Holiday heart syndrome: Difference between revisions

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==Overview==
==Overview==
Holiday heart syndrome is an irregular heartbeat pattern presented in individuals who are otherwise healthy. It can be the result of stress, dehydration, and drinking. Usually this syndrome is associated with [[binge drinking]]. However, it may also occur in patients who usually drink little or no alcohol. <ref name="pmid6559190">{{cite journal |author=Nissen MB, Lemberg L |title=The "holiday heart" syndrome |journal=[[Heart & Lung : the Journal of Critical Care]] |volume=13 |issue=1 |pages=89–92 |year=1984 |month=January |pmid=6559190 |doi= |url=}}</ref>
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 diseases|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 heart rhythms|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 [[Cardiac arrhythmia|arrhythmia]] treatment.<ref name="pmid6559190">{{cite journal |author=Nissen MB, Lemberg L |title=The "holiday heart" syndrome |journal=[[Heart & Lung : the Journal of Critical Care]] |volume=13 |issue=1 |pages=89–92 |year=1984 |month=January |pmid=6559190 |doi= |url=}}</ref>


==Historical Perspective==
==Historical Perspective==
The term was coined by Ettinger et al in 1978.<ref>{{cite journal |author=Ettinger PO, Wu CF, De La Cruz C, Weisse AB, Ahmed SS, Regan TJ |title=Arrhythmias and the "Holiday Heart": alcohol-associated cardiac rhythm disorders |journal=Am. Heart J. |volume=95 |issue=5 |pages=555–62 |year=1978 |month=May |pmid=636996 |doi=10.1016/0002-8703(78)90296-X}}</ref><ref name="pmid6824262">{{cite journal |author=Luck JC, Engel TR |title=Arrhythmias and social drinking |journal=[[Annals of Internal Medicine]] |volume=98 |issue=2 |pages=253 |year=1983 |month=February |pmid=6824262 |doi= |url=}}</ref>
 
* 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.<ref>{{cite journal |author=Ettinger PO, Wu CF, De La Cruz C, Weisse AB, Ahmed SS, Regan TJ |title=Arrhythmias and the "Holiday Heart": alcohol-associated cardiac rhythm disorders |journal=Am. Heart J. |volume=95 |issue=5 |pages=555–62 |year=1978 |month=May |pmid=636996 |doi=10.1016/0002-8703(78)90296-X}}</ref><ref name="pmid6824262">{{cite journal |author=Luck JC, Engel TR |title=Arrhythmias and social drinking |journal=[[Annals of Internal Medicine]] |volume=98 |issue=2 |pages=253 |year=1983 |month=February |pmid=6824262 |doi= |url=}}</ref>


==Pathophysiology==
==Pathophysiology==


* Holiday heart syndrome is defined as "[[arrhythmias]] of the [[heart]], sometimes apparent after a [[vacation]] or weekend away from work, following excessive [[alcohol]]consumption; usually transient". <ref name="pmid8805002">{{cite journal |author=Menz V, Grimm W, Hoffmann J, Maisch B |title=Alcohol and rhythm disturbance: the holiday heart syndrome |journal=[[Herz]]|volume=21 |issue=4 |pages=227–31 |year=1996 |month=August |pmid=8805002 |doi= |url=}}</ref>
* The pathophysiology of holiday heart syndrome, or alcohol-induced arrhythmia, is complex, and thus remains unresolved <ref name="pmid30725870">{{cite journal |vauthors=Brown KN, Yelamanchili VS, Goel A |title= |journal= |volume= |issue= |pages= |date= |pmid=30725870 |doi= |url=}}</ref><ref name="pmid14631348">{{cite journal |vauthors=Sterner KL, Keough VA |title=Holiday heart syndrome: A case of cardiac irritability after increased alcohol consumption |journal=J Emerg Nurs |volume=29 |issue=6 |pages=570–3 |date=December 2003 |pmid=14631348 |doi=10.1016/j.jen.2003.10.002 |url=}}</ref>
* Irregular heartbeats are very serious and result mostly from [[supraventricular tachycardia]]s.
* It may be due to the direct myotoxic effects of alcohol or the indirect effects caused by its metabolism.
* If palpitations continue for longer than a few hours patients should seek medical attention.
 
