Characterizing Patients with Cold Drink-Triggered Atrial Fibrillation

Characterizing Patients with Cold Drink-Triggered Atrial Fibrillation | Authorea try { document.documentElement.classList.add('js'); } catch (e) { } var _gaq = _gaq || []; _gaq.push(['_setAccount', 'G-8VDV14Y67G']); _gaq.push(['_trackPageview']); (function() { var ga = document.createElement('script'); ga.type = 'text/javascript'; ga.async = true; ga.src = ('https:' == document.location.protocol ? 'https://ssl' : 'http://www') + '.google-analytics.com/ga.js'; var s = document.getElementsByTagName('script')[0]; s.parentNode.insertBefore(ga, s); })(); Skip to main content Preprints Collections Wiley Open Research IET Open Research Ecological Society of Japan All Collections About About Authorea FAQs Contact Us Quick Search anywhere Search for preprint articles, keywords, etc. Search Search ADVANCED SEARCH SCROLL Journal of Cardiovascular Electrophysiology This is a preprint and has not been peer reviewed. Data may be preliminary. 6 February 2025 V1 Latest version Share on Characterizing Patients with Cold Drink-Triggered Atrial Fibrillation Authors : Daniel D. DiLena 0009-0006-2252-6486 [email protected] , Jennifer Y. Zhang , Adina S. Rauchwerger , Mary E. Reed , Gregory Marcus M , E. Margaret Warton , and David Vinson 0000-0001-6559-1858 Authors Info & Affiliations https://doi.org/10.22541/au.173888137.73624097/v1 Published Journal of Cardiovascular Electrophysiology Version of record Peer review timeline 744 views 215 downloads Contents Abstract Information & Authors Metrics & Citations View Options References Figures Tables Media Share Abstract Introduction Atrial fibrillation (AF) is a common arrhythmia with significant health implications. Identifying modifiable lifestyle triggers is important in mitigating recurrence and improving patient outcomes. A subset of AF patients has reported cold drinks or foods as triggers, a phenomenon termed “Cold Drink Heart” (CDH). Literature on CDH is scarce and primarily limited to case studies. We sought to characterize patient experiences with CDH and assess the effectiveness of cold trigger avoidance in reducing AF recurrence among affected patients. Methods and Results This was a mixed methods study employing a patient survey enhanced by chart review among patients who self-reported CDH. Participants were recruited during emergency department visits for AF or by contacting the principal investigator directly. The survey addressed demographics and clinical features. We compared those with CDH only and those with both CDH and non-CDH AF episodes. The cohort included 101 respondents (75% male). Median age of CDH onset was 44.5 years. Most respondents (96.8%) reported that cold ingestion did not consistently trigger AF. Rapid onset after ingestion was common, and many reported an association with recent physical exertion. Avoidance of cold ingestion was effective in reducing or eliminating AF episodes in 86.4% of cases, with greater success in CDH-only patients (100.0%). Physician awareness was low, with 52.4% of respondents reporting dismissive attitudes from one or more healthcare providers. Conclusion CDH is poorly understood and has significant implications for AF prevention. Avoidance strategies may be highly effective, especially for CDH-only patients. Further research is needed to validate these findings and increase provider awareness. Title: Characterizing Patients with Cold Drink-Triggered Atrial Fibrillation Daniel D. DiLena, BA a ; Jennifer Y. Zhang, BA a,b ; Adina S. Rauchwerger, MPH a ; Mary E. Reed, DrPH a ; Gregory M. Marcus, MD, MAS c ; E. Margaret Warton, MPH a ; David R. Vinson, MD a,d,e ; on behalf of the Kaiser Permanente CREST Network 1. Division of Research, Kaiser Permanente Northern California, Pleasanton, California 2. Harvard T.H. Chan School of Public Health, Boston, Massachusetts 3. Department of Medicine, University of California, San Francisco, California 4. The Permanente Medical Group, Pleasanton, California 5. Department of Emergency Medicine, Kaiser Permanente Roseville Medical Center, Roseville, California Address for correspondence: Daniel D. DiLena; [email protected] 4480 Hacienda Dr Pleasanton, CA 94588 ORCID: 0009-0006-2252-6486 Co-author email addresses: [email protected] , [email protected] , [email protected] , [email protected] , [email protected] , [email protected] Running title: Cold Drink-Triggered Atrial Fibrillation Disclosures: Dr. Marcus reports receiving funding from the NIH and PCORI; he is a consultant for and equity holder in InCarda. All other authors have nothing to disclose. Word count: 3,235 Data availability statement: The data supporting the findings of this study are made available from the corresponding author upon reasonable request. Funding: This research was supported by The Permanente Medical Group Delivery Science and Applied Research program. Ethhics approval statement: The study was approved by the KP Northern California Institutional Review Board. Patient consent statement: The need for informed consent was waived by the KP Northern California Institutional Review Board due to the anonymous nature of the survey. Introduction Atrial fibrillation (AF) is a common arrhythmia with significant health implications. Identifying modifiable lifestyle triggers is important in mitigating recurrence and improving patient outcomes. A subset of AF patients has reported cold drinks or foods as triggers, a phenomenon termed “Cold Drink