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

Abstract

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.

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References

  1. 1.

    Neumarker KJ (1997) Mortality and sudden death in anorexia nervosa. Int J Eat Disord 21:205–212

    CAS  Article  PubMed Central  Google Scholar 

  2. 2.

    Halmi KA (1974) Anorexia nervosa: demographic and clinical features in 94 cases. Psychosom Med 36:18–26

    CAS  Article  PubMed Central  Google Scholar 

  3. 3.

    Fichter MM, Quadflieg N (2016) Mortality in eating disorder—results of a large prospective clinical longitudinal study. Int J Eat Disord 49(4):391–401

    Article  PubMed Central  Google Scholar 

  4. 4.

    Casiero D, Frishman WH (2006) Cardiovascular complications of eating disorders. Cardiol Rev 14(5):227–231

    Article  PubMed Central  Google Scholar 

  5. 5.

    Gottdiener JS, Gross HA, Henry WL et al (1978) Effects of selfinduced starvation on cardiac size and function in anorexia nervosa. Circulation 58:425–433

    CAS  Article  PubMed Central  Google Scholar 

  6. 6.

    Lelli L, Rotella F, Castellini G, Benni L, Lo Sauro C, Barletta G et al (2015) Echocardiographic findings in patients with eating disorders: a case–control study. Nutr Metab Cardiovasc Dis 25(7):694–696

    CAS  Article  PubMed Central  Google Scholar 

  7. 7.

    Smythe J, Colebourn C, Prisco L, Petrinic T, Leeson P (2020) Cardiac abnormalities identified with echocardiography in anorexia nervosa: systematic review and meta-analysis. Br J Psychiatry 6:1–10

    Google Scholar 

  8. 8.

    Kastner S, Salbach-Andrae H, Renneberg B, Pfeiffer E, Lehmkuhl U, Schmitz L (2012) Echocardiographic findings in adolescents with anorexia nervosa at beginning of treatment and after weight recovery. Eur Child Adolesc Psychiatry 21:15–21

    Article  PubMed Central  Google Scholar 

  9. 9.

    Docx MKF, Gewillig M, Simons A, Vandenberghe P, Weyler J, Ramet J et al (2010) Pericardial effusions in adolescent girls with anorexia nervosa: clinical course and risk factors. Eat Disord 18:218–225

    Article  PubMed Central  Google Scholar 

  10. 10.

    Sutton MGSJ, Plappert T et al (1985) Effects of reduced left ventricular mass on chamber architecture, load, and function: a study of anorexia nervosa. Circulation 72(5):991–1000

    Article  Google Scholar 

  11. 11.

    Olivares JL, Vázquez M, Fleta J, Moreno LA, Pérez-González JM, Bueno M (2005) Cardiac findings in adolescents with anorexia nervosa at diagnosis and after weight restoration. Eur J Pediatr 164(6):383–386

    Article  PubMed Central  Google Scholar 

  12. 12.

    Frölich J, von Gontard A, Lehmkuhl G et al (2001) Pericardial effusions in anorexia nervosa. Eur Child Adolesc Psychiatry 10:54–57

    Article  PubMed Central  Google Scholar 

  13. 13.

    (2013) Diagnostic and statistical manual of mental disorders (DSM-5®). American Psychiatric Pub

  14. 14.

    Garner DM (1991) Eating disorder Inventory-2. Professional manual. Florida: Psychological Assessment Resources

  15. 15.

    Shuter B, Alsani A (2000) Body surface area: Du Bois and Du Bois revisited. Eur J Appl Physiol 82(3):250–254

    CAS  Article  PubMed Central  Google Scholar 

  16. 16.

    Malik M (2001) Problems of heart rate correction in assessment of drug-induced QT interval prolongation. J Cardiovasc Electrophysiol 12:411–420

    CAS  Article  PubMed Central  Google Scholar 

  17. 17.

    Lang RM, Badano LP, Mor-Avi V et al (2016) Recommendations for cardiac chamber quantification by echocardiography in adults: an update from the American Society of Echocardiography and the European Association of Cardiovascular Imaging. Eur Heart J Cardiovasc Imaging 17(4):412

    Article  Google Scholar 

  18. 18.

