Heart rate variability and left ventricular diastolic function in anorexia nervosa

Irreversibility of cardiac autonomic dysfunction in female adolescents diagnosed with anorexia nervosa after short- and long-term weight gain

Anorexia nervosa (AN) patients may present with cardiac autonomic system dysfunction. Power spectral analysis of heart rate variability (HRV) is a reliable noninvasive examination for the quantitative assessment of the central sympathovagal interaction that modulates cardiovascular autonomic function. In the present study, HRV parameters were assessed in female adolescent AN inpatients in the malnourished phase at admission, at discharge when achieving weight restoration, and 24-36 months after discharge, when considered remitted. Nineteen normal-weight female controls were similarly assessed. Spectral analysis of HRV was done with the fast Fourier transform algorithm. At admission and discharge, patients underwent routine laboratory examinations and responded to questionnaires assessing eating-related preoccupations, behaviors, and personality attributes, depression and anxiety. Compared with the controls, AN patients had significantly lower heart-rate and HRV, lower total power and low frequency components, elevated high frequency components, and decreased low to high frequency power ratio as assessed with the power spectral analysis at all three evaluation points. These disturbances were not correlated with the baseline laboratory and psychometric measures. Our preliminary findings suggest that female adolescent AN inpatients may have a cardiovascular autonomic dysfunction in the form of vagal abnormality present not only in malnourished patients, but also persisting following short-term and long-term weight restoration.

Associations between being overweight, variability in heart rate, and well-being in the young men

Abnormalities of the autonomic nervous system have been repeatedly shown in hypertension. We studied the associations between being overweight, blood pressure, cardiac vagal tone as measured by variability in heart rate, and well-being in a large cohort of young men. We hypothesised an inverse correlation between body mass index and the variability in heart rate. Further, we assessed systolic and diastolic blood pressure as traditional indicators of cardiovascular risk. Exclusion criteria were the use of drugs or pharmaceuticals. The following data from 786 men with a mean age of 19.4 years (standard deviation = 1.4, with a range from 16 to 24 years) were analysed in a cross-sectional study: body mass index, sleep duration, sporting activities, psychological well-being, blood pressure, heart rate, and variability in heart rate. Despite the young age of the men in this study, increased values for the body mass index were already associated with a shift in sympathovagal balance trending towards sympathetic dominance. There was also a significant positive correlation between body mass index and systolic and diastolic blood pressure. A multiple stepwise regression analysis showed that significant factors, which were associated with variability in heart rate, were body mass index and sporting activities. In addition, sporting activity and sleep duration had a significant positive impact on psychological well-being. Even in young men, being overweight is associated with increased cardiovascular risk, especially an increased sympathetic and/or lowered cardiovascular tone and increased blood pressure. Our study gives additional motivation for the early prevention and treatment of obesity in childhood and adolescence.

Oxidative stress, l-arginine-nitric oxide and arginase pathways in platelets from adolescents with anorexia nervosa

Anorexia nervosa (AN) is associated with high cardiovascular mortality. Nitric oxide (NO) inhibits platelet function and regulates the cardiovascular homeostasis. The aim of this study was to investigate the l-arginine-NO-GMPc and arginase pathways and oxidative stress in platelets from patients with AN. Intraplatelet l-arginine transport, NOS expression and activity, cGMP levels, platelet aggregation, arginase expression and oxidative stress were measured in adolescent patients with AN (n=11) and healthy controls (n=12). Plasma l-arginine levels were significantly reduced in AN. l-arginine transport, NOS activity and cGMP basal levels were reduced in platelets associated with unchanged platelet aggregability. The expression of NOS isoforms was not affected. TBARS production was diminished, while the activity of superoxide dismutase was elevated in AN patients. There was an overexpression of arginase II in AN. Alterations of l-arginine-NO-GMPc and arginase pathways in platelets can be early predictors of the incidence of cardiovascular disease into adult life in AN.

Deranged secretion of ghrelin and obestatin in the cephalic phase of vagal stimulation in women with anorexia nervosa

BACKGROUND

Vagal activation in the cephalic phase response to food ingestion promotes ghrelin secretion. Because underweight individuals with anorexia nervosa (AN) are characterized by increased vagal tone, we hypothesized an enhanced ghrelin production in the cephalic phase of vagal stimulation. Therefore, we investigated the responses of ghrelin and its recently discovered sibling peptide obestatin to modified sham feeding (MSF) in both AN and healthy women.

