How Do Eating Disorders Affect the Heart? Cardiovascular Complications of Eating Disorders

Eating disorders can lead to severe cardiac problems, including irregular heartbeats, low blood pressure and sudden cardiac death. These issues arise from malnutrition, electrolyte imbalances and dehydration, which can strain the heart. Early intervention and treatment are crucial to address both the eating disorder and prevent long-term cardiovascular damage.

Eating Disorders & Heart Problems

Unlike most other psychiatric conditions, eating disorders often cause physical complications across every major organ system, including the cardiovascular system.

Although suicide represents nearly half the mortality in patients with eating disorders, many of the remaining deaths are likely impacted by cardiovascular complications related to eating disorders including:

• Bradyarrhythmias
• Cardiac structural changes
• Abnormal electrical conduction
• Electrolyte abnormalities
• Hypoglycemia

Patients with eating disorders often seek out care or are referred to a cardiologist to address their cardiovascular complications. Since cardiovascular complications put patients at risk for sudden death, cardiologists play a pivotal role in the identification of eating disorders.

Anorexia & Heart Problems

Up to 80% of patients with anorexia nervosa experience cardiac complications like arrhythmias, hypotension and bradycardia.¹ A low body weight and decreased lean muscle mass puts patients at risk of reduced cardiac mass, which can lead to reduced cardiac output or abnormal cardiac conduction.

Can Bulimia Cause Heart Problems?

Patients with anorexia nervosa are not the only ones at risk for cardiac complications. Patients with bulimia nervosa are also at risk for abnormal heart rhythms, but with the additional risk of ischemic heart disease, which increases the risk for heart attacks and atherosclerosis.

Bradycardia

Bradycardia is the most common cardiovascular complication and the most common complication in general, occurring in up to 95% of patients with anorexia nervosa.² Patients with avoidant restrictive food intake disorder (ARFID) may also have a high frequency of bradycardia, with one study suggesting up to 46% of patients are affected.³

What is a low heart rate with eating disorders?

Bradycardia, low heart rate, includes any heartbeat under 60 beats per minute. Severe and prolonged bradycardia can cause:

• Fainting (syncope)
• Chest discomfort
• Shortness of breath
• Fatigue
• Palpitations, and other nonspecific symptoms

Structural heart disease

Prolonged malnutrition can cause wasting of the cardiac muscle (myocardial atrophy), contributing to structural heart disease in patients with eating disorders and malnutrition.⁴ The loss of cardiac muscle mass causes valvular dysfunction, specifically mitral valve prolapse, sometimes causing chest discomfort and palpitations. Cardiac remodeling and scarring can also develop, potentially increasing the risk for dangerous arrhythmias.

Hypotension

Hypotension (low blood pressure) is another frequent manifestation of eating disorders and malnutrition.⁴ Patients with abnormally low blood pressure can experience:

• Dizziness
• Nausea
• Fatigue
• Blurred vision
• Fainting

Atherosclerosis

Bulimia nervosa is associated with atherosclerosis,⁵ the thickening or hardening of the arteries, typically because of plaque buildup. Atherosclerosis is not fully reversible, and lifestyle changes are necessary to manage coronary artery disease. If left untreated, atherosclerosis can lead to:

• Heart attack
• Stroke
• Reduced blood flow to other vital organs and the extremities

Atherosclerosis can also contribute to the development of coronary artery disease (CAD), also known as ischemic heart disease or coronary heart disease (CHD).

Coronary artery disease

Patients with bulimia nervosa are at risk for coronary artery disease (CAD)⁵ – a narrowing or blockage of the coronary arteries, which supply oxygen-rich blood to the heart, typically due to plaque buildup. CAD develops over time and slowly limits the amount of blood that can reach the heart. Coronary artery disease can cause chest pain, shortness of breath and fatigue. This condition also puts patients at risk for heart attacks and sudden cardiac death.

Pericardial effusion

Around 35% of patients with anorexia nervosa have pericardial effusion, a buildup of too much fluid in the saclike structure around the heart.⁴ The exact mechanism of pericardial effusion in eating disorders isn’t well understood, but may be related to thyroid hormone levels and/or reduced pericardial fat.⁶ Patients with pericardial effusions appear to have a lower BMI (body mass index) and lower triiodothyronine (T3) levels.⁴ In rare instances, this fluid buildup can encroach upon cardiac hemodynamics, impacting cardiac filling (cardiac tamponade).⁶

Eating disorders & electrolyte imbalances

Electrolyte disturbances are also common in patients with eating disorders who purge, like those with bulimia nervosa or anorexia nervosa binge eating and purging subtype (AN-BP).

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
• Abnormal cardiac pumping

Hypomagnesemia is also likely to develop, especially in those who misuse diuretics or alcohol, and can work synergistically with hypokalemia to increase the risk for cardiac conduction abnormalities.