* [[Atrial fibrillation]] is the most common arrhythmia in holiday heart syndrome and can result in very serious consequences such as [[stroke]], but a variety of changes in the intervals and morphology of the [[EKG]] may occur (irregular series of QRS complexes and absent p waves).
=== There are several mechanisms believed to be the causative factor of holiday heart syndrome : ===
* Other frequently observed arrhythmias include [[atrial flutter]], [[atrial tachycardia]], [[junctional tachycardia]], multiple APC's, multiple [[PVC]]'s and [[ventricular tachycardia]]. <ref name="pmid15875505">{{cite journal |author=Alboni P, Gianfranchi L, Pacchioni F, Pedaci M |title=Antiarrhythmic drugs in patients with recurrent atrial fibrillation: where are we? |journal=[[Italian Heart Journal : Official Journal of the Italian Federation of Cardiology]] |volume=6 |issue=3 |pages=169–74 |year=2005 |month=March |pmid=15875505 |doi= |url=}}</ref><ref name="pmid6824246">{{cite journal |author=Greenspon AJ, Schaal SF |title=The "holiday heart": electrophysiologic studies of alcohol effects in alcoholics |journal=[[Annals of Internal Medicine]] |volume=98 |issue=2 |pages=135–9 |year=1983 |month=February |pmid=6824246 |doi= |url=}}</ref>
* In patients with new onset atrial fibrillation and no overt pre-existing heart disease, holiday heart syndrome should be considered as a part of differential diagnosis.


=== Pathophysiology ===
*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.
*It causes oxidative stress to the myocardium by increasing the generation of free radicals and activating the Renin Angiotensin system.
* These metabolites cause [[Oxidation|oxidative damage]], [[Mitochondrial disease|mitochondrial dysfunction]], [[Programmed cell death|cell death]], lower the effects of cardio-protective molecules, alter [[protein synthesis]] and [[calcium transport|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]].
*Acetaldehyde is a major factor responsible for apoptosis which leads to myocytes loss and adverse remodeling <ref name="pmid2913506">{{cite journal |vauthors=Urbano-Marquez A, Estruch R, Navarro-Lopez F, Grau JM, Mont L, Rubin E |title=The effects of alcoholism on skeletal and cardiac muscle |journal=N. Engl. J. Med. |volume=320 |issue=7 |pages=409–15 |date=February 1989 |pmid=2913506 |doi=10.1056/NEJM198902163200701 |url=}}</ref>.
*Another factor responsible in an altered fatty acid metabolism.
*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 <ref name="pmid27931615">{{cite journal |vauthors=Voskoboinik A, Prabhu S, Ling LH, Kalman JM, Kistler PM |title=Alcohol and Atrial Fibrillation: A Sobering Review |journal=J. Am. Coll. Cardiol. |volume=68 |issue=23 |pages=2567–2576 |date=December 2016 |pmid=27931615 |doi=10.1016/j.jacc.2016.08.074 |url=}}</ref>. This high risk of electrical disturbance in the Holiday heart syndrome, is just like dilated cardiomyopathy.
*On a microscopic level, findings in alcoholic cardiomyopathy are indistinguishable and similar to the findings in dilated cardiomyopathy.
*The structure of the mitochondrial reticulum in the myocytes is grossly altered.
* The most common arrhythmia seen in patients with Holiday heart syndrome is Atrial fibrillation, followed by atrial flutter and premature ventricular contractions <ref name="pmid636996">{{cite journal |vauthors=Ettinger PO, Wu CF, De La Cruz C, Weisse AB, Ahmed SS, Regan TJ |title=Arrhythmias and the "Holiday Heart": alcohol-associated cardiac rhythm disorders |journal=Am. Heart J. |volume=95 |issue=5 |pages=555–62 |date=May 1978 |pmid=636996 |doi=10.1016/0002-8703(78)90296-x |url=}}</ref>.


