who were evaluated with a 24‐h Holter monitor showed prolonged periods of bradycardia with mean lowest heart rates of 44 ± 6 beats per minute. In contrast, the mean lowest heart rate in age matched controls was 74 beats per minute . The finding of sinus bradycardia in this population is so pervasive that unexpected elevations in heart rate to the normal range should be viewed with caution as they may represent signs of a secondary process, such as infection …”

Bradycardia in anorexia nervosa

“…There has been a clear positive correlation found between heart rate and body mass index, while a negative correlation exists between QT c and body mass index 2. Although many patients remain asymptomatic despite profound bradycardia, it can be a precursor of a potentially lethal arrhythmia.…”

Medical Complications of Anorexia Nervosa and Bulimia

“…A resting heart rate of less than 60 beats per minute, for example, was seen in 95% of patients in a consecutive series. 56 Sinus bradycardia in and of itself does not require specific therapy, but current guidelines recommend hospitalization for a heart rate less than 40 beats per minute. High-grade atrioventricular block is exceedingly rare and suggests underlying structural heart disease that may be unrelated to anorexia nervosa itself.…”