Heart” (CDH). Literature on CDH is scarce and primarily limited to case studies. We sought to characterize patient experiences with CDH and assess the effectiveness of cold trigger avoidance in reducing AF recurrence among affected patients. Methods and Results This was a mixed methods study employing a patient survey enhanced by chart review among patients who self-reported CDH. Participants were recruited during emergency department visits for AF or by contacting the principal investigator directly. The survey addressed demographics and clinical features. We compared those with CDH only and those with both CDH and non-CDH AF episodes. The cohort included 101 respondents (75% male). Median age of CDH onset was 44.5 years. Most respondents (96.8%) reported that cold ingestion did not consistently trigger AF. Rapid onset after ingestion was common, and many reported an association with recent physical exertion. Avoidance of cold ingestion was effective in reducing or eliminating AF episodes in 86.4% of cases, with greater success in CDH-only patients (100.0%). Physician awareness was low, with 52.4% of respondents reporting dismissive attitudes from one or more healthcare providers. Conclusion CDH is poorly understood and has significant implications for AF prevention. Avoidance strategies may be highly effective, especially for CDH-only patients. Further research is needed to validate these findings and increase provider awareness. Key words Atrial fibrillation, atrial flutter, Cold Drink Heart, trigger avoidance, vagal stimulation Abbreviations list AF , atrial fibrillation CDH , Cold Drink Heart KP , Kaiser Permanente O’CAFÉ trial, Clinical decision support to O ptimize C are of patients with A trial F ibrillation or flutter in the E mergency department Introduction Recent literature has demonstrated growing interest in the role of a variety of acute and lifestyle factors in provoking atrial fibrillation (AF) episodes. 4–6 Identifying modifiable AF triggers could aid in secondary prevention of AF, improving outcomes and potentially mitigating disease progression. 7 Among dietary triggers of AF, alcohol is the most common, best-known, and well-studied. 5,8–11 Cold drinks and foods are less well-known triggers for AF but have been reported to precipitate discrete episodes in a subset of patients. Although data suggest that 5-10% of patients with paroxysmal AF report ingestion of cold drinks or foods as a trigger, 6,12 this phenomenon—referred to here as “Cold Drink Heart” (CDH)—remains poorly understood. First described in the literature approximately 30 years ago, 13 CDH has since been documented primarily through case reports and small series, 14–22 and its clinical implications remain largely unexplored. This is an imminently modifiable potential trigger for which trigger avoidance may have immediate effects. Better characterizing this clinical phenomenon may help AF patients understand why their AF episodes occur when they do. We sought to characterize this condition in detail and to assess the reported effectiveness of avoidance in reducing AF recurrence. Methods Design and Setting This study employed a mixed methods approach, utilizing an online survey for data collection and subsequent chart review for validation, as well as to gather medical history and demographic data. We conducted a cross-sectional survey of patients self-reporting cold ingestion-triggered AF or atrial flutter. The study drew from two settings to generate distinct patient populations: (1) Emergency department (ED) patients of Kaiser Permanente (KP) Northern California, an integrated delivery system comprised of 21 medical centers and over 250 outpatient clinics that provides health care to over 4.5 million patients and (2) an international sample of patients who contacted the principal investigator in response to prior open-access publications on CDH. KP health plan members reflect the racial, ethnic, and socioeconomic diversity of northern California. 23 The study was approved by the KP Northern California Institutional Review Board. Participants from both settings were contacted by telephone or email and invited to take part in the online survey. The survey included questions to collect data on demographics, family history, comorbidities, characteristics of their arrhythmia, treatments, preventive strategies, and clinician support. Supplemental chart review was performed for the KP population to confirm diagnoses and medical history and to calculate CHA₂DS₂-VASc scores. Population The first population included adults (aged 18 years or older) evaluated for AF at one of 16 EDs across KP Northern California participating in the O’CAFÉ trial (Clinical decision support to O ptimize C are of patients with A trial F ibrillation or flutter in the E mergency department). 