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Cardiac Complications of Eating Disorders 

By Daniela Grayeb, MD, FACP, CEDS

Eating disorders are psychological conditions that involve complicated relationships with body image and food. People with these conditions develop unhealthy eating habits and experience mental and physical complications. Individuals with eating disorders have significantly elevated mortality rates, with the highest rates occurring in those with anorexia nervosa.  

Although suicide represents nearly half the mortality in patients with eating disorders, most of the remaining deaths are by cardiac arrest, likely secondary to cardiovascular complications of eating disorders such as bradycardia (low heart rate), hypotension, structural heart disease and electrolyte abnormalities leading to fatal arrhythmias. Cardiac complications tend to occur at advanced eating disorders and chronic malnutrition stages.  

 

Anorexia Nervosa Cardiac Complications 

Anorexia nervosa is an eating disorder characterized by abnormally low body weight, an intense fear of gaining weight and a distorted body perception. People with anorexia place a high value on controlling their weight and shape, using extreme efforts that significantly interfere with their lives. They usually severely restrict their food intake to prevent weight gain or continue losing weight. Cardiac abnormalities among patients with AN are present not only before treatment but can also arise during the refeeding process. 

 

Bradycardia 

Occurring in around 95% of patients, bradycardia (a heart rate less than 60 beats per minute), is one of the most common complications observed in patients with anorexia nervosa. Clinically significant bradyarrhythmias may represent a competing underlying mechanism for this population's high risk of sudden death.  

Low heart rate may result from an increased vagal tone in the body's attempt to conserve energy; however, findings on this topic have been inconsistent. Severe and prolonged bradycardia can cause fainting (syncope), chest pain, hyper- or hypotension or heart failure, leading to death. 

The "Athletic Heart"  

Many patients with an eating disorder may attribute their low heart rate to perceived physical fitness. Since most physicians receive no specific training in identifying or treating eating disorders, it can be easy to take this explanation at face value. However, suppose there is any suspicion that a patient may suffer from an eating disorder. In that case, it is important to remember and explain to the patient the difference between a low heart rate due to physical fitness and bradycardia due to malnutrition. Athletes have a low resting heart rate with only slight increases during activity. In contrast, malnourished patients have a low resting heart rate but exhibit tachycardia (elevated heart rate) with minimal activity. 

 

Hypotension 

Commonly paired with bradycardia is hypotension or low blood pressure. As patients with anorexia restrict their food intake, their body begins to break down tissue — including muscle tissue — for fuel. This muscle loss includes the heart, resulting in a weakened heart that struggles to pump blood throughout the body. Patients with abnormally low blood pressure can experience dizziness, nausea, fatigue or blurred vision. In extreme cases, hypotension can cause cold or clammy skin, confusion, a rapid pulse, shallow breathing or death as the body enters a state of shock.  

 

Structural Heart Disease 

Structural heart disease in patients with eating disorders is attributable to wasting of the cardiac muscle resulting in decreased left ventricular mass and cardiac output. Worse cardiac function is associated with the degree and the duration of malnutrition. Patients with anorexia nervosa are more likely to have mitral valve prolapse, which can be seen in a minority of patients, causing chest pain and heart palpitations.  

 

Pericardial Effusion 

The exact mechanism of pericardial effusion (a buildup of too much fluid in the double-layered, saclike structure around the heart) in eating disorders is poorly understood. Patients with pericardial effusions appear to have a lower BMI (body mass index), lower triiodothyronine, and a longer duration of hospitalizations. 

 

 

Bulimia Nervosa Cardiac Complications 

Bulimia nervosa is a severe, potentially life-threatening eating disorder. People with bulimia may secretly binge — eating large amounts of food with a loss of control over the eating — and then purge, trying to get rid of the extra calories in an unhealthy way. Patients may self-induce vomiting or misuse laxatives, weight-loss supplements, diuretics or enemas after bingeing or exercising excessively to lose weight. 

