nervous system depression, hypotension, hypothermia, coma, re-
spiratory depression and death. Binge drinking is defined as four or
more drinks within two hours for women and five or more drinks
within two hours for men. Heavy drinking is defined as more than
three drinks per day, or more than 12 drinks per week, for women
and men aged 65 and older, and more than four drinks per day or
more than 14 drinks per week for men 65 and younger.
Chronic alcohol use can be associated with hypertension, stroke,
cardiomyopathy, chronic pancreatitis, gastritis and gastrointesti-
nal bleeding, hypogonadism, osteoporosis, brain atrophy, GERD,
chronic liver cirrhosis with esophageal varices, esophagitis, seizure
disorder and cardiac arrhythmias. Even moderate amount of alcohol
use can be carcinogenic, including association with cancers of the
liver, mouth, throat, larynx, esophagus, breast and colon. Chronic
malnourishment secondary to alcohol consumption increases the
risk of vitamin and mineral derangements. Pregnant women can
cause harm to the fetus with alcohol use including miscarriage, fetal
alcohol syndrome and neurocognitive consequences.
“What is the definition of a problem drinker? Someone who drinks
more than his or her doctor.” (old medical joke)
ALCOHOL AND CARDIOMYOPATHY
Alcohol has a toxic, depressant effect on the myocardium and
alcohol-associated hypertension that may be a contributing and
confounding comorbidity in the development of alcoholic cardio-
myopathy. Other factors may include vitamin deficiencies (thia-
mine), gene mutations and antioxidant deficiency. Congestive heart
failure secondary to alcoholic cardiomyopathy can be associated
with atrial fibrillation, which amplifies morbidity and mortality.
In a recent study of alcohol abuse in a large statewide database of
ambulatory surgery, emergency and inpatient care visits, there was
significant increase in each of three outcome variables including
atrial fibrillation (AF), myocardial infarction (MI) and congestive
heart failure (CHF).(2)
ALCOHOL AND CARDIAC DYSRHYTHMIAS
The “Holiday Heart Syndrome” was first described in 1978, linking
alcohol consumption with cardiac arrhythmias including atrial
fibrillation and various atrial and ventricular dysrhythmias after
weekend bouts of drinking. (5) Subsequent reports showed con-
comitant metabolic abnormalities including hypomagnesemia and
hypokalemia in this situation. Alcohol is an arrhythmogenic sub-
stance and putative mechanisms include heightened sympathetic
discharge, tachycardia, shortened refractoriness and progressive
atrial remodeling that predisposes to and triggers atrial fibrillation.
Other pathophysiologic mechanisms of alcohol and AF association
may include obesity, hypertension and sleep-disordered breathing.
(3) It is now well established that even moderate levels of habitual
alcohol consumption are associated with atrial fibrillation. Atrial
fibrillation and atrial flutter have emerged as the most common
symptomatic arrhythmias in the world. One important study stresses
that alcohol use is an important risk factor for AF and even though
a small amount of alcohol has been considered cardioprotective,
these benefits do not extend to AF. Abstinence from any amount of
THE COMPLEXITY OF ALCOHOL
alcohol will be my recommendation in patients who may be prone
to AF or have paroxysmal atrial fibrillation.
IS ALCOHOL USE CARDIOPROTECTIVE?
The analogy of alcohol consumption to the razor-sharp double-edged
sword was best described in an older review article published in
2007.(6) Observational studies have shown that a low level of alcohol
use may protect against ischemic heart disease (IHD) and ischemic
stroke risk, but data are confounding due to the lack of randomized
trials and self-reporting of alcohol use, which is highly unreliable. At
heavier levels of alcohol use, these studies show a consistent J-shaped
curve demonstrating increased risk of stroke, especially hemorrhagic
stroke and dementia.(6) If there indeed are cardio-protective effects,
these may be secondary to a modest rise in HDL levels, decreased
platelet aggregation and improved insulin sensitivity. Divergent
views still exist, however, regarding the advisability of how much,
if any, alcohol to drink. Red wine is favored by some clinicians
(presumably because of flavonoids, antioxidants and resveratrol)
although data remains inconclusive due to lack of randomized
control trials. Recommending moderate daily drinking of alcohol
for cardio-protective reasons is a slippery slope that may be difficult
to navigate because of alcohol’s addictive properties. There appears
to be a fine line between healthy drinking and risky drinking. Al-
though heralded as a gateway to health, moderate alcohol drinking
can be a dangerous assumption. It is to be remembered that people
who indulge in alcohol use for a cardio-protective reason may well
be highly motivated and will change their lifestyles and modify
their other risk factors including dietary modifications, cessation
of smoking, controlling hypertension and dyslipidemia. A recent
editorial in the Journal of the American College of Cardiology
sums up the use of alcohol and the risk of heart disease as follows:
“Alcohol is a potentially addictive and dangerous drug, both for
the cardiovascular system and multiple other organ systems. The
recent infatuation with the potential benefits of light-to-moderate
drinking for CVD protection appears to be based on observational
and subtly confounded data rather than on randomized controlled
trial evidence, and perhaps on more than a little wishful thinking.”
(my emphasis). (4)
Dr. Seyal practices cardiovascular disease medicine with Floyd Memorial Medical
Group-River Cities Cardiology.
REFERENCES:
1. Abraham Lincoln. AZQuotes.com. Retrieved July 28, 2019, from AZquotes.
com website.
2. Whitman IR, Agarwal V, Nah, G et al. Alcohol Abuse and Cardiac Disease.
JACC 2017; 69:13-24.
3. Voskoboinik A, Prabhu S, Ling L et al. Alcohol and Atrial Fibrillation- A Sobering
Review. 2016;68:2567-76.
4. Criqui MH, Thomas IC. Alcohol Consumption and Cardiac Disease. Where Are
We Now? (Editorial) JACC 2017;25-27.
5. Ettinger PO, Wu CF, DeLacuz C,C Jr et al. American Heart journal 1978;95:555-
62.
6. O’Keefe JH, Bybee KA, Lavie CJ. Alcohol and Cardiovascular Health- The ra-
zor-sharp double-edged sword. J Am Coll Cardiol 2007;50:1009-14.
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