Alcohol and Cardiovascular Disease: How Much is Too Much?

Triglyceride-glucose index is associated with all-cause mortality in critically ill patients with alcohol use disorder: a retrospective cohort study

BACKGROUND

The relationship between Triglyceride-glucose (TyG) index and clinical outcomes in patients with alcohol use disorder (AUD) is unclear. The aim of this study was to evaluate the association between TyG index and all-cause mortality in critically ill patients with AUD.

METHODS

We used data from the multi-parameter intelligent monitoring in intensive care IV (MIMIC-IV) database. The patients were equally divided into quartiles. Kaplan-Meier curves were used for survival analysis. The primary endpoint of the study was 28-day mortality, followed by 1-year mortality. We used Cox proportional hazard models to assess the relationship between TyG index and all-cause mortality at different endpoints.

RESULTS

A total of 537 AUD patients were included. Using TyG value as a continuous variable (HR 1.460, 95% CI 1.121-1.903, p = 0.005) and categorical variable (HR 1.447-3.477 from Q2 to Q4, with Q1 as reference), elevated TyG value was significantly associated with increased 28-day mortality. TyG was positively associated with 1-year mortality in AUD patients with an HR of 1.295 (95% CI 1.011-1.659, p = 0.041).

CONCLUSION

TyG index is positively associated with different clinical outcomes of critically ill AUD patients.

Acetic Acid: An Underestimated Metabolite in Ethanol-Induced Changes in Regulating Cardiovascular Function

Acetic acid is a bioactive short-chain fatty acid produced in large quantities from ethanol metabolism. In this review, we describe how acetic acid/acetate generates oxidative stress, alters the function of pre-sympathetic neurons, and can potentially influence cardiovascular function in both humans and rodents after ethanol consumption. Our recent findings from in vivo and in vitro studies support the notion that administration of acetic acid/acetate generates oxidative stress and increases sympathetic outflow, leading to alterations in arterial blood pressure. Real-time investigation of how ethanol and acetic acid/acetate modulate neural control of cardiovascular function can be conducted by microinjecting compounds into autonomic control centers of the brain and measuring changes in peripheral sympathetic nerve activity and blood pressure in response to these compounds.

Sex-Specific Contributions of Alcohol and Hypertension on Everyday Cognition in Middle-Aged and Older Adults

Background: Separate lines of research have linked hypertension and alcohol use disorder to cognition among adults. Despite known sex differences in both of these conditions, studies examining associations on cognition are limited. We aimed to determine whether hypertension impacts the relationship between alcohol use and everyday subjective cognition and whether sex moderates this relationship in middle-aged and older adults. Materials and Methods: Participants (N = 275) 50+ years of age, who reported drinking, completed surveys measuring alcohol use (Alcohol Use Disorder Identification Test consumption items), self-reported history of hypertension, and everyday subjective cognition (Cognitive Failures Questionnaire [CFQ]). Regression was used to test a moderated moderation model examining independent and interactive roles of alcohol use, hypertension, and sex on cognition (CFQ scores: total, memory, distractibility, blunders, and names). Analyses controlled for age, years of education, race, body mass index, smoking status, depressive symptoms, global subjective sleep quality, number of prescription medication used, and number of comorbid medical conditions. Results: Sex moderated the interactive associations of hypertension and alcohol use frequency on CFQ-distractibility. Specifically, in women with hypertension, more alcohol use was associated with greater CFQ-distractibility (B = 0.96, SE = 0.34, p = 0.005). Discussion: Sex moderates the interactive association of hypertension and alcohol use on some aspects of subjective cognition in mid-to-late life. In women with hypertension, alcohol use may exacerbate problems with attentional control. Further exploration of sex- and or gender-specific mechanisms underlying these is warranted.

Alcohol Intake as a Risk Factor for Acute Stroke: The INTERSTROKE Study

BACKGROUND AND OBJECTIVES

There is uncertainty about the association between alcohol consumption and stroke, particularly for low-moderate intake. We explored these associations in a large international study.

METHODS

INTERSTROKE, a case-control study, is the largest international study of risk factors for acute stroke. Alcohol consumption was self-reported and categorized by drinks/week as low (1-7), moderate (7-14 for females and 7-21 for males), or high (>14 for females and >21 for males). Heavy episodic drinking (HED) was defined as >5 drinks on ≥1 day per month. Multivariable conditional logistic regression was used to determine associations.

RESULTS

We included 12,913 cases and 12,935 controls; 25.0% (n = 6,449) were current drinkers, 16.7% (n = 4,318) former drinkers, and 58.3% (n = 15,076) never drinkers. Current drinkers were younger, male, smokers, active, and with higher-paid occupations. Current drinking was associated with all stroke (OR 1.14; 95% CI 1.04-1.26) and intracerebral hemorrhage (ICH) (OR 1.50, 95% CI 1.21-1.84) but not ischemic stroke (OR 1.06; 95% CI 0.95-1.19). HED pattern was associated with all stroke (OR 1.39; 95% CI 1.21-1.59), ischemic stroke (OR 1.29; 95% CI 1.10-1.51), and ICH (OR 1.76; 95% CI 1.31-2.36). High level of alcohol intake was consistently associated with all stroke, ischemic stroke, and ICH. Moderate intake was associated with all stroke and ICH but not ischemic stroke. Low alcohol intake was not associated with stroke overall, but there were regional differences; low intake was associated with reduced odds of stroke in Western Europe/North America (OR 0.66; 95% CI 0.45-0.96) and increased odds in India (OR 2.18; 95% CI 1.42-3.36) (p-interaction 0.037). Wine consumption was associated with reduced odds of all stroke and ischemic stroke but not ICH. The magnitudes of association were greatest in those without hypertension and current smokers.

DISCUSSION

High and moderate intake were associated with increased odds of stroke, whereas low intake was not associated with stroke. However, there were important regional variations, which may relate to differences in population characteristics of alcohol consumers, types or patterns of consumption.

Alcohol consumption and related disorders in Iran: Results from the National Surveillance of Non-Communicable Diseases' Survey (STEPs) 2016

BACKGROUND

Alcohol consumption is a public health concern which is illegal in Iran. Moreover, due to cultural and religious beliefs, the available population-based research findings on alcohol consumption are inadequate. We aimed to provide an estimate on alcohol consumption using a large-scale population-based survey in Iran.

MATERIALS AND METHODS

The National Surveillance of Non-Communicable Risk Factors in Iran was a population-based survey conducted in 2016. The epidemiologic distribution of alcohol consumption and its related disorders were assessed using weighted survey methods and multiple logistic regression models. Age standardized rates were calculated using Iran's national population census in 2016.

