The effect of ingestion of ethyl alcohol, wine and beer on the myocardium of mice

Dose-related ethanol intake, Cx43 and Nav1.5 remodeling: Exploring insights of altered ventricular conduction and QRS fragmentation in excessive alcohol users

BACKGROUND

Chronic, excessive ethanol intake has been linked with various electrical instabilities, conduction disturbances, and even sudden cardiac death, but the underlying cause for the latter is insufficiently delineated.

METHODS

We studied surface electrocardiography (ECG) in a community-dwelling cohort with moderate-to-heavy daily alcohol intake (grouped as >90g/day, ≤90g/day, and nonintake).

RESULTS

Compared with nonintake, heavier alcohol users showed markedly widened QRS duration and higher prevalence of QRS fragmentation (64.3%, 50.9%, and 33.7%, respectively, χ² 12.0, both p<0.05) on surface ECG across the 3 groups. These findings were successfully recapitulated in 14-week-old C57BL/6 mice that were chronically given a 4% or 6% alcohol diet and showed dose-related slower action potential upstroke, reduced resting membrane potential, and disorganized or decreased intraventricular conduction (all p<0.05). Immunodetection further revealed increased ventricular collagen I depots with Cx43 downregulation and remodeling, together with clustered and diminished membrane Nav1.5 distribution. Administration of Cx43 blocker (heptanol) and Nav1.5 inhibitor (tetrodotoxin) in the mice each attenuated the suppression ventricular conduction compared with nonintake mice (p<0.05).

CONCLUSIONS

Chronic excessive alcohol ingestion is associated with dose-related phenotypic intraventricular conduction disturbances and QRS fragmentation that can be recapitulated in mice. The mechanisms may involve suppressed gap junction and sodium channel functions, together with enhanced cardiac fibrosis that may contribute to arrhythmogenesis.

Alcohol and Apoptosis: Friends or Foes?

Alcohol abuse causes 79,000 deaths stemming from severe organ damage in the United States every year. Clinical manifestations of long-term alcohol abuse on the cardiac muscle include defective contractility with the development of dilated cardiomyopathy and low-output heart failure; which has poor prognosis with less than 25% survival for more than three years. In contrast, low alcohol consumption has been associated with reduced risk of cardiovascular disease, however the mechanism of this phenomenon remains elusive. The aim of this study was to determine the significance of apoptosis as a mediating factor in cardiac function following chronic high alcohol versus low alcohol exposure. Adult rats were provided 5 mM (low alcohol), 100 mM (high alcohol) or pair-fed non-alcohol controls for 4–5 months. The hearts were dissected, sectioned and stained with cresyl violet or immunohistochemically for caspase-3, a putative marker for apoptosis. Cardiomyocytes were isolated to determine the effects of alcohol exposure on cell contraction and relaxation. High alcohol animals displayed a marked thinning of the left ventricular wall combined with elevated caspase-3 activity and decreased contractility. In contrast, low alcohol was associated with increased contractility and decreased apoptosis suggesting an overall protective mechanism induced by low levels of alcohol exposure.

Alcoholic cardiomyopathy: a review

Alcohol abuse can cause cardiomyopathy indistinguishable from other types of dilated nonischemic cardiomyopathy. Most heavy drinkers remain asymptomatic in the earlier stages of disease progression, and many never develop the familiar clinical manifestations that typify heart failure. We review the current thinking on the pathophysiology, clinical characteristics, and treatments available for alcoholic cardiomyopathy. The relationship of alcohol to heart disease is complicated by the fact that in moderation, alcohol has been shown to afford a certain degree of protection against cardiovascular disease.

Alcohol and arrhythmias: a comprehensive review

The use of alcohol as a social lubricant has been ubiquitous in human societies since ancient times. It has also long been recognized that alcohol produces undesirable cardiovascular effects, especially when imbibed in excess. Numerous investigators have noted a causal relationship between alcohol and arrhythmias, as well as sudden cardiac death. We have undertaken a comprehensive review of the literature on alcohol as a potential trigger for arrhythmias. We have reviewed the major epidemiological studies undertaken on this subject. We have also explored pathophysiological mechanisms that drive the arrythmogenic effects of alcohol. In conclusion, although there is definite proof in the literature to implicate alcohol as a culprit in arrhythmias, the relationship is complex.

