Holiday Heart Syndrome Differential Diagnoses

Updated: May 30, 2018
  • Author: Lawrence Rosenthal, MD, PhD, FACC, FHRS; Chief Editor: Jose M Dizon, MD  more...
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Diagnostic Considerations

Medicolegal and socioeconomic issues related to the management of patients with acute and/or chronic issues related to alcohol should be considered.

Diagnostic considerations

Diagnostic considerations in individuals with suspected holiday heart syndrome (HHS) may be broadly categorized into complications related to alcohol intoxication and other possible arrhythmias.

Alcohol intoxication

See the Medscape Drugs and Diseases article Alcohol Toxicity for complications associated with alcohol intoxication. In brief, other considerations in patients with suspected HHS involve the excessive use of caffeine or over-the-counter decongestants (ie, pseudoephedrine and recreational substances). Atrial fibrillation may be precipitated by pulmonary embolism, and this possibility should be considered in the appropriate clinical context. [27] One of the most common reasons for presentation to the emergency department is community-acquired pneumonia. Moreover, alcohol intoxication increases the risk for aspiration pneumonia. [28] When these factors are considered together, there are substantial data indicating an association between acute pneumonia and incident atrial fibrillation. [29] Thus, it is reasonable to consider the possibility of pnemonia in the appropriate clinical setting.

Other arrhythmias

Other arrhythmias may include supraventricular tachycardia (sustained or nonsustained), atrial flutter, premature ventricular complexes, or ventricular tachycardia. [1, 2] See the associated links below for details.


Although long-term anticoagulation is indicated for patients with paroxysmal, persistent, or permanent atrial fibrillation plus risk factors for thromboembolism, physicians should 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) ( score. [30, 31]

Differential Diagnoses