RESULTS

At the national level, the prevalence rates of lifetime and current alcohol consumption were 8.00% (95% CI: 7.67-8.32) and 4.04% (95% CI: 3.81-4.27), respectively. The highest prevalence was reported among 25 to 34 year-olds. Individuals of higher socioeconomic status consumed significantly greater levels of alcohol. At provincial level, the highest and lowest percentages of the current alcohol drinking rates in Iran's provinces were, 23.92% (95% CI: 17.56-30.28) and 0.4% (95% CI: 0-1.18) in males, 1.58% (95% CI: 0.22-2.94) and 0% in females, respectively. In urban regions, the highest alcohol consumption rate was more than 22 times greater than the lowest alcohol consumption rate. Current alcohol drinkers were 2 times more prone to injury as compared to nondrinkers (ORadj: 2.0, 95%CI: 1.7, 2.3).

CONCLUSION

In Iran, the prevalence of alcohol consumption is low, although there is a considerable variation of alcohol consumption at provincial level as well as in different gender groups. Therefore, preventive WHO-recommended measures should be adopted more seriously by vulnerable groups.

Causal associations of alcohol consumption with cardiovascular diseases and all-cause mortality among Chinese males

BACKGROUND

The causal effects of moderate alcohol consumption on cardiovascular diseases (CVDs) are continuously debated, especially on coronary artery disease (CAD).

OBJECTIVES

We aimed to explore the causal associations of alcohol consumption with CVDs and all-cause mortality among Chinese males.

METHODS

A prospective cohort study was conducted in 40,386 Chinese males, with 17,676 being genotyped for the rs671 variant in the aldehyde dehydrogenase 2 (ALDH2) gene. A Cox proportional hazards model was conducted to estimate the effects of self-reported alcohol consumption. Mendelian randomization (MR) analysis was performed to explore the causality using rs671 as an instrumental variable.

RESULTS

During the follow-up of 303,353 person-years, 2406 incident CVDs and 3195 all-cause mortalities were identified. J-shaped associations of self-reported alcohol consumption with incident CVD and all-cause mortality were observed, showing decreased risks for light (≤25 g/d) and moderate drinkers (25-≤60 g/d). However, MR analyses revealed a linear association of genetically predicted alcohol consumption with the incident CVD (P-trend = 0.02), including both CAD (P-trend = 0.03) and stroke (P-trend = 0.02). The HRs (95% CIs) for incident CVD across increasing tertiles of genetically predicted alcohol consumption were 1 (reference), 1.18 (1.01, 1.38), and 1.22 (1.03, 1.46). After excluding heavy drinkers, the risk of incident CVD and all-cause mortality was increased by 27% and 20% per standard drink increment of genetically predicted alcohol consumption, respectively.

CONCLUSIONS

Our analyses extend the evidence of the harmful effect of alcohol consumption to total CVD (including CAD) and all-cause mortality, highlighting the potential health benefits of lowering alcohol consumption, even among light-to-moderate male drinkers.

ACO Participation Associated With Decreased Spending For Medicare Beneficiaries With Serious Mental Illness

Serious mental illness (SMI) is a major source of suffering among Medicare beneficiaries. To date, limited evidence exists evaluating whether Medicare accountable care organizations (ACOs) are associated with decreased spending among people with SMI. Using national Medicare data from the period 2009-17, we performed difference-in-differences analyses evaluating changes in spending and use associated with enrollment in the Medicare Shared Savings Program (MSSP) among beneficiaries with SMI. After five years, participation in MSSP ACOs was associated with small savings for beneficiaries with SMI (-$233 per person per year) in total health care spending, primarily related to savings from chronic medical conditions (excluding mental health; -$227 per person per year) and not from savings related to mental health services (-$6 per person per year). Savings were driven by reductions in acute and postacute care for medical conditions. Further work is needed to ensure that Medicare ACOs invest in strategies to reduce potentially unnecessary care related to mental health disorders and to improve health outcomes.

Association Between Changes in Post-hospital Cardiac Symptoms and Changes in Acute Coronary Syndrome-Induced Symptoms of Post-traumatic Stress

Background

After acute coronary syndrome (ACS), one in eight patients develops clinically significant symptoms of Post-traumatic stress disorder (PTSD). We hypothesized that changes in cardiac symptoms from 3 to 12 months after ACS are associated with changes in ACS-induced PTSD symptoms.

Methods

At 3 (n = 154) and/or 12 months (n = 106) post-ACS, patients (n = 156, mean age 59 years, 85% men) completed a clinical interview assessing chest tightness/pain (at rest and/or during exertion), heartbeat symptoms (heart palpitations, racing of heart, heart stumbling or skipping a beat) and PTSD symptoms during the prior 4 weeks. Random mixed regression models examined the association between the onset (or remission) from 3 to 12 months in cardiac symptoms with changes in PTSD symptoms, adjusting for a range of potential predictors of ACS-induced PTSD symptoms.

Results

The onset of chest tightness/pain [estimate = 0.588, 95% confidence interval: 0.275, 0.090; p < 0.001] and of heartbeat symptoms [0.548 (0.165, 0.931); p = 0.005] from 3 to 12 months was independently associated with an increase in total PTSD symptoms. There were also independent associations between the onset of chest tightness/pain and heartbeat symptoms with an increase in PTSD symptom clusters. Specifically, the onset of chest tightness/pain showed associations with an increase in re-experiencing [0.450 (0.167, 0.733); p = 0.027] and avoidance/numbing [0.287 (0.001, 0.574); p = 0.049]. The onset of heartbeat symptoms showed associations with an increase in re-experiencing [0.392 (0.045, 0.739); p = 0.002], avoidance/numbing [0.513 (0.161, 0.864); p = 0.004] and hyperarousal [0.355 (0.051, 0.659); p = 0.022]. An increase in the total number of cardiac symptoms (score range 0–6) was also associated with an increase in total PTSD symptoms [0.343 (0.202, 0.484); p < 0.001]. Psychotherapy in the post-hospital period moderated the association between the change in heartbeat symptoms and the change in total PTSD symptoms [−0.813 (−1.553, −0.074); p = 0.031 for interaction]; the association between the onset of heart beat symptoms and an increase in total PTSD symptoms was weaker in patients who attended psychotherapy [0.437 (−0.178, 1.052); p = 0.16] than in those who did not [0.825 (0.341, 1.309); p < 0.001].