Chronic effects of ethanol on cultured myocardial cells: ultrastructural and morphometric studies

Ultrastructural alterations of the myocardium due to chronic ethanol exposure were investigated using an in vitro system-mouse ventricular myocardial cells in a monolayer culture, which were spontaneously and synchronously contracting-by chronic exposure to 12.5, 50, and 200 mM ethanol for up to 21 days. Morphometric analyses revealed that exposure to 12.5 mM ethanol for 14 days induced an increase in the number of residual bodies, which are lysosomes containing electron-dense, amorphous materials. Some cells exposed to 50 mM ethanol for 14 days contained an accumulation of glycogen granules, increasing in inverse proportion to the mitochondrial volume. The volumetric proportion of myofibrils on day 14 decreased as the ethanol dose became lower, and was in proportion to large and giant mitochondria within the limits of three ethanol groups. Dose-dependent increases in the size and volumetric proportion of mitochondria were observed after the 14-day exposure; at a low dose (12.5 mM) mitochondria of usual size tended to increase, whereas at a high dose (200 mM) giant mitochondria increased. Coincidentally with this mitochondrial increase or gigantism, all ethanol groups showed higher beat rates than the control. Consequently, it is most likely that chronic 14-day exposures to these three ethanol doses remodel the cellular function of the in vitro myocardium in different ways; the 200-mM dose induced mitochondrial hypertrophy, an adaptive response to switch myocardial energy metabolism over to some special one; the 50-mM dose was a boundary dose; and the 12.5-mM dose mostly mimicked the chronic in vivo administration of ethanol and induced slightly degenerative alterations-increased residual bodies and lysosomes, decreased myofibrils and lowered mitochondrial respiratory function.

Mitochondrial oxidative damage and myocardial fibrosis in rats chronically intoxicated with moderate doses of ethanol

Mitochondrial oxidative balance and myocardial fibrosis were investigated in pair-fed rats received ethanol (3%) or saccharose in drinking water for 8 weeks. The concentrations of glutathione, malondialdehyde, protein carbonyls and sulfhydrils were determined. The presence and distribution of fibronectin were detected by immunohistochemistry. The myocardial concentrations of reduced glutathione and protein sulfhydrils were lower in ethanol treated rats. The oxidised/reduced glutathione ratio, the levels of malondialdehyde and protein carbonyls were higher in ethanol-treated rats. The mitochondrial amount of proteins, glutathione and protein sulfhydrils were lower in ethanol treated rats, whereas the content of protein carbonyls and malondialdehyde were higher. Accumulation of fibronectin was detected at subepicardial and subendocardial districts in ethanol-treated rats, with moderate degree of fibrosis in 20% of the cases. In conclusion, moderate ethanol consumption is associated with oxidative damage to heart mitochondria and fibronectin deposition. These oxidative and ultrastuctural changes may be assumed as basic alterations in the development of alcoholic cardiomyopathy.

Experimental heart muscle damage in alcohol feeding is associated with increased amounts of reduced- and unreduced-acetaldehyde and malondialdehyde-acetaldehyde protein adducts

Chronic and excessive alcohol consumption induces defined myocardial lesions characterized by impaired structural, mechanical and biochemical features. The pathogenic mechanisms are unknown, although it is possible that protein adduct formation by reactive metabolites of ethanol may be a contributory process. Hitherto, this has only been tested with respect to antibodies against reduced-acetaldehyde protein adducts in clinical studies, despite the fact that during alcohol toxicity the formation of reduced-acetaldehyde, unreduced-acetaldehyde, malondialdehyde, malondialdehyde-acetaldehyde and hydroxyethyl protein adducts have been reported in non-cardiac tissues. It was our hypothesis that the heart is particularly sensitive to the formation of protein adducts in alcohol toxicity.To test this hypothesis, we analysed hearts from rats fed nutritionally complete liquid diets containing ethanol as 35% of total calories for 6 weeks, using the Lieber-DeCarli pair-feeding protocol. Control rats were treated identically and fed the same diet in which ethanol was replaced by isocaloric glucose. At the end of the feeding period, the hearts were dissected and ventricular muscle analysed. After 6 weeks' ethanol feeding, ELISA analysis showed increased amounts of reduced-acetaldehyde protein adducts (p < 0.01) unreduced-acetaldehyde (p < 0.01) and malondialdehyde-acetaldehyde (p= 0.01) protein adducts. However, malondialdehyde and alpha-hydroxyethyl-protein adducts were not significantly increased in hearts of ethanol-fed rats compared to pair-fed control (p > 0.1 in both instances). This is the first report of acetaldehyde adduct formation in alcoholic cardiomyopathy. This suggests that either immune process may develop or functional impairment of affected proteins may occur.