Patients with bulimia nervosa may have a long-term risk of cardiovascular diseases, such as ischemic cardiac events and conduction disorders, as well as death among women.  

 

Hypokalemia 

Patients who engage in purging, whether they have bulimia nervosa or the binge-purge subtype of anorexia nervosa, are likely to have electrolyte abnormalities. 50% of patients with bulimia have electrolyte abnormalities, with an estimated 13.7-20% of patients with purging behavior experiencing low potassium (hypokalemia). Hypokalemia is one of the most severe complications for patients, as it can lead to various cardiac complications, including cardiac arrhythmias (irregular heartbeat), conduction disturbances and muscle weakness.  

 

Emetine Toxicity 

While patients can use their fingers to induce vomiting, some individuals with bulimia induce vomiting by using medications. To induce vomiting, patients who use ipecac, an anti-parasitic and rapid-acting emetic, may experience cardiac complications due to chronic ingestion of ipecac's active ingredient, emetine. Emetine has a long half-life and can accumulate in the body over time, causing irreversible damage to cardiac myocytes, leading to severe congestive heart failure, ventricular arrhythmias or even death.  

 

Avoidant Restrictive Food Intake Disorder (ARFID) Cardiac Complications 

ARFID is a feeding disturbance characterized by a persistent failure to meet appropriate nutritional or energy needs. Unlike other eating disorders, those with ARFID have no preoccupation with weight or shape. While empirical data on ARFID complications is still budding, malnutrition associated with ARFID may cause similar, although less commonly, complications as other eating disorders, like bradycardia

 

Atypical Anorexia Nervosa (A-AN) Cardiac Complications 

A-AN mirrors anorexia nervosa, but those suffering from it are at a normal or above normal weight. Despite the idea that complications only occur at very low weights, those with A-AN suffer from many of the same complications their underweight counterparts do, including hypotension and bradycardia

 

Are Heart Issues from Eating Disorders Reversible? 

Thankfully, many of the cardiac complications from eating disorders are reversible. Most patients will find complications resolved after weight restoration, including bradycardia, hypotension, and hypokalemia.  

Many structural abnormalities will also improve after weight restoration. However, in rare cases of cardiac tamponade, extra fluid builds up in the space around the heart. Patients may need urgent pericardiocentesis, a procedure that removes the extra fluid causing pressure on the heart and preventing it from pumping well. 

 

How Cardiovascular Problems Affect Eating Disorder Treatment 

Severe cardiac complications necessitate treatment at a medical stabilization unit where patients require close monitoring and slow refeeding to minimize the risk of refeeding syndrome and exacerbating existing complications. Unlike residential treatment programs for eating disorders, medical stabilization programs have the telemetry support needed to assess symptom progression and improvement, as well as same-day lab results that are used to monitor key electrolyte levels affecting the functioning of the heart.  

Compared to standard hospital units, specialized eating disorder medical stabilization units have the expertise to prevent and monitor medical complications, including refeeding syndrome. Medical stabilization units also provide a breadth of other eating disorder levels of care, preparing patients to continue their journey to recovery. 

 

Getting Help for a Severe Eating Disorder 

If you or someone you care about is experiencing severe medical complications due to an eating disorder, ACUTE can help. Reach out to us today to learn more about medical intervention for severe and extreme eating disorders with our experts at ACUTE. With proper care provided by experienced experts, we can help you restore your weight and regain your health. 

 

References 

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  1. J Cardiovasc Electrophysiol. 2020 Feb;31(2):432-439.doi: 10.1111/jce.14338. Epub 2020 Jan 20. Long-term cardiac arrhythmia and chronotropic evaluation in patients with severe anorexia nervosa (LACE-AN): A pilot study 

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Written by

Daniela Grayeb, MD, FACP, CEDS

Daniela Grayeb, MD, FACP, CEDS, is a hospitalist at the ACUTE Center for Eating Disorders & Severe Malnutrition at Denver Health Medical Center. Daniela Grayeb, MD, FACP, CEDS, is a hospitalist at…

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