As American Heart Month comes to a close, Cardiology Advisor would like to bring attention to recent studies highlighting a growing prevalence of eating disorders in the United States, with increasing rates of inpatient and outpatient treatment seeking noted among people of all age groups with these illnesses since the start of the COVID-19 pandemic.1
Along with the associated psychological effects, eating disorders are linked to increased morbidity and mortality due to medical sequelae including cardiovascular dysfunction. The cardiovascular risks associated with eating disorders are especially concerning for girls and women, given the higher risk of both eating disorders and cardiovascular death in women compared to men.1,2
Data on Cardiac Impairment in Eating Disorders
In anorexia nervosa, cardiovascular complications such as QTc prolongation, arrhythmias, hypotension, and sinus bradycardia affect up to 80% of patients and represent a leading cause of death in this group.3 In bulimia nervosa, repeated purging through self-induced vomiting, laxative or diuretic abuse, or other methods can lead to severe electrolyte imbalance and resulting cardiovascular complications such as conduction disturbances.4
Additionally, a range of structural cardiac abnormalities have been observed in patients with eating disorders. “In individuals with longer-standing illness, there can be cardiac muscle weakness resulting in reduced left ventricular mass index, left ventricular atrophy, and possible mitral valve prolapse,” explained Jeff Hopkins, MD, a pediatrician providing medical management in eating disorders treatment at the Atlanta Center for Wellness in Georgia.1 “Pericardial effusions are also a common finding in almost 25% of chronic eating disorder patients.”
While cardiac dysfunction has been reported in patients with binge eating disorder and avoidant/restrictive food intake disorder, further research is needed to elucidate the complications associated with these relatively new diagnoses and other types of disordered eating.1
Various studies have found that structural cardiac abnormalities may be partially or fully reversed with weight restoration and cessation of eating disorder-related behaviors in individuals recovering from anorexia nervosa.3,5,6 In a 2022 study of 29 adult women who had received treatment for adolescent-onset anorexia nervosa more than 20 years earlier, those with normal weight at follow-up demonstrated echocardiographic and EKG parameters that were similar to those of control patients with no eating disorder history.6
Conversely, participants with low weight who still met diagnostic criteria for anorexia nervosa showed significant reductions in left ventricular end-diastolic dimensions, left ventricular mass, and left atrium dimensions when compared to the restored weight group and healthy controls.6
However, another study found persistent cardiac impairment, including increased vagal tone and endothelial dysfunction, in 46% of adult patients who had received treatment for anorexia nervosa as adolescents, with a mean time of 7.4 years from recovery to follow-up.3 Such findings underscore the important role of cardiovascular monitoring for patients with or in recovery from eating disorders.
Clinical Recommendations and Next Steps
Dr Hopkins provided several clinical recommendations regarding the recognition and management of eating disorders. For all patients with known or suspected eating disorders, he recommends a thorough cardiac history and examination, to include resting heart rate and orthostatic blood pressure measurements, baseline ECG, and chemistry panels to assess electrolyte levels.
“When encountering a patient with a possible eating disorder, it is crucial to take the needed time to obtain a detailed history in a nonjudgmental manner to increase the probability that the patient will share their thoughts and habits with the provider, and it is critical to keep a wide differential diagnosis in mind when evaluating patients,” he advised.
Dr Hopkins notes that many patients and some health care providers may attribute bradycardia to “athletic heart,” which can be a dangerous mistake in patients with eating disorders. “Those with a true ‘athletic’ heart will not see a significant increase in heart rate with brief in-office exercise—because they are indeed in good shape, while patients who have bradycardia due to an eating disorder will see a brisk increase in heart rate in response to minimal activity, as they are deconditioned and have weak baseline muscle stamina,” he said.
He adds that anecdotal reports have also indicated an increase in POTS among individuals with anorexia nervosa.1
He recommends that providers become familiar with the resources available in their local community, including nutritionists and mental health therapists specializing in eating disorders, to whom they can refer patients for detailed evaluation and evidence-based nutritional and psychological treatment if indicated. Some patients will also require ongoing consultation with a cardiologist throughout their treatment and recovery.
“Cardiologists need to be a part of the treatment team along with mental health professionals, nutritionists, and primary care providers when there is a known cardiac manifestation of a patient’s eating disorder or a pre-existing cardiac diagnosis,” Dr Hopkins explained. “There are many moving parts as a patient’s weight fluctuates, mental health changes occur, and medications are stopped and started. If a patient has had or develops cardiac abnormalities, the cardiologist will need to provide consultation and advice to the patient and other members of the team in during the care of this complicated, chronic, and potentially deadly disease.”
For providers treating patients with or at risk of eating disorders, he strongly recommends a review of the chapter on cardiac abnormalities in the book Eating Disorders: A Comprehensive Guide to Medical Care and Complications,7 which he cites as one of the most respected sources of information in the medical treatment of this patient population.
With greater awareness of the potential signs of eating disorders, Dr Hopkins notes that “cardiologists may be able to take a more active role in helping to identify these disorders in the early stages of illness when evaluating patients for bradycardia or orthostatic changes.”
Among remaining research gaps in this area, he points to the need for further investigation to determine the causes of some of the cardiac changes observed in individuals with eating disorders, with the aim of developing preventive strategies for these complications.
- Friars D, Walsh O, McNicholas F. Assessment and management of cardiovascular complications in eating disorders. J Eat Disord. Published online January 30, 2023. doi:10.1186/s40337-022-00724-5
- Lucà F, Abrignani MG, Parrini I, et al. Update on management of cardiovascular diseases in women. J Clin Med. 2022;11(5):1176. doi:10.3390/jcm11051176
- Springall GAC, Caughey M, Zannino D, et al. Long-term cardiovascular consequences of adolescent anorexia nervosa. Pediatr Res. Published online February 15, 2023. doi:10.1038/s41390-023-02521-5
- Nitsch A, Dlugosz H, Gibson D, Mehler PS. Medical complications of bulimia nervosa. Cleve Clin J Med. 2021;88(6):333-343. doi:10.3949/ccjm.88a.20168
- Choi SY, Lee KJ, Kim SC, et al. Cardiac complications associated with eating disorders in children: A multicenter retrospective study. Pediatr Gastroenterol Hepatol Nutr. Published online September 5, 2022. doi:10.5223/pghn.2022.25.5.432
- Flamarique I, Vidal B, Plana MT, et al. Long-term cardiac assessment in a sample of adolescent-onset anorexia nervosa. J Eat Disord. Published online 31, 2022. doi:10.1186/s40337-022-00533-w
- Sachs KV, Mehler PS, Krantz MJ. Chapter 7: Cardiac abnormalities and their management. In: Mehler PS, Andersen AE, eds. Eating Disorders: A Comprehensive Guide to Medical Care and Complications. 4th Johns Hopkins University Press; 2022:217-236.