METHODS

Eight AN women and eight age-matched healthy female subjects underwent MSF, with initially seeing and smelling a meal and then chewing the food without swallowing it. Blood samples were drawn before and after MSF for hormone assays.

RESULTS

Circulating ghrelin increased, whereas obestatin decreased after MSF. Compared with healthy women, AN individuals exhibited enhanced ghrelin and obestatin baseline plasma levels and amplified MSF-induced ghrelin increase and obestatin drop. Ghrelin secretion positively correlated with subjects' eating behavior as assessed by the Three-Factor Eating Questionnaire.

CONCLUSIONS

Opposite changes in circulating ghrelin and obestatin occur in the cephalic phase of vagal stimulation, and these changes are amplified in symptomatic AN patients. Given the opposite effects of ghrelin and obestatin on food intake, these findings may have pathophysiologic implications for the dysregulated eating behavior of AN individuals.

Heart rate and blood pressure variability and baroreflex sensitivity in patients with anorexia nervosa

OBJECTIVE

Anorexia nervosa (AN) is considered to have a significant risk for sudden death because of cardiac complications, and abnormalities of the autonomic nervous system might be a cause of cardiac dysfunction. The aim of this study was to investigate autonomic nervous system function in AN patients by analyzing heart rate variability (HRV), blood pressure variability (BPV), and baroreflex sensitivity (BRS).

METHODS

The subjects were 32 AN patients without other psychiatric comorbidities and 37 healthy controls. Beat-to-beat R-R interval and systolic blood pressure recorded in the supine position were analyzed using power spectral analysis and cross-spectrum analysis to quantify the frequency domain properties of HRV, BPV, and BRS. In addition, detrended fluctuation analysis was used to quantify the fractal correlation properties from the scaling exponent alpha1 of HRV.

RESULTS

High frequency power and total power of HRV and BRS were significantly higher in AN patients and low frequency power of BPV, low frequency/High frequency ratio of HRV, and the scaling exponent alpha1 of HRV were significantly lower in AN patients, compared with controls.

CONCLUSIONS

These findings suggest that AN patients have reduced cardiovascular sympathetic nervous responsiveness, increased parasympathetic nervous responsiveness, and increased complexity of the interbeat interval time series compared with healthy controls. Regarding the relationship to prognosis of AN, the study showed conflicting results, and further prospective studies are needed to determine if these results are related to high mortality in AN patients.

Alterations in the autonomic control of heart rate variability in patients with anorexia or bulimia nervosa: correlations between sympathovagal activity, clinical features, and leptin levels

Changes in body composition, hormone secretions, and heart function with increased risk of sudden death occur in eating disorders. In this observational clinical study, we evaluated sympathovagal modulation of heart rate variability (HRV) and cardiovascular changes in response to lying-to-standing in patients with anorexia (AN) or bulimia nervosa (BN) to analyze: a) differences in autonomic activity between AN, BN, and healthy subjects; b) relationships between autonomic and cardiovascular parameters, clinical data and leptin levels in patients with eating disorders. HRV, assessed by power spectral analysis of R-R intervals, blood pressure (BP) and heart rate (HR) were studied by tilt-table test in 34 patients with AN, 16 with BN and 30 healthy controls. Autonomic and cardiovascular findings were correlated with clinical data, and serum leptin levels. Leptin levels were lowered in AN vs BN and healthy subjects (p<0.0001), but both AN and BN patients showed unbalanced sympathovagal control of HRV due to relative sympathetic failure, prevalent vagal activity, impaired sympathetic activation after tilting, independently from their actual body weight and leptin levels. No significant correlations were obtained between HRV data vs clinical data, BP and HR findings, and leptin levels in eating disorders. Body mass indices (BMI) (p<0.02), and leptin levels (p<0.04) correlated directly with BP values. Our data showed alterations of sympathovagal control of HRV in eating disorders. These changes were unrelated to body weight and BMI, diagnosis of AN or BN, and leptin levels despite the reported effects of leptin on the sympathetic activity.

