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

Fingerprint profile of alcohol-associated heart failure in human hearts

BACKGROUND

Excessive alcohol consumption is recognized as a cause of left ventricular dysfunction and leads often to alcohol-induced heart failure. It is thought that 36% of all cases of dilated cardiomyopathy are due to excessive alcohol intake. In addition, since chronic alcohol-consumption is a social behavior that is not always clearly self-reported clinically, it has been difficult to diagnose alcohol-induced heart failure versus heart failure due to idiopathic dilated cardiomyopathy (IDCM). Interestingly, both diseases are associated with left ventricular dysfunction and congestive heart failure.

METHODS

We have created a human heart failure cDNA array for IDCM from nonfailing and failing human hearts. The array contains 1,143 heart specific oligonucleotide probes. This array was used to screen RNA samples from transplant recipients and organ donors with alcohol-related heart failure.

RESULTS

Our study shows that alcohol-induced heart failure has a "specific fingerprint" profile of de-regulated genes. This profile can differentiate patients with pure alcohol-induced heart failure from patients with heart failure from IDCM with alcohol as a complicating or contributing factor. Furthermore, the pattern of gene de-regulation suggests a pivotal role for changes in matrix, cytoskeletal, and structural proteins in the development of clinical heart failure resulting from excessive alcohol consumption.

CONCLUSIONS

We report for the first time a genomic "fingerprint" profile of de-regulated genes associated with human alcohol-induced heart failure. We conclude that the pathogenesis of alcohol-induced heart failure in humans is likely related to changes in architectural (e.g. cytoskeletal), matrix, and/or structural proteins. The reversibility of the disease upon cessation of alcohol consumption makes this a likely pathogenetic mechanism. Nevertheless, there is a point at which extracellular as well as cellular changes result in irreversible heart failure.

Alcohol intake and noncoronary cardiovascular diseases

Moderate drinking has complex associations with cardiovascular diseases other than coronary heart disease. Recent cohort studies examining the relationship between alcohol use and ischemic stroke have shown a modest association, with risk ratios approximating 0.8 and the lowest risk among those who drink less than daily. In contrast, alcohol use is generally associated with an approximate dose-dependent risk for hemorrhagic stroke throughout the full range of intake. Several prospective studies of alcohol intake and congestive heart failure have found lower risk with moderate drinking. This risk is also dose dependent through the moderate range, but its underlying mechanism remains uncertain. Accounting for the lower risk of myocardial infarction associated with moderate intake does not eliminate the observed association. Cohort studies have found no association of long-term alcohol intake with risk of atrial fibrillation below levels of at least 3 standard drinks per day. Finally, two prospective studies have found lower risks of claudication or clinically more severe peripheral arterial disease among moderate drinkers, an association also supported by cross-sectional studies of alcohol intake and ankle-brachial index.

Molecular mechanisms responsible for alcohol-induced myopathy in skeletal muscle and heart

Chronic alcohol abuse has the potential to modulate striated muscle physiology and function. The skeletal muscle alcoholic myopathy is characterized by muscle weakness and difficulties in gait and locomotion, while chronic alcohol consumption ultimately leads to a decrease in cardiac contractility and output. In both tissues a loss of protein mass results in part from a decreased protein synthesis that initially manifests as a defect in translational efficiency. This review focuses on recent developments in understanding the cellular and molecular mechanisms by which alcohol impairs mRNA translation in skeletal and cardiac muscle, including identification of the signaling pathways and biochemical sites negatively impacted. Defective signaling potentially results from resistance to the normal stimulating effects of anabolic hormones (insulin and insulin-like growth factor-I) and nutrients (leucine) as well as increased production of several negative regulators of muscle mass. Overall, the biochemical mechanisms contributing to the pathogenesis of loss of skeletal and cardiac muscle are reviewed.

Myocardial infarction and cardiac complications in emergency department patients admitted to the intensive care unit with gastrointestinal hemorrhage

Patients admitted with significant gastrointestinal hemorrhage (GIH) often experience in-hospital cardiac complications. This retrospective study examined 68 patients admitted from the Emergency Department to the Intensive Care Unit (ICU) over a 1-year period. The patients were 75% Caucasian, 60% male, with a mean age of 57 +/- 19 years. Medical co-morbidity was noted in 70%, and 54% of patients had a history of significant alcohol use. A systolic blood pressure < 100 mm Hg was present in 26%, hemoglobin < 7 mg/dL in 32%, and three patients (4%) expired. Death, acute myocardial infarction or other cardiac complications were noted in 32% of patients. Patients older than 60 years were three times more likely to have a complicated course than were younger patients, and those with a co-morbidity were 14.8 times more likely. Patients with a history of significant alcohol use were 31% less likely to have an inpatient complication than those without such a history. Regression analysis supported the protective effect of a history of significant alcohol use and also demonstrated that a history of peptic ulcer disease was predictive of inpatient complications. Older GIH patients and those with co-morbidities may benefit from ICU disposition given their greater risk. Younger patients presenting with hematemesis and a history of significant alcohol use tended to have fewer complications such that it may be possible to manage these patients outside of the ICU if hemodynamically stable.

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.