Alterations in QT dispersion in the surface electrocardiogram of female adolescents diagnosed with restricting-type anorexia nervosa

doi:10.1016/j.jpsychores.2006.10.023

Journal of Psychosomatic Research

Volume 62, Issue 4, April 2007, Pages 469-472

https://doi.org/10.1016/j.jpsychores.2006.10.023 Get rights and content

Abstract

Objective

QT dispersion (QTd), defined as the difference between the longest interval and the shortest interval in the 12-lead electrocardiogram (ECG), is a measure of myocardial repolarization inhomogeneity. We assessed QTd in malnourished anorexia nervosa (AN) inpatients and following weight restoration.

Methods

QTd analysis, anthropometric evaluations, and laboratory tests were carried out in 30 malnourished female adolescent AN restricting-type (AN-R) inpatients and following weight restoration.

Results

A significant increase was found in weight/height ratio and body mass index from malnourished stage to weight restoration, paralleled by a significant decrease in QTd (70±16 vs. 47±16 ms; P<.0001). No correlations were found between ECG indices and anthropometric and laboratory measures.

Conclusion

Elevated QTd in malnourished AN-R inpatients may indicate possible cardiac autonomic imbalance and/or myocardial damage, likely corrected following weight restoration.

Introduction

Anorexia nervosa (AN) is associated with an exceedingly high mortality rate, which is mostly related to cardiac disturbances [1]. Various electrocardiogram (ECG) abnormalities have been detected in AN, including lengthening of QT interval, which is considered a marker of increased risk for cardiac mortality and morbidity [2].

The maximal interlead difference in QT intervals, referred to as QT dispersion (QTd), might serve as a measure of myocardial repolarization inhomogeneity [3]. QTd is positively correlated with heart rate variability (HRV) (i.e., increased QTd indicates increased sympathetic tone and/or decreased vagal tone) [4], [5]. Accordingly, elevated QTd may represent a predisposing factor for arrhythmic events and sudden death [6], [7], [8], [9].

Several studies [2], [10], [11], although not all [12], found that QT interval and QTd are greater in AN female patients than in non-eating-disorder controls, with the QTd in these patients being inversely correlated with left ventricular mass [10]. A significant decrease in QTd may occur following weight restoration [12].

The aim of the present study was to assess QT interval and QTd in underweight female adolescent AN inpatients and following weight restoration. We hypothesized that the QT interval, heart-rate-corrected QT interval (QTc), and QTd would be elevated in underweight AN patients but would return to normal ranges following weight restoration.

Section snippets

Patients

We studied 30 consecutive AN restricting-type (AN-R) female adolescent (aged 15.7±8.8 years) inpatients. All patients had amenorrhea on admission, and none had comorbidities with cardiovascular risk factors, such as smoking, substance use, diabetes mellitus, and hypertension.

AN-R diagnosis [according to the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) criteria] was achieved independently by two psychiatrists (D.S. and A.Y.) with the Eating Disorders Family

Results

The duration of AN-R before admission was 2.2±2.5 years, and the duration of hospitalization 4.14±4.5 months. Twenty patients had other DSM-IV depressive and anxiety Axis I disorders. No differences were found in any of the parameters assessed between AN-R patients with comorbid diagnoses and AN-R patients without comorbid diagnoses, and between AN-R patients receiving psychotropic medications and AN-R patients not receiving psychotropic medications.

Table 1 summarizes anthropometric and

Discussion

The present naturalistic prospective study shows that malnourished female adolescent AN-R inpatients exhibit prolongation of QT interval and increased QTd, which is within the range reported for at-risk cardiac patients (namely, between 60 and 80 ms, compared to 20–50 ms in normal individuals) [6], [7], [8], [9].

