Light-to-moderate alcohol consumption and prognosis in patients with left ventricular systolic dysfunction

Low-to-Moderate Alcohol Intake and Health Status in Heart Failure Patients

BACKGROUND

Although heart failure (HF) guidelines recommend alcohol abstinence, existing evidence indicates that alcohol may not worsen survival and no data about associations between alcohol and health status (patients' symptoms, function, and quality of life) exist.

METHODS AND RESULTS

Alcohol use was quantified in 420 HF outpatients. The associations between moderate alcohol intake (1 to 60 drinks/month) and health status were assessed by comparing baseline and 1-year Kansas City Cardiomyopathy Questionnaire (KCCQ) and Short Form-12 (SF-12) scores between moderate and nondrinkers. No differences in baseline KCCQ or SF-12 scores between abstainers (n = 245) and moderate drinkers (n = 175) were observed (KCCQ 60.5 +/- 24 versus 61.9 +/- 23.5, P = .55; SF-12 Physical Component Score (PCS) 33.6 +/- 11.2 versus 35.3 +/- 10.2, P = .14; and SF-12 Mental Component Score (MCS) 49.1 +/- 11.1 versus 49.4 +/- 11.4, P = .78). Abstainers and drinkers also had similar 1-year KCCQ scores (65.8 +/- 24.5 versus 69.3 +/- 24.1, P = .23), mortality (10.5% versus 11.6%, P = .72) and HF hospitalizations (18.0% versus 15.4%, P = .51). Multivariable analyses controlling for baseline differences also revealed similar outcomes between abstainers and drinkers-1-year KCCQ change = 4.3 +/- 1.8 versus 5.2 +/- 2.5; P = .75), mortality (OR = 1.33, 95% CI 0.67-2.64), or HF hospitalization (OR = 1.13, 95% CI 0.60-2.11).

CONCLUSION

No relationships between moderate alcohol consumption and health status or 1-year outcomes were identified in this multicenter observational study. These data do not support the need for complete alcohol abstinence for all HF patients among those who drink in moderation.

Alcohol consumption: an overview of benefits and risks

Published health benefits of regular light-to-moderate alcohol consumption include lower myocardial infarction rates, reduced heart failure rates, reduced risk of ischemic stroke, lower risk for dementia, decreased risk of diabetes and reduced risk of osteoporosis. Numerous complimentary biochemical changes have been identified that explain the beneficial effects of moderate alcohol consumption. Heavy alcohol consumption, however, can negatively affect neurologic, cardiac, gastrointestinal, hematologic, immune, psychiatric and musculoskeletal organ systems. Binge drinking is a significant problem even among moderate drinkers and is associated with particularly high social and economic costs. A cautious approach should be emphasized for those individuals who drink even small amounts of alcohol. Physicians can apply the research evidence describing the known risks and benefits of alcohol consumption when counseling their patients regarding alcohol consumption.

Alcohol consumption and prognosis in patients with left ventricular systolic dysfunction after a myocardial infarction

OBJECTIVES

We assessed the influence of alcohol intake on the development of symptomatic heart failure (HF) in patients with left ventricular (LV) dysfunction after a myocardial infarction (MI).

BACKGROUND

In contrast to protection from coronary heart disease, alcohol consumption has been linked to cardiodepressant effects and has been considered contraindicated in patients with HF.

METHODS

The Survival And Ventricular Enlargement (SAVE) trial randomized 2231 patients with a LV ejection fraction (EF) <40% following MI to an angiotensin-converting enzyme inhibitor or placebo. Patients were classified as nondrinkers, light-to-moderate drinkers (1 to 10 drinks/week), or heavy drinkers (>10 drinks/week) based on alcohol consumption reported at baseline. The primary outcome was hospitalization for HF or need for an open-label angiotensin-converting enzyme inhibitor. Analyses were repeated using alcohol consumption reported three months after MI.

RESULTS

Nondrinkers were older and had more comorbidities than light-to-moderate and heavy drinkers. In univariate analyses, baseline light-to-moderate alcohol intake was associated with a lower incidence of HF compared with nondrinkers (hazard ratio [HR] 0.71; 95% confidence interval [CI] 0.57 to 0.87), whereas heavy drinking was not (HR 0.91; 95% CI 0.67 to 1.23). After adjustment for baseline differences, light-to-moderate baseline alcohol consumption no longer significantly influenced the development of HF (light-to-moderate drinkers HR 0.93; 95% CI 0.75 to 1.17; heavy drinkers HR 1.25; 95% CI 0.91 to 1.72). Alcohol consumption reported three months after the MI similarly did not modify the risk of adverse outcome.

