From the Guidelines
Alcohol withdrawal can cause several abnormalities on a 12-lead EKG, most notably QT interval prolongation, which increases the risk of dangerous arrhythmias. Patients experiencing alcohol withdrawal may show sinus tachycardia with heart rates often exceeding 100 beats per minute, reflecting the hyperadrenergic state 1. ST-segment and T-wave changes may also be present, including ST depression and T-wave flattening or inversion. Atrial fibrillation, known as "holiday heart syndrome," can occur during withdrawal, especially in chronic drinkers. Premature ventricular contractions (PVCs) and other ventricular arrhythmias may appear due to electrolyte disturbances, particularly hypomagnesemia and hypokalemia, which commonly accompany alcohol withdrawal.
The EKG changes result from autonomic nervous system hyperactivity, electrolyte imbalances, and direct toxic effects of alcohol and its metabolites on cardiac tissue. The standard 12-lead ECG records potential differences between prescribed sites on the body surface that vary during the cardiac cycle; it reflects differences in transmembrane voltages in myocardial cells that occur during depolarization and repolarization within each cycle 1. Clinicians should monitor these patients closely, correct electrolyte abnormalities, and consider appropriate medications like benzodiazepines to manage withdrawal symptoms and reduce cardiovascular complications.
Key considerations for EKG interpretation in alcohol withdrawal include:
- QT interval prolongation
- Sinus tachycardia
- ST-segment and T-wave changes
- Atrial fibrillation
- Premature ventricular contractions (PVCs) and other ventricular arrhythmias
- Electrolyte disturbances, particularly hypomagnesemia and hypokalemia. Monitoring and management of these EKG changes are crucial to prevent cardiovascular complications in patients undergoing alcohol withdrawal.
From the Research
Effect of Alcohol Withdrawal on EKG
Alcohol withdrawal can have several effects on a 12-lead electrocardiogram (EKG), including:
- Prolongation of the QTc interval, which can increase the risk of cardiac arrhythmias and sudden death 2, 3, 4
- Tachyarrhythmias, such as torsade de pointes, sustained ventricular tachycardia, supraventricular tachycardia, and atrial fibrillation 3
- Changes in ECG intervals, including the QT and QTc intervals 3, 4
Comparison to Acute Coronary Syndrome
Studies have compared the QTc intervals of patients with alcohol withdrawal to those with acute coronary syndrome (ACS), finding:
- Similar QTc intervals in both groups, with a mean QTc of 457 ms in the ACS group and 468 ms in the alcohol withdrawal group 4
- A higher percentage of patients with prolonged QTc intervals in the alcohol withdrawal group (62%) compared to the ACS group (46%) 4
Clinical Implications
The effects of alcohol withdrawal on EKG highlight the importance of:
- Carefully monitoring patients with severe alcohol withdrawal syndromes for cardiac arrhythmias and obtaining an ECG 3, 4
- Avoiding QT-prolonging drugs in patients with alcohol withdrawal, and carefully monitoring the rhythm in these patients 3
- Considering the use of benzodiazepines, such as diazepam, in the treatment of moderate to severe alcohol withdrawal, due to their ability to ameliorate or prevent symptoms and complications 5