Effects of self-induced starvation on cardiac size and function in anorexia nervosa

Momentary physiological indices related to eating disorders: A systematic and methodological review

Eating disorders (ED) are serious psychiatric illnesses, with no everyday support to intervene on the high rates of relapse. Understanding physiological indices that can be measured by wearable sensor technologies may provide new momentary interventions for individuals with ED. This systematic review, searching large databases, synthesises studies investigating peripheral physiological (PP) indices commonly included in wearable wristbands (heart rate [HR], heart rate variability [HRV], electrodermal activity [EDA], peripheral skin temperature [PST], and acceleration) in ED. Inclusion criteria included: (a) full peer-reviewed empirical articles in English; (b) human participants with active ED; and (c) containing one of five wearable physiological measures. Kmet risk of bias was assessed. Ninety-four studies were included (Anorexia nervosa [AN; N = 4418], bulimia nervosa [BN; N = 916], binge eating disorder [BED; N = 1604], other specified feeding and eating disorders [OSFED; N = 424], and transdiagnostic [N = 47]). Participants with AN displayed lower HR and EDA and higher HRV compared to healthy individuals. Those with BN showed higher HRV, and lower EDA and PST compared to healthy individuals. Other ED and Transdiagnostic samples showed mixed results. PP differences are indicated through various assessments in ED, which may suggest diagnostic associations, although more studies are needed to validate observed patterns. Results suggest important therapeutic potential for PP in ED, and larger studies including diverse participants and diagnostic groups are needed to fully uncover their role in ED.

Impact of BMI z-score on left ventricular mechanics in adolescent girls

Background

Adolescent weight disorders ranging from anorexia nervosa (AN) to obesity (OB) can impact the heart by causing opposite alterations in its morphology, suggesting a direct impact of body mass index (BMI) on the heart. Cardiac function is relatively preserved as assessed by standard echocardiography. However, few studies have used 2D speckle-tracking echocardiography (2D-STE), which can detect subtle alterations of left ventricular (LV) function by evaluating deformations. This study aimed to assess the link between the BMI z-score of adolescent girls and myocardial function.

Methods

Ninety-one adolescent girls comprising 26 AN patients (age 14.6 ± 1.9 years), 28 OB patients (age 13.2 ± 1.4 years), and 37 controls (age 14.0 ± 2.0 years) underwent 2D-STE to assess LV morphology and myocardial global and regional deformations.

Results

The BMI z-score of our population ranged from -4.6 to 5.2. LV morphological remodeling was significantly and positively correlated with the BMI z-score (R2 = 0.456, p < 0.0001 for LV mass). Global longitudinal strain (LS) and regional LS recorded at the mid and apical levels were significantly correlated with the BMI z-score (R2 = 0.196, p = 0.0001 and R2 = 0.274, p < 0.0001, respectively, for apical and medial LS). Circumferential strains and twisting mechanics were not correlated with the BMI z-score. Fibrinogen and systolic blood pressure were the main variables explaining the alteration of LS.

Conclusion

We observed that the BMI z-score had an impact on LV mechanics, especially on medial and apical LS. Neither circumferential nor twisting mechanics were altered by the BMI z-score in adolescent girls.

Emotional and autonomic response to visual erotic stimulation in patients with functional hypothalamic amenorrhea

Introduction

Functional hypothalamic amenorrhea (FHA) is a clinical condition associated with high levels of physiological and psychological stress ranging from weight loss to maladaptive behavior and coping skills. A reliable measure of the psychophysiological response to stress and the ability to cope with stimuli is heart rate variability (HRV). Through the sympathetic (SNS) and parasympathetic nervous system (PNS), the autonomic nervous system (ANS) promotes various changes in HRV that reflect the individual's psychophysiological response to stress. FHA patients are characterized by high levels of PNS activation during psychological load, suggesting that parasympathetic hyperactivation could be a pathology marker.

Methods

In the present study, we examine changes in HRV during observation of erotic, neutral, and disgusting images in 10 patients with FHA [(mean ± S.D.) age: 26.8 ± 5.9] and in 9 controls (age: 25.4 ± 6.4; BMI: 22.47 ± 2.97) to assess the differential activation of PNS and SNS between FHA patients and controls matched for age and without other clinical conditions.

Results

Our results showed that FHA patients had significantly higher HRV activation while observing high emotional value images and not during the observation of neutral images confirming a parasympathetic hyperactivation.

Discussion

HRV and cognitive and psychological testing, could provide new insights into understanding such a clinically understudied condition and provide further tools for clinical diagnosis and treatment.

Echocardiographic changes in anorexia nervosa: a pathophysiological adaptation or a disease?

Anorexia Nervosa is one of the most common form of eating disorders. Cardiac involvement occurs in approximately 80% of patients. Few reports focused on the association between body weight fluctuations and echocardiographic abnormalities, considering linear measurements. We describe echocardiographic and clinical features among male and female patients with anorexia nervosa and the effect of weight gain on these parameters. We performed a single center, retrospective study of patients followed at a dedicated multidisciplinary Unit. The study population consisted of 81 patients, mean age 25 ± 11 years, 94% female. Median body mass index was 14.4 kg/m² (25th-75th percentile 12.7-15.6 kg/m²). Patients with body mass index below the median value had more often pericardial effusion, smaller left ventricular mass and left ventricular end-diastolic volume and thinner interventricular septum. However, when indexed to body surface area, left ventricular mass and volumes were within the normal range in 90% of population. Patients with pericardial effusion showed mitral valve abnormalities and lower values of white blood cells and platelets, although within normal limits. Presence of pericardial effusion was not related to inflammatory parameters or low plasma protein levels. In 39 patients who displayed weight gain during a median follow-up of 189 days (25th-75th percentile 47-471), increased left ventricular mass, interventricular septum thickness, white blood cells and platelet count and decreased pericardial effusion were observed. Patients with anorexia nervosa have a specific echocardiographic pattern which seems to be proportional to the body size, suggesting a pathophysiological adaptation to the lack of substrates.