* Several mechanisms are theorized to be responsible for the arrhythmogenicity of alcohol.
==Causes==
* They may be characterized into two broad groups: direct effects on the myocardium and alcohol's effect on traditional risk factors for atrial fibrillation.
* With regard to direct effects on the atrial myocardium, alcohol causes a autonomic nervous system imbalance.
* Alcohol increases sympathetic nervous system (SNS) activity (and its related increased secretion of epinephrine and norepinephrine), with resultant effects including an increased release of calcium into the myocytes from the sarcoplasmic reticulum.
* Increased SNS activity is further evidenced by a marked increase in the incidence of sinus tachycardia and reduced respiratory sinus arrhythmia during acute alcohol intoxication.
* Consequently, the parasympathetic nervous system (PNS) is activated as well, with an increased intermittent vagal tone, which has been shown to also shorten the atrial refractory period and preciptate atrial fibrillation.
* Note that the risk of atrial fibrillation persists into the "hangover" and/or withdrawal phase, which corresponds with an increased sympathetic tone.
* Other direct effects on the myocardium are perhaps less well studied.
** They include the effects of alcohol's primary metabolite acetaldehyde, which is associated with local inflammation and oxidative stress.
**  Alcohol itself can also directly decrease the myocyte sodium current and can affect intracellular pH, ether causing acidosis with low doses or alkalosis with higher doses. Interestingly, these effects may be species specific, with rabbits and humans being similarly affected, whereas canine atria appear unaffected.
* Binge alcohol consumption activates the stress kinase JNK (c-Jun N-terminal kinase) (JNK2), which subsequently phosphorylates (and activates) the CaMKII protein, thereby enhancing CaMKII-driven mishandling of sarcoplasmic reticulum calcium—which prompts aberrant calcium waves and enhances susceptibility to atrial arrhythmia.
* Conversely, CaMKII inhibition eliminates binge alcohol-evoked arrhythmic activities.
* Analysis of electrocardiograms (ECGs) performed following the resolution of arrhythmias in patients who have consumed a large quantity of alcohol shows significant prolongation of the PR, QRS, and QT intervals compared to that of patients who experienced arrhythmias in the absence of alcohol consumption.
* Although ventricular repolarization abnormalities on surface ECG were described, whether ventricular myocardium responds similarly to ethanol is uncertain.


== Epidemiology and Demographics ==
* 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 <ref name="pmid24030078">{{cite journal |vauthors=Tonelo D, Providência R, Gonçalves L |title=Holiday heart syndrome revisited after 34 years |journal=Arq. Bras. Cardiol. |volume=101 |issue=2 |pages=183–9 |date=August 2013 |pmid=24030078 |pmc=3998158 |doi=10.5935/abc.20130153 |url=}}</ref>. So on the whole it is a combination of trigger factors like :


* The frequency with which cardiac arrhythmias can be attributed to alcohol use is unclear owing to differing data.  
* Drinking too much alcohol or caffeine
*Holiday heart syndrome commonly affects individuals younger than 65 years of age.
* Overeating
* Fatigue
* Stress
*[[Dehydration]]
 
== Differentiating Holiday Heart Syndrome from Other Diseases ==
Holiday heart syndrome must be differentiated from
 
* [[Alcoholism]]
*[[Arrhythmia]] like Paroxysmal Supra-ventricular Tachycardia
*[[Atrial fibrillation]]
*[[Atrial flutter]]
* [[Cardiomyopathy|Cirrhotic cardiomyopathy]]
* [[Dilated cardiomyopathy]]
* [[Psychiatric Disorders|Psychiatric problems]]
*Hyperthyroidism and Thyrotoxicosis
*[[Pulmonary embolism]]
 
{| class="wikitable"
|+
!Disorders
!Etiology
!Clinical Presentation
!Laboratory findings
!Electrocardiogram
!Echocardiography
|-
|[[Atrial fibrillation|Atrial Fibrillation]]
|
* Elderly
* Following [[Coronary artery bypass surgery|bypass surgery]]
* [[Mitral valve disease]]
* [[Hyperthyroidism]]
* [[Diabetes mellitus|Diabetes]]
* [[Heart failure]]
* [[Ischemic heart disease]]
* [[Chronic kidney disease]]
* Heavy [[alcohol]] use
* Left chamber enlargement
|
* General fatigue
* Rapid and irregular heartbeat
* Fluttering in the chest
* Dizziness
* Shortness of breath and anxiety
* Fainting
* Sweating
* Chest pain
|
* [[Renal function]] and [[Electrolyte|electrolytes]] are routinely determined.
* Thyroid function tests : [[Thyroid-stimulating hormone]] ([[TSH]]) is commonly suppressed in [[hyperthyroidism]] and of relevance if [[amiodarone]] is administered for treatment.
* [[Complete blood count]]
* Cardiac markers : In acute-onset [[AF]] associated with [[chest pain]], [[Troponin|cardiac troponins]] or other markers of damage to the [[Myocardium|heart muscle]] may be ordered.
* [[Coagulation]] studies ([[International normalized ratio|INR]]/[[aPTT]]) are usually performed, as [[anticoagulant]] medication may be commenced.
|<br />
 