24,25 The pilot study began in February 2021 at three medical centers, and the trial’s intervention phase began in October 2021. Thirteen EDs participated in the trial, the last of which gained access to decision support in May 2022. Enrollment of patients with CDH continued through March 1, 2024. ED patients were eligible for decision support in the O’CAFÉ trial if they had AF or atrial flutter confirmed by electrocardiography. Patients were excluded for any of the following concurrent ED diagnoses: pregnancy, ST-elevation myocardial infarction, acute myo- or pericarditis, acute pneumonia, pulmonary embolism, shock (e.g., septic, hemorrhagic, cardiogenic), recent major thoracic trauma (<48h), thyroid storm, or acute toxidrome (e.g., sympathomimetic or anticholinergic). The clinical decision support tool prompted physicians to ask patients with intermittent AF or atrial flutter about two ingestion triggers: cold drink/food and alcohol (Figure 1). We identified patients with a cold drink or food trigger and invited them to complete the survey. The second population was drawn from those who emailed the principal investigator (DRV) between October 1, 2017, and April 31, 2024, in response to open-access publications on CDH. 16,17 Correspondents who reported a documented diagnosis of AF or atrial flutter and a trigger of cold drink or food were asked by email if they would like to participate in the survey. Those who replied in the affirmative were sent an invitation. Survey The survey for KP Northern California patients had up to 28 questions, depending on patient responses (Supplemental Table 1). Questions were designed to collect information on patient experiences, such as frequency of cold ingestion-triggered AF or flutter as well as any attempts to reduce such episodes, such as avoidance of cold drink or food. Patients were also asked if their AF or flutter episodes occurred following exercise with subsequent ingestion of a cold food or beverage, as this trigger sequence has been reported in the literature. 18,19 Respondents were given the opportunity to elaborate on their responses in unstructured questions throughout the survey, including a free-text option for additional comments at the end. For our non-KP survey, the same 28 questions were presented, as well as six supplemental questions on patient demographics (such as age, sex, and location) and medical history (such as history of illness or if the patient is taking any current medication) (Supplemental Table 2). All characteristics for non-member respondents were self-reported. Medical history and patient demographic data for KP Northern California patients were obtained from electronic health records. Survey respondents were excluded from the study if (1) they were unable to be reached; (2) they were reached but declined to participate in the survey; (3) they reported that their AF or flutter was not intermittent, meaning that they were in permanent AF or flutter; (4) they responded that they were unable to tell when they were in AF or flutter; or (5) they responded that cold drinks or food were not triggers for their AF or flutter or were unsure if these were triggers. Some responses were left out of certain calculations if the corresponding question was not applicable to a given participant. This included participants who reported that their CDH encounter was their first instance of AF or flutter and participants who had experienced only one instance of CDH and thus were incapable of speaking to questions about the effectiveness of avoidance on reducing AF recurrence. Survey Collection The survey was conducted through an online survey platform, SurveyMonkey (SurveyMonkey Inc., San Mateo, California, USA). Respondents were offered a chance to respond to the survey via phone or email. The first population of respondents (KP Northern California patients) were contacted up to five times by phone and twice via email to introduce the study and invite participation. The second population of respondents (non-KP) were contacted via email first with a personalized link and by phone after the initial email only if a phone number had been voluntarily provided. Statistical Analysis Data from the survey were used to calculate medians and percentages among available responses to each question. To compare between (1) respondents who had only CDH and (2) respondents who had CDH and non-CDH AF, a Pearson’s chi-squared test was used to calculate statistically significant differences in categorical responses, and t-test was used to compare continuous variables. Results The studied patients included 101 total respondents over the study period who self-reported having cold drink or food triggers for AF or flutter. Most reported AF only (75, 74.3%), while only 3 respondents (3.0%) reported flutter only, 16 (15.8%) reported both AF and flutter, and 7 (7.0%) said they were unsure which rhythm was triggered by cold ingestion. Of our cohort, 39 (38.6%) were KP Northern California patients with at least one AF-related ED encounter, and 62 (61.4%) were non-KP email volunteers. Table 1 describes characteristics of all survey respondents, stratified by our two patient populations. The cohort was predominantly male and middle aged. Median age of first reported CDH episode was 49 years for the KP population and 41 years for the non-KP population. The median CHA₂DS₂-VASc score of respondents was low, and 26 (25.7%) were taking anticoagulants at the time of the survey. Table 2 characterizes respondent experiences with cold drink or food-induced AF or flutter. Among 94 eligible responses, 3 (3.2%) reported that consuming cold drink or food always triggered an AF or flutter event. Most respondents reported rapid onset of AF following cold ingestion: a few seconds (58, 58.6%) or more than a few seconds but less than a minute (20, 20.2%). A slight majority of respondents (51, 50.5%) reported having only CDH (i.e., all their AF or flutter episodes were caused by cold drink or food triggers), while 48 (47.5%) reported both CDH and non-CDH AF (i.e., AF could occur independently of cold drink or food triggers), and 2 (2.0%) were unsure. Although most