Cardiac Remodeling and Its Determinants in Anorexia Nervosa Adolescents: Impact of Weight Recovery

Cardiovascular alterations in anorexia nervosa (AN) adolescents include bradycardia and decreased systolic blood pressure and left ventricular mass. However, their determinants remain poorly understood. We assessed the associations between morphological and functional left ventricular (LV) remodeling, autonomic control by heart rate variability (HRV) analysis, thyroid hormones and brain natriuretic peptide (BNP) levels in AN female adolescents without or with weight recovery (WR). Fifty-nine female adolescents including 16 AN patients without WR (mean age 13.9 years (10−16)), 10 AN patients with WR (15.7 years (12−18)) and 33 controls (14.1 years (10−18)) underwent night heart rate (HR) recording to measure HRV (and especially SD1/SD2, the ratio between instantaneous (SD1) and long-term (SD2) standard deviation of R-R intervals, reflecting sympatho-vagal balance), speckle tracking echocardiography to assess LV global longitudinal strain (GLS) and blood test for dosage of tri-iodothyronine (T3) hormone and NT-proBNP. Compared to controls, AN patients without WR presented with lower HR (55 ± 7 vs. 68 ± 6 bpm; p < 0.001), parasympathetic hyperactivity, and higher GLS (−19.2 ± 1.8 vs. −16.9 ± 2.8%; p = 0.009). These alterations were partly abolished in AN patients with WR. In a multivariate regression analysis, T3 was the main factor explaining the variance of SD1/SD2, a sympatho-vagal balance marker. NT-proBNP levels were not correlated with cardiac alterations. AN patients had parasympathetic hyperactivity linked with their rate of T3, and a higher GLS. These alterations were partly restored in AN patients with WR.

Left Ventricular Strains and Myocardial Work in Adolescents With Anorexia Nervosa

Background

Anorexia nervosa (AN) is accompanied by bradycardia, low blood pressure (BP) and cardiac morphological remodeling. Systolic and diastolic functions are relatively preserved when assessed by standard ultrasound methods. However, novel advances based on speckle tracking echocardiography (STE), that could detect subtle and early alterations of left ventricular (LV) function, remained poorly used in AN patients.

Objective

The aim of this study was to assess the cardiac function of AN patients by evaluating LV myocardial strains, myocardial work (MW) and LV mechanical dispersion. We hypothesized that LV strains and global myocardial work would be decreased and LV twisting mechanisms enhanced to preserve the systolic function.

Methods

Fifty-nine adolescents including 26 women AN patients (14.6 ± 1.9 yrs. old) with a mean duration of AN of 19 ± 9 months and 33 controls (14.1 ± 2.0 yrs. old) underwent STE to assess LV morphology and myocardial regional strains.

Results

The global longitudinal strain (GLS) was higher in AN patients compared to controls (−18.8 ± 2.0 vs. −16.9 ± 2.8%, p = 0.006). The area under the pressure-strain loop, representing the global MW was not altered but was shifted to the left and downwards in AN patients, due to their lower BP and higher GLS. Intraventricular mechanical dispersion was similar in both groups. Circumferential strains, twisting/untwisting mechanics were preserved.

Conclusion

Our results strongly support that the cardiac morphological remodeling observed in our AN patients was associated with normal ventricular regional myocardial functions. Only GLS was higher in AN patients, but its clinical significance remains to be demonstrated.

Cardiac abnormalities determined by tissue Doppler imaging and arrhythmias in adolescents with anorexia nervosa

BACKGROUND

Anorexia nervosa has a prevalence of 0.5-3% in adolescents, placing this population at increased risk of cardiac anomalies including arrhythmias, pericardial effusion, and myocardial dysfunction. Our objective is to describe cardiovascular anomalies observed by tissue Doppler imaging in patients with anorexia nervosa.

METHODS

We retrospectively reviewed electrocardiogram, Holter, and echocardiography findings in 28 patients diagnosed with anorexia nervosa.

RESULTS

Electrocardiogram was abnormal in 71% of patients with sinus bradycardia observed in 57%. Holter confirmed sinus bradycardia without significant pauses. Prolonged QTc, low voltage, and ectopic beats were each seen in 14% of patients. Wenckebach atrioventricular block was observed in one patient. Supraventricular or ventricular tachycardia was not observed. Echocardiography showed structurally normal heart in all patients. Pericardial effusion was seen in 7.1% of patients and left ventricular mass was decreased in 10.7%. Mean ejection fraction was 0.73 and mean fractional shortening was 38.4%. Tissue Doppler imaging revealed systolic or diastolic dysfunction in four patients with e', a', and s' velocities in the lateral and septal basal segments more than two standard deviations below the mean. Two patients had decreased left ventricular mass but no significant difference in disease duration from the group. Basal segment velocities below one standard deviation were also observed in an additional seven patients.

CONCLUSION

A trend for decreased tissue Doppler imaging velocities was seen in 25.0% of patients, while significant systolic and diastolic dysfunction was seen in 14.3% of patients, associated with a significant reduction in left ventricular mass and independent of disease duration.

Cardiac biomarkers of disordered eating as a function of diagnostic subtypes

OBJECTIVE

The purpose of this study was to identify cardiac biomarkers of disordered eating as a function of diagnostic subtype as assessed via self-report inventory.

METHOD

Mean heart rate (HR), systolic and diastolic blood pressure, mean R wave amplitude (mV), mean T wave amplitude (mV), QTc interval (sec), Tpeak-Tend interval prolongation (sec), QTc interval prolongation (sec), QRS prolongation (sec), and spectral indicators of cardiac dysfunction (LF/HF spectral ratio, HF spectral power) were assessed via electrocardiography among women with no eating disorder symptoms (n = 32), subclinical eating disorder symptoms (n = 92), anorexia nervosa (n = 7), bulimia nervosa (n = 89), binge eating disorder (BED: n = 20), and other specified feeding and eating disorders (OSFED: n = 19).

RESULTS

MANOVA results showed statistically significant group differences. Follow-up tests revealed significantly decreased mean R wave amplitude among participants with self-indicated clinical (bulimia nervosa, binge eating disorder) and subclinical forms of disordered eating compared to asymptomatic controls.

DISCUSSION

Results suggest decreased mean R wave amplitude is a promising cardiac biomarker of disordered eating.

Heart and anorexia nervosa

Anorexia nervosa, one of the more frequent and severe eating disorders, is a chronic psychiatric disease with potentially serious somatic consequences. This behavioral symptomatology leads to weight loss, undernutrition, and more or less severe-potentially life-threatening-somatic complications including respiratory, hepatic, digestive and cardiac features, electrolyte disturbances, endocrine and bone impairment, immunodepression, and related opportunistic infections. In this review, the authors report an overview of cardiac diseases in this disease.

