Do adolescent and young adult females with anorexia nervosa typically have hypotension?

Do People with Anorexia Have Lower Blood Pressure?

Yes, adolescent and young adult females with anorexia nervosa typically present with hypotension as a direct consequence of severe malnutrition and energy deficiency. 1, 2

Cardiovascular Manifestations in Anorexia Nervosa

Blood Pressure Abnormalities

Hypotension is a hallmark cardiovascular finding in patients with anorexia nervosa, particularly those who have lost large amounts of weight or lost weight rapidly. 1, 2 The American Psychiatric Association guidelines specifically recommend assessment of blood pressure and orthostatic blood pressure as part of the initial physical examination for patients with possible eating disorders. 1

• Mean systolic blood pressure values are significantly lower in patients with anorexia nervosa compared to healthy controls. 3
• Both maximal diastolic and mean arterial pressure values are reduced during active periods in anorexic patients. 3
• Frank hypotension can present in severely energy-deficient athletes and is a criterion for hospitalization. 1

Associated Cardiovascular Changes

Beyond simple hypotension, patients with anorexia nervosa demonstrate multiple cardiovascular abnormalities:

• Bradycardia occurs alongside hypotension, with patients showing significantly lower heart rates than controls. 4, 3
• Orthostatic changes are common, with the American Psychiatric Association recommending assessment of orthostatic pulse and orthostatic blood pressure during initial evaluation. 1
• Loss of circadian blood pressure variation occurs, with anorexic patients failing to demonstrate the physiological nighttime fall in blood pressure seen in healthy individuals. 3

Underlying Mechanisms

Autonomic and Hormonal Dysregulation

The hypotension in anorexia nervosa results from multiple interconnected mechanisms:

• Altered autonomic nervous system function resulting from hormonal disturbances and centrally mediated mechanisms contributes to lower blood pressure values. 3
• Hypoestrogenism in amenorrheic patients induces post-menopausal-like cardiovascular physiology, including endothelial dysfunction and renin-angiotensin-aldosterone axis changes. 1
• Neuroendocrine changes including decreased estradiol, decreased leptin, increased cortisol, and decreased thyroid hormones affect cardiovascular regulation. 1

Structural Cardiac Changes

Significant structural cardiac abnormalities accompany the hemodynamic changes:

• Left ventricular mass and left ventricular mass index are significantly reduced in anorexia nervosa patients compared to controls. 4
• These structural changes are largely reversible after refeeding and weight restoration, with echocardiograms showing increased left ventricular diameters and cardiac mass after treatment. 4

Clinical Implications and Monitoring

When to Hospitalize

Hospital treatment is required when hypotension becomes severe enough to indicate medical instability. 5 The American Academy of Family Physicians recommends monitoring vital signs for critical warning signs including hypotension in children with anorexia nervosa. 6

Cardiovascular Stress Response

Anorexic patients demonstrate abnormal cardiovascular reactivity to stress:

• Emaciated anorexic subjects show significantly more cardiovascular reactivity than controls, with failure to lower systolic blood pressure to baseline levels after stress. 7
• This abnormal stress response supports the importance of monitoring stress reactions alongside traditional biological measures. 7

Recovery and Reversibility

Blood pressure normalizes with refeeding and weight restoration:

• Heart rate and blood pressure increase to normal levels found in control groups after successful refeeding. 4
• The cardiovascular abnormalities, including hypotension, are largely reversible with appropriate nutritional rehabilitation and weight restoration. 4

Critical Pitfall to Avoid

Do not wait for laboratory abnormalities to take action—more than half of medically unstable adolescents with eating disorders have normal test results despite having significant cardiovascular compromise including hypotension. 8, 6 The presence of hypotension itself is a clinical indicator of medical instability requiring immediate intervention, regardless of laboratory values.