Holiday heart syndrome: Difference between revisions

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* [[Psychological stress]]
* [[Psychological stress]]
* [[Wolff-Parkinson-White syndrome]]
* [[Wolff-Parkinson-White syndrome]]
*[[Congestive heart failure|Heart failure]]
*Thyroid disease
*Chronic lung disease
*Drugs like [[cocaine]] and [[methamphetamine]]
*Asthma medications and over-the-counter cold and allergy drugs
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|
* Palpitations
* Shortness of breath
* Dizziness
* Sweating
* A pounding sensation in the neck
* Syncope
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|
* [[Electrolyte|Electrolytes]] like Na<sup>+</sup>, K<sup>+</sup>, and Ca<sup>2+</sup> -electrolyte abnormalities is a major factor for paroxysmal supraventricular tachycardia
* Thyroid function tests are done to look for [[hyperthyroidism]], which is a potential cause of paroxysmal supraventricular tachycardia
* [[Complete blood count (CBC)|Complete blood count]]
|
|
* Regular rhythm
* Regular rhythm

Revision as of 20:39, 8 June 2020

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Raviteja Guddeti, M.B.B.S. [2] Aditya Ganti M.B.B.S. [3] Apeksha Gupta, MBBS[4]

Overview

Holiday heart syndrome is a clinical presentation of irregular heartbeat pattern, in individuals who are otherwise healthy. It can be the result of stress, dehydration, and drinking. The most common cause of this syndrome is excessive alcohol consumption. Usually associated with binge drinking, it has also been documented in patients who are not heavy alcohol drinkers. The pathophysiology of holiday heart syndrome, or alcohol-induced arrhythmia, is complex, and therefore not completely understood. The most commonly accepted therapy is that chronic ethanol use in large quantities, leads to cardiac structural and cellular changes through a buildup of ethanol and its metabolites. The incidence and prevalence of holiday heart syndrome is unclear due to conflicting evidence. Left untreated, it may culminate in severe cardiomyopathy, valvular disease, and ultimately death. Some patients may develop end-stage liver disease which also has a poor prognosis. If diagnosed early and treated with measures such as alcohol cessation, the prognosis for holiday heart disease is good, as the disease is reversible. Patients with acute exposure to alcohol can present with a variety of symptoms. Holiday heart syndrome is also known as alcohol-induced atrial fibrillation. The finding on physical examination are characteristic, patients show features of alcohol intoxication and their breath smells of alcohol. There could be changes in the mental status, as the person is intoxicated and sometimes hypotensive. Depending on the cardiac rhythm, the patient may have an irregular or thready pulse. Complete blood count may show macrocytic anemia via an elevated mean corpuscular volume. Sometimes an elevated white blood cell count may be seen as alcoholics have decreased immunity and tend to get sick more often. Complete metabolic panel may show 2:1 aspartate aminotransferase (AST) to alanine aminotransferase (ALT) ratio. Twelve-lead electrocardiography (ECG) is essential to exclude other cardiac pathologies like ischemia, infarction, pulmonary embolism, or hypertrophy. A chest x-ray may show cardiomegaly. An echocardiogram should be performed to evaluate for any structural abnormalities and to assess the cardiac status and function. Echocardiography is the standard diagnostic method for assessment of cardiac chamber enlargement, left ventricular (LV) wall motion abnormalities, hypertrophy, valvular disease, and both systolic and diastolic dysfunction.The mainstay of treatment for holiday heart syndrome depends on the patients vitals at the time of presentation. For unstable patients with atrial fibrillation, cardioversion is the recommended treatment. If the patient is stable, the therapeutic indication is for arrhythmia treatment.[1]

Historical Perspective

  • Holiday Heart Syndrome was first identified back in 1978 (Ettinger et al) who conducted a study on subjects who regularly consumed heavy quantities of alcohol and also took part in a drinking binge prior to the study evaluation.The term was thus coined by Ettinger et al in 1978.[2][3]

