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Cardiac imaging evaluation is mandatory in patients with anorexia nervosa
Accepted Manuscript Cardiac imaging evaluation is mandatory in patients with anorexia nervosa Gilberto Fabián Hurtado-Torres, MD, M.Ed, Rosa Laura Sandoval-Munro, MD. PII:
S0899-9007(15)00528-6
DOI:
10.1016/j.nut.2015.12.031
Reference:
NUT 9671
To appear in:
Nutrition
Received Date: 10 December 2015 Accepted Date: 15 December 2015
Please cite this article as: Hurtado-Torres GF, Sandoval-Munro RL, Cardiac imaging evaluation is mandatory in patients with anorexia nervosa, Nutrition (2016), doi: 10.1016/j.nut.2015.12.031. This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
ACCEPTED MANUSCRIPT Title: Cardiac imaging evaluation is mandatory in patients with anorexia nervosa.
Authors:
Internal Medicine and Clinical Nutrition Dept. Hospital Central Dr. Ignacio Morones Prieto/UASLP. San Luis Potosí, SLP.
M AN U
Faculty of Medicine. University of San Luis Potosí, SLP, Mexico.
SC
Rosa Laura Sandoval-Munro MD.
RI PT
Gilberto Fabián Hurtado-Torres MD, M.Ed.
Corresponding author:
TE D
Gilberto Fabián Hurtado-Torres MD, M. Ed Internal Medicine and Clinical Nutrition Dept. Hospital Central Dr. Ignacio Morones Prieto San Luis Potosí, SLP. México. [email protected]
Address: Av. V. Carranza 2395. Col. Universitaria. CP 78210. San Luis Potosí SLP, México. Phone +52(444)8342763.
EP
Oversight:
All authors had access to the data and a role in writing the manuscript.
AC C
Conflicts of interest: none. Founding source: none.
ACCEPTED MANUSCRIPT
RI PT
Frølich et al have presented the case of a female patient with severe and long standing anorexia nervosa, with a body mass index of 7.8 kg/m2. The patient was hospitalized because of progressive weight loss and critical clinical and biochemical abnormalities 1. Hypophosphatemia, hypokalemia, anemia and increased liver enzymes were described as relevant laboratory abnormal findings. Body composition parameters were not described. Clinical course and nutritional replenishment were successful, with hemolytic anemia as an incidental phenomenon associated with the refeeding syndrome scenario 1.
SC
Markedly elevated alanine aminotransferase at admission was attributed to a combination of starvation-induced hepatocyte autophagy and decreased blood flow to the liver and ischemia 1 . Hypotension and relative tachycardia were present during the initial clinical workup; echocardiography parameters or subrogate biochemical markers of cardiac function, such as natriuretic peptides, are not provided 1.
TE D
M AN U
In a recent review and meta-analysis, Tapper et al. define the mechanism related to ischemic liver injury 2. Given that the liver receives a double blood flow provision from the portal vein and hepatic artery, it is relatively well protected from ischemic injury. The authors underscore hypotension as not the only pre-requisite for the development of liver injury; passive congestion also represents a precondition necessary for ischemic hepatitis, particularly from congestive heart failure. Low cardiac output along with elevated right-sided pressures are major contributors to hepatic ischemic injury, the former by reducing hepatic artery blood flow and the latter by means of passive congestive hepatopathy and increased hepatic sinusoidal pressures, which limit the hepatic anterograde perfusion derived from portal venous flow. This phenomenon is termed "functional portal vein occlusion". In the series revisited by Tapper and coauthors, the vast majority of patients with ischemic hepatitis followed a common course of additional cardiac comorbidities 2.
AC C
EP
Cardiac abnormalities in patients with anorexia nervosa are well described and include reduced ventricular mass, myocardial fibrosis, myxoid material deposition, mitral valve prolapse, low stroke index, systolic dysfunction 3-6, and others. Concurrent anemia contributes negatively beyond the already limited cardiac function 7. Interestingly, functional and structural alterations are reversible after anemia correction, nutritional support, and weight recovery 7- 8.
From the above conditions 2-8, cardiac failure, perhaps just when manifested by subtle tachycardia, could has been a main contributor to liver injury in the patient described by Frølich and co-authors; therefore, routine cardiac imaging evaluation should be a part of the clinical workup of patients with anorexia nervosa even in the absence of overt clinical cardiac failure signs, especially in severe cases, such as the one described.