Sudden cardiac death

The above discussed complications, including cardiac structural changes, bradyarrhythmias, electrolyte abnormalities and conduction abnormalities, may create a perfect storm that increases the risk for sudden cardiac death.^7,8 Sudden death can be instigated through QT prolongation from electrolytes or medications, hypoglycemia or other causes.

Treating Cardiac Complications of Eating Disorders

To safely restore heart health in individuals with eating disorders, a comprehensive medical approach is essential. The essential steps outlined below can prevent harm and support long-term eating disorder recovery.

Cardiac monitoring

Cardiac monitoring is vital in the medical stabilization of eating disorders due to the danger of cardiac complications. Continuous monitoring helps detect early signs of cardiac instability, guiding timely interventions and preventing sudden cardiac arrest. It ensures safe nutritional rehabilitation and supports overall recovery by minimizing medical risks during refeeding and stabilization.

Nutritional rehabilitation

While the cardiac complications of eating disorders can be very dangerous, many of them resolve with weight restoration.⁸ Restoring nutrition helps the body have enough energy to rebuild cardiac tissue, stabilize heart function and correct metabolic imbalances. Without nutritional rehabilitation, cardiac function cannot fully improve, making it a vital step toward long-term physical and psychological healing.

Balancing electrolytes

Timely electrolyte replacement stabilizes heart rhythm and supports safe nutritional rehabilitation. It is a critical step in restoring cardiac health and ensuring a safe, effective recovery process.

Monitoring refeeding syndrome

During refeeding, shifts in electrolytes can worsen the risk without careful correction. Providers should also be mindful of refeeding syndrome – a potentially life-threatening shift in fluids and electrolytes that occurs when nutrition is reintroduced – and utilize frequent laboratory monitoring to prevent its development.

Learn more about refeeding syndrome.

Find Help for Severe Eating Disorders

Cardiac complications from eating disorders are serious. Thankfully, they are also treatable. With early detection and specialized eating disorder treatment, many of the cardiac risks listed above can be reversed. If you or someone you care about is struggling, know that recovery is possible with proper medical care.

References

1. Springall, G. a. C., Caughey, M., Zannino, D., Kyprianou, K., Mynard, J. P., Rudolph, S., Cheong, J., Yeo, M., & Cheung, M. M. H. (2023). Long-term cardiovascular consequences of adolescent anorexia nervosa. Pediatric Research, 94(4), 1457–1464. https://doi.org/10.1038/s41390-023-02521-5
2. Yahalom, M., Spitz, M., Sandler, L., Heno, N., Roguin, N., & Turgeman, Y. (2013). The significance of bradycardia in anorexia nervosa. International Journal of Angiology, 22(02), 083–094. https://doi.org/10.1055/s-0033-1334138
3. Nitsch, A., Watters, A., Manwaring, J., Bauschka, M., Hebert, M., & Mehler, P. S. (2023). Clinical features of adult patients with avoidant/restrictive food intake disorder presenting for medical stabilization: A descriptive study. International Journal of Eating Disorders, 56(5), 978–990. https://www.acute.org/clinical-features-adult-patients-avoidantrestrictive-food-intake-disorder-presenting-medical
4. Sachs, K. V., Harnke, B., Mehler, P. S., & Krantz, M. J. (2015). Cardiovascular complications of anorexia nervosa: A systematic review. International Journal of Eating Disorders, 49(3), 238–248. https://www.acute.org/cardiovascular-complications-anorexia-nervosa-systematic-review
5. Tith, R. M., Paradis, G., Potter, B. J., Low, N., Healy-Profitós, J., He, S., & Auger, N. (2019). Association of bulimia nervosa with long-term risk of cardiovascular disease and mortality among women. JAMA Psychiatry, 77(1), 44. https://doi.org/10.1001/jamapsychiatry.2019.2914
6. Gibson, D., & Mehler, P. (2023). Cardiac tamponade in anorexia nervosa: an argument for conservative management. Annals of Case Reports, 8(4). https://www.acute.org/cardiac-tamponade-anorexia-nervosa-argument-conservative-management
7. Mehler, P. S., Watters, A., Joiner, T., & Krantz, M. J. (2022). What accounts for the high mortality of anorexia nervosa? International Journal of Eating Disorders, 55(5), 633–636. https://www.acute.org/what-accounts-high-mortality-anorexia-nervosa
8. Farasat, M., Watters, A., Bendelow, T., Schuller, J., Mehler, P. S., & Krantz, M. J. (2020). Long‐term cardiac arrhythmia and chronotropic evaluation in patients with severe anorexia nervosa (LACE‐AN): A pilot study. Journal of Cardiovascular Electrophysiology, 31(2), 432–439. https://www.acute.org/long-term-cardiac-arrhythmia-and-chronotropic-evaluation-patients-severe-anorexia-nervosa-lace