Long-term estrogen deficiency lowers regional blood flow, resting systolic blood pressure, and heart rate in exercising premenopausal women

The cardiovascular consequences of hypoestrogenism in premenopausal women are unclear. Accordingly, the influence of menstrual status and endogenous estrogen (E(2)) exposure on blood pressure (BP), heart rate (HR), and calf blood flow in young (18-35 yr) regularly exercising premenopausal women with exercise-associated menstrual aberrations was investigated. Across consecutive menstrual cycles, daily urinary ovarian steroid levels were analyzed, and the area under the curve was calculated to determine menstrual status and E(2) exposure. BP, HR, blood flow, vascular conductance, and resistance were measured at baseline and following ischemic calf exercise. Exercising subjects consisted of 14 ovulatory (ExOv), 10 short-term (anovulatory and <or=100 days amenorrhea; ST-E(2) Def), and 8 long-term (>100 days amenorrhea; LT-E(2) Def) E(2)-deficient women. Nine sedentary ovulatory subjects (SedOv) were also studied. All groups were similar in age (24.8 +/- 0.7 yr), height (164.8 +/- 1.3 cm), weight (57.9 +/- 0.9 kg), and body mass index (21.3 +/- 0.3 kg/m(2)). E(2)-deficient groups had lower (P < 0.002) E(2) exposure compared with ovulatory groups. Resting systolic BP, HR, blood flow, and vascular conductance were lower (P < 0.05) and vascular resistance higher (P < 0.05) in LT-E(2) Def compared with both ovulatory groups. Peak ischemic blood flow, vascular conductance, and HR were also lower (P < 0.05) and vascular resistance higher (P < 0.05) in LT-E(2) Def compared with all other groups. Our findings show that exercising women with long-term E(2) deficiency have impaired regional blood flow and lower systolic BP and HR compared with exercising and sedentary ovulatory women. These cardiovascular alterations represent markers of altered vascular function and autonomic regulation of which the long-term effects remain unknown.

Medical complications in children and adolescents with anorexia nervosa

A gyermek- és serdülőkorban kezdődő anorexia nervosa súlyos, potenciálisan életveszélyes betegség, mely korai halálozáshoz, valamint élethosszig tartó szomatikus és pszichoszociális megbetegedésekhez vezethet. Az állapot jelentős testi szövődményeket okoz a növekvő és fejlődő szervezet csaknem minden szervrendszerében. Bár ezek az eltérések a betegség gyógyulásával, a táplálkozási/táplálási rehabilitációval túlnyomó részben javulnak, némely elváltozás irreverzíbilis marad.A közlemény az elmúlt két évtized idevágó közleményeinek áttekintése alapján összefoglalja a gyermek- és serdülőkorban kezdődő anorexia nervosa szomatikus szövődményeinek evidenciákon alapuló szakirodalmát. Tárgyalja az akut tüneteket, kiemelten foglalkozik a só–víz háztartás zavaraival és az újratáplálási szindrómával, valamint részletezi a kardiovaszkuláris komplikációkat. Összefoglalja a gyermek- és serdülőkori anorexiára speciálisan jellemző elváltozásokat: a csont ásványianyag-tartalom csökkenését és az osteopenia lehetséges terápiás lehetőségeit, valamint a hossznövekedésbeni elmaradást.A szakirodalom áttekintése alapján megállapítható, hogy a gyermek- és serdülőkori anorexia nervosa szomatikus szövődményei különböznek a felnőttek megbetegedéseitől. A sajátságos klinikai megjelenés, a korai kezdet és a hosszú távú következmények ismeretének hiánya miatt szükséges külön tárgyalni a gyermek- és serdülőkori anorexia nervosát a felnőttekétől és felhívni a figyelmet a betegség minél korábbi felismerésének és hatékony terápiájának szükségességére. Egyre nő azon evidenciák száma, melyek az anorexia nervosa felismerésében és kezelésében hangsúlyozzák és elengedhetetlenné teszik a multidiszciplináris szakembercsoportok szerepét.

Heart failure in anorexia nervosa: case report and review of the literature

OBJECTIVE

To report the presentation and causes of heart failure complicating anorexia nervosa (AN).

METHOD

Report of a case of heart failure occurring in a patient with AN and a review of the literature.

RESULTS

A 56 year old woman with a 25 year history of AN binge-purge subtype experienced increasing shortness of breath on exertion, orthopnea, and swelling of the ankles. Investigations revealed a reduced left ventricular ejection fraction. A diagnosis of heart failure caused by severe prolonged protein-calorie malnutrition was made. She was treated with a diuretic, a beta adrenergic blocker and an angiotension enzyme inhibitor. Her cardiac function returned to normal after a year of refeeding. Protein-calorie malnutrition, ipecac toxicity, and deficiencies of thiamine, phosphorus, magnesium, and selenium have been reported to cause heart failure in patients with AN.