Assessment of myocardial vasculature in chronic alcoholics without established cardiomyopathy

Myocardial pathology and cardiac functional abnormalities known to occur in association with chronic alcohol abuse have been attributed to a direct toxic effect of ethanol on the intra-myocardial vasculature: alcohol-induced occlusion of small arteries with consequent secondary ischaemia leads to individual myocyte loss, focal fibrosis and compensatory cardiac hypertrophy. To assess the intra-myocardial arterial vessels an interactive semiautomated, computerised, high-resolution, video image-analysing system was used and the findings from hearts of alcoholics were compared with normal hearts collected at autopsy. The elastic laminae, stained with Van Gieson's stain, acted as the reference points for measurement of the diameters, circumferences and thicknesses of the vessels assessed. It was not possible to demonstrate any statistically significant morphometric changes within intra-myocardial vasculature. The same technique used is readily adaptable for the assessment of the blood vessels in other organs and tissues.

Ethanol-induced inhibition of ventricular protein synthesis in vivo and the possible role of acetaldehyde

We have determined the extent to which acute ethanol administration perturbs the synthesis of ventricular contractile and non-contractile proteins in vivo. Male Wistar rats were treated with a standard dose of ethanol (75 mmol kg-1 body weight; i.p.). Controls were treated with isovolumetric amounts of saline (0.15 mol l-1 NaCl). Two metabolic inhibitors of ethanol metabolism were also used namely 4-methylpyrazole (alcohol dehydrogenase inhibitor) and cyanamide (acetaldehyde dehydrogenase inhibitor) which in ethanol-dosed rats have been shown to either decrease or increase acetaldehyde formation, respectively. After 2.5 h, fractional rates of protein synthesis (i.e. the percentage of tissue protein renewed each day) were measured with a large (i.e. 'flooding') dose of L-[4-3H]phenylalanine (150 mumol (100 g)-1 body weight into a lateral vein). This dose of phenylalanine effectively floods all endogenous free amino acid pools so that the specific radioactivity of the free amino acid at the site of protein synthesis (i.e. the amino acyl tRNA) is reflected by the specific radioactivity of the free amino acid in acid-soluble portions of cardiac homogenates. The results showed that ethanol alone and ethanol plus 4-methylpyrazole decreased the fractional rates of mixed, myofibrillar (contractile) and sarcoplasmic (non-contractile) protein synthesis to the same extent (by approx. 25 per cent). Profound inhibition (i.e. 80 per cent) in the fractional rates of mixed, myofibrillar and sarcoplasmic protein synthesis occurred when cyanamide was used to increase acetaldehyde formation. There was also a significant decrease in cardiac DNA content. The results suggest that acute ethanol-induced cardiac injury in the rat may be mediated by both acetaldehyde and ethanol.

Efeitos da intoxicação crônica com o etanol na evolução da Tripanosomíase cruzi experimental no camundongo

Dois experimentos foram realizados para estudar o efeito da intoxicação crônica com o etanol (solução a 7% como única fonte de líquido) sobre a evolução da infecção pelo T. cruzi em camundongos: (1) animais após 60 dias de infecção com cepa miotrópica do T. cruzi foram submetidos à intoxicação crônica com o etanol durante 6 meses; (2) animais cronicamente intoxicados com etanol durante 5 meses foram infectados com a mesma cepa do T. cruzi e, continuando a ingestão do etanol, foram acompanhados até 45 dias após a infecção. Os animais infectados e tratados com etanol apresentaram, em relação aos que não ingeriram álcool etílico: (a) mortalidade semelhante nos dois experimentos; (b) parasitemia mais alta na fase aguda e parasitemia patente mais freqüente na fase crônica; (b) miocardite com exsudato inflamatório menos intenso e fibrose miocárdica mais extensa na fase crônica; (c) no músculo esquelético, miosite menos intensa e arterite com trombose hialina menos freqüente.