* 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
 
<br />
|
* [[Valvular heart disease]]
* Left and right atrial size
* LV size and function
* Peak RV pressure [[pulmonary hypertension]]
* [[LV hypertrophy]]
* LA [[thrombus]] (low sensitivity)
* Pericardial disease
|-
|[[Atrial flutter|Atrial Flutter]]
|
* [[Elderly]]
* [[Alcohol]]
|
* [[Shortness of breath]]
* [[Chest pain]]
* [[Lightheadedness]] or [[dizziness]]
* [[Nausea]] and, in some patients, [[nervousness]] and feelings of impending doom
 
* [[Anxiety]]
* [[Weakness]]
* [[Syncope]]


== Laboratory Findings ==
<br />
<br />
|
* [[Complete blood count]] is routinely done to look for [[anemia]]
* Differential count to look for elevated white cell count in infectious causes like [[pericarditis]]
* Thyroid function tests are done to look for [[hyperthyroidism]], which is a potential cause of atrial flutter
* Blood gas analysis is done to look for [[hypoxia]] and carbon monoxide poisoning
* [[Erythrocyte sedimentation rate]]
* Urinalysis
* [[Liver function tests]]
* Pre-[[warfarin]] coagulation screen([[INR]]/[[aPTT]])
|
* Irregular or regular rhythm


* Assessment of serum electrolyte levels, particularly potassium and magnesium, in all patients with acute arrhythmias.
* Sawtooth pattern of P waves at 250 to 350 bpm
** Hypomagnesemia and hypokalemia are common in alcoholics, particularly on presentation to the hospital.
* Biphasic deflection in V1
* Twelve-lead electrocardiography (ECG) is essential to exclude other cardiac pathology such as ischemia, infarction, pulmonary embolism, or hypertrophy.
* PR interval varies
* 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.
* QRS interval less than 0.12 seconds, consistent, and normal in morphology


==Treatment==
<br />
All symptoms usually resolve themselves within 24 hours. Specific anti-arrhythmic therapy is not warranted.
|
* Detection of [[left atrial appendage]] and [[right atrial]] appendage [[thrombi]]
* Estimation of blood [[flow velocity]] in the left or right atrium and left and right atrial appendage
* Detection of [[right atrial]] and right atrial appendage [[thrombi]]
* Regular undulatory waves of the posterior [[left atrial]] wall
* Regular undulatory waves of the upper left [[interventricular septum]]
|-
|Cirrhotic cardiomyopathy
|
* Cirrhosis
* Chronic liver failure
|
*[[Dizziness]]
* D[[dyspnea|yspnea]] on [[exertion]]
* Chest pain
*Heart palpitations
*[[Weakness]]
*[[Angina]]
|
* Complete metabolic profile
* Liver function tests
* Urinalysis
* [[Renal function]] and [[Electrolyte|electrolytes]] are routinely determined
* [[Coagulation]] studies ([[International normalized ratio|INR]]/[[aPTT]]) are usually performed
|
* QT interval prolongation,
* Electrical dyssynchrony
|
* Dilated left atrium,
* Thick LV walls,
* Systolic and/or diastolic dysfunction
|-
|Paroxysmal Supraventricular Tachycardia
|
*[[Alcohol]]
*[[Caffeine]]
*[[Nicotine]]
*[[Psychological stress]]
*[[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
|
* Palpitations
* Shortness of breath
* Dizziness
* Sweating
* A pounding sensation in the neck
* Syncope
|
*[[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
* P wave absent or hidden in [[QRS complex|QRS]]
* PR interval absent
* Narrow complexes (< 0.12 s)
|
* To assess for any evidence of significant underlying structural heart disease
|-
|[[Dilated cardiomyopathy|Dilated Cardiomyopathy]]
|
* Idiopathic
* [[Myocarditis]]
* [[Substance abuse]]
* Connective tissue disease
* [[Nutritional deficiencies]]
* Infiltrative diseases
* [[Toxin|Toxins]].
|
* Lateral displacement of the [[Displaced point of maximal impulse|point of maximal impulse]]
* Right ventricular heave
 