Conclusion

Changes in cardiac symptoms between 3 and 12 months after hospitalization are associated with changes in ACS-induced PTSD symptoms. ClinicalTrials.gov #NCT01781247.

Understanding factors influencing uptake of healthy lifestyle practices among adults following a community cardiovascular disease prevention programme in Mukono and Buikwe districts in Uganda: A qualitative study

Introduction

Healthy lifestyle practices including physical activity, healthy diets, non-smoking, reduced alcohol consumption and stress reduction are important in the prevention of metabollic CVD risk factors such as hypertension, overweight and obesity, diabetes and hyperlipidaemia. Owing to current lifestyle changes, the increasing burden of CVD and importance of healthy behaviours, the need for strategies to increase uptake of healthy lifestyles among sub-Saharan African populations are apparent. This study explored the factors influencing uptake of healthy lifestyle practices among adults following implementation of a community CVD prevention programme.

Methods

This was a descriptive qualitative study conducted among purposively selected adults who had engaged in a community CVD prevention programme. Data were collected using in-depth interviews, which were audio recorded and transcribed verbatim. Study transcripts were read into NVIVO 12.6 software for coding and analysis guided by thematic analysis following the semantic approach.

Results

This study found variations in uptake of healthy lifestyle practices for CVD prevention with most changes reported for dietary behaviour especially in vegetable and fruit intake, reduction of salt intake and fats and oils consumption. Changes in physical activity were also notable. On the other hand, participants were slow in making changes in alcohol consumption, smoking behaviours and stress reduction. The barriers to uptake of healthy lifestyle practices were individual such as limited capability or skills, structural such as limited physical activity facilities, and social such as cultural and peer influence. Relatedly, the facilitators of practices uptake were individual including knowledge and personal determination to change, and social including social support from family and the community.

Conclusions

Insights from understanding the uptake of lifestyle practices should guide planning and design of community programmes with an emphasis on removing barriers and strengthening facilitators building on the intermediate motivating factors and considering individual needs and expectations.

Alcohol - The myth of cardiovascular protection

BACKGROUND & AIMS

To investigate potential biases that exist in available epidemiological evidence resulting in negative associations or underestimation of cardiovascular (CV) risk associated with alcohol consumption.

METHODS

UK Biobank involved baseline data collection from 22 assessment centres across the United Kingdom. The cohort consisted of 333 259 alcohol consumers and 21 710 never drinkers. Participants were followed up for a median 6.9 years capturing incident fatal and non-fatal CV events, ischemic heart disease and cerebrovascular disease. Alcohol intake was reported as grams/week.

RESULTS

Using never drinkers as reference, alcohol from all drink types combined (hazard ratios ranging between 0.61 and 0.74), beer/cider (0.70-0.80) and spirits combined, and all wines combined (0.66-0.77) associated with a reduced risk for all outcome measures (all CV events, ischaemic heart disease, cerebrovascular disease). In continuous analysis, alcohol captured from all drink types combined (hazard ratio, 1.08, 95% confidence interval, 1.01-1.14), and beer/cider and spirits combined (1.24, 1.17-1.31) associated with an increased risk for overall CV events, however hazard ratios were stronger for beer/cider and spirits (P < 0.0001). Wine associated with a reduced risk for overall CV events (0.92, 0.86-0.98) and ischemic heart disease (0.75, 0.67-0.84). This negative relationship with overall CV events was lost after excluding ischemic heart disease events (1.00, 0.93-1.08), while the positive association of alcohol captured from beer/cider and spirits remained significant (1.30, 1.22-1.40). This positive association with overall CV events was present even when consuming less than 14 units per week.

CONCLUSIONS

Avoiding potential biases prevents underestimation of cardiovascular risk and indicates that consuming up to 14 units per week also associated with increased CV risk in the general population.

Modeling cholesterol metabolism and atherosclerosis

Atherosclerotic cardiovascular disease (ASCVD) is the leading cause of morbidity and mortality among Western populations. Many risk factors have been identified for ASCVD; however, elevated low-density lipoprotein cholesterol (LDL-C) remains the gold standard. Cholesterol metabolism at the cellular and whole-body level is maintained by an array of interacting components. These regulatory mechanisms have complex behavior. Likewise, the mechanisms which underpin atherogenesis are nontrivial and multifaceted. To help overcome the challenge of investigating these processes mathematical modeling, which is a core constituent of the systems biology paradigm has played a pivotal role in deciphering their dynamics. In so doing models have revealed new insights about the key drivers of ASCVD. The aim of this review is fourfold; to provide an overview of cholesterol metabolism and atherosclerosis, to briefly introduce mathematical approaches used in this field, to critically discuss models of cholesterol metabolism and atherosclerosis, and to highlight areas where mathematical modeling could help to investigate in the future. This article is categorized under: Cardiovascular Diseases > Computational Models.

Alcohol abstinence and mortality in a general population sample of adults in Germany: A cohort study

BACKGROUND

Evidence suggests that people who abstain from alcohol have a higher mortality rate than those who drink low to moderate amounts. However, little is known about factors that might be causal for this finding. The objective was to analyze former alcohol or drug use disorders, risky drinking, tobacco smoking, and fair to poor health among persons who reported abstinence from alcohol drinking in the last 12 months before baseline in relation to total, cardiovascular, and cancer mortality 20 years later.

METHODS AND FINDINGS

A sample of residents aged 18 to 64 years had been drawn at random among the general population in northern Germany and a standardized interview conducted in the years 1996 to 1997. The baseline assessment included 4,093 persons (70.2% of those who had been eligible). Vital status and death certificate data were retrieved in the years 2017 and 2018. We found that among the alcohol-abstinent study participants at baseline (447), there were 405 (90.60%) former alcohol consumers. Of the abstainers, 322 (72.04%) had met one or more criteria for former alcohol or drug dependence or abuse, alcohol risky drinking, or had tried to cut down or to stop drinking, were daily smokers, or self-rated their health as fair to poor. Among the abstainers with one or more of these risk factors, 114 (35.40%) had an alcohol use disorder or risky alcohol consumption in their history. Another 161 (50.00%) did not have such an alcohol-related risk but were daily smokers. The 322 alcohol-abstinent study participants with one or more of the risk factors had a shorter time to death than those with low to moderate alcohol consumption. The Cox proportional hazard ratio (HR) was 2.44 (95% confidence interval (CI), 1.68 to 3.56) for persons who had one or more criteria for an alcohol or drug use disorder fulfilled in their history and after adjustment for age and sex. The 125 alcohol-abstinent persons without these risk factors (27.96% of the abstainers) did not show a statistically significant difference from low to moderate alcohol consumers in total, cardiovascular, and cancer mortality. Those who had stayed alcohol abstinent throughout their life before (42; 9.40% of the alcohol-abstinent study participants at baseline) had an HR 1.64 (CI 0.72 to 3.77) compared to low to moderate alcohol consumers after adjustment for age, sex, and tobacco smoking. Main limitations of this study include its reliance on self-reported data at baseline and the fact that only tobacco smoking was analyzed as a risky behavior alongside alcohol consumption.

