‘Tis the Season: Recognizing and Managing Post-Holiday Health Problems

Ah, the winter holidays: warm memories created when loving families get together to celebrate over home-cooked meals and pass down traditions from generation to generation. Or not.

For health care practitioners, January is the time of year when patients come to primary care clinic with season-specific health problems. New-onset chest pain, in particular, seems to be a common concern. At one end of the spectrum are patients who complain of the burning substernal chest pain associated with heartburn from drinking too much alcohol and eating excessively rich foods. On the other end of the spectrum are patients who present, often acutely or too late, with serious cardiovascular events, including myocardial infarctions, acute heart failure, and strokes. In fact, the days between Christmas and the New Year are some of the deadliest all year.

As we learned in medical school, death rates due to cardiac events go up between December 25 and January 7 in what is known as the “Christmas Holiday Effect.”  The commonly held assumption was that temporally, these cardiovascular deaths are associated with cold weather – not excess holiday cheer. However, a new study published last month in the Journal of the American Heart Association suggests that other factors associated with the holidays are more likely to be the cause of cardiovascular deaths than cold temperatures. [1] In this study, the temporal effect of the holidays on cardiovascular health was examined in a part of the world where cold in December is not an issue: the Southern hemisphere. Researchers found that people living in New Zealand were still more likely to die of cardiac events between December 25 and January 7, even though it is summer there. The cause for the temporal uptick in mortality rates does not appear to be related to cold temperature, infectious diseases, or the arbitrariness of the monthly reporting cycle. However, it is unclear what causes the increase in cardiac deaths.  Is it associated with increased alcohol and food consumption, worse emotional stress, delayed care, or displacement of death until after the holidays (where people modify their time of death until after a significant milestone has occurred)? Additional studies are needed.

The holiday season is also associated with other chest-pain inducing health problems, including what is colloquially known as “holiday heart” and panic attacks. Holiday heart syndrome is described as atrial arrhythmias, usually atrial fibrillation, associated with binging on alcohol.[2] However, a new study suggests that alcohol may increase atrial fibrillation at much smaller doses than previously assumed, through a combination of direct toxicity and by contributing to co-morbidities such as hypertension, obesity, and sleep disorders.[3] Any time patients present with arrhythmias or chest pain, it is important for practitioners to ask about alcohol use while obtaining a clinical history. If the EKG shows arrhythmias, practitioners should also remember to check a blood chemistry and normalize any electrolyte disturbances they discover.

Panic attacks also have a temporal pattern, peaking on weekends and holidays.[4] In contrast, the frequency of people evaluated for panic attacks decreases in the middle of the workweek. Potential reasons for increased panic attacks over the holidays may be that patients are more likely to have down-time to perseverate, may be more likely to consume alcohol and illicit drugs, or perhaps the anticipation of work stress is enough to trigger panic attacks in vulnerable patients.

In any case, these new studies serve to confirm what we have long suspected: the post-holiday clinic is different from the clinic at other times of the year. So, as we prepare to answer our patient’s questions about the best way to manage holiday weight gain, quit smoking, and start an exercise program, let’s take the time to consider what other health problems crop up this time of year and prepare to manage them.

Have you experienced the “Christmas Holiday Effect” in your practice?

[1] Knight J, Schilling C, Barnett A, Jackson R, Clarke P. Revisiting the “Christmas Holiday Effect” in the Southern Hemisphere. J Am Heart Assoc. 2016;5(12)

[2] Carey MG, Al-zaiti SS, Kozik TM, Pelter M. Holiday heart syndrome. Am J Crit Care. 2014;23(2):171-2.

[3] Voskoboinik A, Prabhu S, Ling LH, Kalman JM, Kistler PM. Alcohol and Atrial Fibrillation: A Sobering Review. J Am Coll Cardiol. 2016;68(23):2567-2576.

[4] Kao LT, Xirasagar S, Chung KH, Lin HC, Liu SP, Chung SD. Weekly and holiday-related patterns of panic attacks in panic disorder: a population-based study. PLoS ONE. 2014;9(7):e100913.

 

Dr. V. Silverstein
Durham, NC


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