Cardiac biomarkers of disordered eating: A case for decreased mean R wave amplitude

The purpose of this study was to identify cardiac biomarkers of disordered eating. Mean R wave amplitude (mV), mean T wave amplitude (mV), QRS interval (sec), QTc interval (sec), and Tpeak-Tend interval (sec) were assessed via electrocardiography among women with clinical (n = 53) and subclinical (n = 56) eating disorder symptoms versus asymptomatic controls (n = 32). QRS and QTc intervals were significantly longer and mean T and R wave amplitudes significantly lower among women with clinical symptoms compared to asymptomatic controls. QTc interval length was significantly longer and mean R wave amplitude was significantly lower among women with subclinical symptoms versus asymptomatic controls. Decreased mean R wave amplitude yielded a comparable effect size as QTc when differentiating between asymptomatic and subclinical groups and a larger effect size than QTc when differentiating between asymptomatic and clinical groups, representing a promising clinical biomarker.

Echocardiographic Assessment of Ventricular Function During Exercise in Adolescent Female Patients With Anorexia Nervosa

BACKGROUND

Patients with anorexia nervosa (AN) have altered physiologic responses to exercise. The aim of this study was to investigate exercise capacity and ventricular function during exercise in adolescent patients with AN.

METHODS

Sixty-six adolescent female patients with AN and 21 adolescent female control subjects who exercised to volitional fatigue on a semisupine ergometer, using an incremental step protocol of 20 W every 3 min, were retrospectively studied. Heart rate, blood pressure, and echocardiographic Doppler indices were measured at rest and during each stage of exercise. Fractional shortening, rate-corrected mean velocity of circumferential fiber shortening, stress at peak systole, cardiac output, and cardiac index were calculated. Minute ventilation, oxygen consumption, carbon dioxide production, and respiratory exchange ratio were measured using open-circuit spirometry.

RESULTS

Patients with AN had significantly lower body mass index (16.7 vs 19.7 kg/m², P < .001), total work (1,126 vs 1,914 J/kg, P < .001), and test duration (13.8 vs 20.8 min, P < .001) compared with control subjects. Peak minute ventilation, oxygen consumption, and carbon dioxide production were significantly decreased in patients with AN. Heart rate, systolic blood pressure, cardiac index, fractional shortening, and rate-corrected mean velocity of circumferential fiber shortening demonstrated similar patterns of increase with progressive exercise between groups but were decreased at peak exercise in patients with AN. Body mass index percentile, age, peak oxygen consumption, and peak cardiac output were independently associated with exercise duration.

CONCLUSIONS

Adolescent patients with AN have reduced exercise capacity and peak cardiovascular indices compared with control subjects but normal patterns of cardiovascular response during progressive exercise. Systolic ventricular function is maintained during exercise in adolescents with AN.

Predictors of Complications in Anorexia Nervosa and Atypical Anorexia Nervosa: Degree of Underweight or Extent and Recency of Weight Loss?

PURPOSE

Adolescents with atypical anorexia nervosa (AAN) can experience severe physical complications despite not being underweight, posing questions about the contribution of weight loss to complications experienced in restrictive eating disorders (EDs). This study compared total weight loss and recent weight loss with admission weight as predictors of physical and psychological complications.

METHODS

Retrospective (2005-2010) and prospective (2011-2013) studies were undertaken of 12- to 19-year-old hospitalized adolescents with anorexia nervosa (AN) or AAN, defined as meeting criteria for AN except underweight (≥85% median body mass index). Predictors were total weight loss (from lifetime maximum), recent weight loss (past 3 months), and admission weight. Outcomes were hypophosphatemia, clinical, anthropometric, and psychometric markers during admission.

RESULTS

In 171 participants (AN, 118 [69%]; AAN, 53 [31%]), there was little evidence of an association between weight measures and hypophosphatemia. Greater total weight loss (regression coefficient [Coeff]: -1.70, 95% confidence interval [CI]: -2.77, -.63, p = .002) and greater recent weight loss (Coeff: -3.37, 95% CI: -5.77, -.97, p = .006), but not admission weight, were associated with a lower pulse rate nadir. Greater total weight loss (odds ratio [OR]: 1.70, 95% CI: 1.19, 2.24, p = .003) and greater recent weight loss (OR: 2.12, 95% CI: 1.11, 4.02, p = .02) were also associated with a higher incidence of bradycardia.

CONCLUSIONS

In adolescents with restrictive EDs, total weight loss and recent weight loss were better predictors than admission weight of many physical complications. This suggests that future diagnostic criteria for AN place greater emphasis on weight loss.

Re-feeding syndrome and alcoholic cardiomyopathy: A case of interacting diagnoses

Re-feeding syndrome is an uncommon clinical entity of fluid and electrolyte disorders that typically occurs after re-initiation of enteral nutrition following prolonged fasting. This disorder can be complicated by left ventricular (LV) dysfunction, arrhythmias, and death. Alcohol abuse and anorexia nervosa are independently associated with similar complications. The interaction between these diagnoses can result in significant, but reversible, LV dysfunction. We present the case of a 69-year-old woman with a history of significant alcohol abuse and anorexia nervosa. The patient was admitted to hospital for the management of re-feeding syndrome, which was complicated by significant LV dysfunction. Her LV function normalized following a combination of electrolyte replacement, re-institution of feeding, and abstinence from alcohol. Re-feeding syndrome, anorexia nervosa, and alcohol abuse are conditions that commonly co-exist. These conditions may have a synergistic relationship, potentially resulting in a profound cardiomyopathy. Careful monitoring and aggressive electrolyte replacement may be helpful in identifying this complication and minimizing its potential harm. <Learning objective: Re-feeding syndrome can be complicated by significant myocardial dysfunction, particularly in patients with a history of alcohol abuse or anorexia nervosa, which independently cause cardiac dysfunction. Physicians should be aware of the risk of new cardiomyopathy in patients with these overlapping diagnoses. We review the case of a patient with these conditions who developed a significant reversible cardiomyopathy managed with re-institution of feeding and electrolyte replacement.>.

Cardiac changes in anorexia nervosa

Introduction Anorexia nervosa is an eating disorder, which is associated with many different medical complications as a result of the weight loss and malnutrition that characterise this illness. It has the highest mortality rate of any psychiatric disorder. A large portion of deaths are attributable to the cardiac abnormalities that ensue as a result of the malnutrition associated with anorexia nervosa. In this review, the cardiac complications of anorexia nervosa will be discussed.

METHODS

A comprehensive literature review on cardiac changes in anorexia nervosa was carried out.

RESULTS

There are structural, functional, and rhythm-type changes that occur in patients with anorexia nervosa. These become progressively significant as ongoing weight loss occurs.

CONCLUSION

Cardiac changes are inherent to anorexia nervosa and they become more life-threatening and serious as the anorexia nervosa becomes increasingly severe. Weight restoration and attention to these cardiac changes are crucial for a successful treatment outcome.