CONCLUSIONS

The majority of the alcohol abstainers at baseline were former alcohol consumers and had risk factors that increased the likelihood of early death. Former alcohol use disorders, risky alcohol drinking, ever having smoked tobacco daily, and fair to poor health were associated with early death among alcohol abstainers. Those without an obvious history of these risk factors had a life expectancy similar to that of low to moderate alcohol consumers. The findings speak against recommendations to drink alcohol for health reasons.

Factors associated with alcohol use and abuse in Brazilian primary health care settings

The main goal of this study was to identify the prevalence of alcohol use and associations with selected variables among clients in a primary healthcare setting. A quantitative, cross-sectional study was carried out using structured questionnaires to measure the pattern of alcohol consumption, quality of life and common mental disorders. The results showed that men, people between 18 and 40 years old, with income between $300.00 and 1200.00 and smokers were at a higher risk of problematic alcohol use. Healthcare professionals should include alcohol screening questions to identify the hazardous consumption of alcohol at an early stage and prevent negative consequences.

A neuroimaging investigation into the role of peripheral metabolic biomarkers in the anticipation of reward in alcohol use

BACKGROUND

The relationship between alcohol use and metabolism has focused on the effects of alcohol use on metabolic factors. Metabolic factors, such as triglycerides, cholesterol, and glucose, have been shown to be associated with increased risk for heavy alcohol consumption and alcohol use disorder (AUD). It's been suggested that changes in metabolic factors may play a role in reward seeking behaviors and pathways. Studies on feeding behavior and obesity revealed the role of triglycerides in neural response to food cues in neurocircuitry regulating reward and feeding behaviors. This study aimed to explore the relationship of peripheral metabolism, alcohol use, and reward processing in individuals that use alcohol.

METHODS

Ninety participants from a previously collected dataset were included in the analysis. Participants were treatment seeking, detoxified individuals with AUD and healthy individuals without AUD, with the following metabolic biomarkers: triglyceride, glucose, high- and low-density cholesterol, and HbA1c levels. Participants completed a neuroimaging version of the Monetary Incentive Delay task (MID).

RESULTS

Correlations on peripheral metabolic biomarkers, alcohol use, and neural activity during reward anticipation and outcome during the MID task were not significant. Mediation models revealed triglycerides and high-density cholesterol had significant effects on left anterior insula during anticipation of potential monetary loss and this effect was not mediated by alcohol use.

CONCLUSION

Limbic recruitment by anticipation of monetary rewards revealed an independent relationship with peripheral metabolism and was not affected by individual differences in alcohol use, despite the effects of alcohol use on metabolic markers and reward processing neural circuitry.

Moderate Consumption of Beer and Its Effects on Cardiovascular and Metabolic Health: An Updated Review of Recent Scientific Evidence

There is growing interest in the potential health-related effects of moderate alcohol consumption and, specifically, of beer. This review provides an assessment of beer-associated effects on cardiovascular and metabolic risk factors to identify a consumption level that can be considered “moderate”. We identified all prospective clinical studies and systematic reviews that evaluated the health effects of beer published between January 2007 and April 2020. Five of six selected studies found a protective effect of moderate alcohol drinking on cardiovascular disease (beer up to 385 g/week) vs. abstainers or occasional drinkers. Four out of five papers showed an association between moderate alcohol consumption (beer intake of 84 g alcohol/week) and decreased mortality risk. We concluded that moderate beer consumption of up to 16 g alcohol/day (1 drink/day) for women and 28 g/day (1–2 drinks/day) for men is associated with decreased incidence of cardiovascular disease and overall mortality, among other metabolic health benefits.

The role of dietary salt and alcohol use reduction in the management of hypertension

Introduction: Despite the improved treatment protocol of hypertension, the magnitude of the disease and its related burden remains raised. Hypertension makes up the leading cause of stroke, kidney disease, arterial disease, eye disease, and cardiovascular disease (CVD) growth. Areas covered: This review provides the overview of the role of dietary salt and alcohol use reduction in the management of hypertension, a brief history of alcohol, the vascular endothelium functions, the effects of alcohol use on blood pressure (BP), the mechanisms of alcohol, brief history of salt, the effects of dietary salt intake on BP, and the mechanisms of salt. Expert opinion: Studies found that high dietary salt intake and heavy alcohol consumption have a major and huge impact on BP while both of them have been identified to increase BP. Also, they raise the risk of hypertension-related morbidity and mortality in advance. On the other way, the dietary salt and alcohol use reduction in the management of hypertension are significant in the control of BP and its related morbidity and mortality. Further, studies suggested that the dietary salt and alcohol use reductions are the cornerstone in the management of hypertension due to their significance as part of comprehensive lifestyle modifications.

Low-Dose Ethanol Has Impacts on Plasma Levels of Metabolites Relating to Chronic Disease Risk in SAMP8 mice

The effects of low-dose alcohol on experimental animals are unclear. This study examined plasma metabolites in senescence-accelerated mice 8 (SAMP8) given low-dose ethanol, and compared them with aging progress and skeletal muscle strength. Male SAMP8 mice (10-wk-old) were given drinking water containing 0% (control), 1%, 2%, or 5% (v/v) ethanol for 14 wk. Compared with the control group, only mice who consumed 1% ethanol experienced a lower senescence score at 18 and 23 wk, as well as an increased limb grip strength at 21 wk. Plasma metabolites of control, 1% and 2% ethanol groups were analyzed by capillary electrophoresis-time-of-flight mass spectrometry (CE-TOF/MS). Among the 7 metabolites affected by ethanol, notewhorthy is the positive association of the ethanol levels in drinking water with the levels of α-ketoglutarate (antioxidant and anti-inflammatory metabolite) and hippurate (antioxidant and microbial co-metabolite) (p<0.05). Intriguingly, the levels of 2-hydroxyisobutyrate (the biomarker of energy metabolism and microbial co-metabolite) were higher in the 1% ethanol group (p<0.05), but not in the 2% ethanol group as compared to the control. Furthermore, the levels of some of the metabolites affected were correlated with some variables in the grading score of senescence and muscle strength. This study provides a novel insight into how low-dose ethanol in SAMP8 mice modulates the levels of circulating metabolites relating to chronic disease risk.