    Zoghbi WA, Adams D, Bonow RO et al (2017) Recommendations for noninvasive evaluation of native valvular regurgitation: a report from the american society of echocardiography developed in collaboration with the society for cardiovascular magnetic resonance. J Am Soc Echocardiogr 30(4):303–371

    Article  PubMed Central  Google Scholar 

  19. 19.

    Addetia K, Mor-Avi V, Weinert L, Salgo IS, Lang RM (2014) A new definition for an old entity: improved definition of mitral valve prolapse using three-dimensional echocardiography and color-coded parametric models. J Am Soc Echocardiogr 27(1):8–16

    Article  Google Scholar 

  20. 20.

    Carpentier A, Adams DH, Filsoufi F (2010) Pathophysiology, preoperative valve analysis, and surgical indications. In: Carpentier A, Adams DH, Filsoufi F (eds) Carpentier’s reconstructive valve surgery, 1st edn. Saunders Elsevier, Maryland Heights, pp 43–53

    Chapter  Google Scholar 

  21. 21.

    Klein A, Abbara S, Agler DA, Appleton CP, Asher CR, Hoit B, Hung J, Garcia MJ, Kronzon I, Oh JK, Rodriguez ER, Schaff HV, Schoenhagen P, Tan CD, White RD (2013) American Society of Echocardiography clinical recommendations for multimodality cardiovascular imaging of patients with pericardial disease: endorsed by the Society for Cardiovascular Magnetic Resonance and Society of Cardiovascular Computed Tomography. J Am Soc Echocardiogr 26(9):965-1012.e15

    Article  PubMed Central  Google Scholar 

  22. 22.

    Ramacciotti CE, Coli E, Biadi O, Dell’Osso L (2003) Silent pericardial effusion in a sample of anorexic patients. Eat Weight Disord 8(1):68–71

    CAS  Article  PubMed Central  Google Scholar 

  23. 23.

    Nagueh SF, Smiseth OA, Appleton CP, Byrd BF 3rd, Dokainish H, Edvardsen T et al (2016) Recommendations for the evaluation of left ventricular diastolic function by echocardiography: an update from the american society of echocardiography and the European association of cardiovascular imaging. J Am Soc Echocardiogr 29(4):277–314

    Article  PubMed Central  Google Scholar 

  24. 24.

    Arcelus J, Mitchell AJ, Wales J, Nielsen S (2011) Mortality rates in patients with anorexia nervosa and other eating disorders. A meta-analysis of 36 studies. Meta-Analysis. Arch Gen Psychiatry 68(7):724–731

    Article  PubMed Central  Google Scholar 

  25. 25.

    Silvetti MS, Magnani M, Santilli A, Di Liso G, Diamanti A, Pompei E, Gambarara M, Montecchi F, Ragonese P (1998) The heart of anorexic adolescents. G Ital Cardiol 28(2):131–139

    CAS  PubMed  PubMed Central  Google Scholar 

  26. 26.

    Webb JG, Kiess MC, Chan-Yan CC (1986) Malnutrition and the heart. CMAJ 135(7):753–758

    CAS  PubMed  PubMed Central  Google Scholar 

  27. 27.

    Escudero CA, Potts JE, Lam PY, De Souza AM, Mugford GJ, Sandor GGS (2016) An echocardiographic study of left ventricular size and cardiac function in adolescent females with anorexia nervosa. Eur Eat Disord Rev 24(1):26–33

    Article  PubMed Central  Google Scholar 

  28. 28.

    Billeci L, Brunori E, Scardigli S, Curzio O, Calderoni S, Maestro S, Morales MA (2018) Excessive physical activity in young girls with restrictive-type anorexia nervosa: its role on cardiac structure and performance. Eat Weight Disord 23(5):653–663

    Article  PubMed Central  Google Scholar 

  29. 29.

    Ulger Z, Gürses D, Ozyurek AR, Arikan C, Levent E, Aydoğdu S (2006) Follow-up of cardiac abnormalities in female adolescents with anorexia nervosa after refeeding. Acta Cardiol 61(1):43–49

    Article  PubMed Central  Google Scholar 

  30. 30.

