What is the role of medications in the treatment of holiday heart syndrome (HHS)?

Updated: May 30, 2018
  • Author: Lawrence Rosenthal, MD, PhD, FACC, FHRS; Chief Editor: Jose M Dizon, MD  more...
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Symptoms of acute alcohol toxicity generally resolve spontaneously, and management is largely supportive (ie, intravenous [IV] hydration and correction of electrolyte derangements). Arrhythmia monitoring and observation are sufficient in many patients. In patients with atrial tachyarrhythmias and a rapid ventricular response (eg, atrial fibrillation or flutter), ventricular rate control is important for those who are symptomatic. The use of beta-blockers or nondihydropyridine calcium channel blockers (CCBs) is appropriate. Digoxin is a third-line option; chronic therapy with this drug is rarely indicated. Patients who are hemodynamically unstable should be treated with direct-current cardioversion.

As discussed earlier under Prognosis, although the majority (>90%) of cases of alcohol-related atrial fibrillation self-terminate, approximately 20%-30% will recur within 12 months. [11] When considering the type of atrial fibrillation, moderate to heavy alcohol consumption has been demonstrated to be the strongest risk factor for progression from paroxysmal atrial fibrillation to persistent atrial fibrillation. [25]

As discussed under Diagnostic Considerations, although long-term anticoagulation is indicated for patients with paroxysmal, persistent, or permanent atrial fibrillation plus risk factors for stroke or systemic thromboembolism, it may be prudent to be cautious about anticoagulating patients with expected acute alcohol toxicity, especially if there is a history of possible trauma. Unless high-risk features are present (ie, prior stroke, mechanical heart valve, or other indication for anticoagulation) a reasonable approach may be to allow the patient to recover from the acute episode, and then initiate anticoagulation once they are clinically stable.

Note that when considering initiating anticoagulation, the most recent American College of Cardiology/American Heart Association (ACC/AHA) guidelines do not specifically consider "reversible" causes as a reason to forgo anticoagulation for stroke risk reduction. That is, a single episode of atrial fibrillation may result in a significant change in a patient's medical regimen for the forseeable future. [30]  In this scenario, anticoagulation would be initiated after a patient-physician discussion regarding the risks and benefits of anticoagulation. Integral to this discussion is calculation of both the CHA2DS2VASc (Cardiac failure, Hypertension, Age >75 years [doubled], Diabetes, prior Stroke or TIA [transient ischemic attack] or thromboembolism [doubled], Vascular disease, Age 65-75 years, Sex category) score and the HAS-BLED (Hypertension, Abnormal renal/liver function, Stroke, Bleeding history or predisposition, Labile INR [international normalized ratio], Elderly, Drugs/alcohol concomitantly (https://www.chadsvasc.org/) score. [30, 31]

Because atrial fibrillation with rapid ventricular response (RVR) is the primary acute concern with holiday heart syndrome (HHS), commonly used medications for heart rate control are outlined in the next sections. (Also see the Guidelines section, under Rate Control.) Although there is no clear consensus about what heart rate should be targeted, a goal based on symptoms is reasonable (eg, A heart rate < 85 beats per minute is reasonable in a symptomatic patient, whereas a more lenient heart rate goal is reasonable in an asymptomatic patient.) Other antiarrhythmic medications and anticoagulants are outside the scope of this article. Information regarding these ageents can be found here.

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