* [[S2|S<sub>2</sub>]] at the base
 
* [[Gallop rhythm|S3 gallop]]<nowiki/>s
 
* [[Jugular venous distension]]
 
* [[Peripheral edema]]
|
* Detecting the cause (such as [[thyroid function tests]], [[Toxicology screen (patient information)|toxicology screen]]<nowiki/>ing, and [[Genetic counseling|genetic counselling]])
 
* Assessing the cardiac [[Complication (medicine)|complications]] of the condition
|
* Left [[ventricular hypertrophy]]
* [[Atrial fibrillation]] or [[premature ventricular complex]]<nowiki/>es
* Conduction delays, [[Atrioventricular block|AV nodal block]], or [[left bundle branch block]]
|
* Ventricular and atrial dilatation
 
* Increased left ventricular mass
 
* Global reduction in systolic function
 
* Focal wall motion abnormalities
|-
|[[Hyperthyroidism]]
|
* Primary: [[Graves' disease|Grave's disease]], toxic thyroid nodules and adenoma
* Secondary: [[Pituitary adenoma]]<nowiki/>s and intracranial tumors
* Tertiary:Intracranial tumors involving the [[hypothalamus]]
|
* [[Goiter]]
* [[Palpitations]]
* [[Anxiety]]
* Heat intolerance
* [[Weight loss]]
* [[Diarrhea]]
* [[Exophthalmos|Exophthalmus]]
|
* Elevated T3 and T4 hormones
* [[Thyroid-stimulating hormone|TSH]]: Reduced in 1ry and Elevated in 2ry hyperthyroidism.
* Thyroid stimulating antibodies: Elevated only in [[Graves' disease|Grave's disease]]
|
* [[Sinus tachycardia]]
* [[Atrial fibrillation]]
* High left-ventricular voltage
|The following may be present:
 
* Left ventricular enhanced systolic function
* Enhanced or impaired diastolic function
* [[Congestive heart failure|Heart failure]] with preserved ejection fraction
|-
|[[Pulmonary embolism|Pulmonary Embolism]]
|
* Surgery
* Prolonged immobilization
* Fractures or Trauma
* Oral contraceptives or supplemental [[estrogen]]
* [[Pregnancy]]
* Overweight
* Smoking
* [[Hyper coagulable]] states
* [[Congestive heart failure|Heart failure]]
* [[Cancer]]
 
<br />
|
* [[Tachypnea|Tachypnoea]]
* [[Tachycardia]]
* Fever
* [[Chest pain]]
* [[Hemoptysis]]
* Excessive sweating
* Lightheadedness or [[dizziness]]
|Blood tests:
 
* [[D-dimer]] blood test
* [[Troponin]]
* [[Brain natriuretic peptide|BNP]]: Brain natriuretic peptide
 
<br />On [[CT angiography]]:
 
* Intra-luminal filling defect
 
<br />On [[MRI]]:
 
* Narrowing of involved [[Blood vessel|vessel]]
* No contrast seen distal to [[obstruction]]
* Polo-mint sign (partial filling defect surrounded by contrast)
 
<br />
|
* [[Pulmonary embolism electrocardiogram|S1Q3T3]] pattern representing acute [[right heart]] strain
|
* Direct visualization of [[Thrombus|Thrombi]] in Right atrium or Pulmonary artery
* Right ventricular dilatation
* Right ventricular dysfunction
* Pulmonary artery dilatation
* Normal or hyper-dynamic Left ventricle
|-
|Alcoholism
|
* Acute or chronic alcohol intake
|
* Loss of coordination,
* Flushing of the face.
* Speech abnormalities like slurred speech.
* Damp or clammy skin.
* Mood swings
* Aggression or depression.
* Drowsiness.
|
* [[Blood alcohol content]] (BAC).
 
* [[Macrocytosis]] (enlarged [[Mean corpuscular volume|MCV]])
* Elevated [[Gamma glutamyl transpeptidase|GGT]]
* Moderate elevation of [[Aspartate transaminase|AST]] and [[Alanine transaminase|ALT]] and an AST: ALT ratio of 2:1.
* High [[carbohydrate deficient transferrin]] (CDT)


<br />
<br />
==Overview==
|
==Historical Perspective==
* P-wave and QTc prolongation,
==Classification ==
* T-wave abnormalities
==Pathophysiology==
* QRS complex prolongation.
==Causes==
|
==Differentiating Xyz from Other Diseases==
* To assess for any evidence of significant underlying structural heart disease
|}
 
==Epidemiology and Demographics==
==Epidemiology and Demographics==
==Risk Factors==
 
* 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|atrial fibrillatio]]<nowiki/>n cases precipitated by alcohol drinking.
 