Risk for prolonged QT interval and associated outcomes in children with early restrictive eating patterns

Aim This study aimed to describe the frequency of QTc prolongation in children with restrictive eating disorders early in the course of disease admitted for inpatient therapy, to determine the frequency of associated ventricular arrhythmia, and to evaluate the relationship between QTc interval and concomitant electrolyte abnormalities and rate of weight loss.

METHODS

This was a retrospective cohort study of patients aged 11-25 years with early restrictive eating disorders.

RESULTS

In all, 82 patients met the inclusion criteria (84% female). In total, 9.8% had prolonged QTc interval during hospitalisation. Patients with prolonged QTc had significantly higher resting heart rates (p=0.006), but there was no association with hypokalaemia (p=0.31), hypomagnesaemia (p=0.43), hypophosphataemia (p=1), or rate of weight loss (p=1).

CONCLUSION

Mild QTc prolongation in patients with restrictive eating disorders is not related to electrolyte abnormalities or rate of weight loss in this population, suggesting that investigation about other potential risk factors of prolonged QTc interval may be warranted.

The pathogenesis and treatment of cardiac atrophy in cancer cachexia

Cancer cachexia is a multifactorial syndrome characterized by a progressive loss of skeletal muscle mass associated with significant functional impairment. In addition to a loss of skeletal muscle mass and function, many patients with cancer cachexia also experience cardiac atrophy, remodeling, and dysfunction, which in the field of cancer cachexia is described as cardiac cachexia. The cardiac alterations may be due to underlying heart disease, the cancer itself, or problems initiated by the cancer treatment and, unfortunately, remains largely underappreciated by clinicians and basic scientists. Despite recent major advances in the treatment of cancer, little progress has been made in the treatment of cardiac cachexia in cancer, and much of this is due to lack of information regarding the mechanisms. This review focuses on the cardiac atrophy associated with cancer cachexia, describing some of the known mechanisms and discussing the current and future therapeutic strategies to treat this condition. Above all else, improved awareness of the condition and an increased focus on identification of mechanisms and therapeutic targets will facilitate the eventual development of an effective treatment for cardiac atrophy in cancer cachexia.

Bradycardia in anorexia nervosa

We present a case of a 24-year-old woman initially referred for a permanent pacemaker for symptomatic sinus bradycardia. Further consultations revealed significant weight loss and subsequent psychiatric review confirmed a diagnosis of anorexia nervosa.

Cardiovascular disorders in anorexia nervosa and potential therapeutic targets

Anorexia nervosa (AN) is an eating disorder in which a distorted self-perception of body image and an excessive fear of gaining weight result in extreme restrictions in eating habits. AN may be divided into two types: a "binge-eating/purging type" during which the individual regularly engages in overeating and then purging behavior, and a "restricting type", in which she does not. AN is a serious medical problem in young people in Western societies. It is widely reported that patients with AN exhibit an enhanced mortality rate as compared with age-matched healthy subjects, which has been mainly ascribed to cardiac complications. At least one-third of all deaths in patients with anorexia nervosa are estimated to be due to cardiac causes, mainly sudden death. Cardiovascular complications of AN can be present in up to 80% of cases, and among them alterations in cardiac electrical activity, structure and hemodynamics have been reported as causes of morbidity and mortality. The objective of this brief review is to summarize current knowledge on the main cardiovascular complications of AN, their underlying mechanisms and the possible therapeutic approaches.

The significance of bradycardia in anorexia nervosa

Anorexia 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 ± 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.

Medically treated anorexia nervosa is associated with normal P wave parameters

Anorexia nervosa (AN) is an increasingly common medical condition. Some studies have demonstrated an increased prevalence of atrial premature contractions and anatomical changes in AN patients. Our aim was to investigate P wave parameters and P wave dispersion, an electrocardiographic marker for supraventricular arrhythmias, and its effect on AN. The study group included 48 patients with AN, most hospitalized for a few weeks, and a matched control group. All participants underwent 12-lead electrocardiography (ECG) under strict standards. P wave length and P wave dispersion in each patient were computed from a randomly selected beat and an averaged beat, constructed from 7 to 12 beats, included in a 10-s ECG. There were no statistically significant differences found between the groups for minimal, maximal, average P wave duration and P wave dispersion, calculated either from a random beat or averaged beats. In conclusion, medically treated AN patients who have gained weight have normal P wave parameters, and therefore do not appear to have an increased electrocardiographic risk for atrial fibrillation compared with healthy controls. Further studies are required to evaluate the influence of different disease stages, electrolyte imbalance and other medical complications on P wave parameters and risk for supraventricular arrhythmias in AN patients.

Post-natal myogenic and adipogenic developmental: defects and metabolic impairment upon loss of A-type lamins

A-type lamins are a major component of the nuclear lamina. Mutations in the LMNA gene, which encodes the A-type lamins A and C, cause a set of phenotypically diverse diseases collectively called laminopathies. While adult LMNA null mice show various symptoms typically associated with laminopathies, the effect of loss of lamin A/C on early post-natal development is poorly understood. Here we developed a novel LMNA null mouse (LMNA(GT-/-)) based on genetrap technology and analyzed its early post-natal development. We detect LMNA transcripts in heart, the outflow tract, dorsal aorta, liver and somites during early embryonic development. Loss of A-type lamins results in severe growth retardation and developmental defects of the heart, including impaired myocyte hypertrophy, skeletal muscle hypotrophy, decreased amounts of subcutaneous adipose tissue and impaired ex vivo adipogenic differentiation. These defects cause death at 2 to 3 weeks post partum associated with muscle weakness and metabolic complications, but without the occurrence of dilated cardiomyopathy or an obvious progeroid phenotype. Our results indicate that defective early post-natal development critically contributes to the disease phenotypes in adult laminopathies.

Factors influencing QT prolongation in patients hospitalized with severe anorexia nervosa

BACKGROUND

Anorexia nervosa (AN) carries the highest mortality of any psychiatric disorder largely attributable to sudden cardiac death and suicide. Controversy exists regarding the underlying mechanism of cardiac risk, whether QT prolongation is a consistent feature of the disorder and whether repolarization varies by disease severity. Some of the uncertainty may relate to a lack of standardized electrocardiography (ECG). To date, studies have not utilized centrally adjudicated digital ECG, and most have relied on the Bazett formula for rate-correction, which is suboptimal at the extremes of heart rate often observed in AN.

METHODS

We evaluated a hospitalized cohort of medically compromised, very-low-body mass index (BMI) AN patients. The QT interval was measured with high-precision calipers by a single, blinded electrophysiologist and rate corrected (QTc) using the Fridericia formula. Anatomically corrected left ventricular (LV) mass and resting energy expenditure (REE) were calculated as proxies for disease severity. Proportions exceeding categorical thresholds for QTc prolongation and correlations between admission QTc and disease severity were performed.