Findings concerning ECG changes in AN are inconclusive. Whereas some studies [2], [10], [11] similar to ours found that QT interval and QTd are greater in emaciated AN patients than in

References (28)

S Ishida et al.
Circadian variation of QT interval dispersion: correlation with heart rate variability
J Electrocardiol
(1997)
CS Barr et al.
QT dispersion and sudden unexpected death in chronic heart failure
Lancet
(1994)
A van de Loo et al.
Variability of QT dispersion measurements in the surface electrocardiogram in patients with acute myocardial infarction and in normal subjects
Am J Cardiol
(1994)
F Galetta et al.
QT interval dispersion in young women with anorexia nervosa
J Pediatr
(2002)
L Mont et al.
Reversibility of cardiac abnormalities in adolescents with anorexia nervosa after weight recovery
J Am Acad Child Adolesc Psychiatry
(2003)
E Nahshoni et al.
QT dispersion in the surface electrocardiogram in elderly patients with major depression
J Affect Disord
(2000)
F Roche et al.
Refeeding normalizes the QT rate dependence of female anorexic patients
Am J Cardiol
(2005)
T Rechlin et al.
Alterations of autonomic cardiac control in anorexia nervosa
Biol Psychiatry
(1998)
EL Melanson et al.
Resting and ambulatory heart rate variability in chronic anorexia nervosa
Am J Cardiol
(2004)
C Tomaszewicz-Libudzic et al.
Antimyocardial antibodies in anorexia nervosa
J Am Acad Child Adolesc Psychiatry
(2004)

ICI Neumarker

Mortality and sudden death in anorexia nervosa

Int J Eat Disord

(1997)

I Swenne et al.

Heart risk associated with weight loss in anorexia nervosa and eating disorders: risk factors for QTc interval prolongation and dispersion

Acta Paediatr

(1999)

CP Day et al.

QT dispersion: an indication of arrhythmia risk in patients with long QT intervals

Br Heart J

(1990)

M Nakagawa et al.

Evaluation of autonomic influences on QT dispersion using the head-up tilt test in healthy subjects

Pacing Clin Electrophysiol

(1999)

Cited by (15)