Associations Between Psychiatric Disorders and Alcohol Consumption Levels in an Adult Primary Care Population

Background

Unhealthy alcohol use frequently co‐occurs with psychiatric disorders; however, little is known about the relationship between psychiatric disorders and alcohol consumption levels. Understanding varying levels of unhealthy alcohol use among individuals with a variety of psychiatric disorders in primary care would provide valuable insight for tailoring interventions.

Methods

We conducted a cross‐sectional study of 2,720,231 adult primary care patients screened for unhealthy alcohol use between 2014 and 2017 at Kaiser Permanente Northern California, using electronic health record data. Alcohol consumption level was classified as no reported use, low‐risk use, and unhealthy use, per National Institute on Alcohol Abuse and Alcoholism guidelines. Unhealthy use was further differentiated into mutually exclusive groups: exceeding only daily limits, exceeding only weekly limits, or exceeding both daily and weekly limits. Multivariable multinomial logistic regression models were fit to examine associations between 8 past‐year psychiatric disorders (depression, bipolar disorder, anxiety disorder, obsessive–compulsive disorder, schizophrenia, schizoaffective disorder, anorexia nervosa, and bulimia nervosa) and alcohol consumption levels, adjusting for sociodemographic and health characteristics.

Results

In the full sample [53% female, 48% White, mean (SD) age = 46 (18) years], patients with psychiatric disorders (except eating disorders), compared to those without, had lower odds of reporting low‐risk and unhealthy alcohol use relative to no use. Among patients who reported any alcohol use (n = 861,427), patients with depression and anxiety disorder, compared to those without, had higher odds of exceeding only weekly limits and both limits; patients with bulimia nervosa were also more likely to exceed both limits.

Conclusions

Findings suggest that patients with anxiety disorder, depression, and bulimia nervosa who drink alcohol are more likely to exceed recommended limits, increasing risk of developing more serious problems. Health systems and clinicians may wish to consider implementing more robust screening, assessment, and intervention approaches to support these vulnerable subgroups in limiting their drinking.

[Role of modified cardiovascular risk factors in development of oncologic diseases]

Cardiovascular (CVD) and oncological diseases (OD) are the main causes of death worldwide and account for a heavy burden on economy, disability and mortality in many countries. Clear understanding of the mechanisms shared by CVD and cancer is important for increasing the life span and quality of life in cancer survivors as well as for preventing comorbidities and correct instructing the patients about risk factors and lifestyle modifications. Both groups of diseases share risk factors, including smoking, obesity, diabetes mellitus, alcohol consumption, unhealthy diet, etc. Along with these factors, inflammation may play a key role as it promotes both types of diseases and accompanies obesity, diabetes mellitus, arterial hypertension, and dyslipidemia. Better understanding of the interaction between CVD and cancer will allow creating common effective diagnostic and preventive strategies and safe approaches to the treatment.

Associations between lifestyle, erectile dysfunction and healthcare seeking: a population-based study

Objective: To investigate associations between age, lifestyle and erectile dysfunction (ED) in the general population and to explore associations between age, lifestyle and contact with a general practitioner (GP) regarding ED.Design: Cross-sectional web-based questionnaire study.Setting: The general Danish population.Subjects: A randomly selected sample of 48,910 men aged 20 years and older.Main outcome measures: Prevalence of ED and probability of contacting a GP regarding ED. In logistic regression models we analysed associations between age, smoking status, alcohol consumption, body mass index (BMI), and self-rated physical fitness on both ED and GP contact.Results: A total of 22,198 men (47.6%) completed the question regarding ED. The overall prevalence of ED was 19.3%, varying from 2.3% among men aged 20-29 years to 55.3% among men aged 80 years and above. 31.8% of men reporting ED had contacted a GP regarding ED. Increasing age, current or former smoking, complete alcohol abstinence or alcohol consumption above seven units per week, high BMI, and poor self-rated physical fitness were significantly associated with reporting ED. The proportion of GP contacts was significantly associated with age. Overall, no significant associations between lifestyle and healthcare seeking were observed, although lower odds of GP contact were found when physical fitness was rated as poor.Conclusion: Reporting ED and GP contact were significantly associated with age. Furthermore, lifestyle was significantly associated with reporting ED, but largely not associated with healthcare seeking. These findings are important for future interventions aiming to improve diagnosis and treatment of ED.Key pointsExperiencing erectile dysfunction is frequent in the general population, especially among older men.  • In this large-scale national survey, age and lifestyle were significantly associated with reporting erectile dysfunction.  • Healthcare seeking with erectile dysfunction was significantly associated with age, but not with lifestyle.  • Diagnosis and treatment of erectile dysfunction might be challenged when erectile dysfunction does not lead to healthcare seeking.

Cardiovascular Risk in Women Deprived of Freedom from a Public Prison in Mato Grosso, Brazil

INTRODUCTION

Cardiovascular diseases occur worldwide and have progressively affected the female sex, without distinction of life context; however, the prison environment may intensify the risk of developing them.

AIM

To evaluate the cardiovascular risk in women deprived of freedom from a public prison in Mato Grosso, Brazil.

METHODS

This is a quantitative, cross-sectional and analytical study performed with all incarcerated women from the prison institution in the second half of the years 2016, 2017 and 2018, through a structured questionnaire and statistical analysis through the RStudio.

RESULTS

The results showed that, although participants presented low cardiovascular risk, the BMI values pointed to overweight in all the years analyzed, in addition to the waist-to-height ratio, conicity index, waist circumference and waist-hip ratio presenting similar means or that transcend the established cutoff point. There was an association between the anthropometric variables and age, conjugal status, education, alcoholism, systolic blood pressure, metabolic complications, sleep and a family history of non-communicable chronic diseases. The BMI variable showed association with all anthropometric variables related to cardiovascular risk, except to WHR.

CONCLUSION

When considering the ambience factor, modifiable risk factors may negatively influence the long-term health of these women, particularly in relation to the cardiovascular system. The found scenario, in relation to the cardiovascular risk, points to the need for interventions, regarding the clinical condition and life-styles adopted by this population.

Trends in alcohol consumption in relation to cause-specific and all-cause mortality in the United States: a report from the NHANES linked to the US mortality registry

BACKGROUND

Excessive alcohol use is the third leading cause of mortality in the United States, where alcohol use consistently increased over the last decades. This trend is currently maintained, despite regulatory policies aimed to counteract it. While the increased health risks resulting from alcohol use are evident, some open questions regarding alcohol use and its consequences in the US population remain.

