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Cold drink heart—cold food- or drink-induced paroxysmal AF—is poorly understood, yet has significant implications for AF prevention, according to research.

Cold drink heart (CDH) describes paroxysmal atrial fibrillation (AF) or flutter triggered within seconds or minutes of ingesting cold food or beverages. A recent study that appeared in Journal of Cardiovascular Electrophysiology found that CDH remains poorly understood, yet has significant implications for AF prevention, and avoidance strategies may be highly effective, especially for patients whose AF is otherwise idiopathic.

Study author David R. Vinson, MD, Kaiser Permanente Adjunct Investigator, Emergency Physician, and Research Chair, discussed his research team’s findings with Physician’s Weekly (PW).

PW: Who coined the term “cold drink heart”?

Dr. Vinson: I introduced the phrase in a 2020 essay I published after our initial 2016 case report. People with cold food- and drink-induced paroxysmal atrial fibrillation/flutter began emailing me, and I needed a shorthand way of referring to this condition in our exchanges, so I began to use “cold drink heart.” It’s been used ever since.

What motivated you to characterize patient experiences with CDH and study the impact of trigger avoidance?

The enthusiastic global response to our first case report’s publication revealed that patients appreciated the validation the report provided, especially after clinicians had dismissed their claims that cold drinks had precipitated an AF episode. Through scores of exchanges, I learned which techniques helped them reduce recurring episodes. Beyond case reports, nothing existed that characterized patients with CDH, described their experiences, or detailed their AF avoidance techniques. We conducted this survey to gain a better understanding of what these patients were experiencing, both with the condition and its treatment. The survey results let us answer these important questions: “How effective is trigger avoidance?” and “In which patients is it most effective?” The answers will equip physicians with the information they need to help their patients determine if they have CDH and empower them to manage it.

How do you define lifestyle triggers for AF, and which are most common?

Lifestyle triggers are behaviors that can provoke an AF episode—alcohol ingestion (even as little as one to two drinks), sleep deprivation, exercise, and large meals are typical. However, many AF episodes seem to start on their own without an identifiable trigger.

Were any results unexpected?

We were surprised by how frequently CDH was associated with an emergency department (ED) visit. Nearly three-quarters of non-Kaiser Permanente Northern California members were admitted to the ED for AF evaluation and treatment, which explains the strong motivation our respondents had to avoid further episodes of CDH. It makes sense to steer clear of icy drinks if that means fewer bouts of AF with its distressing symptoms and inconvenient, potentially costly, ED visits. We also found it surprising that more than one-third of our respondents noted that cold drinks were particularly likely to incite an AF episode during or following physical exertion. That’s a strong argument for patients with CDH to hydrate with room temperature beverages.

Did any physical exertion stand out, and how did you define “recent” physical exertion in terms of time to AF?

The types of physical exertion varied from serious cardiovascular exercise to brisk walks in the neighborhood to moderate yardwork. We defined “recent” as within the prior 30 minutes, but the time gap may be closer to 5 to 10 minutes. This needs to be further explored.

How should physicians proceed if they suspect a patient may have CDH?

Physicians should ask patients with intermittent episodes of AF or atrial flutter if they’ve noticed that cold drinks or food—like ice water or ice cream—trigger an AF episode within a few seconds or minutes of ingestion. The majority of patients with CDH have unpredictable responses to cold ingestion: most of the time cold drinks or food do not precipitate AF, but sometimes they do. Also, many people with CDH also have AF episodes that have no known trigger.

If CDH is present, physicians can suggest to their patients that they avoid cold foods and drinks and monitor whether this reduces their AF episodes. They can also suggest mitigation techniques that respondents have reported success with, such as sipping—not gulping—cold liquids, warming cold liquids momentarily in the mouth before swallowing, and forgoing straws.

What do you hope physicians take away from your study?

Physicians should recognize that cold drinks and food really can trigger AF episodes and atrial flutter. The AF episodes rarely occur every time someone eats or drinks something cold, but when they do occur, they develop within seconds or minutes. Some patients with CDH suffer episodes only after cold ingestion, while others also experience AF episodes that result from other known triggers or from no trigger at all. Physicians should ask patients with paroxysmal AF about cold triggers. If CDH is present, physicians can partner with their patients to develop strategies to avoid these triggers and to reduce AF episodes.

Over half of respondents reported dismissive encounters with healthcare professionals. Why is skepticism common, and how would you address it?

Cold drink-induced AF is real—it has a plausible physiological explanation, a characteristic pattern of occurrence, and effective methods of prevention—but because it has received little research attention, we physicians didn’t learn about it in medical school and haven’t read about it in the literature. It’s not surprising that many physicians dismiss it as unsubstantiated, but we’re hoping to change that. It would be great if this initial study inspires researchers to address other questions about CDH and expand our understanding of this understudied condition.

What were the main limitations of your study?

Our study was relatively small. The participants may not be representative of the larger population of patients with CDH. Much of the data was self-reported and may be subject to recall bias. Because this was a survey study, we were unable to quantitatively confirm qualitative data, such as the relative effectiveness of cold drink avoidance. Ours is the first survey to characterize patients with CDH. Much larger studies are needed across a wider range of patients before we can understand the full range of experiences and the best ways to manage CDH.

What are your next steps?

We’ve developed and implemented a decision support tool to help our emergency medicine physicians care for patients with AF and atrial flutter. Built into the app is a reminder to physicians to ask their patients with intermittent AF about cold food and drink triggers. We hope to expand the use of the decision support tool throughout Kaiser Permanente. We will also be informing our colleagues in other specialties—particularly cardiology and primary care—about this condition to optimize care of patients with CDH.

Where can physicians learn more about CDH?

There are several informative case reports on CDH worth reading that we reference in our survey study, as well as an open-access essay that summarizes what I learned from the many generous patients who shared their stories with me.