Holiday heart syndrome

Das Ferien- Herz- Syndrom, auch als HHS bezeichnet,  wurde von Philip Ettinger erstmals im Jahre 1978 beschrieben (Schörken 2024). Dieser beobachtete 24 Patienten, die nach einem Rauschtrinken am Wochenende mit plötzlichem Vorhofflimmern stationär eingeliefert werden mussten (Jain 2024).

Unter einem Ferien- Herz- Syndrom (HHS) versteht man plötzlich einsetzende Herzrhythmusstörungen während des Urlaubs (Herold 2020), die innerhalb von 24 – 48 Stunden nach einem exzessiven Alkoholkonsum bei ansonsten gesunden Personen auftreten (Schörken 2024).

HHS can occur both in people who drink alcohol regularly and in people who only drink very rarely. It is triggered by binge drinking. In around 35 - 62 % of cases, atrial fibrillation occurs 12 - 36 hours after binge drinking (Jain 2024).

The most common manifestation of HHS is atrial fibrillation, but atrial flutter, paroxysmal atrial tachycardia and isolated ventricular extrasystoles have also been described (Tonelo 2013).

HHS is typically caused by excessive alcohol consumption (Herold 2020).

It has also been described following stress, lack of sleep and the consumption of energy drinks (Bellmann 2022).

HHS has a complex and multifactorial pathophysiology. Excessive alcohol consumption leads to:

- Electrolyte imbalances: These lead to electrolyte imbalances. Potassium and magnesium imbalances in particular promote arrhythmias.

- Direct cardiotoxic effects: Ethanol and its metabolites have a toxic effect on cardiomyocytes.

- Inflammatory processes: Alcohol promotes the release of inflammatory cytokines, which in turn can impair cardiac function.

- Influence on the autonomic nervous system: Alcohol promotes sympathetic stimulation and parasympathetic inhibition. Both lead to an increased heart rate and excitability of the heart (Schörken 2024).

The cardiac arrhythmia primarily manifests itself as paroxysmal atrial fibrillation (Schörken 2024).

- Palpitations

- Thoracic pain

- Dizziness (Schörken 2024)

- Shortness of breath

- General weakness (Jain 2024)

- Restlessness

- Anxiety (Bellmann 2022)

In addition to the physical examination, a laboratory test, a 12-lead ECG, a chest X-ray and an echocardiogram should be performed (Jain 2024).

12-lead ECG

ECG may primarily show atrial fibrillation, but may also show atrial flutter, atrial tachycardia, ventricular tachycardia, supraventricular extrasystoles or ventricular extrasystoles (Bellmann 2022)

Chest X-ray

Signs of pulmonary vasocongestion or signs of cardiomegaly may be present, especially in chronic alcohol consumption (Jain 2024).

Echocardiography

During echocardiography, the size of the left ventricle and atrium in particular should be determined, as well as any wall motion abnormalities, systolic and diastolic function and indications of any valve disease (Jain 2024).

If there is evidence of HHS, laboratory tests should be carried out:

- Blood count (chronic alcoholics often show anemia or thrombocytopenia)

- potassium

- magnesium

- Natriuretic peptides of the brain (BNP)

- troponin

- Kidney and liver values (Jain 2024)

Alcoholic cardiomyopathy: This is caused by years of excessive alcohol consumption (Schörken 2024).

- CHD

- pulmonary embolism

- pneumonia

- Dilated cardiomyopathy

- Thyrotoxicosis

- Substance abuse of cocaine or amphetamines (Jain 2024)

- Development of persistent atrial fibrillation

- Life-threatening arrhythmias

- Development of dilated cardiomyopathy

- Embolic apoplexy

- Systemic thromboembolism

- Death (Jain 2024)

The patient should be connected to a heart telemetry monitor in order to be able to observe the development of the heart rate (Jain 2024).

Any electrolyte imbalances should be compensated (Schörken 2024).

In the case of an HHS, the heart rhythm should be stabilized. In most cases, however, mere observation and monitoring are sufficient (Jain 2024).

Drugs such as beta-blockers (e.g. bisoprolol, carvedilol, metoprolol [Jain 2024]) or antiarrhythmic drugs can be used (Schörken 2024).

If the patient shows signs of clinical instability such as hypotension, altered mental status, clinical signs of shock, acute heart failure, etc., synchronized cardioversion may be considered (Jain 2024).

Anticoagulation

According to the latest guidelines of the American College of Cardiology/American Heart Association (ACC/AHA), reversible causes of atrial fibrillation should also be anticoagulated to reduce the risk of apoplexy (Jain 2024).

Overall, the prognosis for HHS is good. As a rule, complete recovery occurs within a few days (Schörken 2024).

On the other hand, it has been shown that recurrence of atrial fibrillation can occur in 20 - 30 % within 12 months (Jain 2024).

However, episodes do not recur if the patient lives an abstinent life (Tonelo 2013).

HHS can be prevented by moderating alcohol consumption (Schörken 2024).

1. Bellmann B, Nolte J, Antwerpes F, Ostendorf N et al. (2022) Holiday- Heart- Syndrome. DocCheck Flexikon doi: https://flexikon.doccheck.com/en/Holiday-Heart-Syndrome
2. Jain A, Yelamanchili V S, Brown K N, Goel A (2024) Holiday Heart Syndrome. StatPearls Treasure Island Bookshelf ID: NBK537185. doi: https://pubmed.ncbi.nlm.nih.gov/30725870/
3. Herold G et al (2020) Internal medicine. Herold publishing house 287, 936
4. Kasper D L, Fauci A S, Hauser S L, Longo D L, Jameson J L, Loscalzo J et al. (2015) Harrison's Principles of Internal Medicine. Mc Graw Hill Education
5. Schörken H, Wienbergen H (2024) Update on the Holiday Heart Syndrome. Herzmedizin für Ärzte und Fachpersonal. doi: https://herzmedizin.de/fuer-aerzte-und-fachpersonal/kardiologie-interdisziplinaer/praevention/holiday-heart-syndrom.html#:~:text=Das%20Holiday%2DHeart%2DSyndrom%20(,bei%20ansonsten%20gesunde%20Personen%20auftreten.
6. Tonelo D, Providencia R, Goncalves L (2013) Holiday heart syndrome revisited after 34 years. Arq Bras Cardiol. 101 (2) 183 - 189