OBJECTIVES

The current work aims to evaluate the relation between alcohol consumption trends over a period of 15 y with all-cause and cause-specific mortality. In addition, we evaluate the adequacy of the current alcohol recommended limits according to the 2015-2020 US Dietary Guidelines for Americans (USDGA).

METHODS

This was a prospective population-based study defined by the NHANES conducted over the period 1999-2014 linked to US mortality registry in 2015.

RESULTS

The sample, composed of 34,672 participants, was observed for a median period of 7.8 y, totaling 282,855 person-years. In the present sample, 4,303 deaths were observed. Alcohol use increased during the period 1999-2014. Alcohol use above the current US recommendations was associated with increased all-cause and cause-specific mortality risk, ranging from 39% to 126%. A proportion of these deaths, ranging from 19% to 26%, could be theoretically prevented if US citizens followed current guidelines, and 13% of all-cause deaths in men could be avoided if the current US guidelines for women (1 standard drink/d) were applied to them.

CONCLUSIONS

The present study provides evidence in support of limiting alcohol intake in adherence to the USDGA recommendations.

Drink types unmask the health risks associated with alcohol intake - Prospective evidence from the general population

BACKGROUND & AIMS

Uncertainty still exists on the impact of low to moderate consumption of different drink types on population health. We therefore investigated the associations of different drink types in the form of beer/cider, champagne/white wine, red wine and spirits with various health outcomes.

METHODS

Over 500,000 participants were recruited to the UK Biobank cohort. Alcohol consumption was self-reported as pints beer/cider, glasses champagne/white wine, glasses of red wine, and measures of spirits per week. We followed health outcomes for a median of 7.02 years and reported all-cause mortality, cardiovascular events, ischemic heart disease, cerebrovascular events, and cancer.

RESULTS

In continuous analysis after excluding non-drinkers, beer/cider and spirits intake associated with an increased risk for all-cause mortality (beer/cider: hazard ratio, 1.56; 95% confidence interval, 1.45-1.68; spirits: 1.47; 1.35-1.60), cardiovascular events (beer/cider: 1.25; 1.17-1.33; spirits: 1.25; 1.16-1.36), ischemic heart disease (beer/cider:1.12; 0.99-1.26 [P = 0.056]; spirits: 1.17; 1.02-1.35), cerebrovascular disease (beer/cider: 1.63; 1.32-2.02; spirits: 1.59; 1.25-2.02) and cancer (beer/cider: 1.14; 1.05-1.24; spirits: 1.14; 1.03-1.26), while both champagne/white wine and red wine associated with a decreased risk for ischemic heart disease only (champagne/white wine: 0.84; 0.72-0.98; red wine: 0.88; 0.77-0.99).

CONCLUSIONS

Our findings do not support the notion that alcohol from any drink type is beneficial to health. Consuming low levels of beer/cider and spirits already associated with an increased risk for all health outcomes, while wine showed opposite protective relationships only with ischemic heart disease.

Alcohol use and its consequences in the Czech Republic

OBJECTIVE

Alcohol consumption is associated with substantial public health burden. This article summarises available information on the patterns and prevalence of alcohol use in the Czech Republic with a focus on the heavy alcohol use and its health and social consequences.

METHODS

A non-systematic literature review was conducted. The data sources included primarily 3 series of surveys in the adult population, 2 series of surveys in the school population, routine monitoring system of per capita alcohol consumption, routine statistics on alcohol-related morbidity and mortality, and alcohol-related crime.

RESULTS

In recent years the registered alcohol consumption in the Czech Republic has been very high; 9.8 litres of pure alcohol were consumed per capita in 2017. Recently, the prevalence of hazardous alcohol consumption in the adult population has reached 16.8-17.6% and harmful alcohol consumption 9.0-9.3%. From 12% to 17% of adult population and 12% of adolescent population were heavy episodic drinkers. Alcohol-related disorders are disproportionately higher (2-3 times) among men. Mortality for alcohol-related causes fully attributable to alcohol (AAF = 100%) and their proportion in overall mortality is on increase.

CONCLUSIONS

Alcohol consumption as well as the prevalence of heavy episodic drinking in the Czech Republic belongs among the highest globally. On the other hand, declines in alcohol use have been recently observed among children and adolescents. Available data on alcohol-related morbidity indicate stable situation, though alcohol-related mortality is increasing. Alcohol-related burden is rather underestimated and evidence-based alcohol policy should be increasingly implemented.

Benefits and Risks of Moderate Alcohol Consumption on Cardiovascular Disease: Current Findings and Controversies

Alcohol has a hormetic physiological behavior that results in either increased or decreased cardiovascular risk depending on the amount consumed, drinking frequency, pattern of consumption, and the outcomes under study or even the type of alcoholic beverage consumed. However, the vast majority of studies elucidating the role of alcohol in cardiovascular and in the global burden of disease relies on epidemiological studies of associative nature which carry several limitations. This is why the cardiovascular benefits of low–moderate alcohol consumption are being questioned and perhaps might have been overestimated. Thus, the aim of this review was to critically discuss the current knowledge on the relationship between alcohol intake and cardiovascular disease. Besides new evidence associating low and moderate alcohol consumption with decreased risk of cardiovascular disease, several questions remain unanswered related to the concrete amount of safe consumption, the type of alcoholic beverage, and the age-, sex-, and genetic/ethnical-specific differences in alcohol consumption.

Lifetime Drinking Trajectories and Nonfatal Acute Myocardial Infarction

BACKGROUND

The relation of lifetime drinking trajectories to coronary heart disease is not well understood.

METHODS

Cases hospitalized for a nonfatal acute myocardial infarction (AMI) and healthy population-based controls matched on age and sex completed a physical examination and an interview covering known AMI risk factors and a detailed lifetime drinking history. Distinct lifetime drinking trajectories based on ounces of ethanol consumed per decade between ages 10 and 59 years were derived and characterized according to lifetime drinking patterns associated with each. Sex-specific multiple logistic regression analyses were conducted to estimate AMI risk among participants who never drank regularly compared to lifetime drinking trajectories and risk associated with distinct trajectories among former and current drinkers.