==Natural History, Complications, and Prognosis==
==Natural History, Complications, and Prognosis==


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=== Prognosis ===
=== 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.
* If diagnosed early and treated with alcohol cessation, the prognosis for holiday heart disease is good as the disease is reversible.


==Diagnosis ==
==Diagnosis ==
=== Diagnostic Study of Choice===
=== History and Symptoms===
=== History and Symptoms===


* Patients with HHS often have a history of previous alcohol exposure.
* 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.  
* A history of alcoholism should alert physicians to concomitant illnesses such as alcohol-related cardiomyopathy and chronic liver disease.  
* These coexisting illnesses have important prognostic implications and affect patient management.


Patients with acute exposure to alcohol can present with a variety of symptoms.
=== Symptoms ===
Patients suffering from Holiday heart Syndrome suffer from the following symptoms:
 
*[[Dizziness]]
* D[[dyspnea|yspnea]] on [[exertion]]
* Chest pain
* Unconsciousness
* Heart palpitations.
**[[Palpitations]] are the most common symptom when a patient presents to the hospital for [[atrial fibrillation]].
**These can be intermittent or persistent, depending on the presence or absence of a sustained [[arrhythmia]] and the ventricular response to [[atrial fibrillation]].
*[[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 


To reiterate, when holiday heart syndrome (HHS) is considered, alcohol-induced atrial fibrillation is generally what is implied. With that in mind, palpitations are the most common symptom when a patient presents to the hospital for atrial fibrillation. <sup>[1, 3]</sup> These can be intermittent or persistent, depending on the presence or absence of a sustained arrhythmia and the ventricular response to atrial fibrillation. Patients with rapid ventricular responses can present with near syncopal symptoms, dyspnea on exertion, fatigue, weakness, or angina.
<br />
===Physical Examination===
===Physical Examination===


* On physical examination, the patient with holiday heart syndrome may show signs of [[alcohol intoxication]] and have [[alcohol]] on the breath.<ref name="pmid3593617">{{cite journal |vauthors=Koskinen P, Kupari M, Leinonen H, Luomanmäki K |title=Alcohol and new onset atrial fibrillation: a case-control study of a current series |journal=Br Heart J |volume=57 |issue=5 |pages=468–73 |date=May 1987 |pmid=3593617 |pmc=1277202 |doi=10.1136/hrt.57.5.468 |url=}}</ref>
* On physical examination, there may be a strong evidence of [[alcohol intoxication]] and strong odor of alcohol in their breath.<ref name="pmid3593617">{{cite journal |vauthors=Koskinen P, Kupari M, Leinonen H, Luomanmäki K |title=Alcohol and new onset atrial fibrillation: a case-control study of a current series |journal=Br Heart J |volume=57 |issue=5 |pages=468–73 |date=May 1987 |pmid=3593617 |pmc=1277202 |doi=10.1136/hrt.57.5.468 |url=}}</ref>


* Depending on the [[cardiac rhythm]], the patient may have an [[Irregular heart rhythms|irregular]] or thready pulse.  
* Depending on the [[cardiac rhythm]], the patient may have an [[Irregular heart rhythms|irregular]] or thready pulse.  
* Cardiac auscultation is usually normal, except for an "i[[Irregularly irregular pulse|rregularly irregular]]" pulse.  
* Presence of an "i[[Irregularly irregular pulse|rregularly irregular]]" pulse.
* Mental status findings may be impaired, consistent with [[alcohol intoxication]] or [[hypotension]] if present.
*Protodiastolic (S3), and Presystolic (S4) heart sounds may be heard.
*[[Hypotension]]
*In advanced cases, signs of [[right heart failure]] like jugular venous distention, [[ascites]], and peripheral edema are seen.