Pathophysiology

  • The pathophysiology of holiday heart syndrome, or alcohol-induced arrhythmia, is complex, and thus remains unresolved.[4]
  • It may be due to the direct myotoxic effects of alcohol or the indirect effects caused by its metabolism.
  • The most accepted theory is that chronic ethanol consumption in large quantity, leads to cardiac structural and cellular changes through the accumulation of ethanol and its metabolites.
  • These metabolites cause oxidative damage, mitochondrial dysfunction, cell death, lower the effects of cardio-protective molecules, alter protein synthesis and impair calcium transport.
  • The most common metabolite responsible for these changes is acetaldehyde, which is produced by the liver by a chemical reaction with alcohol dehydrogenase.
  • It is believed to cause arrhythmias by increasing the systemic and intra-myocardial catecholamines (epinephrine and norepinephrine), thus causing the imbalance in the autonomic nervous system.
  • It also causes the activation of the Parasympathetic Nervous System, thus causing increased vagal tone and slowing the refractory period of atrium.
  • This high risk of electrical disturbance in the Holiday heart syndrome, is just like dilated cardiomyopathy.
  • On a microscopic level, patients with Holiday heart have visible changes to the structure of the mitochondrial reticulum in the myocytes.
  • Apart from the electrical similarity with dilated cardiomyopathy, the gross changes seen at the tissue level are similar in a patient with Holiday heart syndrome.
  • The most common arrhythmia seen in patients with Holiday heart syndrome is Atrial fibrillation, followed by atrial flutter and premature ventricular contractions.

Causes

  • The most common cause of holiday heart syndrome is excessive alcohol consumption. The risk is further accentuated by binge drinking episodes by people who already have a chronic drinking background. So on the whole it is a combination of trigger factors like :
  • Drinking too much alcohol or caffeine
  • Overeating
  • Fatigue
  • Stress
  • Dehydration

Differentiating Holiday Heart Syndrome from Other Diseases

Holiday heart syndrome must be differentiated from

Disorders Etiology Clinical Presentation Laboratory findings Electrocardiogram Echocardiography
Atrial Fibrillation
  • General fatigue
  • Rapid and irregular heartbeat
  • Fluttering in the chest
  • Dizziness
  • Shortness of breath and anxiety
  • Fainting
  • Sweating
  • Chest pain

  • Irregularly irregular rhythm
  • Absent P wave
  • Fibrillatory waves
  • PR interval absent
  • QRS interval less than 0.12 seconds, consistent, and normal in morphology in the absence of aberrant conduction


Atrial Flutter


  • Irregular or regular rhythm
  • Sawtooth pattern of P waves at 250 to 350 bpm
  • Biphasic deflection in V1
  • PR interval varies
  • QRS interval less than 0.12 seconds, consistent, and normal in morphology


Paroxysmal Supraventricular Tachycardia
  • Palpitations
  • Shortness of breath
  • Dizziness
  • Sweating
  • A pounding sensation in the neck
  • Syncope
  • Electrolytes like Na+, K+, and Ca2+ -electrolyte abnormalities is a major factor for paroxysmal supraventricular tachycardia
  • Thyroid function tests are done to look for hyperthyroidism, which is a potential cause of paroxysmal supraventricular tachycardia
  • Complete blood count
  • Regular rhythm
  • P wave absent or hidden in QRS
  • PR interval absent
  • Narrow complexes (< 0.12 s)
Dilated Cardiomyopathy
  • S2 at the base
  • Ventricular and atrial dilatation
  • Increased left ventricular mass
  • Global reduction in systolic function
  • Focal wall motion abnormalities
Hyperthyroidism
  • Elevated T3 and T4 hormones
  • TSH: Reduced in 1ry and Elevated in 2ry hyperthyroidism.
  • Thyroid stimulating antibodies: Elevated only in Grave's disease
The following may be present:
  • Left ventricular enhanced systolic function
  • Enhanced or impaired diastolic function
  • Heart failure with preserved ejection fraction
Pulmonary Embolism


Blood tests:


On CT angiography:

  • Intra-luminal filling defect


On MRI:

  • Narrowing of involved vessel
  • No contrast seen distal to obstruction
  • Polo-mint sign (partial filling defect surrounded by contrast)


  • Direct visualization of Thrombi in Right atrium or Pulmonary artery
  • Right ventricular dilatation
  • Right ventricular dysfunction
  • Pulmonary artery dilatation
  • Normal or hyper-dynamic Left ventricle

Epidemiology and Demographics

  • The incidence and prevalence of holiday heart syndrome is unclear due to conflicting evidence. It is a common presentation in the emergency room, around 35-62% of atrial fibrillation cases precipitated by alcohol drinking.

Natural History, Complications, and Prognosis

Natural History

Complications

Prognosis

  • The overall prognosis of Holiday Heart Syndrome depends on the presence of any underlying heart disease.
  • If diagnosed early and treated with alcohol cessation, the prognosis for holiday heart disease is good as the disease is reversible.

Diagnosis

History and Symptoms

  • The attacks occur more frequently either in the early morning or late at night, but have also been reported during daytime.
  • Patients often give a history of heavy alcohol intake prior to the episode.
  • A history of alcoholism should alert physicians to concomitant illnesses such as alcohol-related cardiomyopathy and chronic liver disease.

