Cardiovascular risk factors and serious health events in individuals with eating disorders: a systematic review.

Abstract

Background: This systematic review aimed to determine how cardiovascular risk factors are associated with serious adverse health events in individuals with eating disorders, aiming to inform clinical decision-making about hospital admission and monitoring.

Main body: We searched 15 multidisciplinary databases from inception to October 2025 following PRISMA guidelines. Eligible studies needed to compare outcomes between individuals with eating disorders who exhibited specific cardiovascular parameters (e.g., resting heart rate, blood pressure, QTc prolongation) and those who did not. Eligible outcomes were serious adverse health events, including death, cardiac arrest, malignant arrhythmias and/or cardiac failure. Of 14,034 de-duplicated records, six studies met inclusion criteria, all focusing exclusively on anorexia nervosa (AN). Only two provided high-confidence evidence. Hypotension at admission was associated with 8.65-fold increased likelihood of in-hospital mortality (95% CI 5.45, 13.7). Composite cardiac complications predicted 3.29-fold increased odds of mortality (95% CI 1.27, 8.55). The evidence for QTc prolongation was insufficient and for the presence of bradycardia was low confidence. Postural hypotension, postural tachycardia, resting tachycardia, and heart rate variability were not examined in any eligible study.

Conclusion: Limited evidence exists for the predictive validity of most cardiovascular parameters for serious adverse health events in eating disorders. Hypotension emerged as the clearest predictor; however, the absence of evidence should not be interpreted as evidence of absence. Current clinical guidelines appropriately adopt a cautious approach given this evidence gap. Large-scale, multi-site cohort studies are needed to establish which cardiovascular parameters predict imminent risk and to examine eating disorder diagnoses beyond AN.