RESULTS

Two lifetime drinking trajectories were derived, early peak and stable. Early peak trajectories were characterized by earlier onset of regular drinking, less frequent drinking, more drinks per drinking day, fewer total drinks, more frequent drunkenness per drinking year, and reduced alcohol intake or abstention by middle age. Never drinking regularly, reported by significantly more women than men, was associated with significantly higher AMI risk than stable lifetime drinking trajectories among men and in the sex-combined analysis of former drinkers only. Compared to stable lifetime drinking trajectories, early peak trajectories were associated with significantly higher AMI risk among male former drinkers, among sex-combined former drinkers, and among female current drinkers.

CONCLUSIONS

Epidemiological studies of alcohol and health in populations over age 35 may have underestimated the impact of heavy episodic drinking during adolescence and emerging adulthood on the cardiovascular system.

Association Between Alcohol Use and Angina Symptoms Among Outpatients From the Veterans Health Administration

BACKGROUND

Alcohol use is associated with angina incidence, but associations between alcohol use and experience of angina among patients with coronary artery disease (CAD) have not been described.

METHODS

Outpatients with CAD from 7 clinics in the Veterans Health Administration were surveyed; alcohol use was measured using the validated Alcohol Use Disorders Identification Test-Consumption scores categorized into 6 groups: nondrinking, low-risk drinking, and mild, moderate, severe, and very severe unhealthy alcohol use. Three domains of self-reported angina symptoms (frequency, stability, and physical function) were measured with the Seattle Angina Questionnaire. Linear regression models evaluated associations between alcohol use groups and angina symptoms. Models were adjusted first for age and then additionally for smoking, comorbidities, and depression.

RESULTS

Patients (n = 8303) had a mean age of 66 years. In age-adjusted analyses, a U-shaped association was observed between alcohol use groups and all angina outcomes, with patients in nondrinking and severe unhealthy alcohol groups reporting the greatest angina symptoms and lowest functioning. After full adjustment, no clinically important and few statistically important differences were observed across alcohol use in angina stability or frequency. Patients in the nondrinking group had statistically greater functional limitation from angina than those in all groups of unhealthy alcohol use, though differences were small. Patients in all groups of unhealthy alcohol use did not differ significantly from those with low-risk drinking.

CONCLUSIONS

Alcohol use was associated with some small statistically but no clinically important differences in angina symptoms among patients with CAD. This cross-sectional study does not support a protective effect of low-level drinking on self-reported angina.

Tacrolimus exposure after liver transplantation for alcohol-related liver disease: Impact on complications

BACKGROUND

Alcohol-related liver disease (ALD) is one of the main indications for liver transplantation (LT). For 20 years, tacrolimus (Tac) is the cornerstone immunosuppressive drug used after LT and is very efficient for the prevention of rejection. Nevertheless, the major drawback of long-term use of Tac is the risk for developing dose-dependent adverse effects.

OBJECTIVE

The aim of the present study was to assess the impact of Tac exposure (trough concentrations and concentration/dose (C/D) ratio) during the first year after LT, on short- and long-term complications after LT for ALD.

METHODS

All patients who underwent a LT for ALD at Lyon Edouard Herriot Hospital from October 1990 to September 2010, and who were treated with Tac for at least one year after LT, were analyzed.

RESULTS

The study population consisted in 251 patients, mean age 53.4 ± 7.3 years, and followed during 11.6 ± 4.8 years. Post-LT complications included severe infectious events (44.6%), malignancies (41.4%), arterial hypertension (49.4%) dyslipidemia (44.2%), diabetes (18.7%) and cardiovascular events (15.5%). De novo hypertension, cardiovascular event, CMV infection, non-melanoma skin cancers and HCC recurrence after transplantation were significantly associated with higher Tac trough blood concentration. In addition, Tac fast-metabolizers (defined as C/D < 1.8) had significantly more impaired renal function at 1, 5, and 10 years and more cardiovascular events, PTLD, diabetes and hypertension than slow-metabolizers.

CONCLUSION

Our results strongly support that, in addition to blood trough concentrations, Tac metabolism, as estimated by the simple C/D ratio, could be an efficient parameter in daily practice to identify LT patients at risk to develop long term general complications of Tac.

The Consumption of Alcoholic Beverages and the Prevalence of Cardiovascular Diseases in Men and Women: A Cross-Sectional Study

Associations between alcohol consumption and the prevalence of cardiovascular diseases have been the subject of several studies for a long time; however, the presence and nature of any associations still remain unclear. The aim of the study was to analyze the associations between the consumption of alcoholic beverages and the prevalence of cardiovascular diseases in men and women. The data of 12,285 individuals aged 37-66 were used in the analysis. Multiple logistic regression models were utilized to estimate odds ratios and confidence intervals. The multivariable models included several potential confounders including age, education, marital status, body mass index (BMI), physical activity, smoking, coffee consumption, and statin use. The analyses were performed separately for men and women. In the model adjusted for confounders, the consumption from 0.1 to 10.0 g of alcohol/day was related to a lower risk of coronary disease and stroke (p < 0.05), and the consumption from 0.1 to 15.0 g/day was related to a lower risk of hypertension in women (p < 0.05). In men, in the adjusted model, there were no associations between alcohol consumption and the occurrence of hypertension or stroke. The risk of circulatory failure was significantly lower in the group in which participants drank more than 20.0 g of alcohol/day (p < 0.05) compared to nondrinkers. The risk of coronary disease was lower in drinkers at every level of alcohol consumption (p < 0.05) compared to nondrinkers. Alcohol consumption was related to a lower prevalence of cardiovascular diseases (CVD), both in men and women.

Genetic determinants of beverage consumption: Implications for nutrition and health

Beverages make important contributions to nutritional intake and their role in health has received much attention. This review focuses on the genetic determinants of common beverage consumption and how research in this field is contributing insight to what and how much we consume and why this genetic knowledge matters from a research and public health perspective. The earliest efforts in gene-beverage behavior mapping involved genetic linkage and candidate gene analysis but these approaches have been largely replaced by genome-wide association studies (GWAS). GWAS have identified biologically plausible loci underlying alcohol and coffee drinking behavior. No GWAS has identified variants specifically associated with consumption of tea, juice, soda, wine, beer, milk or any other common beverage. Thus far, GWAS highlight an important behavior-reward component (as opposed to taste) to beverage consumption which may serve as a potential barrier to dietary interventions. Loci identified have been used in Mendelian randomization and gene×beverage interaction analysis of disease but results have been mixed. This research is necessary as it informs the clinical relevance of SNP-beverage associations and thus genotype-based personalized nutrition, which is gaining interest in the commercial and public health sectors.