Symptoms

Patients suffering from Holiday heart Syndrome suffer from the following symptoms:

  • Dizziness
  • Dyspnea on exertion
  • Chest pain
  • Unconsciousness
  • Heart palpitations.
  • Fatigue
  • Weakness
  • Angina
  • Other signs of alcohol intoxication. Patients with acute exposure to alcohol can present with a variety of symptoms.The most common symptoms are :
    • palpitations during exertion
    • reduced physical ability
    • palpitations at rest
    • shortage of breath during exertion
    • anxiety
  • Some patients can also have uncommon symptoms like:
    • Swollen legs
    • Nausea
    • Anxiety

Physical Examination

  • On physical examination, the patient with holiday heart syndrome may show signs of alcohol intoxication and strong odor of alcohol in their breath.[6]

Laboratory Findings

  • Twelve-lead electrocardiography (ECG) is essential to exclude other cardiac pathology such as ischemia, infarction, pulmonary embolism, or hypertrophy.
  • A chest x-ray may show cardiomegaly.
  • An echocardiogram should be performed to evaluate for any structural abnormalities and to assess cardiac function.
  • Echocardiography is the standard of care for assessment of cardiac chamber enlargement, left ventricular (LV) wall motion abnormalities, hypertrophy, valvular disease, and both systolic and diastolic dysfunction.
  • Liver disease is often a feature holiday heart syndrome as alcohol damages the liver. Therefore, ultrasound of the liver may reveal liver cirrhosis.

Treatment

Usually the symptoms associated with holiday heart syndrome, that is atrial fibrillation and other conduction abnormalities, dissipate with appropriate rest and hydration within a couple of hours. But if they persist longer or the symptoms get severe, medical attention is required.The mainstay of treatment for holiday heart syndrome depends on the patients vitals at the time of presentation. The patient will be attached to a heart monitor to evaluate the rhythm of the heart and confirm the diagnosis.The mainstay of treatment for holiday heart syndrome depends on the patients vitals at the time of presentation.

  • If the patient presents with atrial fibrillation, an IV line is started for hydration and depending on the heart rate, medication is administered to slow the heart rate.
  • If the patient is unstable and has atrial fibrillation, cardioversion is the recommendation.
  • If the patient is stable, the therapeutic indication is for arrhythmia treatment.
    • Complete alcohol cessation was needed to see a reversal of the disease process,
    • The patient must be encouraged to join alcoholics anonymous (AA) and other support groups.
  • Patients presenting to the emergency department with sustained tachyarrhythmia secondary to acute alcohol toxicity usually can be observed with electrocardiographic monitoring.

Prevention

  • Drink in moderate quantities.
  • Replace electrolytes like potassium and others which are lost through urination. Drink sufficient water as dehydration is a major cause of electrolyte imbalances.
  • Limit the intake of salt and sugar in diet, as it can raise the blood pressure.
  • Control stress, which can increase your heart rate and blood pressure.

References

  1. Nissen MB, Lemberg L (1984). "The "holiday heart" syndrome". Heart & Lung : the Journal of Critical Care. 13 (1): 89–92. PMID 6559190. Unknown parameter |month= ignored (help)
  2. Ettinger PO, Wu CF, De La Cruz C, Weisse AB, Ahmed SS, Regan TJ (1978). "Arrhythmias and the "Holiday Heart": alcohol-associated cardiac rhythm disorders". Am. Heart J. 95 (5): 555–62. doi:10.1016/0002-8703(78)90296-X. PMID 636996. Unknown parameter |month= ignored (help)
  3. Luck JC, Engel TR (1983). "Arrhythmias and social drinking". Annals of Internal Medicine. 98 (2): 253. PMID 6824262. Unknown parameter |month= ignored (help)
  4. Brown KN, Yelamanchili VS, Goel A. PMID 30725870. Missing or empty |title= (help)
  5. Bhardwaj P, Chaudhury S (January 1996). "HOLIDAY HEART SYNDROME: A Case Report". Med J Armed Forces India. 52 (1): 61–62. doi:10.1016/S0377-1237(17)30840-7. PMC 5530300. PMID 28769342.
  6. Koskinen P, Kupari M, Leinonen H, Luomanmäki K (May 1987). "Alcohol and new onset atrial fibrillation: a case-control study of a current series". Br Heart J. 57 (5): 468–73. doi:10.1136/hrt.57.5.468. PMC 1277202. PMID 3593617.

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