A Case Report of Cold Drinks and Food as a Trigger of Paroxysmal Atrial Fibrillation

Introduction

Atrial fibrillation is the most prevalent cardiac arrhythmia and is estimated to affect 1% to 2% (or > 3 million) Americans. ¹ Atrial fibrillation and atrial flutter are often linked to concomitant conditions, such as hypertension, coronary artery disease, valvular disease, cardiomyopathy, obesity, and obstructive sleep apnea. ² Stimulation of the autonomic nervous system is also thought to play an important role in the induction of paroxysmal atrial fibrillation and atrial flutter. ³ Counseling patients on triggers of paroxysmal atrial fibrillation and atrial flutter can help prevent the recurrence of these common supraventricular arrhythmias. Most triggers include easily modifiable lifestyle choices, including alcohol, exercise, and lack of sleep. Lesser-known triggers are parasympathetic nervous system and vagal stimulation can trigger atrial fibrillation and atrial flutter, especially in patients with no structural heart disease. ⁴ Increases in vagal tone as a cause of atrial fibrillation have been frequently associated with sleep and food consumption. ⁵ However, there have been only a few reports of consumption of cold beverages as a trigger of paroxysmal atrial fibrillation episodes.

The authors present a case of a 63-year-old woman with new diagnoses of paroxysmal atrial flutter and atrial fibrillation, who discerned that ingestion of cold food and beverages triggered recurrent episodes of palpitations due to atrial fibrillation. This case report was prepared following the CAse REport (CARE) Statement and Checklist guidelines. ⁶

Case

A 63-year-old woman presented with a sustained episode of typical atrial flutter and subsequent paroxysmal atrial fibrillation. Her past medical history included diet-controlled type 2 diabetes, hypertension, and asthma, as well as giant cell tumor of the tendon sheath (pigmented villonodular synovitis), status post surgical excision on imatinib. She had no prior diagnoses of coronary artery disease, heart failure, or other dysrhythmia.

The patient initially presented to the emergency department after home blood pressure measurements in preparation for a routine telehealth visit revealed a heart rate of 150 bpm. Electrocardiogram confirmed typical atrial flutter with 2:1 AV block (Figure 1). Treatment with intravenous diltiazem and oral metoprolol was initiated, and she was admitted to the hospital. As her heart rate did not respond, a transesophageal echocardiogram was performed, which revealed no evidence of left atrial thrombus. She thus underwent direct-current cardioversion with restoration of sinus rhythm. On discharge, she was prescribed dabigatran for anticoagulation with a CHA₂DS₂-VASc score of 3 and oral metoprolol XL 50 mg daily for rate control, as well as cardiology follow-up.

Figure 1:

Atrial flutter with 2:1 conduction recorded on a 12-lead electrocardiograph.

Fifteen days after discharge, she noticed palpitations and recorded atrial fibrillation with a heart rate up to 180 bpm on her KARDIA device (AliveCor, Mountain View, CA). After discussing risks and benefits with her cardiologist, metoprolol was discontinued, and she was started on sotalol 80 mg twice a day and was titrated up to 160 mg twice a day due to continued symptomatic atrial fibrillation episodes on lower doses. The patient was diagnosed with moderate sleep apnea and started using continuous positive airway pressure. Three months after the initial diagnosis, she contracted a mild breakthrough case of COVID-19 and recovered. Five months after her initial diagnosis of atrial flutter, she continued to experience breakthrough episodes of palpitations due to paroxysmal atrial fibrillation and was referred to cardiac electrophysiology for pulmonary vein isolation procedure.

In the course of the patient’s atrial flutter and fibrillation, she was able to identify triggers to her episodes of atrial arrhythmias, which included lack of sleep and ingestion of cold beverages and foods. More than 5 episodes occurred and were confirmed with her home KARDIA device after consumption of cold beverages and foods, such as mango juice (Figure 2), cold soda (Figure 3), and refrigerated fruits (Figure 4). She also noted that the speed of ingestion increased reproducibility of triggered atrial fibrillation episodes.

