Atrial fibrillation triggered by cold drinks: increasing clinician and patient awareness

We enjoyed reading the case report “The cold drink heart” by Cantwell, published recently in the BUMC Proceedings.¹ The author portrays a 56-year-old physician who experienced four episodes of paroxysmal atrial fibrillation (AF) over the course of several years, each triggered by ingestion of cold drink or food. The initial episode occurred during the first few sips of a frozen margarita. AF was confirmed electrocardiographically and spontaneously cardioverted the following night. The remaining three episodes had different cold triggers, including ice cream, iced tea, and sorbet. Reassuringly, the patient had a normal cardiac workup and never experienced AF without an associated cold drink or dessert trigger. This is the best scenario, in which trigger identification and avoidance provide complete prevention of AF recurrence.

We thank Cantwell for adding to the growing body of literature describing AF triggered by the ingestion of cold substances, also known as cold drink heart.² Most of the literature documenting the occurrence of this understudied phenomenon consists of case reports.^3–6 Given the absence of epidemiological studies, the true prevalence of this condition is unknown. A University of California San Francisco online survey of 957 patients with symptomatic paroxysmal AF examining patient-identified triggers found that up to 7.5% and 5.0% of survey participants identified the ingestion of cold beverages and cold foods as triggers, respectively.⁷ Only recently have researchers begun to explore how trigger avoidance may reduce AF recurrence.⁸

The lack of awareness of cold drink heart among physicians and patients has meaningful clinical implications. In 2016, we published our first case report on this topic, describing an otherwise healthy 29-year-old man who experienced two separate episodes of AF after ingesting cold slushy ice drinks.³ The first treating physician was able to cardiovert the AF but failed to identify the cause. This oversight led the physician to omit from his discharge instructions any mention about cold drink avoidance. Several years later, this patient had a similar episode of AF, again precipitated by a cold slushy ice drink. Had his medical team helped him make the connection between cold drinks and incident AF, he could have instituted simple lifestyle changes to avoid that second AF episode and the need for another trip to the emergency department for cardioversion.

Since publishing this open access case report in 2016, one of us has received emails from scores of patients around the world, all reporting similar episodes of cold drink heart. After the first 16 emails, I published an essay describing lessons these correspondents taught me on how better to listen to patients and learn from them—a critical component of care allowing clinicians to partner with their patients on long-term AF management.² In many of these cases, the patients, rather than their treating physicians, discerned the connection between their cold beverage consumption and the sudden onset of paroxysmal AF. These patients were grateful for the validation our case report provided them, especially since many of their physicians had dismissed the link the patients had claimed between ingestion of cold drinks/food and incident AF. Failing to perceive the causal connection, physicians miss the opportunity to partner with their patients on trigger avoidance to reduce the risk of AF recurrence and overall AF burden.

Dr. Cantwell published this case report to educate the medical community about this common but underappreciated AF trigger. Our research team has a similar aim. In 2022, we launched a stepped-wedge cluster randomized pragmatic trial that provides our emergency physicians a clinical decision support tool of “best practices” for the emergency management of AF and atrial flutter.⁹ We are using this clinical app to remind our emergency physicians to inquire about common drink triggers that may precipitate AF. When such a trigger is identified, the physicians can provide meaningful, clinically relevant advice to patients on trigger avoidance. To complement the pragmatic arm of the trial, we are also undertaking a patient survey to characterize those with cold drink heart.

We are grateful to the many magnanimous patients, including the physician discussed in Cantwell’s case report, who allow researchers to publish their experiences with cold drink heart. This information is helpful for researchers studying the condition, patients experiencing it, and physicians treating it. We hope this growing body of literature improves the recognition and prevention of this often-overlooked condition.

—David R. Vinson, MD
The Permanente Medical Group, the Kaiser Permanente Northern California Division of Research, and the KP CREST Network, Oakland, California
drvinson@ucdavis.edu https://orcid.org/0000-0001-6559-1858
—Aidan R. Campbell
New York University, New York City, New York
https://orcid.org/0000-0003-4475-2629

—Edward Qiao, BS
California Northstate University College of Medicine, Elk Grove, California
https://orcid.org/0009-0004-2901-6337