differences between the groups were not statistically significant, the CDH-only group demonstrated significantly greater success in avoidance as a strategy for reducing recurrent episodes (P=0.002; Central Illustration). Among respondents who reported avoiding cold drink and food regularly (i.e., “always” and “usually” avoiding cold triggers) and could attest to the effectiveness of this strategy (n=59), 51 (86.4%) reported that their AF was either eliminated or greatly reduced. For respondents who experienced CDH in addition to non-CDH AF and avoided cold drink and food regularly (n=29), 21 (72.4%) stated that their AF episodes were either eliminated or greatly reduced. In contrast, among the CDH-only group (n=51), 29 (56.9%) reported avoiding cold drink or food regularly, and 100% of these patients reported that their AF was either eliminated or greatly reduced. Respondents who could not attest to the effectiveness of this strategy, for example, those who reported that it was too soon to tell if avoidance was making a difference, were excluded from the above calculations. Table 3 includes excerpts from unstructured responses. The most frequently reported types of cold-drink triggers included ice-water, cold alcoholic drinks, and smoothies and other blended beverages. Some reported that the likelihood of AF was related to the speed with which they consumed the beverage in question. When asked about avoidance, respondents reported several effective behavioral modifications in lieu of complete avoidance, such as reducing speed of ingestion or avoiding rapid gulping, eliminating straw use, allowing drinks to warm to room temperature, or warming liquids in their mouth before swallowing. Among the self-identified non-KP population (n=62), most (47, 75.8%) reported seeking care in the ED for their AF episodes. For the complete cohort, 82 (81.2%) reported describing CDH to a physician, and of these, more than half (43, 52.4%) reported that some or all physicians had dismissed the association of cold ingestion and AF occurrence. When asked whether the respondents currently had at least one physician who understands cold drinks to be a trigger for them (n=88), 42 (47.7%) said yes, while 22 (25.0%) said no and 24 (27.3%) were unsure. Discussion In this first-of-its-kind cross-sectional survey of patients with cold drink-triggered AF, we characterized respondents and their self-reported experiences with CDH. To date, the literature on this topic has been comprised almost entirely of case reports. 13–22,26 In the hierarchy of clinical evidence, case reports are low on the scale. 27 Case reports, however, have a vital role to play in the early recognition and understanding of underappreciated diagnoses, as is the case with CDH. 28 But as our exposure to this population of patients continued to grow, 17 we realized a more systematic description of patients with CDH was needed, even if the cohort was assembled by convenience sampling. Demographically, the study cohort had a preponderance of men (75%) and a relatively young age of CDH onset (median age 44.5 years). The case literature on this condition, though limited and beset with selection bias, can still serve as a comparison. The 11 reported cases favored men (8 to 3) over women and had a median age of 43 years. 13–22,26,29 Both CDH cohorts differ demographically from more typical samples of patients with incident AF. In the recent, large prospective U.K. HARMS2-AF study, incident AF was identified in approximately 18,000 patients. The AF cohort was predominantly male (68.8%) with a median age at the time of AF onset of 63.0 years (IQR 59.0–66.0). 30 The CDH cohorts had a similar male predominance but a younger age of AF onset (40s vs. 60s). If validated in larger, more representative samples, AF triggered by cold drink or food ingestion may have a younger age of onset than more typical AF. Our survey identified certain attributes that may increase the likelihood of developing AF symptoms following cold ingestion. First, a significant proportion of respondents (36.5%) reported that AF was often triggered by cold ingestion following physical activity, and some reported that this was always the case for their CDH episodes. Multiple case studies report this trigger sequence. 18,19 Multiple respondents further elaborated on this in the free text portion of our survey (Table 3). While the underlying mechanism could not be elucidated by the current study, an exacerbation after exercise suggests a vagotonic effect. Indeed, heightened vagal tone appears to trigger AF, 31,32 and esophageal stimulation such as with a cold drink, may acutely increase such an autonomic response. Alternatively, as the esophagus lies directly behind and often in contact with the posterior left atrium, direct cold mechanical irritation of the left atrium may also be responsible, which also could be exacerbated post-exercise due to the relative increase in vagal tone. Many also described their CDH episodes to be correlated with the speed of ingestion, describing that rapid swallowing or gulping of cold beverages was more likely to precipitate an AF event. Others reported that behavioral modifications, as noted above, successfully eliminated or reduced the likelihood of CDH occurring. Although a majority of respondents found that most of their AF episodes were associated with cold ingestion, it was rare that consuming cold food or drink precipitated an AF event. In other words, most respondents were