DISCUSSION

If shortness of breath occurs in AN it may be a symptom of heart failure. The diagnosis is further suggested by increased jugular venous pressure, increasing shortness of breath on exertion, and pulmonary crepitations at the bases of the lungs on physical examination. The chest x-ray usually shows pulmonary venous redistribution, the electrocardiogram may be normal, and the echocardiogram should document a reduced left ventricular ejection fraction. Standard medical therapy for heart failure should be started. In addition, a history of ipecac use should be taken, deficiencies should be corrected, and weight restoration can reverse cardiac abnormalities.

Short-term fasting-induced autonomic activation and changes in catecholamine levels are not mediated by changes in leptin levels in healthy humans

OBJECTIVE

In animal models, the adipocyte-secreted hormone leptin increases energy expenditure by increasing sympathetic outflow but its role in humans remains to be elucidated. We evaluated whether inducing hypoleptinaemia (with and without administration of leptin at replacement doses) for 3 days would influence catecholamine levels and sympathetic and parasympathetic activity in healthy humans.

METHODS

We studied six normal-weight subjects in the General Clinical Research Center (GCRC) under three conditions: baseline fed state (control study) and two 72-h fasting studies (to decrease leptin levels), with administration of either placebo or replacement-dose recombinant methionyl human leptin (r-metHuLeptin) in a randomized, double-blind fashion. In each condition, 24-h urinary catecholamine levels, heart rate and heart rate variability (HRV), a standard tool for assessing cardiac autonomic modulation, were measured.

RESULTS

Study parameters remained stable during the control condition and the baseline assessment of all three studies. In response to 72-h fasting, which decreased serum leptin levels by 80%, 24-h urinary norepinephrine and dopamine levels and heart rate increased while cardiac vagal modulation decreased (all P < 0.05). Replacement-dose r-metHuLeptin to keep leptin levels within the physiological range during fasting did not alter fasting-associated changes in heart rate, catecholamine levels or cardiac vagal tone.

CONCLUSIONS

The findings of this controlled, interventional study indicate that changes in heart rate, catecholamine levels and cardiac vagal modulation associated with 72-h fasting are independent of regulation by leptin. Thus, changes in leptin levels within the physiological range do not seem to play a role in regulating autonomic function during short-term starvation in healthy humans.

Anorexia nervosa and second-degree atrioventricular block (Type I)

OBJECTIVE

This is the first case report of a second-degree heart block (Mobitz Type I) described in a patient with anorexia nervosa (AN).

METHOD

We present the case of a 20-year-old woman with AN and second-degree heart block. Pertinent reports in the literature regarding atrioventricular conduction abnormalities as well as cardiac rhythm disturbances are reviewed.

RESULTS AND CONCLUSION

Although this patient's second-degree heart block may represent an intrinsic conduction abnormality unrelated to her AN, the importance of the validation of medical conditions during the treatment of AN is discussed.

Cardiovascular complications of eating disorders

Eating disorders (anorexia nervosa and bulimia) are associated with the highest mortality rate of any psychiatric disorder. Much of this mortality and morbidity stem from cardiovascular complications such as arrhythmia related to a prolonged QTc interval and/or electrolyte disorders, hypotension, and bradycardia. Structurally, the heart in patients with eating disorders is atrophic, which may relate to longstanding hypovolemia. These patients have low cardiac output and demonstrate increased peripheral vascular resistance despite the presence of hypotension. The treatment of eating disorders is incremental caloric feeding, which can have its own intrinsic cardiovascular risk (refeeding syndrome) manifested by arrhythmia, tachycardia, congestive heart failure, and sudden cardiac death. Patients will require close monitoring and slower refeedings to minimize the risk of these complications.

Changes of pain perception, autonomic function, and endocrine parameters during treatment of anorectic adolescents

OBJECTIVES

The underlying mechanisms of reduced pain perception in anorexia nervosa (AN) are unknown. To gain more insight into the pathology, the authors investigated pain perception, autonomic function, and endocrine parameters before and during successful treatment of adolescent AN patients.

METHOD

Heat pain perception was assessed in 15 female adolescent AN patients and matched controls. Results were correlated with autonomic and endocrine parameters (free triiodothyronine, free cortisol). Autonomic function was studied using heart rate variability and pupillary light reflex assessment. To investigate the influence of therapy on these parameters, data were obtained at three different time points.

RESULTS

Heat pain thresholds were significantly increased in the acute state and decreased after weight had been regained for 6 months. Similarly, an increased parasympathetic tone was present in the acute state only. The relative amplitude of the pupillary light reflex showed a positive correlation to pain thresholds over time and predicted disease progression. In addition, the authors found a negative correlation between increased pain thresholds and low free cortisol.

