Q: 28 year old female who has recently started her care for severe Anorexia nervosa on an outpatient basis presented with the complaint of "not feeling well". ER physician wants to admit her to the ICU for observation. Today, the patient's physical exam appears to be unchanged from the description of previous outpatient visits, but you notice that even though today her heart rate is normal, she was consistently bradycardic in heart rate of 40s during her previous outpatient visits.


 Answer:  Bradycardia is a normal finding in patients with severe Anorexia nervosa and should be treated as normal. Hospital admission is required for bradycardia only if heart rate is less than 40 to rule out any pathology. On the contrary, normal heart rate in patients with severe known Anorexia nervosa should be taken very seriously as this represents “relative tachycardia” in these patients, and may be a clinical symptom of impending heart failure or early sign of refeeding syndrome, both of which can have significant clinical implications.



References:

1. Krantz MJ, Mehler PS. Resting tachycardia, a warning sign in anorexia nervosa: case report. BMC Cardiovasc Disord 2004; 4:10. 

2. Galetta F, Franzoni F, Prattichizzo F, et al. Heart rate variability and left ventricular diastolic function in anorexia nervosa. J Adolesc Health 2003; 32:416. 

3. Derman T, Szabo CP. Why do individuals with anorexia die? A case of sudden death. Int J Eat Disord 2006; 39:260.