Figure 2:

Atrial fibrillation recorded on KARDIA device, triggered by ingestion of cold mango juice.

Figure 3:

Atrial fibrillation recorded on KARDIA device, triggered by ingestion of a cold soft drink.

Figure 4:

Atrial fibrillation recorded on KARDIA device, triggered by ingestion of cold pears.

The patient was able to modify how she consumed food to avoid atrial fibrillation episodes. Small sips of cold fluids and small bites of food would not trigger an event. However, consumption of higher viscosity liquids such as smoothies and food boluses such as slices of melon consistently triggered transient atrial fibrillation that lasted for a few hours.

Discussion

Consumption of cold beverages is a known cause of atrial fibrillation and has been noted in several case reports. ⁷ One large patient survey conducted at the University of California, San Francisco, had patients self-identify triggers for atrial fibrillation and found that the consumption of cold beverages and cold foods was a trigger in up to ~7.5% and ~5.0%, respectively. ⁸ The mechanism is not completely understood but is likely multifactorial. ⁹

The physical passage of food contents through the esophagus and their passing by the left atrium can trigger tachyarrhythmias, also called deglutition-induced atrial tachycardia. ⁹ This is a well-known phenomenon that has been reproduced in prior studies by inflating a balloon in the esophagus. ¹⁰ The anatomic proximity of the esophagus to the left atrium allows for a potential influence of esophageal phenomenon and pathology on initiation of cardiac arrhythmias. This is corroborated by a close association of hiatal hernias and gastroesophageal reflux disease as a trigger for atrial fibrillation. ¹¹ Deglutition-induced atrial tachycardia is thought to occur in ~0.6% of patients with paroxysmal atrial arrhythmias. ¹² Cold foods and drinks are more likely to cause cooling of the left atrium through the esophagus, which may also play a role in the trigger of atrial fibrillation. ¹³ Our patient noticed that quick or large volume ingestion of cold food or drinkscould induce atrial fibrillation, which is consistent with a deglutition mechanism contributing to triggering atrial fibrillation in her case.

The autonomic stimulation of a cold food bolus through the esophagus may also stimulate a vasovagal response. Cardiac function is affected by the autonomic system, and the parasympathetic component of the cardiac function is primarily mediated by the vagus nerve. ¹⁴ Cold food ingestion can trigger neural pathways that increase vagal tone. Vagal stimulation is thought to cause atrial fibrillation in some patients by reducing the action potential duration and refractory period of atrial myocytes. In addition, vagal innervation of the ganglionic plexi located near the pulmonary vein can cause increased susceptibility to arrythmias. ^14,15 Vagal stimulation can play a key role in triggering atrial fibrillation in patients without evidence of structural heart disease. ¹⁵ Our patient had a history of hypertension and diabetes. The left ventricular dysfunction noted on initial transesophageal echocardiography performed during atrial flutter with rapid ventricular response was likely mediated by her tachycardia as subsequent echocardiograms in sinus rhythm showed normalization of left ventricular function.

By recognizing cold beverages and deglutition as factors that can contribute to paroxysmal atrial fibrillation, physicians can better advise and educate patients on practical modifications to help avoid potential triggers of atrial fibrillation. ¹⁶ Lifestyle changes such as fractioning food intake and avoiding known triggers, such as icy or cold liquids, can help reduce the burden of atrial fibrillation and improve quality of life in some patients.

Conclusion

Ingestion of cold foods is not widely recognized as a trigger for atrial fibrillation and atrial flutter. Patients who have similar cold food–induced atrial fibrillation or atrial flutter have expressed gratitude in the publication of case reports that validate their condition. ¹⁷ It is important for patients and physicians to recognize cold food consumption as a potential trigger for atrial fibrillation and atrial flutter episodes. Improved recognition will allow for better trigger avoidance and a reduction in arrhythmia recurrence.