Long-term intracoronary ethanol administration electrophysiologic and morphologic effects

The long-term intracoronary infusion of ethanol was used to evaluate the potential of ethanol to produce myocardial injury and cardiac rhythm disturbances. In 22 dogs, electrophysiologic testing was performed 48 hr after cessation of alcohol administration. Multiple premature ventricular beats occurred spontaneously in 3 dogs with spontaneous sustained monomorphic ventricular tachycardia observed in 1 dog. Provocative ventricular pacing produced ventricular tachycardia lasting 20 or more beats in 13 animals with sustained tachycardia observed in 3 animals. Provocative ventricular pacing in the presence of lidocaine or epinephrine produced sustained ventricular tachycardia in an additional 4 dogs. The electrophysiologic properties of Purkinje fibers from the zone receiving ethanol were altered when compared to the control zone. The resting membrane potential was decreased (-76 +/- 2 mV vs. -85 +/- mV, p less than 0.001) with a decrease in action potential amplitude (91 +/- 4 vs. 109 +/- 2 mV, p less than 0.001) and phase 0 upstroke (231 +/- 27 vs. 456 +/- 25 V/sec, p less than 0.02). Prolonged refractoriness was observed in the ethanol zone without a prolongation of action potential duration. Intramural lesions observed within the left circumflex distribution varied from focal acute myofibrillar degeneration and necrosis to severe local scarring. The data suggest that intracoronary ethanol administration at human abuse levels of blood alcohol concentrations produces histologic and electrophysiologic injury in the canine heart. The electrophysiologic ch changes provide a substrate sufficient for the induction and maintenance of ventricular arrhythmia.

The preventive effect of verapamil on ethanol-induced cardiac depression: phosphorus-31 nuclear magnetic resonance and high-pressure liquid chromatographic studies of hamsters

Alcoholic depression of left ventricular function was produced in normal hamsters by the administration of increasing concentrations of alcohol in drinking water (up to 50%) for 6 months. The result was assessed by phosphorus-31 nuclear magnetic resonance of isolated perfused hearts and high-pressure liquid chromatography of freeze-clamped tissues. Hemodynamic data and myocardial oxygen consumption were also monitored. Alcoholic hamsters had significantly higher inorganic phosphate and lower ATP levels, while maintaining normal intracellular pH, phosphocreatine, and creatine. Although coronary flow and oxygen consumption were maintained at normal levels, hamsters ingesting 50% ethanol had significantly lower left ventricular developed pressure and dP/dt. Treatment with verapamil during long-term ethanol consumption prevented the development of these metabolic and functional abnormalities. It is hypothesized that alcohol produces membrane abnormalities leading to adverse ion flux, and that these are largely prevented by concurrent administration of verapamil.

Morphological alterations due to long term alcohol intake in rats

The myocardium and blood vessels of 20 rats kept for one year on DeCarli and Lieber's liquid diet containing alcohol to 36% of total Joules were examined with routine histological, histochemical and electron microscopical methods. No changes in the gross anatomy, histology, histochemistry and electron microscopy of the arteries, veins and capillaries were found. Subcellular damage of the atrial and ventricular myocardial cells was observed. A varying number of mitochondria were affected in each of the animals: degenerated mitochondria, mitochondria with electron lucent matrix, with concentric cristae, of bell shape, with negative succinic dehydrogenase activity or vacuolated mitochondria were found. In 10% the myofibrils, and in 30% the sarcoplasmic reticulum were damaged. Secretion and lipofuscin granules increased in number in 25% of the animals. It is concluded that although the submicroscopic alcoholic alterations are similar to some of those reported in experimental ischaemia, the decrease in myocardial blood flow may not be held solely responsible for the alcoholic damages. A toxic effect of alcohol, acetaldehyde and catecholamine is postulated.

Amiodarone-induced ultrastructural changes in canine myocardial fibers

Chronic clinical toxicity with amiodarone, a unique antiarrhythmic drug, is associated with intracellular myelinoid inclusion bodies in skin, cornea, lung, liver and lymph nodes. The present study was designed to develop a canine animal model to study amiodarone concentration and onset of formation of myelinoid inclusion bodies in the cardiac tissue. Amiodarone was given intravenously in a single dose (40 mg/kg body weight) or multiple doses (40 mg/kg IV + 10 mg/kg IV X 7 days). Amiodarone concentration in the heart was high after a single dose but electron microscopic examination showed a normal ultrastructure. Numerous myelinoid inclusion bodies were found in the myofibrils of the left atria and right and left ventricles after only 7 days of amiodarone treatment. Myelinoid inclusion bodies were identified in several subcellular locations including intercalated disc but most were in close proximity of the mitochondria, sometimes touching and indenting the mitochondrial membrane. The antiarrhythmic effect of the schedule of intravenous amiodarone for 7 days used in this study was minimal, and this correlated with unexpectedly low myocardial levels of the drug and its metabolite. The results are consistent with our previous data of an antiarrhythmic effect with a single intravenous dose of 40 mg/kg body weight associated with high myocardial levels of amiodarone. We conclude that a single large dose of amiodarone with high tissue level may not cause myelinoid inclusion bodies, but they can be readily identified in all heart chambers after only 1 week of amiodarone treatment. This model would be useful to study amiodarone-induced ultrastructural changes in the heart.