T-wave morphology among medically treated patients with Anorexia Nervosa
2020, Journal of Psychiatric Research
Citation Excerpt :
QT dispersion (QTd), an electrocardiographic marker of repolarization-related arrhythmias was also reported to be abnormally high (Galetta et al., 2002; Krantz et al., 2005; Takimoto et al., 2004; Ulger et al., 2006) or normal (Bomba et al., 2018) in different groups of patients with AN. It has been suggested that increased QTd may be associated with decreased left ventricular mass (Galetta et al., 2002), and that abnormally high QTd values may normalize following weight restoration (Nahshoni et al., 2007). Our research group reported that medically-treated AN patients who gained weight and had normal serum electrolyte values had normal QT variability index, a marker of repolarization instability (Nussinovitch et al., 2012).
Anorexia nervosa (AN) has the highest rate of mortality of any psychiatric disorder, and cardiovascular complications occur in up to 80% of patients with AN and account for up to 30% of mortality. A controversy exists as to whether patients with AN are prone to develop electrocardiographic abnormalities related to repolarization.
We aim to study previously unexplored T wave morphology markers in medically-treated patients with AN. Fifty-eight patients with AN (32 with restricting type and 26 with binge-eating/purging type) and 82 healthy controls were included in the study. ECGs were conducted under strict conditions and total cosine R-to-T (TCRT) and T-wave morphology dispersion (TMD) were computed according to accepted standards for a random beat and for an averaged beat. Forty-six AN patients were hospitalized (79.3%) during the study for a mean duration of 1.5 ± 1.1 months. AN patients had comparable QTc, TCRT, mean TMD, TMDpre, TMDpost and TCRTc values to those of healthy adults. Flattened T wave occurred slightly more often among AN patients than in controls (1.57 ± 1.23 leads affected compared with 1.11 ± 0.80 leads, respectively, p = 0.017). QTc, TCRT and TMD parameters' values were unaffected by the clinical type of AN.
In conclusion, weight-restored AN patients are characterized by T wave flattening, but normal other T wave morphology parameters, which seemingly reflects an overall low risk of repolarization-associated ventricular arrhythmias. Long-term follow-up studies should be conducted to evaluate the prognostic significance of these novel repolarization markers in untreated patients or early in the refeeding phase.
Medical Complications of Anorexia Nervosa and Bulimia Nervosa
2019, Psychiatric Clinics of North America
Association between depression severity and cardiac autonomic modulation
2016, Journal of Psychosomatic Research
Citation Excerpt :
A similar result was found in conversion patients [25]. QTd was also found to be altered in anorexia nervosa [26]. The first study that analyzed QTd in depressed individuals without cardiovascular disease included 18 depressive patients taking antidepressants and 9 without depression.
Changes in autonomic modulation are found in depressive patients. QT dispersion is a convenient measure of cardiac autonomic modulation (CAM). As both QT dispersion and depression are related to changes in CAM, this study aimed to examine if there was an association between depression severity and QT dispersion.
The selected sample (n = 60) derived from 236 women who were recruited via a campaign for breast cancer prevention. The women selected to participate were all non-smokers and were not taking any drug that could interfere with the results. After applying inclusion and exclusion criteria, 60 women were selected. QT dispersion (QTd) and rate-corrected QTd (QTcD) were calculated in 37 physically and mentally healthy women and 23 nontreated depressive women. Univariate ANOVA(s) were used to test group differences. The 17-item Hamilton Depression Rating Scale (HDRS17) was scored to measure depression severity. The relationship between depression severity and cardiac autonomic modulation was analyzed by the best curve that fit the raw data of the HDRS17 scores and the QT dispersion variables.
The QTd and QTcD were significantly smaller in non-depressed in relation to the depressed women. The best curve that fit the raw data of depression severity (HDRS17) and the two measurements of cardiac autonomic modulation (QTd and QTcD) was a cubic equation for both QTd and QTcD. An increase in QTd and QTcD were observed until the HDRS17 score reached 20 points.
There is a significant positive relationship between depression severity and cardiac autonomic modulation in mild and moderate depression.
Electrocardiographic abnormalities in anorexia nervosa: A critical review of the literature
2015, Revista Colombiana de Psiquiatria
La anorexia nervosa (AN) es un trastorno de la conducta alimentaria y, entre sus causas de mortalidad, las arritmias cardiacas y la muerte súbita son frecuentes, por lo que es indispensable la monitorización electrocardiográfica. Se han descrito muchos hallazgos con resultados contradictorios, por lo que es necesaria una revisión crítica de la literatura científica.
Revisión de los estudios relevantes sobre cambios electrocardiográficos en AN, consultados en PubMed desde 1974 hasta febrero de 2014, utilizando los términos MeSH: Eating disorders, nervosa anorexia, sinusal bradycardia, QT prolongation, QT dispersion, electrocardiography, EKG, electrocardiogram.
Las dos alteraciones más comunes reportadas incluyen la bradicardia sinusal y los cambios en la repolarización evidenciados en prolongación del QT e incremento de su dispersión. Los trastornos electrolíticos parecen ser la causa de estas alteraciones en algunos pacientes, pero otras razones se discuten en detalle, como la desviación del eje del QRS a la derecha, la alteración en variabilidad de la frecuencia cardiaca, R en derivación V6 de bajo voltaje, disminución de la amplitud del QRS y onda T y alargamiento del QRS. La mayoría de los autores hablan de reversibilidad de los cambios después del tratamiento.
Estos resultados siguen apoyando la necesidad de valorar a los pacientes con AN con electrocardiogramas inicial y de seguimiento, para el diagnóstico temprano y tratamiento de alteraciones cardiovasculares relacionadas con alta morbimortalidad. También apoyan la necesidad del uso racional de psicofármacos para no aumentar el riesgo de arritmias cardiacas y muerte súbita.