1. Frølich J, Palm CV, Støving RK. To the limit of extreme malnutrition. Nutrition 2016;32(1):146-8. doi: 10.1016/j.nut.2015.08.024.
ACCEPTED MANUSCRIPT
AC C
EP
TE D
M AN U
SC
RI PT
2. Tapper EB, Sengupta N, Bonder A. the incidence and outcomes of ischemic hepatitis: a systematic review with meta-analysis. Am J Med. 2015;128(12):1314-21. doi: 10.1016/j.amjmed.2015.07.033. Epub 2015 Aug 21. 3. Oflaz S, Yucel B, Oz F, Sahin D, Ozturk N, Yaci O, et al. Assessment of myocardial damage by cardiac MRI in patients with anorexia nervosa. Int J Eat Disord. 2013;46(8):862-6. doi: 10.1002/eat.22170. Epub 2013 Aug 7. 4. de Simone G, Scalfi L, Galderisi M, Celentano A, Di Biase G, Tammaro P, et al. Cardiac abnormalities in young women with anorexia nervosa. Br Heart J. 1994;71(3):287-92. 5. Romano C, Chinali M, Pasanisi F, Greco R, Celentano A, Rocco A, et al. Reduced hemodynamic load and cardiac hypotrophy in patients with anorexia nervosa. Am J Clin Nutr. 2003;77(2):308-12. 6. Lamzabi I, Syed S, Reddy VB, Jain R, Harbhajanka A, Arunkumar P. Myocardial changes in a patient with anorexia nervosa: a case report and review of literature. Am J Clin Pathol. 2015;143(5):734-7. doi: 10.1309/AJCP4PLFF1TTKENT. 7. Moe GW, Ezekowitz JA, O'Meara E, Lepage S, Howlett JG, Fremes S, et al. The 2014 Canadian Cardiovascular Society Heart Failure Management Guidelines Focus Update: anemia, biomarkers, and recent therapeutic trial implications. Can J Cardiol. 2015;31(1):3-16. doi: 10.1016/j.cjca.2014.10.022. Epub 2014 Dec 19. 8. Mont L, Castro J, Herreros B, Paré C, Azqueta M, Magriña J, et al. Reversibility of cardiac abnormalities in adolescents with anorexia nervosa after weight recovery. J Am Acad Child Adolesc Psychiatry. 2003;42(7):808-13.
S0899-9007(15)00528-6
DOI:
10.1016/j.nut.2015.12.031
Reference:
NUT 9671
To appear in:
Nutrition
Received Date: 10 December 2015 Accepted Date: 15 December 2015
Please cite this article as: Hurtado-Torres GF, Sandoval-Munro RL, Cardiac imaging evaluation is mandatory in patients with anorexia nervosa, Nutrition (2016), doi: 10.1016/j.nut.2015.12.031. This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
ACCEPTED MANUSCRIPT Title: Cardiac imaging evaluation is mandatory in patients with anorexia nervosa.
Authors:
Internal Medicine and Clinical Nutrition Dept. Hospital Central Dr. Ignacio Morones Prieto/UASLP. San Luis Potosí, SLP.
M AN U
Faculty of Medicine. University of San Luis Potosí, SLP, Mexico.
SC
Rosa Laura Sandoval-Munro MD.
RI PT
Gilberto Fabián Hurtado-Torres MD, M.Ed.
Corresponding author:
TE D
Gilberto Fabián Hurtado-Torres MD, M. Ed Internal Medicine and Clinical Nutrition Dept. Hospital Central Dr. Ignacio Morones Prieto San Luis Potosí, SLP. México. [email protected]
Address: Av. V. Carranza 2395. Col. Universitaria. CP 78210. San Luis Potosí SLP, México. Phone +52(444)8342763.
EP
Oversight:
All authors had access to the data and a role in writing the manuscript.
AC C
Conflicts of interest: none. Founding source: none.
ACCEPTED MANUSCRIPT
RI PT
Frølich et al have presented the case of a female patient with severe and long standing anorexia nervosa, with a body mass index of 7.8 kg/m2. The patient was hospitalized because of progressive weight loss and critical clinical and biochemical abnormalities 1. Hypophosphatemia, hypokalemia, anemia and increased liver enzymes were described as relevant laboratory abnormal findings. Body composition parameters were not described. Clinical course and nutritional replenishment were successful, with hemolytic anemia as an incidental phenomenon associated with the refeeding syndrome scenario 1.