Ultrastructural and histochemical observations in human and experimental alcoholic cardiomyopathy

The morphologic features of alcoholic cardiomyopathy in human sudden death compared with those of experimental alcoholic cardiomyopathy (6 weeks of alcohol administration and simultaneous inhibition of catalase activity) proved to be nearly identical. Regular and similar alterations in alcoholic cardiomyopathy in both human victims of sudden death and experimental rats are described as a complex of alterations characteristic of alcoholic cardiomyopathy. This complex of changes was used as the basis for morphologic diagnosis of endomyocardial biopsy in two groups of patients: I) chronic alcoholics (second to third stages), and II) patients with clinically diagnosed congestive cardiomyopathy. Typical signs of alcoholic cardiomyopathy were found in 9 of the 11 patients in the first group and in 6 of 18 in the second group. The fact that the features of alcoholic cardiomyopathy were not found in all cases of chronic alcoholism supports the hypothesis that the administration of alcohol itself is not sufficient for the development of this disease. The level of enzyme activity in the metabolism of alcohol appears to be of great importance. This hypothesis is confirmed by experiments with rats in which this disease developed only when there was simultaneous alcohol administration and inhibition of catalase activity. Histochemical study showed that the alterations of enzyme (both energetic and alcohol metabolism) in rats were similar to those found in the biopsy specimens from patients with alcoholic cardiomyopathy. Certain questions regarding the pathogenesis of alcoholic cardiomyopathy are discussed.

Mitochondrial respiration after cardiac perfusion with ethanol or acetaldehyde

Hemodynamics, energetics, and mechanics of isolated working rat hearts were studied during perfusion with Krebs-Henseleit medium containing either ethanol (24 +/- 2 mM) or acetaldehyde (74 +/- 6 microM). After 60-min perfusion with agent, mitochondria were isolated from the hearts and assayed polarographically using glutamate, alpha-keto-glutarate, pyruvate-malate, and succinate-rotenone substrates. Hemodynamic and mechanical function of the ethanol-treated hearts declined significantly more than that of control hearts during the 60-min perfusion. The acetaldehyde-perfused hearts did not differ from the controls. A 90-sec washout period reversed the ethanol-induced depression of physiologic function. Respiratory function (respiratory control ratio and Qo2) of mitochondria isolated from the ethanol- and acetaldehyde-treated hearts was slightly, though not significantly, depressed compared with control hearts. These data indicate that ethanol and acetaldehyde, at physiologically significant concentrations, have dissimilar effects on cardiac hemodynamics and mechanics: ethanol has a direct depressive effect which is reversible; acetaldehyde has no significant effect. Mitochondrial respiration is not irreversibly affected by brief exposure to ethanol or acetaldehyde at the concentrations tested.

Is the rat a suitable model for studying alcoholic cardiomyopathy? Hemodynamic studies at various stages of chronic alcohol ingestion

Three groups of wistar rats with chronic alcohol consumption were studied: 10% ethanol for 6 months, 20% ethanol for 7 months, 20% ethanol for 12 months. In the intact heart in situ, left ventricular parameters of pressure, volume, and blood flow were recorded. On the average, body weight and heart weight of the alcohol-fed rats (A) were diminished by 10% as compared with controls (C). If end-diastolic volume is related to heart weight, no significant differences in the pressure-volume relations between C and A were obtained. There were no differences in the rate of pressure rise, nor in the end-systolic pressure-volume relations. According to these findings and the results of other authors, it is concluded that the rat is not very suitable for studying "alcoholic cardiomyopathy".

Effect of chronic alcohol ingestion on the heart and blood pressure of spontaneously hypertensive rats

