Atrial Fibrillation in Father and Son after Ingestion of Cold Substances CHUN W. TAN, MD; JOSEPH L. GERRY, MD; D. LUKE GLANCY, MD
ABSTRACT: A man and his father each developed atrial fibrillation after the ingestion of a frozen sweet. In the son, atrial fibrillation recurred with the subsequent ingestion of cold beverages. Neither patient had documented episodes of atrial fibrillation at any other time. The son also had multiple other episodes of palpitation, suggesting brief episodes of atrial fibrillation, and these
occurred only with the ingestion of cold substances. Possible mechanisms include direct cooling of the left atrium through the wall of the esophagus and autonomic stimulation by the cold substance. KEY INDEXING TERMS: Paroxysmal atrial fibrillation; Familial; Cold substance ingestion; Hypothermia. [Am J Med Sci 2001; 321(5):355–357.]
trial fibrillation commonly develops in subjects with severe generalized hypothermia1,2 but has rarely been reported as a result of eating frozen food.3 We describe here a man and his father, each without significant heart disease, who developed atrial fibrillation after eating snowballs, popular New Orleans summer-time refreshments consisting of cones of flavored, shaved ice. Case Reports
Case 1. In 1988, at age 42, S.G., Jr., who for a year or two had noted transient palpitations after drinking cold beverages, developed a sustained episode of atrial fibrillation after eating a snowball. He was taking no drugs and was normotensive (139/83 mm Hg). Physical examination, blood count, electrolytes, chest radiograph, echocardiogram, and serum total thyroxine level (6.9 g/dL) were normal. He was treated with digoxin and quinidine and reverted to sinus rhythm the next day (Figure 1). He subsequently was able to complete 1 minute of stage 5 of a standard Bruce treadmill exercise test without chest discomfort or electrocardiographic abnormality. Heart rate rose from 102 beats/min before exercise to 165 at peak exercise and fell to 102 five minutes after exercise. He continued to have brief episodes of palpitation after drinking cold beverages; in 1991, after drinking cold Slim Fast and 10-K, he had another sustained episode of atrial fibrillation requiring treatment (Figure 2). Recently, his episodes of palpitation have been rare because he assiduously avoids swallowing anything cold. He has developed mild high blood pressure, treated with a thiazide diuretic, and has diet-controlled hyperlipidemia, but otherwise enjoys excellent health. Case 2. S.G., Sr., a physician, has had atrial premature beats for many years. He has long-standing hyperlipidemia and new-
From the Section of Cardiology, Department of Medicine, Louisiana State University Health Sciences Center and University Hospital, New Orleans, Louisiana (CWT, DLG); and St. Tammany Parish Hospital, Covington, Louisiana (JLG). Submitted July 5, 2000; accepted November 21, 2000. Correspondence to: D. Luke Glancy, M.D., Section of Cardiology, Department of Medicine, Louisiana State University Health Sciences Center, 1542 Tulane Avenue Room 441, New Orleans, LA 70112 (E-mail: [email protected]
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Figure 1. Electrocardiographic rhythm strips on S.G., Jr., on May 22, 1988, showing atrial fibrillation (top) and subsequent sinus rhythm (bottom).
onset diabetes mellitus, both diet-controlled. Because of a recent episode of atypical chest pain and his multiple risk factors for coronary disease, coronary arteriograms and a left ventriculogram were performed and were normal. In 1999, at age 79, he developed atrial fibrillation after ingesting a snowball so rapidly that it made the center of his chest uncomfortably cold. Sinus rhythm returned the following day after the administration of propafenone (Figure 3). His echocardiogram was normal, as were thyroid function tests, blood count, and electrolytes. He has had no further episodes of atrial fibrillation and has not eaten another snowball. His only medications are valsartan for long-standing mildly elevated blood pressure and bicalutamide for prostate cancer in remission after radiation treatment. This patient is an only child. Neither of his parents, his wife, nor his only other child, a daughter, has had atrial fibrillation.
Discussion Atrial fibrillation frequently develops with generalized hypothermia, whether accidental1,2 or induced in the operating room.4 Its incidence is inversely related to core temperature. Sinus rhythm almost invariably returns as normothermia is restored. 355
Familial Cold-Induced Atrial Fibrillation
Figure 2. Electrocardiogram of S.G., Jr., in 1991, showing atrial fibrillation with a rapid ventricular response. Otherwise, the electrocardiogram is normal.