CONCLUSIONS

In patients with LV dysfunction after an MI, light-to-moderate alcohol intake either at baseline or following MI did not alter the risk for the development of HF requiring hospitalization or an open-label angiotensin-converting enzyme inhibitor.

Alcohol use and prognosis in patients with coronary heart disease

Substantial evidence has shown that moderate drinkers have lower rates of coronary heart disease (CHD) than abstainers, but the effects of alcohol consumption among patients with established CHD are less clear. Alcohol intake has important effects on risk factors for reinfarction, including higher levels of high-density lipoprotein cholesterol and triglycerides, lower levels of fibrinogen and other prothrombotic factors, lower fibrinolytic potential, and antiplatelet activity. Studies of patients at risk for CHD, such as those with diabetes, hypertension, and hyperlipidemia, have shown that the association of moderate drinking and CHD is at least as strong as it is in the general population. Most recently, studies have found that survivors of acute myocardial infarction who drink moderately have a risk of death approximately 20%-30% lower than do abstainers or rare drinkers. Nonetheless, the risks and benefits of alcohol use remain complex, even among patients with CHD, and no simple recommendation regarding alcohol consumption can be made for all patients.

Cardiovascular manifestations of substance abuse: part 2: alcohol, amphetamines, heroin, cannabis, and caffeine

The abuse of alcohol is associated with chronic cardiomyopathy, hypertension, and arrhythmia. Abstinence or using alcohol in moderation can reverse these cardiovascular problems. Alcohol is also distinguished among the substances of abuse by having possible protective effects against coronary artery disease and stroke when used in moderate amounts. Amphetamines (eg, speed, ice, ecstasy) have many of the cardiovascular toxicities seen with cocaine, including acute and chronic cardiovascular diseases. Heroin and other opiates can cause arrhythmias and noncardiac pulmonary edema, and may reduce cardiac output. Cardiovascular problems are less common with cannabis (marijuana) than with opiates, but major cognitive disorders may be seen with its chronic use. It is still controversial whether caffeine can cause hypertension and coronary artery disease, and questions have been raised about its safety in patients with heart failure and arrhythmia.

Influence of gender and reported alcohol intake on mortality in nonischemic dilated cardiomyopathy

Between 1994-1998, we retrospectively studied a cohort of 396 consecutive patients with dilated cardiomyopathy, mean age 53 +/- 15 years, 74% men. The history of alcohol intake was abstracted from the medical records. During a follow-up period of 42 +/- 26 months, 83 (76% men) patients died and 15 (80% men) underwent cardiac transplantation. Men were younger and more likely to have a history of excessive alcohol intake compared with women. Gender significantly modified the risk of alcohol consumption on mortality. Although alcohol intake increased the mortality risk in women, it was protective toward death in men (hazards ratios for death were 7.3 vs. 0.44). The effect of alcohol intake on outcome was reassessed after classifying the patients into 4 groups: group 1: life-long nondrinkers; group 2: former drinkers; group 3: moderate drinkers; and group 4: heavy drinkers. Similar findings were seen. This study demonstrated that the risk of reported alcohol intake on mortality is related to gender in patients with nonischemic heart failure. Our findings deserve further study, including a larger number of females, as a possible way to improve outcome in such patients.

Effect of alcohol consumption on endothelial function in men with coronary artery disease

An inverse relationship between moderate alcohol consumption and coronary artery disease (CAD) has been observed in several epidemiologic studies. Whether improvement of endothelial function is involved in this beneficial effect is unknown. We investigated endothelial function of the brachial artery in 108 men with CAD, 54 of whom consumed alcohol on at least 1 day per week. Brachial artery diameter responses to hyperemic flow (FMD) and to administration of nitroglycerin (NTG) spray were measured using high- resolution ultrasonography. Coronary risk factors and hyperuricemia were present more frequently among drinkers, who also had higher concentrations of triglyceride and apolipoproteins C2, C3, and E. FMD was greater in drinkers (P<0.0001), while NTG-induced dilation was not. Multiple regression analysis showed alcohol consumption to be one of the factors favorably influencing FMD. These findings suggest that alcohol consumption may improve endothelial function in men with CAD.

Alcoholic cardiomyopathy: is it dose-dependent?