The effect on the heart of a combination of high blood pressure and chronic alcohol ingestion was studied in spontaneously hypertensive rats (SHR) fed ethanol in their drinking water in concentrations of 0%, 5% and 20% for sixteen weeks. Normotensive Wistar rats were used as controls (NCR). In addition some SHR were given alcohol for a shorter period of eight weeks at the end of which time there were no significant differences in mean arterial blood pressure between the groups. After sixteen weeks of ethanol the mean arterial pressure had fallen in those SHR receiving 20% ethanol to 136 +/- 24 mmHg compared to control (180 +/- 27 mmHg; P less than 0.001). This was associated with a lower left ventricular (LV)dp/dt (control 4800 +/- 872 mmHg sec-1; 20% ethanol group = 3450 +/- 1588 mmHg sec-1; P less than 0.025) and a reduced LV weight (corrected for body weight) due to an apparent lack of development of LV hypertrophy between eight and sixteen weeks. Similarly LV volume (corrected for LV weight), did not change from eight weeks to sixteen weeks in those SHR receiving 20% ethanol in contrast to the 0% ethanol SHR group in whom LV volume fell as LV hypertrophy developed. 5% Ethanol had no significant effect on mean arterial pressure, LV peak dp/dt, LV weight or LV volume. In the NCR ethanol had little effect on mean arterial pressure but those receiving 20% ethanol had significantly smaller LV volumes without any increase in LV weight probably reflecting blood volume depletion. Ethanol did not produce any blood pressure elevation in the NCR. No rats (SHR or NCR) developed overt heart failure or a typical cardiomyopathy. However, this study has shown that a high intake of ethanol reduces the blood pressure of a hypertensive rat most likely by its direct toxic action on the myocardium. Thus with chronic alcohol ingestion hypertension can be masked but may still contribute significantly to the development of myocardial disease.

Morphometric analysis of the rabbit myocardium after chronic ethanol feeding - early capillary changes

Male rabbits were fed with ethanol for 3 weeks. 10 ml of a 20% ethanol solution were applied daily with a stomach tube. The macroscopic, histologic and ultrastructural investigation of the hearts did not reveal and structural alterations. Morphometrically, the endothelial cells of the capillaries were changed, whereas the muscle cells did not show any abnormalities. The quantitative data indicate that the numerical density of endothelial cells is increased, whereas the volume density is not changed. This type of quantitative reaction pattern may be characterized as "proliferation" of endothelial cells. The proliferation is possibly related to ethanol-induced metabolic changes similar to chronic hypoxia. On the other hand, there is some evidence that the alteration is part of a general activation of mesenchymal cells in various organs after ethanol ingestion. The alteration is probably an early stage of the proliferation of capillaries.

Alcohol and malnutrition in the pathogenesis of experimental alcoholic cardiomyopathy

In this study, the morphology and the catecholamine levels of the myocardium in both well-nourished and malnourished alcohol-fed rats were examined. Alcohol has been administered to rats for 16 weeks. Rats fed a diet containing alcohol corresponding to 40 per cent. of total calorific intake and inadequate amounts of calories and nutrients developed morphological changes in the heart, while the controls did not. In addition, an increase in cardiac noradrenaline concentration and heart: body weight ratio could be observed. There were no differences in myocardial morphology and catecholamine concentration between well-nourished rats fed alcohol as 35 per cent. of the calorific intake and pair-fed controls. A dispute exists about whether alcohol is directly toxic to the heart or indirectly injurious due to associated dietary deficiency. The present results, taken together, make the theory of cardiotoxicity of alcohol an unlikely one, at least in the case of the rat; and they offer considerable support for the hypothesis that the association between chronic consumption of alcoholic beverages and cardiomyopathy is a result of a primary multifactorial nutritional deficiency, resulting from displacement of nutrient-associated calories by the "empty" calories--devoid of protein, vitamins, and minerals--of alcohol, and/or a secondary nutritional deficiency due to injurious effects of alcohol on the liver, pancreas and intestine. It is suggested that continued exposure to high levels of catecholamine, directly related to malnutrition, may play a role in the development of myocardial pathology.

Cardiovascular effects of alcohol

Epidemiologic studies suggest that moderate consumption of alcohol provides some degree of protection against ischemic heart disease. On the other hand, cerebrovascular accidents and overall mortality are increased at all levels of alcohol intake. Thus, it is inappropriate to advise abstainers to begin to drink alcoholic beverages as a protective measure for coronary artery disease. Acute ingestion of large amounts of alcohol leads to a negative inotropic effect on the myocardium, together with inhibition of a variety of biochemical reactions in subcellular organelles of the heart. Chronic alcoholism is associated with the development of a congestive cardiomyopathy (alcoholic cardiomyopathy), which is independent of vitamin B1 deficiency or other nutritional deficits.