A Review of Alcohol-Related Harms: A Recent Update

In the early decades of the 20th century, discussions regarding alcohol were dominantly directed toward its therapeutic uses, but authorities now state that any level of alcohol consumption poses negative effects on health. Over recent months, increased attention has been devoted to disease burdens attributable to alcohol use worldwide. As more and more studies are conducted to illuminate the harmful effects of alcohol on different body systems, the mounting evidence generated requires documentation and publication. The current review was aimed at providing an overview of the recent literature on the adverse consequences of alcohol consumption.

Arterial stiffness and hypertension status in Afro-Caribbean men

OBJECTIVE

African ancestry individuals are at high risk for hypertensive cardiovascular disease (CVD) and could benefit from early detection of arterial stiffening. We tested the association between the 2017 ACC/AHA hypertension categorizations, which include new blood pressure (BP) cutoffs and a definition for elevated BP, and arterial stiffness in 772 Afro-Caribbean men aged 50+ years (mean 64 years).

METHODS

Arterial stiffness was assessed by brachial-ankle pulse-wave velocity (PWV) using a waveform analyzer. Hypertension groups were based on the 2017 ACC/AHA guidelines and by pharmacologic control status. Multiple linear/logistic regression was used to determine the association of PWV with BP and hypertension.

RESULTS

Mean (SD) PWV was 1609 (298) cm/s and was independently correlated with age, SBP, pulse, diabetes, height, and alcohol intake (all P < 0.02). After adjusting for these, in men aged at least 65 years, those with stage 1 or uncontrolled stage 2 hypertension had significantly greater PWV than all other groups (all P < 0.05). Men with controlled hypertension had similar PWV to those with elevated BP (P = 0.7); however, this was significantly greater than men with normal BP (all P < 0.05). Patterns were similar, but with smaller effect sizes, in men aged less than 65 years (all P < 0.05 except controlled hypertension versus elevated or normal BP were not significant).

CONCLUSION

In these high-risk Afro-Caribbeans: stage 1 hypertension is associated with increased PWV, which supports the new guidelines; and, pharmacologic control appears to partially protect men from increased PWV. Longitudinal studies are needed to determine optimal PWV and timing of antihypertensive treatment for preventing future CVD.

Advances in Understanding the Molecular Basis of the Mediterranean Diet Effect

Increasingly, studies showing the protective effects of the Mediterranean diet (MedDiet) on different diseases (cardiovascular, diabetes, some cancers, and even total mortality and aging indicators) are being published. The scientific evidence level for each outcome is variable, and new studies are needed to better understand the molecular mechanisms whereby the MedDiet may exercise its effects. Here, we present recent advances in understanding the molecular basis of MedDiet effects, mainly focusing on cardiovascular diseases but also discussing other related diseases. There is heterogeneity in defining the MedDiet, and it can, owing to its complexity, be considered as an exposome with thousands of nutrients and phytochemicals. We review MedDiet composition and assessment as well as the latest advances in the genomic, epigenomic (DNA methylation, histone modifications, microRNAs, and other emerging regulators), transcriptomic (selected genes and whole transcriptome), and metabolomic and metagenomic aspects of the MedDiet effects (as a whole and for its most typical food components). We also present a critical review of the limitations of the studies undertaken and propose new analyses and greater bioinformatic integration to better understand the most important molecular mechanisms whereby the MedDiet as a whole, or its main food components, may exercise their protective effects.

Alcohol consumption and low-risk drinking guidelines among adults: a cross-sectional analysis from Alberta's Tomorrow Project

INTRODUCTION

Moderate to heavy alcohol consumption is a risk factor for all-cause mortality and cancer incidence. Although cross-sectional data are available through national surveys, data on alcohol consumption in Alberta from a large prospective cohort were not previously available. The goal of these analyses was to characterize the levels of alcohol consumption among adults from the Alberta's Tomorrow Project in the context of cancer prevention guidelines. Furthermore, we conducted analyses to examine the relationships between alcohol consumption and other high-risk or risk-related behaviours.

METHODS

Between 2001 and 2009, 31 072 men and women aged 35 to 69 years were enrolled into Alberta's Tomorrow Project, a large provincial cohort study. Data concerning alcohol consumption in the past 12 months were obtained from 26 842 participants who completed self-administered health and lifestyle questionnaires. We conducted cross-sectional analyses on daily alcohol consumption and cancer prevention guidelines for alcohol use in relation to sociodemographic factors. We also examined the combined prevalence of alcohol consumption and tobacco use, obesity and comorbidities.

RESULTS

Approximately 14% of men and 12% of women reported alcohol consumption exceeding recommendations for cancer prevention. Higher alcohol consumption was reported in younger age groups, urban dwellers, those with higher incomes and those who consumed more red meat. Moreover, volume of daily alcohol consumption was positively associated with current tobacco use in both men and women. Overall, men were more likely to fall in the moderate and high-risk behavioural profiles and show higher daily alcohol consumption patterns compared to women.

CONCLUSION

Despite public health messages concerning the adverse impact of alcohol consumption, a sizeable proportion of Alberta's Tomorrow Project participants consumed alcohol in excess of cancer prevention recommendations. Continued strategies to promote low-risk drinking among those who choose to drink could impact future chronic disease risk in this population.

Reducing the Global Burden of Cardiovascular Disease, Part 1: The Epidemiology and Risk Factors

Current global health policy goals include a 25% reduction in premature mortality from noncommunicable diseases by 2025. In this 2-part review, we provide an overview of the current epidemiological data on cardiovascular diseases (CVD), its risk factors, and describe strategies aimed at reducing its burden. In part 1, we examine the global epidemiology of cardiac conditions that have the greatest impact on CVD mortality; the predominant risk factors; and the impact of upstream, societal health determinants (eg, environmental factors, health policy, and health systems) on CVD. Although age-standardized mortality from CVD has decreased in many regions of the world, the absolute number of deaths continues to increase, with the majority now occurring in middle- and low-income countries. It is evident that multiple factors are causally related to CVD, including traditional individual level risk factors (mainly tobacco use, lipids, and elevated blood pressure) and societal level health determinants (eg, health systems, health policies, and barriers to CVD prevention and care). Both individual and societal risk factors vary considerably between different regions of the world and economic settings. However, reliable data to estimate CVD burden are lacking in many regions of the world, which hampers the establishment of nationwide prevention and management strategies. A 25% reduction in premature CVD mortality globally is feasible but will require better implementation of evidence-based policies (particularly tobacco control) and integrated health systems strategies that improve CVD prevention and management. In addition, there is a need for better health information to monitor progress and guide health policy decisions.