RESULTS

Among 19 patients, mean BMI was 12.3 kg/m(2), and 95% were female. The majority (68%) of patients were receiving QT-prolonging drugs. Four patients (21%) had QTc prolongation. Two of these patients (10.5%) exceeded the 500 ms threshold for marked QTc-prolongation, though each had concomitant factors contributing to delayed repolarization. The QTc interval was not significantly correlated with LV mass, LV mass index, BMI or REE.

CONCLUSIONS

Although delayed cardiac repolarization was observed among a medically compromised cohort of patients with anorexia nervosa, the QTc interval was not a reliable correlate of disease severity despite digital ECG adjudication and optimal rate correction.

Echocardiographic findings in adolescents with anorexia nervosa at beginning of treatment and after weight recovery

Anorexia nervosa (AN) is an eating disorder with somatic complications. The aim of the study was to analyse echocardiographic abnormalities in patients with AN at initial examination and after weight restoration. A total of 173 consecutively admitted adolescents (aged 12-17 years), diagnosed with DSM-IV AN (307.1) were evaluated in a child and adolescent psychiatric department of a major university hospital from December 1997 to August 2008. In addition, 40 healthy adolescents of the same age with normal weight were examined. In patients with AN, 34.7% had a pericardial effusion (PE) which was clinically silent. In contrast, none of the controls presented with PE (p < 0.001). No differences across AN subtypes were observed. Patients with PE showed significantly lower body mass index (BMI) (p = 0.016) than patients without PE. They had more prominent low-T3 syndrome (p = 0.003) and longer duration of hospitalisation (p = 0.008) after controlling for BMI at admission. Remission of PE was observed in 88% of the patients after weight restoration. Left ventricular end-diastolic and end-systolic dimensions in AN were significantly lower than in controls (p < 0.001). There were no differences in interventricular septum thickness, posterior wall thickness and fractional shortening. This report indicates that adolescents with AN show cardiac abnormalities in comparison to healthy young women. Furthermore, PE is a frequent cardiac complication in patients with AN and it is associated with BMI, low T3 serum levels and duration of hospitalisation.

Left ventricular structural remodeling in health and disease: with special emphasis on volume, mass, and geometry

The changes in left ventricular (LV) structure and geometry that evolve after myocardial injury or overload usually involve chamber dilation and/or hypertrophy. Such architectural remodeling can be classified as eccentric or concentric. Consideration of LV volume, mass, and relative wall thickness (or mass/volume) allows classification of LV remodeling that includes virtually all LV remodeling changes that are seen in health and disease. These various architectural changes generally include the development of LV hypertrophy in a pattern that is closely related to the type of injury or overload, and they are accompanied by differences in cardiac function and hemodynamics. Some patterns of remodeling are associated with adverse outcomes whereas others appear to be adaptive and physiologic without adverse consequences. Considering all patients with LV hypertrophy as a homogenous group is inconsistent with our understanding of the various remodeling patterns that are discussed in this review.

Hospital catering systems and their impact on the sensorial profile of foods provided to older patients in the UK

Impaired sensorial perception is very common in older people and low sensorial quality of foods is associated with decreased appetite and dietary intake. Hospital undernutrition in older patients could be linked to sensorial quality of hospital food if the quality were low or inappropriate for older people. The aim of this study was to examine changes in the sensorial quality of different foods that occur as a result of the food journey (i.e. freezing, regeneration, etc.) in the most common hospital catering systems in the UK. A trained sensory panel assessed sensorial descriptors of certain foods with and without the hospital food journey as it occurs in the in-house and cook/freeze systems. The results showed effects of the food journey on a small number of sensorial descriptors related to flavour, appearance and mouthfeel. The majority of these effects were due to temperature changes, which caused accumulation of condensation. A daily variation in sensorial descriptors was also detected and in some cases it was greater than the effect of the food journey. This study has shown that changes occur in the sensory quality of meals due to hospital food journeys, however these changes were small and are not expected to substantially contribute to acceptability or have a major role in hospital malnutrition.

Cancer causes cardiac atrophy and autophagy in a sexually dimorphic manner

Approximately one-third of cancer deaths are caused by cachexia, a severe form of skeletal muscle and adipose tissue wasting that affects men more than women. The heart also undergoes atrophy in cancer patients, but the mechanisms and the basis for apparent sex differences are unclear. In a mouse colon-adenocarcinoma model, cancer causes a loss of cardiac mass due to a decrease in cardiac myocyte size that is associated with reduced levels of all sarcomeric proteins. Unlike skeletal muscle cachexia, atrophic hearts do not upregulate the ubiquitin-proteasome system or its activity but increase autophagy. Thus, cancer causes cardiac atrophy by a mechanism distinct from that in skeletal muscle. Male tumor-bearing mice have a more severe phenotype than females, including greater cardiac mass loss and mortality, a more robust pro-inflammatory response to the tumor, and greater cardiac autophagy. In females, estrogen protects against cancer-induced cardiac atrophy and body weight loss by signaling through its receptor. Sex differences in cardiac atrophy need to be considered during the treatment of patients suffering from chemotherapy-induced cardiomyopathy to prevent exacerbation of cardiac dysfunction.

The relationship between QTc changes and nutrition during weight loss after gastroplasty

Electrocardiograms, serum electrolytes, plasma concentrations of pre-albumin and retinol-binding globulin, and dietary intakes were analyzed in 22 women during weight loss after gastroplasty surgery for morbid obesity. QT interval corrected for heart rate (QTc) was prolonged (greater than 0.44 sec) in 32% (95% confidence limits 14-55%) on one or more occasions. No clinical or electrocardiographic complications were seen. Occurrence of QTc prolongation was significantly (p less than 0.05) associated with protein intake below recommendation and with low plasma pre-albumin concentrations. QTc prolongation was not associated with mineral intake and occurred in spite of normal serum levels of calcium (uncorrected and albumin-corrected), magnesium, potassium and sodium. Because QTc prolongation may precede fatal arrhythmias, adequate protein intake is mandatory during weight reduction.

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.

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.

