Table 3 Points of enquiry in the cardiovascular history and their clinical relevance in patients with eating disorders

Shortness of breath

Although rare, shortness of breath in AN may be a symptom of congestive heart failure (CHF). The presence of orthopnoea, paroxysmal nocturnal dyspnoea, or breathlessness worsened on exertion increases the index of suspicion for CHF [24].

Palpitations

Palpitations are often benign but may indicate arrhythmia, valvular dysfunction, or autonomic dysfunction [25]. Tachycardia at rest is a worrisome sign in AN, often indicating a separate underlying cause, e.g. infection [25]. Arrhythmias and autonomic dysfunction can cause syncope [5].

Chest pain

Mitral valve prolapse is a possible cause of chest pain in patients with AN and there have been case reports of ischaemic heart disease [5, 25]. Mitral valve prolapse related chest pain may be associated with palpitations and dizziness [75]. Chest pain in young people is usually benign and is non-cardiac in 96% of cases, but in individuals with EDs may represent cardiovascular compromise [72, 75]. Non-cardiac chest pain may be musculoskeletal, psychogenic, gastrointestinal or pulmonary in origin [76]. AN may predispose individuals to spontaneous pneumothorax and this should therefore be considered as a rare but serious differential for chest pain among this group [77, 78].

Syncope and presyncope

Discussed in-text under Cardiovascular abnormalities: Risk stratification and how to respond.

Purging behaviours

Frequent vomiting, as well as abuse of laxatives and diuretics, can cause potassium depletion, predisposing to cardiac arrhythmias [79]. Syrup of ipecac is sometimes used to induce emesis among youth with AN. Ipecac is cardiotoxic and increases the risk of cardiomyopathy [79].

Weight history

Cardiovascular complications are more severe with significant weight loss and low BMI [25]. The degree and rapidity of weight loss should be quantified. In the context of weight stability, failure to gain weight at the expected rate may be equally concerning.

Medical history, medication history

The presence of comorbidities increases cardiac risk. Psychotropic medications, including antipsychotics and antidepressants can adversely affect the heart [80].