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Holiday Heart Block: Alcohol-induced PR Prolongation

      Presentation

      Consumption of large quantities of alcohol has a number of well-known consequences, but the effect endured by one patient is rather remote. A 27-year-old black man was brought to the emergency department after suffering head trauma that initially left him unconscious. His score on the Glasgow Coma Scale was 14, denoting a mild head injury. Physical examination on admission revealed that the patient had a monocular hematoma. Computed tomography excluded intracranial bleeding and other serious injuries. Laboratory values revealed an increased serum alcohol concentration of 6.3 g/L, indicating acute alcohol intoxication. A urine screen for illicit drugs was negative. The patient was not on any regular medication.

      Assessment

      An electrocardiogram (ECG) showed a sinus rhythm with a heart rate of 84 beats per minute, a first-degree atrioventricular block, and a prolonged PR interval of 338 ms (Figure 1). Furthermore, nonspecific ST-segment elevations were noted in leads II, III, and aVF, a pattern compatible with benign early repolarization. Both the QRS interval and the QT interval, corrected for heart rate, were within normal ranges.
      Figure thumbnail gr1
      Figure 1The electrocardiogram (ECG) demonstrated sinus rhythm with a prolonged PR interval of 338 ms, indicating first-degree atrioventricular block. The 27-year-old patient, otherwise healthy, had alcohol poisoning.
      The patient was monitored and a repeat ECG, performed 3 hours later, after admission, showed complete recovery of the atrioventricular conduction delay, as documented by a normal PR interval of 166 ms (Figure 2). Twelve hours later, a third ECG confirmed a stable sinus rhythm with a normal heart rate of 91 beats per minute and a normal PR interval. Finally, Holter monitoring was carried out for a 24-hour period to exclude any high-degree atrioventricular block. No PR prolongation or second- or third-degree atrioventricular block was evident. Echocardiography was unremarkable, and in particular, it ruled out any structural heart disease, and the left ventricular ejection fraction was normal.
      Figure thumbnail gr2
      Figure 2Another ECG, obtained 3 hours after the first, demonstrated complete recovery of the atrioventricular conduction with a normal PR interval of 166 ms.

      Diagnosis

      Atrioventricular block induced by alcohol consumption is very rarely reported. Although this is a transient phenomenon, the patient's heart rhythm must be monitored to exclude high-degree atrioventricular block. Intoxication might aggravate the conduction delay in patients with preexisting atrioventricular-nodal disease, thus triggering high-degree atrioventricular block, but at present, there are no published data to substantiate this hypothesis.

      Management

      Acute alcohol poisoning, sometimes accompanied by unconsciousness, is still a major health concern, particularly among young people. Up to 40% of all emergency department visits are attributed to alcohol-related problems.
      • Charalambous M.P.
      Alcohol and the accident and emergency department: a current review.
      The incidence of alcohol intoxication in men is twice that in women.
      Excessive alcohol consumption can result in low blood pressure, coma, respiratory failure, and even sudden cardiac death.
      • Behr E.R.
      • Casey A.
      • Sheppard M.
      • et al.
      Sudden arrhythmic death syndrome: a national survey of sudden unexplained cardiac death.

      Wilson JF, Laine C, Goldmann DR, Sox HC. In the clinic: alcohol use. Ann Intern Med. 2009;150:ITC3-1. doi:10.7326/0003-4819-150-5-200903030-01003. Available at: http://annals.org/article.aspx?articleid=744361.

      Arrhythmic problems—the so-called holiday heart syndrome—can occur in otherwise healthy subjects; these include supraventricular tachyarrhythmias, the most common of which is atrial fibrillation.
      • Greenspon A.J.
      • Schaal S.F.
      The “holiday heart:” electrophysiologic studies of alcohol effects in alcoholics.
      A potential mechanism could be dysregulation of the autonomic system, which increases cardiac sympathetic stimulation by inhibiting the parasympathetic nerve activity affecting sinus node function.
      • Boschloo L.
      • Vogelzangs N.
      • Licht C.M.
      • et al.
      Heavy alcohol use, rather than alcohol dependence, is associated with dysregulation of the hypothalamic-pituitary-adrenal axis and the autonomic nervous system.
      And, as in our patient, alcohol intoxication can induce atrioventricular block in a structurally normal heart.
      • Carstairs S.D.
      • Clark R.F.
      Atrioventricular block due to acute ethanol intoxication.
      Binge drinking has been associated with both PR- and QT-prolongation.
      • Lorsheyd A.
      • de Lange D.W.
      • Hijmering M.L.
      • Cramer M.J.
      • Van de Wiel A.
      PR and QTc interval prolongation on the electrocardiogram after binge drinking in healthy individuals.
       Therefore, patients need to be monitored for atrioventricular block and if necessary, be paced temporarily until atrioventricular conduction has recovered from alcohol intoxication.

      References

        • Charalambous M.P.
        Alcohol and the accident and emergency department: a current review.
        Alcohol Alcohol. 2002; 37: 307-312
        • Behr E.R.
        • Casey A.
        • Sheppard M.
        • et al.
        Sudden arrhythmic death syndrome: a national survey of sudden unexplained cardiac death.
        Heart. 2007; 93: 601-605
      1. Wilson JF, Laine C, Goldmann DR, Sox HC. In the clinic: alcohol use. Ann Intern Med. 2009;150:ITC3-1. doi:10.7326/0003-4819-150-5-200903030-01003. Available at: http://annals.org/article.aspx?articleid=744361.

        • Greenspon A.J.
        • Schaal S.F.
        The “holiday heart:” electrophysiologic studies of alcohol effects in alcoholics.
        Ann Intern Med. 1983; 98: 135-139
        • Boschloo L.
        • Vogelzangs N.
        • Licht C.M.
        • et al.
        Heavy alcohol use, rather than alcohol dependence, is associated with dysregulation of the hypothalamic-pituitary-adrenal axis and the autonomic nervous system.
        Drug Alcohol Depend. 2011; 116: 170-176
        • Carstairs S.D.
        • Clark R.F.
        Atrioventricular block due to acute ethanol intoxication.
        J Emerg Med. 2011; 41: 298-300
        • Lorsheyd A.
        • de Lange D.W.
        • Hijmering M.L.
        • Cramer M.J.
        • Van de Wiel A.
        PR and QTc interval prolongation on the electrocardiogram after binge drinking in healthy individuals.
        Neth J Med. 2005; 63: 59-63