able to regularly consume cold food or drink without triggering any AF symptoms. It was common that respondents developed AF only when associated with cold ingestion, but that cold exposure rarely precipitated AF. These findings emphasize the unpredictability of AF triggers. The correlation between cold ingestion and AF symptoms may vary from patient to patient and may be affected by additional factors. As mentioned above, certain characteristics may contribute to a greater likelihood of AF symptoms developing in the context of cold ingestion, including rapid ingestion and recent physical exertion. Additional factors including other well-established triggers such as stress or alcohol 5,8–11 may contribute to heightened susceptibility to cold drinks or foods as triggers. Importantly, these data demonstrate that CDH occurs absent alcohol. Our survey’s self-reported results found success with cold drink avoidance in 86.4% of all eligible responses and 100% in those who had AF only with cold ingestion. Our findings are consistent with a growing body of literature suggesting that certain dietary triggers are directly correlated with the onset of AF symptoms. The effectiveness of avoiding cold food and drink in preventing recurrent episodes has yet to be quantified in a large population of patients with CDH, but many respondents of this survey reported employing this method with high success rates. This was especially true among those who develop AF exclusively in the context of cold ingestion. The higher rate of reported effectiveness among those who had AF only with cold ingestion suggests a need for individualized management strategies in AF patients. Physician education on a wide range of triggers will help to maximize care for patients with AF. A thorough discussion of possible triggers may enable a more personalized approach to AF care to minimize AF recurrence. Less than half of respondents (47.7%) at the time of the survey reported having at least one physician who understood that ingestion of cold drink or food could trigger AF. Among those who reported this trigger to their physician, over half (52.4%) reported some degree of dismissal from physicians. Others described in the free text portion that call center nurses, Emergency Medical Services personnel, and other medical professionals had denied this association or downplayed its seriousness. This represents a significant lack of awareness of this phenomenon among healthcare personnel and reinforces the imperative for further study, education, and outreach. The study on AF decision support from which the KP patients were recruited includes a prompt to remind providers to inquire about cold food or drink and alcohol. 24,25 Anecdotally, some survey respondents from this group described learning about this potential association from a physician. Embedding decision support in the electronic health record and reminding physicians to discuss triggers with their AF patients may help to standardize and optimize care for these patients. Our findings add to the literature additional patient voices and self-reported experiences of CDH. Continued investigation into modifiable AF triggers, including cold food and drink, will likely prove beneficial in understanding AF and improving patient outcomes. Further study will be required to assess the prevalence of CDH among an unselected population of AF patients, and importantly, the generalizability of our findings around the effectiveness of cold drink avoidance and other behavioral modifications in reducing AF recurrence. Additional comparisons between people with CDH and a general population of AF patients will confirm the age discrepancy observed in the present study and may help to elucidate how treatment strategies may align with or diverge from standard AF care. Heritability of AF has been well-established in the literature, 1 and although few of our survey respondents reported family members with the same cold drink trigger, it is unclear whether there may be a genetic component to susceptibility to cold ingestion as a trigger for AF. 14 Additionally, longitudinal studies will be important in identifying whether CDH predisposes one to chronic AF later in life. Expanding this body of literature will be important to spread awareness of this phenomenon to patients and providers alike. Finally, determining who has CDH may have other clinical utility, such as helping to identify with further research those more or less likely to be amenable to various therapies for AF. For example, those with CDH may be found to more greatly benefit from ablation or a particular antiarrhythmic drug. Limitations This study was limited in nature by its design, which utilized a cross-sectional survey format and cannot be used to determine causality. Much of the data was self-reported and may be subject to some degree of recall bias or other inaccuracies in responses. Additionally, participants were recruited via convenience sampling, with over half volunteering, which may limit the generalizability of our findings. Participants were included only if they were able to be reached by phone or had access to the internet to complete the survey independently. Lack of digital literacy and inability to communicate over the phone may have introduced some degree of selection bias. These factors may have contributed to the lower average age observed in the present study. Lastly, some patients described this encounter as being their very first experience with AF, and as such, it is difficult to establish a pattern of cold drink or food ingestion and arrhythmia. Conclusion In this patient survey, we characterized patients who experience AF or flutter triggered by cold drink or food, termed “Cold Drink Heart.” Patients who avoided cold beverages or food were able to significantly reduce or even eliminate recurrent AF or flutter episodes, especially patients who experienced AF or flutter exclusively triggered by cold drink or food. Further investigation into CDH is needed to establish a better understanding of its frequency among a general population of AF patients. N-of-1 trials may help to prospectively establish the effectiveness of avoiding cold food and drink in a CDH population. 