Echocardiographic abnormalities in 124 severely malnourished adult anorexia nervosa patients: frequency and relationship with body composition and biological features

Abstract

Background Anorexia Nervosa (AN) is a complex psychiatric disorder that can lead to specific somatic complications. Heart abnormalities are frequently reported, while their frequency and associated factors in severely malnourished AN patients remain poorly defined. Objectives This study aimed to characterize echocardiographic abnormalities in severely malnourished AN patients and to assess associated clinical, biological and related body composition features. Methods Between January 2013 and January 2015, all severely malnourished adult patients with AN (Mental Disorders, 4th Edn.-DSM IVr) were included in a monocentric study performed in in a highly specialized AN inpatient unit. Electrocardiogram (ECG) and echocardiography were used to assess both heart rhythm and function. All inpatients underwent a Doppler echocardiography procedure after undergoing combined blood volume adjustment, micronutrients deficiencies supplementation and electrolyte disorders correction. Right Ventricular (RV) and Left Ventricular (LV) systolic and diastolic functions were collected and compared to 29 healthy normal subjects in a control group. Results One hundred and 24 patients (119 (96%) women, 5 (4%) men) with a mean age of 30.1 ± 11 years old and an average Body Mass Index (BMI) of 12 kg/m2 were included. Ninety patients (73%) had been diagnosed with AN Restrictive type (AN-R), 34 (27%) an AN Binge eating/Purging type (AN-BP). Eighteen patients (15%) disclosed an abnormal Left Ventricular Ejection Fraction (LVEF) (< 52% for male and < 54% for female). LVEF impairment was associated with AN-BP patients (p < 0.017) and hypertransaminasemia (AST and/or ALT ≥2 N) (p < 0.05). Left Ventricular mass (LV mass) and Left Ventricular End Diastolic Diameter (LVEDD) were significantly reduced in patients (p < 0.001, p < 0.001). Left and right ventricular tissue Doppler Imaging Velocities (TDI) peak were reduced in patients: Septal and Lateral LV Sm velocities peaks respectively 10 ± 2 cm/s (vs 14 ± 2 cm/s in controls, p < 0.001), 12 ± 3 cm/s (vs 16 ± 3 cm/s in controls, p < 0.001), basal RV Sm velocity peaks at 14 ± 3 cm/s (vs 19 ± 3 cm/s in controls, p < 0.001). Additionally, LV and RV diastolic velocity peaks were reduced: LV septal and lateral velocity peaks were respectively 13 ± 3 cm/s (vs 18 ± 2 cm/s p < 0.001), 12 ± 3 cm/s (vs 22 ± 4 cm/s, p < 0.001) and RV diastolic velocity peaks at 14 ± 3 cm/s (vs 21 ± 4 cm/s p < 0.001). LV diastolic velocity TDI peaks were significantly associated with hypertransaminasemia (p < 0.05) and tended to be associated with a low all body Fat-Free Mass Index (FFMI) (using Dual-energy X- ray Absorptiometry (DXA) (HOLOGICQDR 4500) (p = 0.056). Thirty-four patients (27%) had a pericardial effusion and were significantly associated with a decreased all body FFMI (p < 0.036). Conclusion Heart abnormalities are frequent in malnourished patients with AN, particularly in AN-BP type. Both liver enzymes and body composition abnormalities tended to be associated with heart dysfunction (non-significant association). Prospective studies are needed to better characterize and describe the evolution of cardiac abnormalities during the refeeding period and subsequent weight restoration.

Emergency room presentations of people with anorexia nervosa

“…Takotsubo cardiomyopathy can also be seen in patients with AN, and may be attributable to the stress of the psychological condition plus severe malnutrition. However, the cardiac ejection fraction is generally normal in people with AN; only 15% had a reduced ejection fraction in one reported series [ 42 ].…”

A Comprehensive Review of Complications and New Findings Associated with Anorexia Nervosa

“…Our understanding of cardiac structure and function in patients with AN continues to progress with comprehensive, modern, and dynamic echocardiographic evaluations and more recently cardiac MRI (CMRI) studies. A retrospective study evaluated Doppler echocardiograms in adult patients with AN with an average BMI of 12 (N = 124) [90]. All AN patients had subclinical cardiac impairments and 15% had reduced ejection fraction (EF).…”

“…Interestingly, AN-BP and hypertransaminasemia were independently associated with a reduced EF. Consideration for echocardiogram should be made in patients with AN (especially AN-BP) with hypertransaminasemia to prevent complications of heart failure with refeeding [90]. Doppler echocardiography used to assess aortic stiffness by pulse wave velocity in adolescent AN patients found increased arterial stiffness [91].…”

Management of the malnourished patient: it’s now time to revise the guidelines

“…In an echocardiographic study of 124 severely malnourished adult patients with anorexia nervosa, Hanachi et al [ 12 ] found that subclinical myocardial impairment was common. In their study, 27% of participants had pericardial effusions and 15% had evidence of left ventricular systolic dysfunction, which was associated with elevated transaminases and a diagnosis of anorexia nervosa – binge eating purging type.…”