Should a chest pain workup for patients with eating disorders be deferred until after refeeding (restoration of adequate nutrition) or initiated upon admission?

From the Guidelines

For patients with eating disorders presenting with chest pain, it's crucial to conduct a thorough cardiac workup on admission rather than waiting until after refeeding. This approach is supported by the understanding that cardiac complications, including arrhythmias and sudden cardiac death, are significant concerns in individuals with eating disorders, particularly those with severe malnutrition [ 1 ]. The initial evaluation should include an ECG, cardiac biomarkers (troponin), electrolytes (particularly potassium, magnesium, and phosphate), and possibly an echocardiogram depending on the clinical presentation.

Key Considerations

• Chest pain in eating disorder patients may indicate serious cardiac complications, including arrhythmias, cardiomyopathy, or even heart failure.
• The risk of cardiac complications is highest during early refeeding, making baseline assessment crucial [ 1 ].
• Severe malnutrition can cause structural cardiac changes, electrolyte abnormalities, and autonomic dysfunction that predispose patients to potentially life-threatening cardiac events.
• While some cardiac abnormalities may improve with nutritional rehabilitation, delaying evaluation could miss critical findings that would affect management decisions, including refeeding rate, electrolyte replacement protocols, and cardiac monitoring requirements.

Management Approach

• Continuous cardiac monitoring is often warranted during early refeeding, especially in severely malnourished patients with bradycardia, hypotension, or ECG abnormalities [ 1 ].
• The "re-feeding syndrome" characterized by cardiac, neurological, and hematological complications triggered by fluid and electrolyte disturbances during the re-feeding of chronically starved individuals, underscores the need for careful management [ 1 ].
• Low weight, low body mass index, and rapid weight loss immediately preceding assessment are the most important independent predictors of QTc interval prolongation, highlighting the importance of early intervention [ 1 ].

From the Research

Chest Pain Workup for Eating Disorders

• The decision to workup chest pain in patients with eating disorders on admission or wait until they are refed is not explicitly addressed in the provided studies 2, 3, 4, 5, 6.
• However, it is essential to note that chest pain is a common symptom in patients with eating disorders, with a high incidence of typical and atypical angina 4.
• The pathophysiology, etiology, and risk factors of chest pain among adolescents with anorexia nervosa are unique and should be considered in the workup 5.
• Electrocardiogram (ECG) parameters can be useful in predicting myocardial injury and assessing prognosis in patients with acute pulmonary embolism, which may be relevant to patients with eating disorders 6.
• Patients with eating disorders should be screened for chest pain and other risk factors for coronary heart disease, regardless of their weight loss history or method 4.
• A comprehensive workup for chest pain in patients with eating disorders may involve a physical examination, orthostatic vital signs, and testing, such as a metabolic panel with magnesium and phosphate levels, and electrocardiography, when indicated 3.

Considerations for Refeeding

• Refeeding patients with eating disorders can help stabilize their cardiovascular health, with a recommended weight gain of 2.2 to 4.4 lb per week 3.
• However, the timing of the chest pain workup in relation to refeeding is not explicitly addressed in the provided studies.
• It is crucial to consider the patient's overall health status, including their nutritional status, when deciding on the timing of the workup.

Importance of Early Intervention

• Early intervention may decrease the risk of long-term pathology and disability in patients with eating disorders 3.
• Clinicians should interpret disordered eating and body image concerns and carefully monitor patients' height, weight, and body mass index trends for subtle changes 3.
• A unified, evidence-based therapeutic approach, including a dietitian, therapist, and caregivers, is essential for effective management of eating disorders 3.