What to do for electrocardiogram (ECG) abnormalities in patients with eating disorders?

From the Guidelines

For ST abnormalities in patients with eating disorders, immediate medical evaluation is essential, and treatment should involve careful refeeding with electrolyte monitoring and supplementation, as recommended by the American Psychiatric Association 1. Contact a healthcare provider right away as these ECG changes can indicate serious cardiac complications. Some key points to consider in the management of eating disorders include:

• Initial psychiatric evaluation should include weighing the patient, quantifying eating and weight control behaviors, and identifying co-occurring health conditions, including co-occurring psychiatric disorders 1.
• Laboratory assessment should include a complete blood count and a comprehensive metabolic panel, including electrolytes, liver enzymes, and renal function tests 1.
• An electrocardiogram should be done in patients with a restrictive eating disorder, patients with severe purging behavior, and patients who are taking medications that are known to prolong QTc intervals 1.
• Patients with an eating disorder should have a documented, comprehensive, culturally appropriate, and person-centered treatment plan that incorporates medical, psychiatric, psychological, and nutritional expertise, commonly via a coordinated multidisciplinary team 1. Treatment typically involves careful refeeding with electrolyte monitoring and supplementation, particularly potassium, magnesium, and phosphate. Initial refeeding should start at 1,000-1,200 calories daily and increase gradually by 200-300 calories every 2-3 days while monitoring vital signs and electrolytes. Specific electrolyte replacements may include potassium chloride 40-80 mEq daily, magnesium oxide 400-800 mg daily, and phosphate supplements as needed. Cardiac monitoring through regular ECGs is crucial during refeeding. These interventions are necessary because malnutrition and electrolyte imbalances in eating disorders can cause dangerous heart rhythm disturbances, reduced heart muscle mass, and prolonged QT intervals. The goal is to correct the underlying nutritional deficiencies while carefully monitoring for refeeding syndrome, which can worsen cardiac complications if calories are increased too rapidly. Additionally, the American Psychiatric Association recommends that patients with anorexia nervosa who require nutritional rehabilitation and weight restoration have individualized goals set for weekly weight gain and target weight 1. Adults with anorexia nervosa should be treated with an eating disorder-focused psychotherapy, which should include normalizing eating and weight control behaviors, restoring weight, and addressing psychological aspects of the disorder 1. Similarly, adults with bulimia nervosa should be treated with eating disorder-focused cognitive-behavioral therapy and a serotonin reuptake inhibitor, such as 60 mg fluoxetine daily, either initially or if there is minimal or no response to psychotherapy alone by 6 weeks of treatment 1. Patients with binge-eating disorder should be treated with eating disorder-focused cognitive-behavioral therapy or interpersonal therapy, in either individual or group formats 1. Overall, a comprehensive and multidisciplinary approach is necessary for the effective management of eating disorders and the prevention of cardiac complications.

From the Research

Diagnosis and Treatment of Eating Disorders

• Eating disorders are potentially life-threatening conditions that require early intervention and a unified, evidence-based therapeutic approach 2.
• Clinicians should carefully monitor patients' height, weight, and body mass index trends for subtle changes and interpret disordered eating and body image concerns 2.
• Treatment options may include cognitive behavior interventions, family-based therapy, and pharmacotherapy, with evidence supporting select antidepressants or topiramate for bulimia nervosa and lisdexamfetamine for binge-eating disorder 2, 3.

Pharmacologic Treatment of Eating Disorders

• Medications are a useful adjunct to nutritional and psychotherapeutic treatments for eating disorders, with antidepressants commonly used to treat bulimia nervosa 3.
• Binge eating disorder can be treated with antidepressants, medications that diminish appetite, or with lisdexamfetamine, while anorexia nervosa does not generally respond to medications 3.
• Recent evidence supports modest weight restoration benefits from olanzapine for anorexia nervosa 3.

Initial Evaluation and Treatment

• The primary care setting provides an important opportunity for critical medical and psychosocial intervention, with updated diagnostic criteria for anorexia nervosa and bulimia nervosa 4.
• Family-based treatment is helpful for adolescents with anorexia nervosa, whereas short-term psychotherapy, such as cognitive behavior therapy, is effective for most patients with bulimia nervosa 4.
• Treatment is most effective when it includes a multidisciplinary, team-based approach 4.

Molecular Bases and Treatment Challenges

• Eating disorders have devastating consequences to human health, involving social, mental, emotional, physical, and life-threatening aspects 5.
• There is a crucial lack of efficient clinical treatment for eating disorders, with a need for new perspectives, avenues, and strategies to be developed 5.
• Eating disorders are disabling, deadly, and costly mental disorders that considerably impair physical health and disrupt psychosocial functioning, with disturbed attitudes towards weight, body shape, and eating playing a key role in their origin and maintenance 6.