Review of the refeeding syndrome

Refeeding syndrome describes a constellation of metabolic disturbances that occur as a result of reinstitution of nutrition to patients who are starved or severely malnourished. Patients can develop fluid and electrolyte disorders, especially hypophosphatemia, along with neurologic, pulmonary, cardiac, neuromuscular, and hematologic complications. We reviewed literature on refeeding syndrome and the associated electrolyte abnormalities, fluid disturbances, and associated complications. In addition to assessing scientific literature, we also considered clinical experience and judgment in developing recommendations for prevention and treatment of refeeding syndrome. The most important steps are to identify patients at risk for developing refeeding syndrome, institute nutrition support cautiously, and correct and supplement electrolyte and vitamin deficiencies to avoid refeeding syndrome. We provide suggestions for the prevention of refeeding syndrome and suggestions for treatment of electrolyte disturbances and complications in patients who develop refeeding syndrome, according to evidence in the literature, the pathophysiology of refeeding syndrome, and clinical experience and judgment.

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.

Early detection of cardiac dysfunction in patients with anorexia nervosa by tissue Doppler imaging

BACKGROUND

Cardiac damage is a major complication of chronic starvation. The aim of this study was to evaluate the changes of left ventricular function in patients with anorexia nervosa by means of pulsed tissue Doppler imaging.

METHODS

A total of 20 females (age 22.4+/-4.3 years) with overt anorexia nervosa, 20 matched healthy thin females with body mass index < 19 kg/m2 and 20 matched healthy normal-weight females underwent both standard echocardiography and tissue Doppler imaging. Myocardial systolic wave (Sm) and early (Em) and atrial (Am) diastolic waves were measured on the basal lateral segment and the basal interventricular septum from the apical four-chamber view.

RESULTS

When compared with control groups, the anorexia nervosa group showed lower left ventricular mass (p < 0.0001), lower Sm peak of both lateral wall (6.5+/-0.9 vs. 9.4+/-2.1 and vs. 9.5+/-1.9 cm/sec, p < 0.001) and septum (5.6+/-1.5 vs. 8.6+/-1.6 and vs. 8.8+/-1.5 cm/sec, p < 0.001), and comparable Em, Am and Em/Am ratio. The ratio between transmitral peak E and Em was significantly greater in anorexic patients than in controls (lateral wall: 8.1+/-0.1 vs. 6.8+/-0.2 and vs. 6.9+/-0.2, p < 0.001; septum: 10.8+/-0.4 vs. 8.8+/-0.5 and vs. 8.8+/-0.3, p < 0.001). No differences were observed between thin and normal-weight females. In the anorexia nervosa group, S(m) peak was significantly related to left ventricular mass indexed, at both septum (r = 0.55, p < 0.02) and lateral wall (r = 0.49, p < 0.03) levels.

CONCLUSIONS

These results show that anorexia nervosa is associated with left ventricular systolic dysfunction, which is related with the reduction of cardiac mass. Tissue Doppler imaging can give useful information in the identification of regional left ventricular dysfunction, in addition to traditional parameters.

Refeeding normalizes the QT rate dependence of female anorexic patients

We postulated that dynamic alterations in QT interval adaptation could characterize patients with anorexia nervosa (AN) and could be restored after weight gain. To assess ventricular repolarization features, we evaluated the QT dynamicity along RR intervals from 24-hour electrocardiographic data of patients with AN before and after refeeding. Ten young women with AN (19 +/- 3 years) were included in the study. The QT/RR slope was found significantly enhanced compared with normals (-1.82 +/- 0.62 vs -1.40 +/- 0.30; p < 0.05). This slope returned to normal range values after refeeding. The QT/RR slope was significantly correlated with the body mass index (r = 0.59; p < 0.007) in the patient group.

Effects of anorexia nervosa on clinical, hematologic, biochemical, and bone density parameters in community-dwelling adolescent girls

OBJECTIVE

Anorexia nervosa (AN) is an eating disorder that leads to a number of medical sequelae in adult women and has a mortality rate of 5.6% per decade; known complications include effects on hematologic, biochemical, bone density, and body composition parameters. Few data regarding medical and developmental consequences of AN are available for adolescents, in particular for an outpatient community-dwelling population of girls who have this disorder. The prevalence of AN is increasing in adolescents, and it is the third most common chronic disease in adolescent girls. Therefore, it is important to determine the medical effects of this disorder in this young population.

METHODS

We examined clinical characteristics and performed hematologic, biochemical, hormonal, and bone density evaluations in 60 adolescent girls with AN (mean age: 15.8 +/- 1.6 years) and 58 healthy adolescent girls (mean age: 15.2 +/- 1.8 years) of comparable maturity. Nutritional and pubertal status; vital signs; a complete blood count; potassium levels; hormonal profiles; bone density at the lumbar and lateral spine; total body, hip, and femoral neck (by dual-energy x-ray absorptiometry) and body composition (by dual-energy x-ray absorptiometry) were determined.

RESULTS

All measures of nutritional status such as weight, percentage of ideal body weight, body mass index, lean body mass, fat mass, and percentage of fat mass were significantly lower in girls with AN than in control subjects. Girls with AN had significantly lower heart rates, lower systolic blood pressure, and lower body temperature compared with control subjects. Total red cell and white cell counts were lower in AN than in control subjects. Among girls with AN, 22% were anemic and 22% were leukopenic. None were hypokalemic. Mean age at menarche did not differ between the groups. However, the proportion of girls who had AN and were premenarchal was significantly higher compared with healthy control subjects who were premenarchal, despite comparable maturity as determined by bone age. Ninety-four percent of premenarchal girls with AN versus 28% of premenarchal control subjects were above the mean age at menarche for white girls, and 35% of premenarchal AN girls versus 0% of healthy adolescents were delayed >2 SD above the mean. The ratio of bone age to chronological age, a measure of delayed maturity, was significantly lower in girls with AN versus control subjects and correlated positively with duration of illness and markers of nutritional status. Serum estradiol values were lower in girls with AN than in control subjects, and luteinizing hormone values trended lower in AN. Levels of insulin-like growth factor-I were also significantly lower in girls with AN. Estradiol values correlated positively with insulin-like growth factor-I, a measure of nutritional status essential for growth (r = 0.28). All measures of bone mineral density (z scores) were lower in girls with AN than in control subjects, with lean body mass, body mass index, and age at menarche emerging as the most important predictors of bone density. Bone density z scores of <-1 at any one site were noted in 41% of girls with AN, and an additional 11% had bone density z scores of <-2.

CONCLUSIONS

A high prevalence of hemodynamic, hematologic, endocrine, and bone density abnormalities are reported in this large group of community-dwelling adolescent girls with AN. Although a number of these consequences of AN are known to occur in hospitalized adolescents, the occurrence of these findings, including significant bradycardia, low blood pressure, and pubertal delay, in girls who are treated for AN on an outpatient basis is of concern and suggests the need for vigilant clinical monitoring, including that of endocrine and bone density parameters.