Alcohol is a known myocardial depressant. In a dose-dependent fashion, one can show progressive decline in left ventricular systolic function. This observation has been used to implicate alcohol as a major cause of up to 30% of all dilated cardiomyopathies. However, it is not well recognized that there appears to be a biphasic cardiovascular effect based on the chronic dose of alcohol ingested. At low to moderate doses, studies suggest that alcohol has a favorable impact on cardiovascular outcomes. In other words, patients who have one to two glasses of alcohol per day have fewer myocardial infarctions and an improved survival. Large trials, such as the Physician Health Study, indicate that this benefit may be over wide ranges of doses, from one to seven glasses per week. When this is looked at in higher-risk diabetic patients, the benefit of low to moderate doses of alcohol persists. Together, this information suggests that low to moderate doses of alcohol improve cardiovascular risk, and this benefit may exceed the risk of hypertension or heart failure. It is equally important to recognize the serious down side to alcohol ingestion. At chronic high-dose intake of alcohol, there is a direct relationship to elevated blood pressure. Also, prolonged exposure to alcohol increases the likelihood of developing congestive heart failure. Combining the negative cardiovascular effects with potential danger to other organs, such as the liver, underscores the risk for high-dose alcohol. Therefore, there is a biphasic dose response to alcohol. At low to moderate doses, patients experience an overall cardiovascular benefit; it is only when a critical threshold is reached by high-dose alcohol that one observes the toxic effects. Patients on low to moderate ingestion of alcohol should be reassured, but those on high doses should be strongly encouraged to abstain due to potential toxic effects of alcohol.

Alcohol and heart failure

BACKGROUND

Current heart failure (HF) guidelines note that alcohol use should be discouraged or restricted in patients with HF resulting from left ventricular systolic dysfunction. Existing knowledge is limited in the area of HF and alcohol.

METHODS AND RESULTS

The purpose of this article is to review the evidence regarding the acute and long-term use of alcohol in the setting of HF. In addition, general aspects about alcohol and alcoholic beverages that are important for understanding and interpreting alcohol-related literature are reviewed and that can be used when discussing alcoholic beverage use with patients with HF.

CONCLUSIONS

There is some emerging evidence that suggests light drinking (1 to 14 drinks per week) is safe and even beneficial in HF patients with ischemic left ventricular dysfunction (LVD). However, there are no effects of light drinking in HF patients with nonischemic LVD. Clinicians should reinforce the importance of evidence based pharmacologic and nonpharmacologic therapies in HF.

Balancing the risks and benefits of moderate drinking

The risks of excessive alcohol intake are well known, and heavy drinkers should decrease their intake or stop drinking. On the other hand, in comparison with non-drinkers, moderate drinkers are at much lower risk of cardiovascular disease and certain other diseases and have lower total mortality. Thus, middle-aged or older men and post-menopausal women with no contraindications to alcohol use should be informed that they have, on average, net health benefits from the regular consumption of small-to-moderate amounts of alcohol.

Prevention of heart failure

In light of the increasing prevalence, morbidity, and mortality of heart failure, preventative strategies are urgently needed. Risk factors include coronary artery disease, renal insufficiency, diabetes, and smoking. Essential strategies for prevention of heart failure are modification of risk factors for its development, and detection and treatment of asymptomatic left ventricular dysfunction (ALVD). In patients with ALVD, angiotensin-converting enzyme (ACE) inhibitor and beta-blocker therapy can prevent progression to symptomatic heart failure. Additional recently identified preventative strategies include ACE inhibitor therapy for all coronary artery disease and diabetic patients, clopidogrel therapy in acute coronary syndromes, and avoidance of calcium channel blockers and alpha-blockers as first-line antihypertensive therapy.

Antithrombotic effect of polyphenols in experimental models: a mechanism of reduced vascular risk by moderate wine consumption

Epidemiological studies have suggested that cardiovascular disease can be decreased by moderate wine consumption, but an overall quantitative estimation of the relationship between wine intake and vascular risk is lacking. A meta-analysis was therefore performed on 19 studies selected on the basis of the availability of specific information on the cardiovascular relative risk (RR) associated with wine consumption. A significant risk reduction (RR: 0.66, 95% CI 0.57-0.75) was associated with moderate (1-2 drinks or 150-300 mL/d) versus no wine consumption. In five studies which excluded ex-drinkers as reference group, the overall RR associated with wine consumption was 0.61 (95% CI 0.57-0.75). A dose-response relation between wine intake and vascular risk resulted in a J-shaped curve, with a significant risk reduction at about 300 mL/d (trend analysis p = 0.032). Two studies were also performed to investigate the effects of wine polyphenols on experimental thrombosis in rats. Supplementation for 10 days with alcohol-free red wine--but not white wine or alcohol--induced a significant reduction of stasis-induced venous thrombosis, an effect blunted by NO synthase inhibitor L-NAME. In rats with diet-induced hyperlipidemia, alcohol-free red wine supplementation significantly delayed the thrombotic occlusion of an artificial prosthesis inserted into the abdominal aorta, but did not affect the increased cholesterol and triglyceride levels. TRAP values were significantly higher in animals receiving alcohol-free wine. Altogether these experimental data support an antithrombotic role of polyphenols in the reduced vascular risk associated with moderate wine consumption in man, as shown by our epidemiological studies.