As early as 1920, Wilson and Finch described the effects of drinking iced water on T-wave morphology and postulated direct cooling of the posteroinferior surface of the apex of the left ventricle as the cause of the changes.5 Subsequently, others noted that the ingestion of frozen food3 or gastric cooling by lavage6 occasionally resulted in atrial fibrillation. Such reports are rare, however, despite the fact that virtually everyone swallows cold beverages, ice cream, etc., especially on hot days. The mechanism(s) by which swallowing cold substances induces atrial fibrillation is not clear. The simplest explanation is that the left atrium, which lies directly in front of the esophagus, is significantly cooled by the cold material adjacent to it and that focal left atrial hypothermia is responsible for
Figure 3. Electrocardiograms on S.G., Sr., on July 2, 1999, showing atrial fibrillation (top) and subsequent sinus rhythm (bottom). Both electrocardiograms demonstrate nonspecific Twave changes. Q waves are present III, aVF, but there is no history of myocardial infarction, and the results of coronary arteriograms and a left ventriculogram performed the same year were normal.
the fibrillation. Alternatively, activity of the autonomic nervous system may play the major role. Vagal stimulation slows heart rate and shortens atrial refractoriness nonuniformly, thus accentuating dispersion of refractoriness and facilitating reentry.7,8 Increased sympathetic influence favors abnormal automaticity and triggered activity.8 Paroxysms of atrial fibrillation have been ascribed both to heightened vagal activity and to sympathetic stimulation.8,9 Although atrial fibrillation is probably not unusual in families with many octogenarians and/or whose members have serious heart disease, its familial occurrence is uncommon among younger patients without significant heart disease.10,11 A familial influence would seem to be operative in our father and son, not only in predisposing them to atrial fibrillation, but also in the specificity of the trigger. Although asymptomatic episodes of atrial fibrillation can never be excluded, neither patient has had any documented atrial fibrillation or symptoms suggesting the arrhythmia in any circumstance other than swallowing a cold substance. In the son, palpitations, presumably caused by short runs of atrial fibrillation or other atrial arrhythmia, are predictably reproduced by swallowing things cold and have never occurred otherwise. Both of them have found the solution to their problem: they avoid swallowing cold substances. Careful questioning about the circumstances surrounding the onset of atrial fibrillation might uncover more such patients in whom the management of this often-vexing arrhythmia could be simplified. While this article was undergoing revision, we treated an 18-year-old man who developed atrial fibrillation after eating ice cream rapidly, and he spontaneously reverted to sinus rhythm overnight in the hospital. For 3 years before admission, episodes of palpitation had occurred frequently after March 2001 Volume 321 Number 5
Tan, Gerry, and Glancy
ingesting cold substances and not at any other time. No family member had any similar problems. Physical examination was normal except for obesity. Electrocardiograms showed early repolarization 3 years before admission and nonspecific T-wave changes immediately after reversion to sinus rhythm. A cardiac echo-Doppler study was entirely normal. He has been advised to avoid cold substances or to ingest them slowly. Acknowledgements We thank Brenda Kuss for her assistance with the manuscript. References 1. Okada M. The cardiac rhythm in accidental hypothermia. J Electrocardiol 1984:17:123– 8. 2. Clements SD, Hurst JW. Diagnostic value of electrocardiographic abnormalities observed in subjects accidentally exposed to cold. Am J Cardiol 1972:29:729 –34.
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3. Brodsky MA, Orlov MV, Allen BJ, et al. Frozen yogurt near deep-freeze. Am J Cardiol 1994:73:627– 8. 4. Schwab RH, Lewis DW, Killough JH, et al. Electrocardiographic changes occurring in rapidly induced deep hypothermia. Am J Med Sci 1964:248:290 –303. 5. Wilson FN, Finch R. The effects of drinking iced water upon the form of the T deflection of the electrocardiogram. Heart 1923:10:275– 8. 6. Herman R, Harrell R. Cardiovascular effects of gastric hypothermia. South Med J 1967:60:152–5. 7. Tsuji H, Fujiki A, Tani M, et al. Quantitative relationship between atrial refractoriness and the dispersion of refractoriness in atrial vulnerability. Pacing Clin Electrophysiol 1992:15:403–10. 8. Coumel P, Lecleroq JK, Attuel P, et al. Autonomic influences in the genesis of atrial arrhythmias. Atrial flutter and fibrillation of vagal origin. In: Narula OS, editor. Cardiac arrhythmias: electrophysiology, diagnosis and management. Baltimore: Williams & Wilkins; 1979. p. 243. 9. Coumel P. Paroxysmal atrial fibrillation. a disorder of autonomic tone? Eur Heart J 1994:15:9 –16. 10. Wolff L. Familial auricular fibrillation. N Engl J Med 1943: 229:396 – 8. 11. Gould WI. Auricular fibrillation. Report on a study of familial tendency, 1920 –1956. Arch Intern Med 1957:100: 916 –26.