Characteristics of the increase in plasma brain natriuretic peptide level in left ventricular systolic dysfunction, associated with muscular dystrophy in comparison with idiopathic dilated cardiomyopathy

To determine whether the plasma brain natriuretic peptide level increases differentially in muscular dystrophy and idiopathic dilated cardiomyopathy, we investigated the plasma brain natriuretic peptide level and echocardiographic parameters in patients with similarly low left ventricular ejection fraction. The plasma brain natriuretic peptide level was lower, and the left ventricular end-diastolic diameter was shorter in the patients with muscular dystrophy than in those with idiopathic dilated cardiomyopathy. The correlation between the plasma brain natriuretic peptide and left ventricular ejection fraction was shifted downward in the patients with muscular dystrophy compared with those with idiopathic dilated cardiomyopathy. Those between the brain natriuretic peptide and left ventricular end-diastolic diameter were superimposable, although the data from the muscular dystrophy patients were located at the shorter left ventricular end-diastolic diameter side. The plasma brain natriuretic peptide level may differentially increase in the two diseases with similar left ventricular systolic dysfunction. Differences in the left ventricular distension and in the physical activity might explain at least partially the different plasma brain natriuretic peptide levels.

Alteration of the QT Rate Dependence in Anorexia Nervosa

Myocardial repolarization has been evaluated in patients with anorexia nervosa (AN) with conflicting results. The authors postulated that dynamic alterations in QT interval adaptation could characterize these patients. This study compared QT dynamicity along RR intervals from 24-hour ECG data of patients with and without AN. Twenty-five patients (23 women) fulfilling the Diagnostic and Statistical Manual (DSM IV) criteria for AN were included in the study. All underwent 24-hour ECG Holter recordings, allowing QT and RR measurements, and heart rate variability (HRV) analysis in free-living conditions. A group of 25 sex- and age-matched healthy subjects served as controls. Compared with controls, AN patients presented with relative bradycardia, more particularly during night periods but neither mean QT nor corrected mean QT length (calculated using Bazett formula) over the 24 hours of monitoring differed. However, QT/RR slope was found significantly enhanced compared with normals (-2.00 +/- 0.53 vs - 1.42 +/- 0.40) (P = 0.006): QT length related to heart rate was found longer for a heart rate <55 beats/min in AN. Mean 24-hours QT length appears unaltered in AN in the absence of electrolytic disorders. However, the QT/RR relationship was enhanced reflecting the specific autonomic imbalance encountered in this population. The clinical implications of such findings need to be discussed since an equivalent enhancement of QT/RR slope has been described after myocardial infarction in patients presenting life-threatening ventricular arrhythmias.

Refeeding syndrome in patients with gastrointestinal fistula

OBJECTIVE

Although refeeding syndrome has been well documented in starved patients, obese patients, those with anorexia nervosa, malnourished elderly individuals, and certain postoperative patients, little is known about the presence and the importance of refeeding syndrome in patients with gastrointestinal fistula and insufficient nutrition support over the long term. The objective of this study was to estimate the morbidity of this syndrome in these patients, to assess the safety and efficacy of our graduated refeeding regimen, and to emphasize the importance of this syndrome.

METHODS

One hundred fifty-eight patients with gastrointestinal fistula during the past 2 y were reviewed.

RESULTS

Fifteen of these patients were diagnosed as having refeeding syndrome. They were started on the refeeding procedure according to our regimen, and changes in their serum levels of electrolytes were recorded. The symptoms and signs they presented were noted. All patients were successfully advanced to full nutrition support. During the refeeding procedure, patients presented with weakness, paralysis of limbs, slight dyspnea, paresthesia, tachycardia, edema, and diarrhea. Serum phosphorus concentration decreased in all patients within 24 h of refeeding, reaching a mean nadir after 3.3 +/- 1.5 d and another 6.1 +/- 2.1 d to return to above 0.70 mM/L upon phosphorus supplementation. Three patients treated with growth hormone presented more severe hypophosphatemia (<0.20 mM/L) than the others.

CONCLUSIONS

1) Refeeding syndrome occurs commonly in patients with malnutrition secondary to gastrointestinal fistula. 2) Alterations in phosphate metabolism are central to the refeeding syndrome. 3) Supplementation with electrolytes (including especially phosphate) and vitamins is the focal point of the treatment of this syndrome. 4) Growth hormone treatment may aggravate hypophosphatemia.

Reversibility of cardiac abnormalities in adolescents with anorexia nervosa after weight recovery

OBJECTIVE

Anorexia nervosa is a life-threatening condition, with significant risk for death due to cardiac complications. The objective of this study was to analyze the cardiac involvement in anorexia nervosa and to study the reversibility of cardiac abnormalities.

METHOD

Thirty-one consecutive adolescents (aged 12 to 17 years) with a diagnosis of anorexia nervosa were evaluated from January 1998 to January 1999 at the Hospital Clínic (University of Barcelona, Catalonia, Spain). An electrocardiogram, an echocardiogram, a 24-hour Holter recording with heart rate variability, an exercise test, and a tilt test were performed at initial examination and after refeeding (3 to 18 months later).

RESULTS

The basal body mass index was 15.2 +/- 2 kg/m2. Sinus bradycardia was found in 35% of patients, 93% showed a decreased left ventricular mass, and 70% had a diminished thickness of cardiac walls. The Holter recordings showed nocturnal bradycardia in 60% with an increased heart rate variability. After refeeding, a significant decrease in QT interval (p <.05) and QT dispersion (p <.01) was observed. Echocardiograms showed an increase in cardiac diameters (p <.01), left ventricular mass (p <.001), and cardiac output (p <.001). There was also an improvement in the exercise capacity (p <.05) and a normalization of the heart rate and heart rate variability (p <.05).

CONCLUSION

Cardiac structural and functional abnormalities provoked by anorexia nervosa are reversible in young adolescents after refeeding.

Heart rate variability and left ventricular diastolic function in anorexia nervosa

PURPOSE

To investigate the cardiac effects of starvation in a group of adolescents with anorexia nervosa (AN).

METHODS

Twenty-five patients with AN (range 13-20 years), compared with 25 age-matched thin and 25 age-matched control women with body mass index > 20 Kg/m(2), underwent a complete clinical evaluation, including echocardiogram and 24-hour electrocardiogram monitoring to evaluate heart rate variability (HRV) indices.