===Laboratory Findings===
===Laboratory Findings===


* The following laboratory findings can help in diagnosis of holiday heart syndrome.
* The following laboratory findings can help in diagnosis of holiday heart syndrome.
** [[Complete blood count]] may show [[macrocytic anemia]] via an elevated [[mean corpuscular volume]].
**[[Complete blood count]] may show [[macrocytic anemia|macrocytosis]] via an elevated [[mean corpuscular volume]] and increase in hemoglobin
** Sometimes an elevated [[white blood cell count]] may be seen as alcoholics have decreased [[immunity]] and tend to get sick more often.
**Thrombocytopenia
** Complete metabolic panel may show 2:1 [[aspartate aminotransferase]] (AST) to [[alanine aminotransferase]] (ALT) ratio.  
**Elevated [[white blood cell count]] may be seen
** [[Magnesium]] and [[thiamine]] are commonly low in alcoholics.
** Complete metabolic panel may show 2:1 [[aspartate aminotransferase]] (AST) to [[alanine aminotransferase]] (ALT) ratio, suggestive of alcoholic liver disease
**Increased serum levels of gamma-glutamyl transpeptidase.
**[[Magnesium]] and [[thiamine]] are commonly low in alcoholics.
** Urine tests also exist including ethyl glucuronide and [[ethyl sulfate]] , which are both biomarkers signifying the breakdown of alcohol.
** Urine tests also exist including ethyl glucuronide and [[ethyl sulfate]] , which are both biomarkers signifying the breakdown of alcohol.
** [[Gamma-glutamyl transpeptidase|Gamma-glutamyl transferase]] may be high in these patients.  
**[[Gamma-glutamyl transpeptidase|Gamma-glutamyl transferase]] may be high in these patients.
** Another blood test to identify alcohol use is [[Phosphatidyl ethanolamine|phosphatidyl ethanol]] (PEth), a marker.  
** Another blood test to identify alcohol use is [[Phosphatidyl ethanolamine|phosphatidyl ethanol]] (PEth), a marker.
** This is typically measured in blood and can indicate moderate to heavy drinking.  
** This is typically measured in blood and can indicate moderate to heavy drinking.
** Carbohydrate-deficient transferrin is useful to identify patients who have relapsed following a period of abstinence.
** Carbohydrate-deficient transferrin is useful to identify patients who have relapsed following a period of abstinence.


* Twelve-lead electrocardiography (ECG) is essential to exclude other cardiac pathology such as [[ischemia]], [[infarction]], [[pulmonary embolism]], or [[hypertrophy]].
* 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]].
*ECG may show arrhythmias like atrial fibrillation [AF], QT interval prolongation, increased QRS duration and conduction abnormalities like left bundle branch block
* An echocardiogram should be performed to evaluate for any structural abnormalities and to assess cardiac function.
* A chest x-ray may show [[cardiomegaly]]
* [[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.
* [[Echocardiography]], performed to evaluate for any structural abnormalities and to assess cardiac function, 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]].  
* Liver disease is often a feature holiday heart syndrome as alcohol damages the [[liver]]. Therefore, ultrasound of the liver may reveal [[liver cirrhosis]].  


===Electrocardiogram ===
=== X-ray===
===Echocardiography and Ultrasound===
===CT scan===
=== MRI===
===Other Imaging Findings===
===Other Diagnostic Studies===
==Treatment==
==Treatment==
===Medical Therapy===
Usually the symptoms associated with holiday heart syndrome, that is atrial fibrillation and other conduction abnormalities, dissipate with appropriate rest, hydration and no additional treatment within 6 to 12 hours, once alcohol intake is stopped. 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.
===Interventions===
 
=== Surgery===
* 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.
===Primary Prevention===
 
===Secondary Prevention===
* If the patient is unstable and has atrial fibrillation, [[cardioversion]] is the recommendation.
* If the patient is stable, the therapeutic indication is for [[Cardiac arrhythmia|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 [[Electrocardiogram|electrocardiographic]] monitoring.
 
== Prevention ==
 
* On a broader level, the main treatment for alcoholic cardiomyopathy is abstinence from alcohol <ref name="pmid2481567">{{cite journal |vauthors=Morelli S, De Marzio P, Suppa M, Gnecchi M, Giordano M, Aguglia F, Balsano F |title=[Holiday heart syndrome: spontaneous reversibility of the electrocardiographic and echocardiographic alterations] |language=Italian |journal=Cardiologia |volume=34 |issue=8 |pages=721–4 |date=August 1989 |pmid=2481567 |doi= |url=}}</ref>.
* 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==
==References==
{{Reflist|2}}
{{Reflist|2}}

Latest revision as of 13:54, 16 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][5]
  • It may be due to the direct myotoxic effects of alcohol or the indirect effects caused by its metabolism.

