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

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. 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. 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. People with eating disorders can develop changes in the way that the heart and circulation function during the disorder and may need care in a hospital setting to avoid having serious health outcomes or death. Clinicians may use signs like a low heart rate, low blood pressure, or ECG changes to decide whether someone needs hospital admission and close monitoring but the variable way these decisions are made can cause confusion and anxiety in those affected. Whilst we know heart-related changes are common in eating disorders, and that serious outcomes, including death, happen more often than in the general population it is less clear is which specific heart-related signs suggest a higher immediate risk. This matters because monitoring and hospital care should be targeted to people at greatest immediate risk. In this review, we looked for studies comparing the risk of serious health outcomes in people with eating disorders with and without specific heart-related signs. After screening more than 14,000 records, we found only six relevant studies, all in anorexia nervosa. Two stronger studies suggested that low blood pressure is likely to indicate a higher risk of dying in hospital, and that people who had multiple heart related changes were at higher risk of death over time. For other commonly used signs, the evidence was limited or unclear. Larger, well-designed studies are needed to help avoid both missing people who need hospital care urgently and admitting people when community care with close follow-up may be safer and more helpful.