Markers of Cardiovascular Dysfunction in Adolescents With Anorexia Nervosa

Abstract

Background. Cardiovascular complications contribute to the high morbidity and mortality rate among children with anorexia nervosa (AN). Advances in cardiac imaging permit a more comprehensive assessment of myocardial performance in children that could not be previously obtained with conventional imaging. Myocardial strain analysis is an emerging quantitative echocardiographic technique to characterize global and regional ventricular function in children. Objective. To assess global and regional left ventricular (LV0 function in children newly diagnosed with AN with conventional and quantitative 2-dimensional speckle tracking echocardiographic (2DSTE)–derived strain imaging. Materials. In a cross-sectional study of 30 patients with AN (DSM-5) and 14 age-, sex-, and race-matched healthy children, markers of cardiovascular risk, conventional and 2DSTE measures of LV function, and structure were evaluated and compared. The AN cohort was further stratified by behavioral patterns (restrict, exercise, or purge). Results. Conventional measures and LV global strain were similar between controls and children with AN. A subgroup of AN children with purging behavior had LV remodeling characterized by significantly decreased LV mass index. Regional ventricular function at the apex, as measured by strain, was also decreased in all AN patients. Percent change from ideal body weight, body mass index Z-score, electrolyte profiles, heart rate, and blood pressure were similar. Conclusions. Subclinical regional ventricular dysfunction is present in children with AN. Ventricular remodeling exists in a subgroup of children with AN in association with purging behavior. Future studies may utilize strain imaging to identify those AN patients who are at an increased risk for developing significant cardiac dysfunction.

Cardiac abnormalities identified with echocardiography in anorexia nervosa: systematic review and meta-analysis

“…When the LVM was standardised for height, the anorexia nervosa group had a reduced LVM/height ratio, which was statistically significant when compared with both healthy controls with a BMI >20 kg/m 2 (mean difference 7.42 g/m, 95% CI 4.65-10.2 g/m; SMD 1.98, 95% CI 1.24-2.73; P < 0.001; see Fig. 2) 10,11,13,17,18,20,25,29 and thin controls with a BMI of 18 kg/m 2 (SMD 2.07, 95% CI 0.76-3.39, P = 0.002; see Supplementary Fig. 2).…”

“…13,29 Based on ejection fraction and fractional shortening eight studies did not report left ventricular function outside the normal range. 11,12,15,17,18,20,23,26 In two studies the ejection fraction was significantly reduced compared with the control group. 13,25 Beyond ejection fraction, fractional shortening, stroke volume and cardiac output, other techniques for assessing the left ventricular were described.…”

“…The E peak and A peak were both statistically significantly reduced. Morris et al, 2017 11 Left ventricular dimensions: Left ventricular dimensions were quantified in the included studies, using M-Mode assessment of the left ventricular internal diameters. Eleven out of twelve studies describing left ventricular dimensions found a difference in either the systolic, diastolic or wall dimensions in the anorexic population compared with the normal range.…”

“…13,25 Beyond ejection fraction, fractional shortening, stroke volume and cardiac output, other techniques for assessing the left ventricular were described. There were five studies that described impaired systolic function in patients with anorexia nervosa, 11,18,20,27,29 including a subgroup of patients with anorexia nervosa with purging behaviour with significantly decreased apical segmental longitudinal strain (the rate at which the myocardium develops contractile power) values. 11 Franzoni et al found that cyclic variation in myocardial integrated backscatter was significantly lower in the anorexia group than in the control group when adjusted for body weight, reflecting poor contractile performance of the myocardial wall.…”

Medical complications of anorexia nervosa

“…One possibility is subclinical left ventricular systolic dysfunction as manifested by abnormalities in myocardial torsion and global longitudinal systolic strain. 19,20 Another possibility is focal regional fi brosis as a nidus for malignant ventricular arrhythmia, which has been suggested by late gadolinium enhancement on magnetic resonance imaging. 21 We believe further investigation of subclinical cardiovascular dysfunction and long-term arrhythmia monitoring and larger populationbased cohort studies are needed to address the ongoing inordinately high risk of sudden cardiac death in this generally young population.…”