CONCLUSION

Increased pain thresholds are associated with increased parasympathetic tone and a hypothyroid state in AN. This may either indicate common central mechanisms or suggest a causative interaction.

Low-K+ dependent QT prolongation and risk for ventricular arrhythmia in anorexia nervosa

BACKGROUND

QT prolongation and ventricular arrhythmia have been proposed as the mechanism for sudden death in anorexia nervosa. The prevalence and the cause of QT prolongation remain controversial.

OBJECTIVES

1) to evaluate ventricular repolarization in patients with anorexia; 2) to evaluate factors that may influence repolarization, with focus on electrolyte plasma levels and heart rate.

METHODS

29 patients with anorexia, age 22 +/- 5 years, BMI 13.8 +/- 1.5 were compared to 14 control female subjects, age 23 +/- 2 years, BMI 20.7 +/- 1.1. QT interval and QT dispersion were measured. Whenever a low potassium (<3.5 mEq/l) was found, ECG was repeated after normalization of serum levels. Heart rate and its variability in the frequency domain (LF/HF ratio) were evaluated.

RESULTS

Three patients (10.3%) showed severe hypokalemia (K(+) levels <2.0 mEq/l). In 2 patients, QT was severely prolonged (QT(c) 600 and 670 msec) and in one case associated with ventricular arrhythmia. QT(c) after K(+) plasma levels normalization was 392 +/- 25 in anorexia vs. 407 +/- 19 msec in controls, p = 0.08. Heart rate was 55 +/- 11 in anorexia vs. 66 +/- 8 beats per minute (BPM) in controls, p = 0.002. The LF/HF ratio was 1.79 +/- 1.35 in anorexia and 3.66 +/- 2.64 in controls, p = 0.006.

CONCLUSIONS

QT interval is usually normal in patients with anorexia. QT prolongation and ventricular arrhythmia may develop in the setting of severe hypokalemia, exposing patients to high risk of sudden cardiac event. Resting heart rate is lower in anorexia than in controls with the spectral indices of sympatho-vagal balance indicating a prevalence of vagal activity.

How should the clinician evaluate and manage the cardiovascular complications of anorexia nervosa?

Five to twenty percent of patients with anorexia nervosa die from their illness. One half of those patients die of medical complications (Steinhavsen, 2002). Malnutrition, dehydration, and electrolyte abnormalities may precipitate death by inducing heart failure or fatal arrhythmias. Patients and their families commonly call upon physicians to evaluate acute and ongoing risks of malnutrition and purging behaviors. Concerns about medical compromise currently tend to determine or influence insurance coverage of medical and psychiatric treatment of patients with eating disorders. There is very limited published data to guide clinicians in the evaluation, ongoing monitoring, or treatment. Surprisingly, no consensus exists regarding recommendations for either the ongoing evaluation of cardiac parameters or the clinical implications of common findings.

Linear and non-linear heart rate variability measures in chronic and acute phase of anorexia nervosa

Previous results on heart rate variability (HRV) analysis in anorexia nervosa (AN) include some apparently conflicting data. In order to find out the reason for different results and to improve understanding of autonomic control in AN we compare HRV in acute and chronic AN. Spectral powers, fractal scaling exponent and sample entropy were computed from 24 h RR series derived from Holter ECG recordings in 17 anorexic patients, nine chronic and eight healthy women. We found that all linear and non-linear HRV measures change in different direction in acute and chronic AN. Acute AN is characterized by decreased HR and increased HRV. In chronic AN, HR is increased, HRV reduced and the difference between awake and sleeping values is high. HRV measures are associated with body mass index only in chronic AN. As HRV measures are significantly different between acute and chronic AN, we propose that HRV analysis might provide additional data in clinical practice.

Medical complications in adolescents with anorexia nervosa: a review of the literature

The purpose of the current article is to summarize the evidence-based medical complications and treatments that are both common and unique to adolescents with anorexia nervosa (AN). Recent literature relating to the cardiovascular complications, refeeding syndrome, alterations in linear growth, impaired bone mineral accretion, and structural and functional brain changes was reviewed. The literature suggests that the medical complications in adolescents with AN are different from those reported in adults. The unique clinical presentation, the early onset, and the unknown impact of these complications underscore the need for early identification and treatment of AN in adolescents. AN is a serious disorder with significant and often life-threatening medical complications. The increasing growth of evidence highlights the importance of early identification and treatment by an interdisciplinary team of health care providers who have expertise in managing adolescents with AN and their medical sequelae.