Anorexia nervosa is an eating disorder in which cardiac arrhythmias and sudden death are frequent causes of mortality, which makes electrocardiographic monitoring indispensable in these patients. There are many suggestive findings but results are contradictory, making a critical review of the scientific literature is necessary.
The most relevant studies on electrocardiographic (EKG) changes in patients with AN, found in PubMed from 1974 to February 2014, were reviewed using the MeSH terms: eating disorders, nervosa anorexia, sinus bradycardia, QT prolongation, QT dispersion, electrocardiography, EKG, and electrocardiogram.
The two most common EKG findings reported in the literature are sinus bradycardia and changes in depolarization, as shown by prolongation and increased dispersion of the QT interval. Electrolyte disturbances seem to be the cause of these disturbances in some patients, but other reasons are also discussed in detail, such as QRS right axis deviation, disturbances of heart rate variability, low R wave voltage in V6, amplitude decrease of the QRS and T wave, and QRS prolongation. The majority of authors report that these changes are reversible after treatment of AN.
These findings support the need for initial and follow-up EKGs in patients with AN and for early diagnosis and treatment of cardiovascular disturbances that are associated with morbidity and mortality. They also support the need for the rational use of psychopharmacology, and that does not increase the risk of arrhythmias and sudden death in these patients.
QT variability among weight-restored patients with Anorexia nervosa
2012, General Hospital Psychiatry
Anorexia nervosa (AN) may be complicated by cardiac arrhythmias and sudden death. A single study reported an increased QT variability index (QTVI), a marker for cardiac arrhythmogenicity, in AN patients. The aim of the current study was to further evaluate repolarization dynamics in a large cohort of patients with AN without electrolyte abnormalities and to evaluate previously unreported repolarization dynamics parameters.
Forty-three AN patients and 45 age- and sex-matched controls were included in the study. Twenty-nine AN patients were hospitalized for a mean time of 1.5±1.1 months. The rest were ambulatory AN patients. Electrocardiograms were conducted under strict standards. QT variability index, normalized QT variability (QTVN) and power spectral analysis of QT dynamics were conducted with designated computer software.
None of the patients had an electrolyte imbalance. Although mean QT was higher in AN patients compared with controls, QTc results were similar following corrections for RR interval. There was no significant difference in QTVI, QTVN and power spectral analysis parameters among groups. The results of QTVI and QTVN were comparable to those previously published for healthy individuals. During 3 years of follow-up, no patient developed arrhythmias or suddenly died.
Medically treated AN patients who gained weight and had normal serum electrolytes appeared to have normal QTc and QT variability indexes, reflecting a nonincreased risk for cardiac arrhythmias. We suggest that weight normalization, medical treatment and lack of electrolyte abnormalities are responsible in part for these results. Further evaluation of the prognostic significance of QTVI and QTVN in AN is warranted.
Alterations in QT dispersion in the surface electrocardiogram of female adolescent inpatients diagnosed with bulimia nervosa
2010, Comprehensive Psychiatry
Citation Excerpt :
Bulimia nervosa diagnosis (according to the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition [DSM-IV] criteria) was established independently by 2 senior child and adolescent psychiatrists (DS and AY) using the Eating Disorders Family History Interview [18,19]. This is a structured clinical interview designed to gather detailed information on weight and eating history that has been extensively used in the study of ED patients, including in our previous electrographic study in AN [13,20]. Other DSM-IV Axis I psychiatric disorders were similarly established with the Structured Clinical Interview for DSM-IV Axis I Disorders–Patient Edition (Version 2.0) [21].
Increased QT dispersion (QTd) reflects cardiac autonomic imbalance and indicates elevated risk for cardiac arrhythmias. In the present study, we assessed heart rate, QT and corrected QT intervals, and QTd in 20 acutely ill bulimia nervosa adolescent inpatients on admission and discharge. A significant decrease in QTd was found between admission and discharge (67 ± 13 milliseconds vs 55 ± 12 milliseconds, respectively; P = .0005). The decrease in QTd values correlated significantly with the decrease in the frequency of bingeing/purging behaviors (r = 0.51, P = .022). No significant correlations were found between the electrocardiographic indices and other clinical and laboratory measures. The elevated QTd in malnourished bulimia nervosa patients might indicate a cardiac autonomic imbalance that is most likely corrected after symptomatic improvement.

View all citing articles on Scopus

^☆: This study was conducted at Safra Children's Hospital, Sheba Medical Center.

View full text

Original articleShort communicationAlterations in QT dispersion in the surface electrocardiogram of female adolescents diagnosed with restricting-type anorexia nervosa☆

Abstract

Objective

Methods

Results

Conclusion

Introduction

Section snippets

Patients

Results

Discussion

J Electrocardiol

Lancet

Am J Cardiol

J Pediatr

J Am Acad Child Adolesc Psychiatry

J Affect Disord

Am J Cardiol

Biol Psychiatry

Am J Cardiol

J Am Acad Child Adolesc Psychiatry

Mortality and sudden death in anorexia nervosa

Int J Eat Disord

Heart risk associated with weight loss in anorexia nervosa and eating disorders: risk factors for QTc interval prolongation and dispersion

Acta Paediatr

QT dispersion: an indication of arrhythmia risk in patients with long QT intervals

Br Heart J

Evaluation of autonomic influences on QT dispersion using the head-up tilt test in healthy subjects

Pacing Clin Electrophysiol

Original article
Short communication
Alterations in QT dispersion in the surface electrocardiogram of female adolescents diagnosed with restricting-type anorexia nervosa☆