RESULTS

Compared to both thin and control women, patients with AN had greater HRV time domain indices (SDNN: 246.5 +/- 32.4 vs. 170.4 +/- 24 ms and vs. 181 +/- 21.2 ms, p <.001), and in the frequency domain a lower LF/HF ratio (4.2 +/- 1.3 vs. 6.7 +/- 1.2 and vs. 6.8 +/- 1.3 ms, p <.001). AN patients showed reduced left ventricular mass with normal systolic function and typical diastolic patterns, characterized by a lower peak velocity transmitral flow in late diastole (peak A: 35.9 +/- 8.5 vs. 45.2 +/- 7.3 cm/sec and vs. 46.6 +/- 6.3 cm/sec, p <.01), a comparable peak velocity in early diastole (peak E: 92.7 +/- 12.1 vs. 83 +/- 6.2 and vs. 86.8 +/- 9.1 cm/sec, ns) and, subsequently, a greater E/A ratio (2.8 +/- 0.7 vs. 1.8 +/- 0.3 and vs. 1.9 +/- .5, p <.01) than thinness and control groups. Moreover, SDNN was also positively related to E/A ratio (r =.54, p <.01).

CONCLUSIONS

Our findings demonstrate a cardiovascular vagal hyperactivity in AN, which appears to influence the ventricular diastolic dynamics. HRV and diastolic function analysis may represent useful tools in monitoring anorexia-induced cardiac modifications.

Anorexia nervosa medical issues

Anorexia nervosa is an increasingly common chronic psychiatric disorder with a multitude of medical complications. Most of these complications are reversible if there is timely restoration of body weight. A few of them, particularly osteoporosis, refeeding complications, and cardiac arrhythmia, are potentially much more serious. In the end, a multidisciplinary team approach with input from a primary care provider who is familiar with these medical sequelae, together with psychiatric and dietary expertise, can effectuate a successful outcome.

Reduced hemodynamic load and cardiac hypotrophy in patients with anorexia nervosa

BACKGROUND

Anorexia nervosa is associated with lower left ventricular mass (LVM) and systolic dysfunction. Whether these abnormalities reflect chronic protein-energy malnutrition or are primarily related to lower cardiac workload is unclear.

OBJECTIVE

The objective of the study was to verify whether low LVM in anorexia nervosa is explained by low hemodynamic load.

DESIGN

Ninety-one women with anorexia nervosa [macro x +/- SD age: 20.5 +/- 6.1 y; body mass index (in kg/m(2)): 15.6 +/- 1.9; group 1] and 62 normal-weight female control subjects (age: 22.5 +/- 5.5 y; body mass index: 20.9 +/- 1.2; group 2) underwent Doppler echocardiography. LVM was evaluated as the percentage predicted by body height, sex, and stroke work (systolic blood pressure x stroke volume).

RESULTS

The left ventricular chamber dimension was smaller and the chamber walls were thinner in group 1 than in group 2, which resulted in significantly lower LVM and LVM indexes (P < 0.0001). Ejection fraction, heart rate, stroke volume, and cardiac output were significantly (P < 0.007) lower in group 1, but peripheral resistance was substantially higher (P < 0.0001). The deviation of LVM from predicted values was lower and the proportion of subjects with inadequate LVM was significantly higher in group 1 than in group 2 (P < 0.0001). This difference was attenuated after adjustment for body weight and heart rate. There were no relations between LVM and laboratory tests in group 1.

CONCLUSIONS

Anorexia nervosa is a condition of low hemodynamic load that leads to low LVM. Even with adjustment for stroke work, however, LVM is lower than would be predicted by height, because of the effect of body weight reduction (ie, wasting of lean body mass).

QT interval dispersion in young women with anorexia nervosa

OBJECTIVES

To evaluate the degree of QT dispersion in a group of young women in the starvation phase of anorexia nervosa (AN) and its relation to left ventricular (LV) mass.

STUDY DESIGN

Sixteen patients with self-induced starvation were matched with 16 women of normal weight and 16 constitutionally thin women (body mass index <20 kg/m2). Starving patients and control patients underwent an electrocardiogram and echocardiogram. QT intervals were measured from surface electrocardiograms and QT dispersion was defined as the difference between maximum QT and minimum QT occurring in any of the 12 leads.

RESULTS

LV-chamber mass was significantly less in women with AN than in thin and normal-weight women. QT dispersion was significantly greater in AN than in the thin and control groups (QT dispersion: 50 +/- 14 vs 34 +/- 9 and 37 +/- 11 ms, P <.001; QT interval dispersion corrected for heart rate: 49+12 vs 34 +/- 9 and 36 +/- 7 ms, P <.01, respectively). A significant relation between QT dispersion and LV-mass index (r = -0.726, P <.01), and between QTc dispersion and LV mass index (r = -0.693, P < 0.01) were found only in the patients with AN.

CONCLUSION

Starving patients show an increased QT dispersion related to reduced LV mass. This result could represent a useful indicator of arrhythmic risk and sudden death in AN.

The 12-lead electrocardiogram in anorexia nervosa: A report of 2 cases followed by a retrospective study

Anorexia nervosa (AN) has been associated with various cardiac disorders and several electrocardiographic abnormalities, the most prominent being sudden death and prolonged QT duration and dispersion. We report 2 cases of AN with marked repolarization abnormalities, the first clearly related to electrolyte imbalance, the second without a good explanation from metabolic, electrolytic or pharmacological sources. A retrospective analysis of 47 other consecutive patients with AN showed that sinus bradycardia was the most common ECG finding, but that QT or QTc interval prolongation was not a typical feature, being present in only 1 patient. The sole variable slightly correlated with QTc duration was the serum potassium concentration. Consequently, marked repolarization changes (QT interval and/or T wave morphology) in AN should not be taken as a feature of the disease, but should call for the search of potential causes such as metabolic and electrolytic disturbances, drug effects, or a possible genetic component.

The importance of the refeeding syndrome

In this review we discuss the refeeding syndrome. This potentially lethal condition can be defined as severe electrolyte and fluid shifts associated with metabolic abnormalities in malnourished patients undergoing refeeding, whether orally, enterally, or parenterally. It can be associated with significant morbidity and mortality. Clinical features are fluid-balance abnormalities, abnormal glucose metabolism, hypophosphatemia, hypomagnesemia, and hypokalemia. In addition, thiamine deficiency can occur. We describe which patient groups are more at risk for this syndrome and the clinical management of the condition.

Left ventricular mass and systolic function in human immunodeficiency virus-infected patients after weight loss

Transthoracic echocardiography was performed on 27 patients with human immunodificiency virus after weight loss and in 20 lean controls. Left ventricular mass index was significantly higher and left ventricular fractional shortening was significantly lower in patients with human immunodificiency virus after weight loss than in lean, normal controls.