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People with anorexia nervosa have abnormalities in multiple body systems, from persistent hypoglycemia to muscle wasting. However, 80% of patients with severe anorexia nervosa have cardiac abnormalities. There is good and bad news in this study of echocardiographic changes in patients with severe anorexia nervosa.
Anorexia is such a challenging illness for patients, families, and clinicians. So, let’s start with the good news. All of the echocardiographic abnormalities that we will examine here appear to reverse with weight restoration. This article from Jodie Smythe and colleagues at Oxford is a review of previous echocardiographic studies in which they pooled together findings on 4 variables: Left ventricular mass and size, left ventricular systolic and diastolic function, valvular disorders and pericardial effusions, and the findings on what happens to these variables after weight restoration. Let’s look at each of these changes.
First, a decrease in left ventricular mass: The authors suggest this could be a function of decreased preload and afterload and direct atrophy akin to what is happening in skeletal muscle. Next, there is a reduction in cardiac output, reflecting changes in both systolic and diastolic function. Also, mitral valve prolapse is common—the prevalence in these studies ranges from 53% to 83%. For comparison, in 1 case-control study with thin controls, the mitral valve prolapse rate was 13%. Finally, pericardial effusions were seen in 25% of patients. The proposed mechanisms include myocardial wasting and the loss of pericardial fat, which could cause pericardial layer separation. The authors noted 2 case reports in which patients required pericardiocentesis.
Now, back to the good news that the authors emphasized just as much as their concerning findings. These changes, including the cardiac structural changes, tend to resolve with weight restoration, although it is not easily achieved. As a caution, the authors also note that refeeding can lead to new cardiac problems with an abrupt increase in metabolic processes, which can increase preload and induce electrolyte abnormalities.
They noted 4 cardiomyopathy cases associated with refractory hypoglycemia, 1 of which may have been exacerbated by refeeding. So, in that context, let me offer you a brief aside to understand better cardiac pathophysiology, even though it is not a common finding in anorexia. I recalled this rare cardiomyopathy, the Takotsubo variant, sometimes called broken heart syndrome, usually seen in postmenopausal women. The name comes from a round-bottom, narrow-neck Japanese pot whose shape resembles the dysfunctional left ventricle seen in this stress-related cardiac condition. It is like having an MI complete with ST-segment elevation and increased cardiac enzymes without any vessel narrowing. Fortunately, the syndrome is usually self-limiting with full recovery of ventricular function.
Thus, a case report in anorexia noted that reduced estrogen levels in postmenopausal women might alter the endothelial function and vasomotor reactivity, creating this greater vulnerability to a sympathetic nervous system-mediated myocardial stunning. So, perhaps the reduced estrogen levels in a young woman with severe anorexia might create the same risk, especially in the sympathetic drive created by severe hypoglycemia. Perhaps an abrupt refeeding could increase insulin and acutely lower glucose further.
In summary, this article reminds us that anorexia nervosa is associated with significant cardiac abnormalities, which, fortunately, are likely to normalize when weight restoration is achieved.
Abstract
Cardiac abnormalities identified with echocardiography in anorexia nervosa: systematic review and meta-analysis
Jodie Smythe, Claire Colebourn, Lara Prisco, Tatjana Petrinic, Paul Leeson
Background: Anorexia nervosa affects most organ systems, with 80% suffering from cardiovascular complications.
Aims: To define echocardiographic abnormalities in anorexia nervosa through systematic review and meta-analysis.
Method: Two reviewers independently assessed eligibility of publications from Medline, EMBASE and Cochrane Database of Systematic Reviews registries. Studies were included if anorexia nervosa was the primary eating disorder and the main clinical association in described cardiac abnormalities. Data was extracted in duplicate and quality-assessed with a modified Newcastle-Ottawa scale. For continuous outcomes we calculated mean and standardised mean difference (SMD), and corresponding 95% confidence interval. For dichotomous outcomes we calculated proportion and corresponding 95% confidence interval. For qualitative data we summarised the studies.
Results: We identified 23 eligible studies totalling 960 patients, with a mean age of 17 years and mean body mass index of 15.2 kg/m2. Fourteen studies (469 participants) reported data suitable for meta-analysis. Cardiac abnormalities seen in anorexia nervosa compared with healthy controls were reduced left ventricular mass (SMD 1.82, 95% CI 1.32-2.31, P < 0.001), reduced cardiac output (SMD 1.92, 95% CI 1.38-2.45, P < 0.001), increased E/A ratio (SMD -1.10, 95% CI -1.67 to -0.54, P < 0.001), and increased incidence of pericardial effusions (25% of patients, P < 0.01, 95% CI 17-34%, I2 = 80%). Trends toward improvement were seen with weight restoration.
Conclusions: Patients with anorexia nervosa have structural and functional cardiac changes, identifiable with echocardiography. Further work should determine whether echocardiography can help stratify severity and guide safe patient location, management and effectiveness of nutritional rehabilitation.
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Reference
Smythe, J., Colebourn, C., Prisco, L., Petrinic, T., & Leeson, P. (2020). Cardiac abnormalities identified with echocardiography in anorexia nervosa: Systematic review and meta-analysis. The British Journal of Psychiatry, 1-10
