Cardiological repercussions of eating disorders

Eating disorders (EDs) are serious disorders that primarily affect adolescents and young adults, posing a significant threat to their health and well-being. Many of the serious health consequences of these disorders are related to secondary cardiovascular abnormalities. Cardiovascular complications can occur in up to 80% of individuals with EDs and account for 30% of their mortality.

Cardiac complications are associated with both restrictive and compulsive forms of eating disorders; in the case of anorexia nervosa, they are mainly related to malnutrition, and in bulimia nervosa, to electrolyte imbalances (potassium, calcium, sodium and magnesium).

Main heart conditions

People who experience significant food restriction are at greater risk of developing heart structure abnormalities, as the loss of fat and muscle also affects this organ. Thus, prolonged malnutrition leads to a loss of the heart's ability to contract and relax.

In people with anorexia nervosa, a thinning of the ventricular walls and a decrease in the size of the heart chambers are observed, which can sometimes lead to symptoms of heart failure, meaning the heart is unable to perform its function adequately. These changes in the heart's structure often also involve mitral valve prolapse (displacement), which becomes insufficient and unable to properly deliver blood to the left ventricle; and pericarditis, the accumulation of inflammatory fluid in the sac surrounding the heart (pericardium). Both are dangerous conditions that threaten the heart's normal function.

In addition, people with anorexia nervosa frequently present with low blood pressure, dizziness, especially upon standing or bending over, and a low heart rate or sinus bradycardia. These symptoms are due to a slow metabolism and reduced vagal tone (tone of the vagus nerve), caused by the lack of food. The severity of the bradycardia is associated with low weight and the duration of the disorder. Occasionally, high heart rates (tachycardia) have been described in people with anorexia, but these are usually caused by anemia, acute infection, or a protective adaptive response to caloric restriction. In any case, these situations are concerning and should be monitored.

Anorexia nervosa can cause thinning of the walls of the ventricles and a decrease in the size of the heart chambers, which can sometimes lead to heart failure.

The decrease in heart rate (sinus bradycardia) and impaired ventricular relaxation determine the severity of anorexia nervosa and are correlated with body mass index (BMI). In other words, a lower BMI is associated with a higher risk of cardiovascular disease and fatality.

On the other hand, fluid and electrolyte imbalances secondary to purging in people with bulimia nervosa (low blood potassium, calcium, sodium, and magnesium) are associated with heart rhythm disorders, known as arrhythmias. These arrhythmias can also be caused by the effects of medications used to treat depression, increase urination, or induce vomiting.

Some of these cardiac arrhythmias, along with abnormalities in the heart's structure, have been described as possible causes of sudden death in people with eating disorders. Furthermore, a history of bulimia increases long-term cardiovascular risk in women, raising the risk of heart attack, angina, electrical conduction disorders, and death in adulthood.

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Another cardiovascular factor secondary to malnutrition is the presence of abnormalities in peripheral blood vessels. Symptoms include cold intolerance, poor peripheral circulation, and lower skin temperature, resulting in a bluish discoloration, especially in the feet and hands, and occasionally in the face. These symptoms are often painful and resolve with refeeding.

Having had bulimia increases long-term cardiovascular risk, increasing the risk of heart attack, angina, and death in adulthood.

Most cardiovascular abnormalities resolve completely with nutritional restoration, normalisation of eating behaviour, and elimination of purging. However, some of these conditions, such as heart failure, can persist after refeeding, increasing the risk of death.

Therefore, it is essential that individuals with an eating disorder undergo a thorough cardiological evaluation. Admission criteria will not only depend on the degree of malnutrition and response to treatment, but will also include the presence of cardiac symptoms such as syncope (fainting), an extremely low heart rate, an abnormal electrocardiogram, or an electrolyte imbalance in the blood.

Practical tips for preventing cardiovascular problems

• It's advisable to monitor your heart rate with a heart rate monitor. If you experience bradycardia (less than 50 beats per minute), you should avoid physical activity and drink water.
• If you have low blood pressure, try not to get up too quickly. When you get out of bed or after bending down, you may feel dizzy and suffer a fall or faint. Try sitting on the edge of the bed or in a chair for five minutes before standing up; this will help prevent dizziness and a fall.
• Drink water to avoid dehydration and maintain your well-being. You should drink at least 200 ml of water (one glass) four times a day. If you don't want to drink it all at once, you can drink 50 ml every hour.
• Vomiting, laxatives, and diuretics, in addition to eliminating fluid from the body, wash away ions important for heart function. Watch for the appearance of:
  • Headache
  • Nausea
  • Dizziness
  • Confusion
  • Muscle cramps and weakness
  • Tingling sensations
  • Dry tongue and skin
  • Abdominal inflammation and poor intestinal motility.

If you experience any of these symptoms, you are likely suffering from an electrolyte imbalance and dehydration. If left untreated, this can lead to a dangerous situation, even death. You should explain your symptoms to a doctor so they can correct the imbalance immediately or go to the emergency room.

• Chest pain, palpitations, shortness of breath, dizziness, and fainting are symptoms of heart problems. If you experience these symptoms, tell your doctor so they can examine you or go to the emergency room, as you may be in a life-threatening situation due to cardiovascular instability.
• You should maintain an exercise programme agreed upon with a healthcare professional. Physical exercise can help increase your motivation and energy levels, and reduce discomfort. However, excessive exercise combined with insufficient nutrients can lead to dangerous muscle breakdown. Remember that the heart is a muscle, and its malfunction can be fatal.

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