Holiday Heart Syndrome—real or myth?
proactive approach with risk stratification
By Ramon F. Abarquez, Jr. MD, EFACC, FAsCC, FPCP, FPCC, CSPSH
Academician, National Academy of Science and Technology Professor Emeritus, College of Medicine, University of the Philippines Chair, Philippine Medical Association Continuing Medical Education Commission
EACH HOLIDAY SEASON, particularly during the Yuletide long vacation, solicited or not, the health advisory is usually moderation rather than ‘binge’ activities. However, should everyone celebrating the ‘Birth of the Lord’ be over-cautious? Or is there a ‘limited-few’ who are at greater adverse risk? The challenge for physicians is to identify these individuals who are at risk so they could be properly forewarned and adequately treated.
The coming holidays maybe a solemn ceremonial to some or a festive reunion to the majority. But more importantly, reflective opportunities should be primordial. Why? The season may translate into clinically preventable morbidity and mortality consequences.
The “Holiday Heart” syndrome was coined in 1978, to describe patients who had atrial fibrillation following ‘binge alcohol’ drinking. (Glatter, Curr Treat Options Cardiovasc Med. 2012;14(5):529-35)
Is ‘binge drinking’ also prone to an episode of ventricular fibrillation leading to sudden death that may be a random occurrence or weather-related? In a mortality review in Australia, (January 1, 2008 to December 31, 2009) most cases had holiday-related deaths. (Bierton, Forensic Sci Med Pathol. 2012; Oct 12) Usually the ‘at-risk-individual’ is more prone to be the victim. Thus, considerable options for risk stratification with positive action plans can result into opportunities for a progressive quality of life improvement that should be incorporated in any New Year’s ‘must-do’ resolution.
Assessing risk profile
Poor prognosis is related to target organ damage and not to the mere presence of high BP, dyslipidemia, DM, obesity or smoking.”Heart burns” or reflux esophagitis caes, even with medical therapy, are also at risk of sudden death in a retrospective Finnish study. (Rantanen, Am J Gastroenterols.2007;102(2):246-53); and especially among those patients taking domperidone (Prescrire Int. 2012;21(129):183)
Cases with post-prandial bradycardia (Mizumaki,J Cardiovasc Electrophysiol. 2007;18(8):839-44) or hyperglycemia related AF are also at higher risk. (Kato, J Cardiol. 2006;48(5):269-720) particularly among cases with ‘full-stomach’ (Ikeda, J Cardiovasc Electrophysiol. 2006;17(6):602-7)
Diabetic cases with post-prandial reactive hypoglycemia (Brun, Diabetes Metab.2000;26(5):337-51.) can develop AV blocks. (Okamoto, Intern Med. 1997;36(8):579-81) A year after diagnosis of ‘unspecified chest pain’ attributable to cardiac, gastrointestinal, respiratory, psychological or musculoskeletal etiologies and after adjustment for age, sex and number of primary consultations, the odds of an eventual diagnosis of heart failure or coronary heart disease were 4.7 and 14.9 times greater, respectively compared to control, Similarly, the odds of a diagnosis of gastro-esophageal reflux disease (GERD), hiatus hernia or peptic ulcer disease were associated with at least threefold risk more than those with psychological, respiratory and musculoskeletal impression.
More importantly, mortality rate was increased among patients with “unspecified chest pain” during a mean follow-up period of 4 years with 842 of 13 740 (6.12 percent) patients dead in the unspecified chest pain cohort, compared with 710 of 20 000 (3.55 percent) patients in the control cohort. (Ruigomez, Family Practice 2006;23 (2):167-174)
The role of cigarette smoking on cardiac arrhythmia is less clearly defined wherein pro-fibrotic effect of nicotine on myocardial tissue with consequent increased susceptibility to catecholamine could be the mechanism. (D’Alessandro, Eur J Prev Cardiol. 2012;19(3):297-305) More importantly however, after the ‘no-smoking law’ in restaurants and work-place was enforced in Olmstead County, Minnesota, the incidence of acute MI and sudden cardiac death decreased by 33 percent and 17 percent respectively in 18 months despite the persistent prevalence of hypertension, DM, dyslipidemia and obesity. (Hurt, Arch Intern Med.2012;29:1-7) Furthermore, mothers smoking 1-10 and > 10 sticks of cigarettes daily give a 2.93 and 4.36 times more infant sudden death, respectively.
Binge eating, drinking
During holidays with festive moods, binge eating and drinking are widely hypothesized to be related to idiopathic tachyarrhythmias that can lead to sudden death.(Fuenmayor, Int J Cardiol. 1997 ;59(1):101-3.) Dysrrhythmias are considered to be frequently alcohol-related and confirmed by positive screening test for alcoholism. Among 289 patients (aged < 65 years) admitted for supraventricular tachyarrhythmias, 35.3 percent had idiopathic arrhythmia with a known drink related onsettime, specifi cally more often among chronic alcohol abusers. Arrhythmia, independent of the most recent ethanol use, occurred during weekends (47 percent), during weekdays (22 percent; p = 0.040) compared to out-of-hospital population (12 percent; p = 0.002). However, the increased frequency of problem drinkers among patients with weekend-onset idiopathic arrhythmias was only relative since the number of abstainers and non-problem drinkers have decreased. (Kupari, Am J Cardiol. 1991;67(8):718-22) However, even among those with no known cardiac disease, the most frequent tachyarrhythmia is atrial fi brillation and less frequently, but with worse prognosis, is ‘torsades de pointes’ polymorphic ventricular tachycardia. (Treibal, Vnitr Lek.2008;54(4):410-4)