Cardiac metabolsim: its contributions to alcoholic heart disease and myocardial failure

Changes in cardiac metabolism in myocardial failure and after alcohol ingestion are discussed. The main effect of alcohol ingestion is loss of cardiac contractility. Since heart muscle does not contain alcohol dehydrogenase, its toxicity is probably the result of a direct toxic effect of ethanol and acetaldehyde on the myocardial cell, possibly involving various membrane systems. Alcohol inhibits mitochondrial respiration and the activity of enzymes in the tricarboxylic acid cycle, and its interferes with both mitochondrial calcium uptake and binding. Ethanol profoundly affects myocardial lipid metabolism. Acetaldehyde diminishes myocardial protein synthesis and inhibits Ca++-activated myofibrillar ATPase. In myocardial failure, a series of possibilities may be responsible for the loss of contractility. Excitation-contraction coupling could be disturbed at the level of the sarcolemma, at the sarcoplasmic reticulum, at the mitochondria, and between calcium and the regulatory proteins. Deficiencies in Ca++ delivery systems of excitation-contraction coupling on the myosin ATPase activity could be responsible for the dimunition in cardiac contractility. Mitochondrial function may also be involved, since mitochondria from failing human hearts are defective with respect to respiratory control and calcium accumulation. Under certain conditions, the relationship of mitochondria to calcium sequestration is very important in influencing contractility. The involvement of contractile and regulatory proteins in myocardial failure cannot be excluded.

Alcohol consumption, cardiovascular risk factors, and mortality in two Chicago epidemiologic studies

Multivariate analysis of the association at baseline between problem drinking and cardiovascular risk factors among 1,233 white male employees of the Chicago Peoples Gas Company age 40-59 showed the 38 problem drinkers with significantly higher blood pressures and cigarette consumption and significantly lower relative weights than the others. Similar analysis among 1,899 white male employees of the Hawthorne Works of the Western Electric Company in Chicago age 40-55 showed the 117 men consuming 5 or more drinks per day with significantly higher blood pressures and cigarette use than the others. No significant differences were recorded between heavy drinkers and the others in serum cholesterol level. The gas company problem drinkers had significantly higher 15-year mortality rates from all causes, cardiovascular diseases, coronary heart disease, and sudden death. These differences could not be entirely explained by their blood pressure, smoking, and relative weight status. The Western Electric heavy drinkers had increased 10-year mortality rates both for all causes and noncardiovascular causes.

Intramyocardial small-vessel disease in chronic alcoholism

A morphologic study of the small (50 to 200 micron) intramyocardial coronary arteries was performed. The cases chosen for study were selected from a relatively young group of patients without clinical evidence of alcoholic cardiomyopathy or pathologic evidence of large coronary artery disease, in order to evaluate alterations in the small vessels which could possibly be attributed to the chronic alcoholic state. Five basic vascular abnormalities were described. The most common alteration found in all nine cases was vascular wall edema (48 per cent), followed by perivascular fibrosis (42 per cent), vascular sclerosis (36 per cent), subendothelial humps (13 per cent), and vascular wall inflammation (11 per cent). The significance and pathogenesis of these changes were discussed. Primary endothelial cell damage was proposed as a common pathogenic mechanism for all five types of vascular abnormality. It was suggested that following endothelial damage, fluid and macromolecules penetrate into the vessel wall or into the perivascular space where, by incompletely understood processes, they induce vascular wall myocytes to produce collagen, elastin, and basement membrane-like substances. Evidence supporting this mechanism was derived from the common observation of vascular wall edema, from the occasional presence of erythrocytes and leukocytes within the vessel wall, and from experimental data in the literature. Several possible etiologic agents were implicated in the pathogenesis of endothelial and vessel wall injury. These included alcohol itself, acetaldehyde, biogenic amines, and magnesium deficiency. It is probable, however, that there are multiple etiologic factors which affect the small cardiac vessels of the chronic alcoholic. Finally, the proposal was advanced that the nonspecific pathology of the myocardium in chronic alcoholism may be a result of ischemia secondary to disease of the small intramyocardial coronary ateries.

Heart norepinephrine concentration after chronic alcohol ingestion in the rat

The effect of long-term alcohol ingestion on the norepinephrine concentration of the heart was investigated in rats. The alcoholic animals showed a highly significant increase in cardiac norepinephrine concentration as compared with the corresponding controls. It is further suggested that continued exposure to high levels of norepinephrine may play a role in the development of cardiomyopathy in chronic alcoholism.