Disorders of Fuel Metabolism: Medical Complications Associated with Starvation, Eating Disorders, Dietary Fads, and Supplements

Disorders of fuel metabolism as they relate to abnormal fuel intake,abnormal fuel expenditure, and dietary supplements are the focus of this article. The emergency physician should be aware of the medical complications that can occur as a result of starvation states,eating disorders, fad diets, hypermetabolic states, and ergogenic aids. Knowledge and understanding of the complications associated with these disorders will facilitate the diagnosis and management of patients who present to the emergency department with any of the disorders reviewed.

Spectral analysis of heart period variability in anorexia nervosa

The aim of this study was to investigate the response of autonomic cardiac control to postural change using spectral analysis, in patients with anorexia nervosa. Spectral components of total variability as well as of low and high frequencies were analyzed for 17 anorexic patients with mean body mass index (14.9 ? 1.9) kg/m2 and for 9 healthy age-matched women with body mass index (20.3 ? 1.7) kg/m2, in supine and standing postures. During standing posture, increased heart rate in all subjects was accompanied by the decrease in total variability and high frequency spectral powers. In supine posture, anorexic patients demonstrated the reduced low frequency spectral power. Compared to control women, during standing posture anorexic patients showed higher heart rate, reduced total variability and high frequency spectral powers. Statistically significant correlation was noticed between body mass index and spectral power of low frequency in both supine and standing posture. Alterations in autonomic cardiac control induced by anorexia nervosa could be estimated by spectral analysis of heart period variability.

Resting tachycardia, a warning sign in anorexia nervosa: case report

Background

Among psychiatric disorders, anorexia nervosa has the highest mortality rate. During an exacerbation of this illness, patients frequently present with nonspecific symptoms. Upon hospitalization, anorexia nervosa patients are often markedly bradycardic, which may be an adaptive response to progressive weight loss and negative energy balance. When anorexia nervosa patients manifest tachycardia, even heart rates in the 80–90 bpm range, a supervening acute illness should be suspected.

Case presentation

A 52-year old woman with longstanding anorexia nervosa was hospitalized due to progressive leg pain, weakness, and fatigue accompanied by marked weight loss. On physical examination she was cachectic but in no apparent distress. She had fine lanugo-type hair over her face and arms with an erythematous rash noted on her palms and left lower extremity. Her blood pressure was 96/50 mm Hg and resting heart rate was 106 bpm though she appeared euvolemic. Laboratory tests revealed anemia, mild leukocytosis, and hypoalbuminemia. She was initially treated with enteral feedings for an exacerbation of anorexia nervosa, but increasing leukocytosis without fever and worsening left leg pain prompted the diagnosis of an indolent left lower extremity cellulitis. With antibiotic therapy her heart rate decreased to 45 bpm despite minimal restoration of body weight.

Conclusions

Bradycardia is a characteristic feature of anorexia nervosa particularly with significant weight loss. When anorexia nervosa patients present with nonspecific symptoms, resting tachycardia should prompt a search for potentially life-threatening conditions.

The Cardiovascular Effects of Chronic Hypoestrogenism in Amenorrhoeic Athletes

In premenopausal women, the most severe menstrual dysfunction is amenorrhoea, which is associated with chronic hypoestrogenism. In postmenopausal women, hypoestrogenism is associated with a number of clinical sequelae related to cardiovascular health. A cardioprotective effect of endogenous oestrogen is widely supported, yet recent studies demonstrate a deleterious effect of hormone replacement therapy for cardiovascular health. What remain less clear are the implications of persistently low oestrogen levels in much younger amenorrhoeic athletes. The incidence of amenorrhoea among athletes is much greater than that observed among sedentary women. Recent data in amenorrhoeic athletes demonstrate impaired endothelial function, elevated low- and high-density lipoprotein levels, reduced circulating nitrates and nitrites, and increased susceptibility to lipid peroxidation. Predictive serum markers of cardiovascular health, such as homocysteine and C-reactive protein, have not yet been assessed in amenorrhoeic athletes, but are reportedly elevated in postmenopausal women. The independent and combined effects of chronic hypoestrogenism and exercise, together with subclinical dietary behaviours typically observed in amenorrhoeic athletes, warrants closer examination. Although no longitudinal studies exist, the altered vascular health outcomes reported in amenorrhoeic athletes are suggestive of increased risk for premature cardiovascular disease. Future research should focus on the presentation and progression of these adverse cardiovascular parameters in physically active women and athletes with hypoestrogenism to determine their effects on long-term health.