There are several mechanisms believed to be the causative factor of holiday heart syndrome :

  • 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.
  • It causes oxidative stress to the myocardium by increasing the generation of free radicals and activating the Renin Angiotensin system.
  • 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.
  • Acetaldehyde is a major factor responsible for apoptosis which leads to myocytes loss and adverse remodeling [6].
  • Another factor responsible in an altered fatty acid metabolism.
  • 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 [7]. This high risk of electrical disturbance in the Holiday heart syndrome, is just like dilated cardiomyopathy.
  • On a microscopic level, findings in alcoholic cardiomyopathy are indistinguishable and similar to the findings in dilated cardiomyopathy.
  • The structure of the mitochondrial reticulum in the myocytes is grossly altered.
  • The most common arrhythmia seen in patients with Holiday heart syndrome is Atrial fibrillation, followed by atrial flutter and premature ventricular contractions [8].

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 [9]. 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


Cirrhotic cardiomyopathy
  • Cirrhosis
  • Chronic liver failure
  • QT interval prolongation,
  • Electrical dyssynchrony
  • Dilated left atrium,
  • Thick LV walls,
  • Systolic and/or diastolic dysfunction
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)
  • To assess for any evidence of significant underlying structural heart disease
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
Alcoholism
  • Acute or chronic alcohol intake
  • Loss of coordination,
  • Flushing of the face.
  • Speech abnormalities like slurred speech.
  • Damp or clammy skin.
  • Mood swings
  • Aggression or depression.
  • Drowsiness.


  • P-wave and QTc prolongation,
  • T-wave abnormalities
  • QRS complex prolongation.
  • To assess for any evidence of significant underlying structural heart disease

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, there may be a strong evidence of alcohol intoxication and strong odor of alcohol in their breath.[11]

Laboratory Findings

  • Twelve-lead electrocardiography (ECG) is essential to exclude other cardiac pathology such as ischemia, infarction, pulmonary embolism, or hypertrophy.
  • ECG may show arrhythmias like atrial fibrillation [AF], QT interval prolongation, increased QRS duration and conduction abnormalities like left bundle branch block
  • A chest x-ray may show cardiomegaly
  • Echocardiography, performed to evaluate for any structural abnormalities and to assess cardiac function, 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, hydration and no additional treatment within 6 to 12 hours, once alcohol intake is stopped. 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

  • On a broader level, the main treatment for alcoholic cardiomyopathy is abstinence from alcohol [12].
  • 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. Sterner KL, Keough VA (December 2003). "Holiday heart syndrome: A case of cardiac irritability after increased alcohol consumption". J Emerg Nurs. 29 (6): 570–3. doi:10.1016/j.jen.2003.10.002. PMID 14631348.
  6. Urbano-Marquez A, Estruch R, Navarro-Lopez F, Grau JM, Mont L, Rubin E (February 1989). "The effects of alcoholism on skeletal and cardiac muscle". N. Engl. J. Med. 320 (7): 409–15. doi:10.1056/NEJM198902163200701. PMID 2913506.
  7. Voskoboinik A, Prabhu S, Ling LH, Kalman JM, Kistler PM (December 2016). "Alcohol and Atrial Fibrillation: A Sobering Review". J. Am. Coll. Cardiol. 68 (23): 2567–2576. doi:10.1016/j.jacc.2016.08.074. PMID 27931615.
  8. Ettinger PO, Wu CF, De La Cruz C, Weisse AB, Ahmed SS, Regan TJ (May 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.
  9. Tonelo D, Providência R, Gonçalves L (August 2013). "Holiday heart syndrome revisited after 34 years". Arq. Bras. Cardiol. 101 (2): 183–9. doi:10.5935/abc.20130153. PMC 3998158. PMID 24030078.
  10. 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.
  11. 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.
  12. Morelli S, De Marzio P, Suppa M, Gnecchi M, Giordano M, Aguglia F, Balsano F (August 1989). "[Holiday heart syndrome: spontaneous reversibility of the electrocardiographic and echocardiographic alterations]". Cardiologia (in Italian). 34 (8): 721–4. PMID 2481567.

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