4,33 Increasing physician awareness of the condition is imperative to improving management and care of patients with AF or flutter. References 1. Virani SS, Alonso A, Benjamin EJ, et al. Heart Disease and Stroke Statistics-2020 Update: A Report From the American Heart Association. Circulation . 2020;141(9):e139-e596. doi:10.1161/CIR.00000000000007572. 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Triggers screen from clinical decision support tool to assist with the treatment of ED patients with primary AF or atrial flutter Central Illustration . Cold Drink Heart (CDH) survey population and comparison of self-reported success of trigger avoidance between the “CDH AF only” and the “both CDH and non-CDH AF” groups; the former reported greater success of cold drink avoidance in reducing AF recurrence. Table 1. Patient Survey Respondent Characteristics – the Cohort after Exclusions Age in years, median (IQR) 56 (44-65) 56 (46-66) 57 (44-63) Female, m (%) 26 (25.7) 13 (21.0) 13 (33.3) Patients with AF only, n (%) 75 (74.3) 34 (87.2) 41 (66.1) CHA₂DS₂-VASc score, median (IQR) 1 (0-2) 1 (0-3) 1 (0-2) On anticoagulants, n (%) 26 (25.7) 8 (21.0) 18 (29.0) Age of first AF or flutter episode, median (IQR) 44.5 (32-58) 48.5 (34.4-59.5) 40.5 (30-56.3) Age of first CDH episode, median (IQR) 44.5 (32.25-59.5) 49 (40-62.5) 41 (30-57) Table 2. Cold Drink Heart Illness Characteristics Ever sought care in ED for CDH episode 85 (84.2) After ingesting cold drink or food, AF or flutter occurs (n=94) Always 3 (3.2) Often 14 (15.0) Sometimes 23 (24.5) Rarely 54 (57.4) Of all AF or flutter episodes, cold food or drink was associated (n=99) Always 51 (51.5) Often 19 (19.2) Sometimes 15 (15.2) Rarely 14 (14.1) Cold drink after exercise (n=96) 35 (36.5) Reported concomitant brain freeze* (n=100) 19 (19) * Brain freeze was defined in our survey as headaches that are sudden in onset, severe, and brief in duration that occur at least sometimes with consumption of cold drink or food. Table 3. Quotations from free text entries of survey participants with Cold Drink Heart “I notice stress with the cold drinks make my episodes more likely.” “I only get arrhythmia after drinking. I can always physically tell exactly when it occurs, and generally, while I am drinking. I can chug a cold drink and make it happen. It seems to happen more easily when I am warm from activity.” “I think it was interesting that doctors generally dismiss the connection between a cold drink and AF. I know from experience that it is a thing. Your inquiry into exercise is a good idea. I had just run 13 miles in warm weather when I triggered the AF. Thanks for doing this research.” “I had two distinct episodes of scary AF that both happened after exercise at the same fitness facility drinking from the same super cold water dispenser. I recognize that guzzling very cold beverages after exercise can cause AF and so I have avoided that practice. So far no more episodes.” “By avoiding cold beverages immediately post exercise I have avoided repeat AF.” “This has been a recent event for me but the 3 times I experienced an AF episode were immediately after ingesting ice cold water or lemonade, following physical activity. Cannot be a coincidence.” “It has happened four times, and each time it followed quickly the ingestion of very cold liquids. It occurred very shortly afterwards, as if I had turned on a light switch.” “When I think about all my episodes of AF, most were associated with cold beverages.” “If I take large ”gulps” of cold water or a protein shake almost 100%. If I ”sip” a cold drink never so I have had to change my behavior of cold drink consumption. If I forget I am just about guaranteed AF with RVR.” “Icee’s or Smoothies for me do this every time if I take a big swallow or consume it too fast.” “It has occurred only twice since the original episode. After the last incident I found the article on CDH and have avoided gulping cold beverages.” Supplemental Table 1 . Survey questions 1 First Name Free text response 2 Last Name Free text response 3 Is your atrial fibrillation or flutter intermittent, meaning does it seem to come and go? Yes, my atrial fibrillation or flutter comes and goes; No, I am in atrial fibrillation or flutter all the time; I am not sure (please explain) 4 Can you tell at least sometimes when your heart goes into atrial fibrillation or flutter? Yes, I can sometimes tell when my heart goes into atrial fibrillation or flutter; No, I do not know when I am in atrial fibrillation or flutter; I am not sure (please explain) 5 Which of the following ways have you used to tell when your heart is in atrial fibrillation or flutter (choose all that apply)? I know by my symptoms, how it feels; I used a wearable