A 25-year-old G2P1 female with a past medical history of fetal demise 4-5 months prior to this Emergency Department (ED) visit presents with chest pain and palpitations that started at 1:00 AM, approximately 10 hours prior to arrival. Her pain is central and constant without associated cough, shortness of breath, or increased work of breathing. She reports one similar episode of palpitations that resolved spontaneously 2 weeks ago. Mourning a recent loss, she has been drinking approximately 7 beers per shift in her new job as a bartender over the past several months. Her last drink was 2 days ago. She has no history of dysrhythmia, venous thromboembolism, diabetes mellitus, hypertension, alcohol use disorder, or alcohol withdrawal. There is no family history of sudden cardiac death. An index ECG was obtained in triage (Figure 1).
Interpretation:
Rate:166; Rhythm: irregular; Axis: normal; Intervals: PR: n/a; P-waves: absent; QRS complex: narrow; ST segment/T waves: inverted T waves in III, aVF
The patient was admitted to the Cardiac ICU and diagnosed with alcohol use disorder with acute withdrawal with a reported history of more than 3 months of daily alcohol consumption of 5-7 drinks. In this case, the patient’s atrial fibrillation, seen in Figure 1, was likely triggered by her abrupt cessation of drinking over the previous 2 days, pushing her into acute alcohol withdrawal. Of note, both chronic alcohol use and acute alcohol use binges can results in hyperadrenergic states when cessation of alcohol occurs, which can present with arrhythmias such as atrial fibrillation.
Discussion:
Atrial fibrillation (afib) is characterized by disorganized atrial electrical activity and contraction resulting in “irregularly irregular” ventricular response. The prevalence increases with age and may be acute, transient, paroxysmal, or chronic in nature. There are various underlying causes, which include the following per the “P-HEARTS” mnemonic:
Pericarditis
Hypertension
Embolism
Atherosclerosis (MI)
Alcohol (withdrawal, holiday heart)
Rheumatic heart disease/Mitral valve disease
Thyrotoxicosis
Stimulants
Sepsis
Although most commonly seen in older patients (70-80 years of age), an increasing number of patients with afib are less than 65 years old at initial presentation. This may be attributable to increasing rates of risk factors such as hypertension, obesity, and maladaptive lifestyle behaviors (e.g. alcohol use) among the younger population.
An irregular heartbeat precipitated by an acute alcohol binge (most commonly atrial fibrillation) has been referred to as “holiday heart syndrome,” a term first coined by Ettinger et al. in 1978, as a higher incidence of binge drinking is often seen in relation to holidays. Holiday heart syndrome remains a common presentation in the ED, comprising up to 35-62% of all cases of afib. While initial studies evaluated regular habitual drinkers, subsequent studies have found increased risk of afib in those who participated in binge drinking without prior habitual alcohol use (Thornton JR, The Lancet. 1984).
According to three large meta-analyses, moderate habitual consumption increases the incidence of afib in a dose-dependent manner, with men and women equally affected. Further, while most studies evaluating incidence and prevalence rates largely included male participants, a randomized controlled trial called the “Women’s Health Study” was conducted in the US evaluating rates of afib among women. This trial demonstrated that heavy consumption of two or more alcoholic drinks per day was associated with a small but statistically significant increased risk of afib among healthy, middle-aged women (Conen D, et al., JAMA. 2008).
Pathophysiology:
Sustained short-term alcohol consumption may induce electrical atrial remodeling, producing an arrhythmogenic atrial substrate (Figure 2). In patients without prior afib, there is a significant reduction in short-term heart rate variability (HRV) following acute alcohol ingestion. This “hyperadrenergic state” of an increased ratio between low- and high-frequency components of HRV persists at least 24 hours after intoxication, which may explain why some patients present with afib within several days after a binge (Holiday Heart Syndrome) or after abrupt cessation of habitual alcohol use, as in this case.
Figure 2. Proposed pathophysiological mechanism for alcohol-associated atrial fibrillation (Brundel et al., Nat Rev Dis Primers 2022).
Management:
A meta-analysis of multiple prospective, randomized, double blind and retrospective cohort studies showed that diltiazem was likely to achieve rate control (Figure 2) faster than metoprolol, although both appear safe and effective (Long et al., J Emerg Med 2022). As always, physicians are to use their clinical judgement in selecting a medication based upon the individual patient, clinical status, and the patient’s respective co-morbidities.
Figure 3. ECG in our patient after rate control with two liters of IV normal saline and diltiazem 10 mg IV x2.
Take Away Points:
In the ED, we often associate afib with rapid ventricular response with an older population. While it is important to recognize certain arrhythmias such as Wolff-Parkinson-White Syndrome and Brugada Syndrome among the younger patient population, it is not uncommon for younger patients to present with atrial fibrillation.
Those without prior habitual alcohol use can present to the ED with acute onset of atrial fibrillation after an episode of binge drinking.
Authored by Leslie Cachola, MD and Ari Edelheit, MD.
References:
1. Bhonsale A et al. Mortality, hospitalization, and cardiac interventions in patients with atrial fibrillation aged <65 years. Circulation: Arrhythmia and Electrophysiology 17.5.
Blumberg G and Simon, E. EM@3AM – atrial fibrillation. EMdocs.net. Accessed 20 Jan 2025 at https://www.emdocs.net/em3am-atrial-fibrillation/
Brundel, B.J.J.M., Ai, X., Hills, M.T. et al. Atrial fibrillation. Nat Rev Dis Primers 8, 21 (2022). https://doi.org/10.1038/s41572-022-00347-9https://doi.org/10.1161/CIRCEP .123.012143
Conen D, Tedrow UB, Cook NR, Moorthy MV, Buring JE, Albert CM. Alcohol Consumption and Risk of Incident Atrial Fibrillation in Women. JAMA. 2008;300(21):2489–2496. doi:10.1001/jama.2008.755
Ettinger, Philip O., et al. “Arrhythmias and the ‘Holiday Heart’: alcohol associated cardiac rhythm disorders.” American Heart Journal 95.5 (1978): 555-562.
Long B, Keim SM, Gottlieb M, Stiell IG. What is the Best Agent for Rate Control of Atrial Fibrillation With Rapid Ventricular Response?. J Emerg Med. 2022;63(3):467-476. doi:10.1016/j.jemermed.2022.07.014
Nickson, C. Atrial fibrillation. Life in the Fast Lane. Accessed 20 Jan 2025 at https://litfl.com/atrial-fibrillation/
Thornton, J. R. “Atrial fibrillation in healthy non-alcoholic people after an alcoholic binge.” The Lancet 324.8410 (1984): 1013-1015.