Cardiac conduction abnormalities produced by chronic alcoholism

While conduction disturbances and arrhythmias are seen frequently in alcoholic cardiomyopathy, the specific relationship of these changes to ethyl alcohol has been unclear. To investigate the long-term effects of ethanol upon cardiac conduction, alcoholism was induced in 11 male mongrel dogs for 7 to 33 (mean 14.4) months by feeding up to 36 per cent of total daily calories as ethanol while adequate nutrition was maintained. His and left bundle branch electrograms in the intact anesthetized animals were recorded along with high-speed, high-frequency ECG's. While resting left ventricular pressures, volumes, and stroke outputs were normal, H-Q time was prolonged in the alcoholic animals drinking for longer than one year (35 +/- 3 msec., normals 26 +/- 1 msec.-P less than 0.001). QRS widening (to 80 +/- 4 msec.) was also evident after one year as compared with normals (62 +/- 2 msec.-P less than 0.001), and both H-Q and QRS alterations correlated with duration of intake. These changes were less after shorter ingestion periods, could not be reproduced in normals by acute ethanol infusion, and were not associated with ventricular hypertrophy, inflammation, or necrosis. No abnormalities of atrial conduction were noted. Morphologic correlates of the conduction abnormalities included accumulation of Alcian Blue-positive interstitial material as well as dilatation and localized swelling of the nonspecialized region of the intercalated discs in ventricular muscle and Purkinje fibers. Thus, prolonged ethanol intake in the absence of evident malnutrition resulted in demonstrable intraventricular conduction abnormalities and morphologic alterations which were related to duration of ingestion, consistent with a cumulative toxic effect of ethanol.

The effects of chronic alcohol ingestion in mice on contractile properties of cardiac and skeletal muscle: a comparison with normal and dehydrated-malnourished controls

In vitro isometric contractile tension was measured in heart and skeletal muscle in 3 groups of mice: 1. a control group, 2. a group maintained for 27 weeks on 20% alcohol, and 3. a group whose fluid intake was restricted to the extent equaling that which occurred in the alcohol treated animals. Results showed a reduction in cardiac twitch tension in both the alcohol and fluid restricted group, as compared to normal controls. We therefore consider that dehydration per se may play an important role in the etiology of alcoholic cardiomyopathy.

Effect of ethanol infusion on the ultrastructure of human myocardium

To study the influence of a moderate dose of ethanol on the ultrastructure of myocardium in patients with heart disease, a 7·5% solution of ethanol was infused in six patients with myocardial and valvular disease, who underwent diagnostic cardiac catheterization. Before and after infusion of ethanol an endomyocardial biopsy was performed and the specimens were examined by electron microscopy. After ethanol all six patients revealed alterations in the mitochondrial structure and three of them also showed significant dilatation of the sarcoplasmic reticulum. Cardiac output increased in three of the patients, whereas in two patients a decrease of cardiac output was measured.

The results suggest that the infusion of even small amounts of ethanol is able to provoke structural alterations of myocardial cell organelles and, therefore, possible impairment of myocardial function.

The effect of prolonged administration of ethanol on cardiac metabolism and performance in the dog

The effect of prolonged administration of alcohol on mitochondrial function and high-energy phosphate (ATP) of heart muscle was investigated in dogs. Animals were divided into two groups, a control group and a group that received alcohol. In the experimental series, dogs received 400 ml of a 25% solution of alcohol added to the food and drinking water. Measurements were carried out after ethanol had been withheld for 2 days. Total myocardial blood flow, cardiac output, and myocardial O(2) consumption remained at control levels. Measurement of cardiac contractility using the maximal rate of left ventricular pressure rise (dP/dt(max)) showed no change in animals exposed to alcohol. When the afterload of the heart was increased with angiotensin, a slight but not significant decline in cardiac contractility was observed. Activities of various intramitochondrial and extramitochondrial enzymes were measured in both groups. After alcohol administration, the primarily intramitochondrial isocitrate dehydrogenase diminished. ATP in heart muscle of dogs exposed to alcohol declined, and mitochondrial oxygen consumption and respiratory control indices diminished. These observations suggest that the primary lesion leading to alteration of myocardial performance is a biochemical malfunction of the mitochondria, which at this early stage is not reflected in changes in myocardial contractility.

The cardiomyopathies--current perspectives

This paper is designed to provide a contemporary overview of primary myocardial disease. The cardiomyopathies are dealt with in the light of both pathophysiologic and etiologic classifications. A relatively simple diagnostic approach is based upon these classifications together with the clinical manifestations of the cardiomyopathies. The essential principles of the natural history are summarized, and treatment is dealt with in terms of specific curatives, general pharmacologic measures, and management of factors that modify, aggravate, or contribute to the development of primary myocardial disease.