    Kollai M, Kollai B (1992) Cardiac vagal tone in generalised anxiety disorder. Br J Psychiatry 161:831–835

    CAS  Article  PubMed Central  Google Scholar 

  31. 31.

    Yahalom M, Spitz M, Sandler L, Heno N, Roguin N, Turgeman Y (2013) The significance of bradycardia in anorexia nervosa. Int J Angiol 22(2):83–94

    Article  PubMed Central  Google Scholar 

  32. 32.

    Di Vasta AD, Walls CE, Feldman HA, Quach AE, Woods ER, Gordon CM, Alexander ME (2010) Malnutrition and hemodynamic status in adolescents hospitalized for anorexia nervosa. Arch Pediatr Adolesc Med 164(8):706–713

    Google Scholar 

  33. 33.

    Lamzabi I, Syed S, Reddy VB, Jain R, Harbhajanka A, Arunkumar P (2015) Myocardial changes in a patient with anorexia nervosa: a case report and review of literature. Am J Clin Pathol 143(5):734–737

    Article  PubMed Central  Google Scholar 

  34. 34.

    Vázquez M, Olivares JL, Fleta J, Lacambra I, González M (2003) Cardiac disorders in young women with anorexia nervosa. Rev Esp Cardiol 56(7):669–673

    Article  PubMed Central  Google Scholar 

  35. 35.

    Caregaro L, Favaro A, Santonastaso P, Alberino F, Di Pascoli L, Nardi M, Favaro S, Gatta A (2001) Insulin-like growth factor 1 (IGF-1), a nutritional marker in patients with eating disorders. Clin Nutr 20(3):251–257

    CAS  Article  PubMed Central  Google Scholar 

  36. 36.

    Krantz MJ, Lee D, Donahoo WT, Mehler PS (2005) The paradox of normal serum albumin in anorexia nervosa: a case report. Int J Eat Disord 37(3):278–280

    Article  PubMed Central  Google Scholar 

  37. 37.

    Lang RM, Badano LP, MorAvi V, Afilalo J, Armstrong A, Ernande L, Flachskampf FA, Elyse F, Goldstein SA, Kuznetsova T, Lancellotti P, Muraru D, Picard MH, Rietzschel ER, Rudski L, Spencer KT, Tsang W, Voigt JU (2015) Recommendations for cardiac chamber quantification by echocardiography in adults: an update from the American Society of Echocardiography and the European Association of Cardiovascular Imaging. J Am Soc Echocardiogr 28(1):1–3914

    Article  PubMed Central  Google Scholar 

  38. 38.

    Teichholz LE, Kreulen T, Herman MV, Gorlin R (1976) Problems in echocardiographic volume determinations: echocardiographic-angiographic correlations in the presence of absence of asynergy. Am J Cardiol 37(1):7–11

    CAS  Article  PubMed Central  Google Scholar 

  39. 39.

    Burup Kristensen C, Steensgaard-Hansen F, Aagaard Myhr K, Jørgen Løkkegaard N, Høyer Finsen S, Hassager C, Møgelvang R (2020) Left ventricular mass assessment by 1- and 2-dimensional echocardiographic methods in hemodialysis patients: changes in left ventricular volume using echocardiography before and after a hemodialysis session. Kidney Med 2(5):578–588

    Article  Google Scholar 

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Acknowledgements

We thank Doctor Elena Epis and Doctor Emilio Bergamelli for the contribution in data collection and our sonographer, Alessia Zaniboni and Dario Sansalone, for the high quality of their work.

Funding

This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.

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All authors contributed equally to the manuscript and read and approved the final version of the manuscript.

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Correspondence to G. Santangelo.

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The data underlying this article will be shared on reasonable request to the corresponding author.

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All study procedures were approved by the Partners Healthcare Institutional Review Board (protocol number 2020/ST/193) and carried out in accordance with the Declaration of Helsinki.

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Freely given informed consent to collect data was obtained from participants.

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Santangelo, G., Bursi, F., Toriello, F. et al. Echocardiographic changes in anorexia nervosa: a pathophysiological adaptation or a disease?. Intern Emerg Med (2021). https://doi.org/10.1007/s11739-021-02871-0

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Keywords

  • Anorexia nervosa
  • Echocardiography
  • Pericardial effusion
  • Mitral regurgitation