‘Holiday Heart’ in women

by Carolyn Thomas  ♥ @HeartSisters

Here’s something to keep in mind as you ponder your party planner this season.  Some people are apparently so extremely sensitive to alcohol that even moderate amounts – sometimes just a single drink – can trigger episodes of the heart arrhythmia known as paroxysmal atrial fibrillation. This unusual syndrome is also what doctors often call “Holiday Heart“.

Atrial fibrillation (AF) is a common heart rhythm disturbance that can produce significant symptoms. It is a rapid and irregular heart arrhythmia, caused by chaotic electrical impulses in the atria of the heart (the two upper chambers). In many cases, AF is caused by underlying heart disease or by aging. But often, it seems to have no identifiable cause. In cases of Holiday Heart, however, the possible cause may be an unusual sensitivity to alcohol consumption.  And in women, some Holiday Heart symptoms can look significantly different than those observed in our male counterparts.    

In paroxysmal atrial fibrillation, the arrhythmia starts suddenly, and after a time, stops suddenly. Patients may experience the sudden onset of rapid heart rate, palpitations, and often dizziness or shortness of breath. When their doctors do an EKG, they will find evidence of paroxysmal atrial fibrillation.

Holiday Heart Syndrome was first identified back in 1978 (Ettinger et al) with a study on subjects who consumed alcohol heavily and regularly; in addition, these subjects took part in a weekend or holiday drinking binge immediately prior to the study’s evaluation.

Based on their results, researchers coined the term Holiday Heart Syndrome, associated with “heavy ethanol consumption in a person without other clinical evidence of heart disease”.

They determined that this syndrome typically resolved rapidly with spontaneous recovery during subsequent abstinence from alcohol use.

Holiday Heart can be easily overlooked by physicians, warns cardiologist Dr. Richard Fogoros. He writes:

“The association between the paroxysmal atrial fibrillation and alcohol ingestion may be missed (because there really hasn’t been much alcohol ingestion). The appropriate therapy is simply to avoid drinking alcohol.  Any alcohol.”

Alcohol is already known to produce atrial fibrillation if ingested in large enough quantities, even in “normal” individuals. Up to 60% of people who engage in heavy binge drinking, for example, will develop episodes of atrial fibrillation. Doctors are generally well aware of this phenomenon.

But in Holiday Heart, even a small amount of alcohol can trigger an episode of this atrial fibrillation. Holiday Heart Syndrome should be considered as a possible  diagnosis in patients without structural heart disease and with new-onset atrial fibrillation.

As cardiologist Dr. John Mandrola (one of my favourite electrophysiologists) explains in his article, Conflicting Stories on Alcohol and Heart Disease:

“In most new cases of AF, or AF associated with normal hearts, there are specific sites in the heart’s atrium which act as triggers.  These sites are often within muscle bundles of the pulmonary veins.

“These nests of irritable cells begin firing for a reason.  In normal hearts particularly, such triggering begins ‘out of the blue’ – often with no easily identifiable reasons.   For some, even small amounts of alcohol can induce firing of these trigger sites.

“How alcohol affects the heart is highly varied and the exact mechanisms remain obscure. Along with alcohol’s propensity to induce AF trigger sites, it also induces both an ‘on alert’ state of high adrenaline as well as impaired sleep.  All these effects create a vulnerable state that favors AF.” 

Holiday Heart syndrome now most commonly refers to the association between alcohol use and rhythm disturbances, particularly one called supraventricular tachyarrhythmias, in apparently healthy people.

According to researchers reporting in the Journal of Studies on Alcohol in 2005(1), these attacks happen more frequently in the early morning and late at night, but higher frequency has also been reported during daytime. A possible explanation is that arrhythmia often starts in younger patients at night and in older ones during the day. A weekly variation has also been reported, with fewer attacks on Saturdays.

And despite the syndrome’s festive-sounding name of Holiday Heart, one 1999 study reported in the European Heart Journal did find an annual variation with fewer attacks during the last months of the year.

Cardiologists at the Cleveland Clinic (widely considered the #1 heart institute in North America) remind us that men in general tend to have atrial fibrillation more often than women do.

Women are more likely to have atrial fibrillation associated with valve disease, while men more often have atrial fibrillation associated with coronary artery disease.

The incidence of atrial fibrillation increases in both men and women with age, and when they also have hypertension and diabetes. The Copenhagen Heart Study also showed that women with atrial fibrillation had an increased risk for stroke and cardiovascular death compared to men. This is particularly true in women older than age 75 who have atrial fibrillation.

Although Holiday Heart Syndrome can recur, its clinical course is benign, and specific anti-arrhythmic therapy is usually not recommended.

A Swedish study(2) published in 2004 found that there may actually be a range of factors triggering this particular type of arrhythmia, including:

• psychological stress – the most common factor (54%)
• physical exertion (42%)
• fatigue (41%)
• alcohol consumption (34%)
• coffee (25%)
• infections (22%)

Of the patients in which alcohol consumption was considered a triggering factor, red wine and spirits produced significantly more episodes of arrhythmia than white wine.

Symptoms accompanying this arrhythmia for both men and women included:

• palpitations during exertion (88%)
• reduced physical ability (87%)
• palpitations at rest (86%)
• shortage of breath during exertion (70%)
• anxiety (59%)

Women were found to have a number of additional Holiday Heart symptoms that were significantly  different than those found in men, such as:

• swollen legs (women 21%, men 6%)
• nausea (women 36%, men 13%)
• anxiety (females 79%, males 51%)

According to the Cleveland Clinic, women who have paroxysmal atrial fibrillation may also have a faster heart rate response than men, and tend to have longer episodes compared to their male counterparts.

Some reports have also indicated that recreational use of marijuana may have similar effects on the heart.  Marijuana smoking affects the circulatory system and can trigger a number of cardiovascular events, particularly for those users who have previously experienced heart palpitations during heavy ingestion. For example, Swiss researchers at the University Hospital Geneva suggested in 2005:

“Marijuana smoking should be included in the list of possible triggers in young adults presenting with paroxysmal atrial fibrillation, once cardiac disease and other common causes of atrial fibrillation have been excluded.”

See also:

• The ‘Merry Christmas Coronary’ and the ‘Happy New Year Heart Attack’
• “Alcohol Helps Heart Bypass Patients!” – Good News or Bad Reporting?
• Is Alcohol Unsafe for All Women?
• A Rock Drummer’s Take on Atrial Fibrillation
• Why are Women With Atrial Fibrillation Treated Differently?

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(1)  Uyarel H, Ozdol C, Gencer AM, Okmen E, Cam N. “Acute alcohol intake and QT dispersion in healthy subjects”. J Stud Alcohol. Jul 2005;66:555-8

(2)  Hansson, A et al; “Arrhythmia-provoking factors and symptoms at the onset of paroxysmal atrial fibrillation”. BioMed Central, Cardiovascular  Disorders. 2004; 4: 13.

 

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