ECG (Apple Watch or KardiaMobile); I used a wearable ECG monitor prescribed by my doctor; From a blood pressure cuff; I used a different form of an ECG monitor or a different form of pulse recording (not mentioned above); This was confirmed during a medical visit; Other (please specify) 6 Do cold beverages or cold foods (like ice cream) ever trigger your atrial fibrillation or flutter? Yes, they can trigger my atrial fibrillation; Yes, they can trigger atrial flutter; Yes, they can trigger both; Yes, but I am not sure which rhythm they can trigger; No, I have not noticed these as triggers; I am not sure if cold beverages or cold foods are triggers 7 After you have a cold food or beverage, approximately how often does atrial fibrillation or flutter occur? Always; Often; Sometimes; Rarely; Never; Other (please specify) 8 Out of all your atrial fibrillation or flutter episodes, approximately how often did they begin after ingesting cold food or beverage? Always; Often; Sometimes; Rarely; Never; Other (please specify) 9 Has your atrial fibrillation or flutter ever been triggered by cold food or beverage ingested shortly after exercising (within 30 minutes)? Yes; No; I am not sure 10 Out of all your cold food or beverage-induced atrial fibrillation or flutter episodes, about what percentage began after ingesting cold food or beverage shortly after exercising (within 30 minutes)? Always; Often; Sometimes; Rarely; Never; Other (please specify) 11 How old were you (approximately) when you had your first episode of atrial fibrillation or atrial flutter? If you cannot remember, please indicate in the field below. Free text response 12 How old were you (approximately) when you had your first episode of atrial fibrillation or flutter triggered by cold beverage or food? If you cannot remember, please indicate in the field below. Free text response 13 What is the typical time gap between drinking a cold beverage or eating cold food and developing atrial fibrillation or flutter? A few seconds; More than a few seconds but less than 1 minute; Between 1-5 minutes; Greater than 5 minutes 14 Based on your experience, which cold beverage or food items have you found are most likely to trigger your atrial fibrillation or flutter? Free text response 15 To what degree have you avoided these cold triggers to avoid going into atrial fibrillation or flutter? I always avoid cold beverages and foods that could trigger atrial fibrillation or flutter; I usually avoid cold beverages and foods that could trigger atrial fibrillation or flutter; I rarely avoid cold beverages and foods that could trigger atrial fibrillation or flutter; I never avoid cold beverages and foods that could trigger atrial fibrillation or flutter; I am not sure 16 Has avoiding these cold triggers reduced the frequency of or eliminated your episodes of atrial fibrillation or flutter? Avoiding cold triggers has completely eliminated my atrial fibrillation or flutter; Avoiding cold triggers has greatly reduced the frequency of my atrial fibrillation or flutter episodes; Avoiding cold triggers has somewhat reduced the frequency of my atrial fibrillation or flutter episodes; Avoiding cold triggers has barely reduced the frequency of my atrial fibrillation or flutter episodes; Avoiding cold triggers has not affected the frequency of my atrial fibrillation or flutter episodes 17 Have you ever had an ablation procedure to treat your atrial fibrillation or flutter? Yes, to treat my atrial fibrillation; Yes, to treat my atrial flutter; Yes, but I am not sure for which; No; I am not sure 18 Did your ablation procedure help reduce atrial fibrillation or flutter triggered by cold beverage or food? Yes, my atrial fibrillation or flutter is no longer triggered by cold beverage or food.; Yes, but my atrial fibrillation or flutter is still triggered by cold beverage or food sometimes.; No, my atrial fibrillation or flutter triggered by cold beverage or food was not improved by the ablation procedure.; Other (please specify) 19 After your ablation procedure, how often is your atrial fibrillation or flutter still triggered by cold beverage or food? Always; Often; Somewhat; Rarely; Never; Other (please specify) 20 Have your episodes of atrial fibrillation or flutter triggered by cold beverage or food caused you to seek care in the emergency room? No, never; Yes, 1-2 times; Yes, 3-5 times; Yes, 6 or more times; I am not sure 21 Have you ever explained to a physician that your atrial fibrillation or flutter can be triggered by cold beverage or food? No, never; Yes, but only once to one doctor; Yes, more than once to one or more doctors; I am not sure 22 Why have you not explained this trigger to a physician? Free text response 23 Have physicians ever dismissed your explanation that your atrial fibrillation or flutter can be triggered by cold beverage or food? Yes, they have all dismissed it; Yes, some have dismissed it; No, none have ever dismissed it; I am not sure 24 Do you have at least one physician now who understands that your atrial fibrillation or flutter can be triggered by cold beverage or food? Yes; No; I am not sure 25 Brain freeze (or ice cream) headaches are sudden, severe but brief headaches that occur with cold beverage or food. When you have developed atrial fibrillation or flutter triggered by cold beverage or food, did the cold beverage or food also trigger a brain freeze (or ice cream) headache? Yes, brain freeze headaches occur every time I also develop atrial