Holiday heart syndrome

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Holiday heart syndrome: -        is an irregular heartbeat pattern seen in patients who are otherwise healthy

-        It is associated with binge drinking, which is common during the holiday season.

-        Atrial fibrillation (AFib) is the most common arrhythmia seen in holiday heart syndrome.

Causes of AFib:

-        Catecholamine excess or increased sensitivity:

o   Exogenous (eg. adrenaline infusion)

o   Endogenous

  • Subarachnoid haemorrhage
  • Phaeochromocytoma
  • Thyrotoxicosis

-        Atrial distension:

o   Pulmonary hypertension

  • Primary
  • secondary, such as OSA, PE, pulmonary fibrosis

-        Abnormality of conducting system

o   Congenital cardiac disease, eg. septal defect

o   Infiltrative cardiac disease, eg. amyloidosis, sarcoidosis

o   Ischemic heart disease

o   Haemochromatosis/iron overload

o   Hypothermia

-        Increased atrial automaticity / irritation:

o   Alcohol (“holiday heart”)

o   Caffeine

o   Electrolyte derangement (hypokalaemia, hypomagnesaemia)

o   Myocarditis

Complications of AFib:

  • Loss of atrial systole (aka “atrial kick”) (normally responsible for about 20% of ventricular filling)
  • Decreased diastolic filling time due to tachycardia
  • Rate-related cardiomyopathy (can occur over weeks)
  • Atrial thrombus formation

Management of AFib:

  • determine if the patient is stable or unstable
  • Unstable features:
  • chest pain
  • dyspnea
  • heart failure
  • hypotension
    • Electrical cardioversion
      • 120 to 200 J (biphasic) and 200 J for monophasic devices
      • provide procedural sedation

-        Management of stable patients:

o   Seek and treat underlying cause first!

  • replace electrolytes (e.g. K > 4 mmol/L, Mg > 0.9 mmol/L)
  • treat cause (e.g. ischemia, sepsis, thyroid function)

o   rate control vs rhythm control

  • Rhythm control:
  • essential in unstable patients
  •      If less than 48 hours of AFib onset
  • Rate control:
  • Diltiazem (0.25 mg/kg IV (max 20 mg) administered over 2 mins followed by 0.35 mg/kg IV (max 25 mg) administered over 5 mins if no resolution
  • Metoprolol 5 mg IV q15 min
  • Avoid calcium channel blockers in decompensated heart failure (digoxin is preferred)

o   Anticoagulation (based on the CHA2DS2-VASc score)

Sources: Life in the Fastlane, EMDOCS

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