SC
Markedly elevated alanine aminotransferase at admission was attributed to a combination of starvation-induced hepatocyte autophagy and decreased blood flow to the liver and ischemia 1 . Hypotension and relative tachycardia were present during the initial clinical workup; echocardiography parameters or subrogate biochemical markers of cardiac function, such as natriuretic peptides, are not provided 1.
TE D
M AN U
In a recent review and meta-analysis, Tapper et al. define the mechanism related to ischemic liver injury 2. Given that the liver receives a double blood flow provision from the portal vein and hepatic artery, it is relatively well protected from ischemic injury. The authors underscore hypotension as not the only pre-requisite for the development of liver injury; passive congestion also represents a precondition necessary for ischemic hepatitis, particularly from congestive heart failure. Low cardiac output along with elevated right-sided pressures are major contributors to hepatic ischemic injury, the former by reducing hepatic artery blood flow and the latter by means of passive congestive hepatopathy and increased hepatic sinusoidal pressures, which limit the hepatic anterograde perfusion derived from portal venous flow. This phenomenon is termed "functional portal vein occlusion". In the series revisited by Tapper and coauthors, the vast majority of patients with ischemic hepatitis followed a common course of additional cardiac comorbidities 2.
AC C
EP
Cardiac abnormalities in patients with anorexia nervosa are well described and include reduced ventricular mass, myocardial fibrosis, myxoid material deposition, mitral valve prolapse, low stroke index, systolic dysfunction 3-6, and others. Concurrent anemia contributes negatively beyond the already limited cardiac function 7. Interestingly, functional and structural alterations are reversible after anemia correction, nutritional support, and weight recovery 7- 8.
From the above conditions 2-8, cardiac failure, perhaps just when manifested by subtle tachycardia, could has been a main contributor to liver injury in the patient described by Frølich and co-authors; therefore, routine cardiac imaging evaluation should be a part of the clinical workup of patients with anorexia nervosa even in the absence of overt clinical cardiac failure signs, especially in severe cases, such as the one described.
1. Frølich J, Palm CV, Støving RK. To the limit of extreme malnutrition. Nutrition 2016;32(1):146-8. doi: 10.1016/j.nut.2015.08.024.
ACCEPTED MANUSCRIPT
AC C
EP
TE D
M AN U
SC
RI PT
2. Tapper EB, Sengupta N, Bonder A. the incidence and outcomes of ischemic hepatitis: a systematic review with meta-analysis. Am J Med. 2015;128(12):1314-21. doi: 10.1016/j.amjmed.2015.07.033. Epub 2015 Aug 21. 3. Oflaz S, Yucel B, Oz F, Sahin D, Ozturk N, Yaci O, et al. Assessment of myocardial damage by cardiac MRI in patients with anorexia nervosa. Int J Eat Disord. 2013;46(8):862-6. doi: 10.1002/eat.22170. Epub 2013 Aug 7. 4. de Simone G, Scalfi L, Galderisi M, Celentano A, Di Biase G, Tammaro P, et al. Cardiac abnormalities in young women with anorexia nervosa. Br Heart J. 1994;71(3):287-92. 5. Romano C, Chinali M, Pasanisi F, Greco R, Celentano A, Rocco A, et al. Reduced hemodynamic load and cardiac hypotrophy in patients with anorexia nervosa. Am J Clin Nutr. 2003;77(2):308-12. 6. Lamzabi I, Syed S, Reddy VB, Jain R, Harbhajanka A, Arunkumar P. Myocardial changes in a patient with anorexia nervosa: a case report and review of literature. Am J Clin Pathol. 2015;143(5):734-7. doi: 10.1309/AJCP4PLFF1TTKENT. 7. Moe GW, Ezekowitz JA, O'Meara E, Lepage S, Howlett JG, Fremes S, et al. The 2014 Canadian Cardiovascular Society Heart Failure Management Guidelines Focus Update: anemia, biomarkers, and recent therapeutic trial implications. Can J Cardiol. 2015;31(1):3-16. doi: 10.1016/j.cjca.2014.10.022. Epub 2014 Dec 19. 8. Mont L, Castro J, Herreros B, Paré C, Azqueta M, Magriña J, et al. Reversibility of cardiac abnormalities in adolescents with anorexia nervosa after weight recovery. J Am Acad Child Adolesc Psychiatry. 2003;42(7):808-13.