fibrillation or flutter triggered by cold beverage or food; Yes, brain freeze headaches occur sometimes when I develop atrial fibrillation or flutter triggered by cold beverage or food; No, I have never had a brain freeze headache when I develop atrial fibrillation or flutter triggered by cold beverage or food; I am not sure 26 Does anyone in your immediate biological family also have atrial fibrillation or flutter? (if yes, choose all that apply) Yes, at least one parent; Yes, at least one sibling; Yes, at least one child; No; I don’t know 27 Does anyone in your immediate biological family also have atrial fibrillation or flutter that is triggered by cold beverage or food? (if yes, choose all that apply) Yes, at least one parent; Yes, at least one sibling; Yes, at least one child; No; I don’t know 28 Is there anything else about your atrial fibrillation or flutter triggered by cold beverage or food that you’d like us to know? Free text response Supplemental Table 2. Additional demographic and medical history-related questions for non-KP respondents 3 Age (in years) Free text response 4 What biological sex were you assigned at birth? Male; Female 5 Country of Current Residence Free text response 31 Has a healthcare provider ever told you that you have a diagnosis of: (Yes; No; Unsure) Congestive heart failure or ejection fraction < 35%; Hypertension (high blood pressure); Diabetes mellitus (Type 1 or Type 2); Aortic plaque; History of stroke; History of transient ischemic attack (TIA); History of systemic thromboembolism (for example, blood clot in legs [deep vein thrombosis], or lungs [pulmonary embolism], or intestines [mesenteric ischemia]); History of myocardial infarction (heart attack); Have you had a Watchman procedure to reduce your stroke risk? 32 Are you taking an oral anticoagulant to prevent strokes related to your atrial fibrillation or flutter? If so, then select the one you are taking. Warfarin ( Coumadin or Jantoven ), or Acenocoumaron ( Acebron, Acenomac, Acitrom, Azecar, Coarol, Fortonol, Isquelium, Mini-Sintrom, Neo Sintrom, Nistrom, Saxiom, Sin 4, Sinkum, Sinkum 4, Sinthrome, Sintrom, Syncumar, Trombostop, or Venohem ); Rivaroxaban ( Xarelto ) ; Dabigatran (Pradaxa); Edoxaban (Savaysa or Lixiana ); Apixaban (Eliquis) ; Other anticoagulants for preventing strokes related to afib or flutter (please specify); I am not taking an oral anticoagulant. 33 Which of the following rate-slowing or rhythm control medications are you currently taking to treat your atrial fibrillation or flutter? Choose all that apply. A beta-blocker. This includes: Atenolol ( Tenormin or Senormin ), bisoprolol ( Zebeta ), carvedilol ( Coreg ), metoprolol ( Kapspargo Sprinkle, Lopressor, or Toprol ), nadolol ( Corgard ), propranolol ( Hemangeol, Inderal, or InnoPran ), or timolol ( Blocadren ); A calcium channel-blocker. This includes: Diltiazem ( Cardizem, Cartia XT, Dilacor, Dilt-XR, Diltzac, Matzim LA, Taztia, Tiadylt, or Tiazac ); Amiodarone ( Cordarone, Nexterone, or Pacerone ); Digoxin ( Digitek, Digox, Lanoxin, Lanoxicaps, or Toloxin ); Disopyramide ( Norpace or Rhythmodan ); Dofetilide ( Tikosyn ); Dronedarone ( Multaq ); Flecainide ( Tambocor ); Procainamide ( Pronestyl, Procan, or Procanbid ); Propafenone ( Rythmol ); Quinidine ( Quin-G, Cardioquin, Quinora, Quinidex Extentabs, Quinaglute Dura-Tabs, or Quin-Release ); Sotalol ( Betapace, Sorine, or Sotylize ); Verapamil ( Calan, Isoptin, Verelan, or Covera ); Other medications for rate-slowing or rhythm control for your afib or flutter (please specify); I am not taking any of the above medications to treat my atrial fibrillation or flutter. Information & Authors Information Version history V1 Version 1 06 February 2025 Peer review timeline Published Journal of Cardiovascular Electrophysiology Version of Record 12 Jun 2025 Published Copyright This work is licensed under a Non Exclusive No Reuse License. Collection Journal of Cardiovascular Electrophysiology Keywords basic: atrial fibrillation/atrial arrhythmias clinical: electrophysiology – atrial arrhythmias Authors Affiliations Daniel D. DiLena 0009-0006-2252-6486 [email protected] Kaiser Permanente Division of Research View all articles by this author Jennifer Y. Zhang Kaiser Permanente Division of Research View all articles by this author Adina S. Rauchwerger Kaiser Permanente Division of Research View all articles by this author Mary E. Reed Kaiser Permanente Division of Research View all articles by this author Gregory Marcus M University of California San Francisco Department of Medicine View all articles by this author E. Margaret Warton Kaiser Permanente Division of Research View all articles by this author David Vinson 0000-0001-6559-1858 Kaiser Permanente Division of Research View all articles by this author Metrics & Citations Metrics Article Usage 744 views 215 downloads .FvxKWukQNSOunydq8rnd { width: 100px; } Citations Download citation Daniel D. DiLena, Jennifer Y. Zhang, Adina S. Rauchwerger, et al. Characterizing Patients with Cold Drink-Triggered Atrial Fibrillation. Authorea . 06 February 2025. DOI: https://doi.org/10.22541/au.173888137.73624097/v1 If you have the appropriate software installed, you can download article citation data to the citation manager of your choice. Simply select your manager software from the list below and click Download. For more information or tips please see 'Downloading to a citation manager' in the Help menu . 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