Case-control and cohort studies of moderate alcohol consumption and stroke

The Fluid Aspect of the Mediterranean Diet in the Prevention and Management of Cardiovascular Disease and Diabetes: The Role of Polyphenol Content in Moderate Consumption of Wine and Olive Oil

A growing interest has emerged in the beneficial effects of plant-based diets for the prevention of cardiovascular disease, diabetes and obesity. The Mediterranean diet, one of the most widely evaluated dietary patterns in scientific literature, includes in its nutrients two fluid foods: olive oil, as the main source of fats, and a low-to-moderate consumption of wine, mainly red, particularly during meals. Current mechanisms underlying the beneficial effects of the Mediterranean diet include a reduction in inflammatory and oxidative stress markers, improvement in lipid profile, insulin sensitivity and endothelial function, as well as antithrombotic properties. Most of these effects are attributable to bioactive ingredients including polyphenols, mono- and poly-unsaturated fatty acids. Polyphenols are a heterogeneous group of phytochemicals containing phenol rings. The principal classes of red wine polyphenols include flavonols (quercetin and myricetin), flavanols (catechin and epicatechin), anthocyanin and stilbenes (resveratrol). Olive oil has at least 30 phenolic compounds. Among them, the main are simple phenols (tyrosol and hydroxytyrosol), secoroids and lignans. The present narrative review focuses on phenols, part of red wine and virgin olive oil, discussing the evidence of their effects on lipids, blood pressure, atheromatous plaque and glucose metabolism.

Alcohol Consumption and Incident Stroke Among Older Adults

Objectives

This study examines the relationship between alcohol consumption and incident stroke among older adults and tests whether alcohol consumption contributes to observed race and sex differences in stroke.

Method

Data are from a U.S. national cohort of black and white adults aged 45 and older, the REasons for Geographic And Racial Differences in Stroke (REGARDS) study. Current and past drinking levels were reported at baseline (2003-2007). Participants who had never had a stroke were followed for adjudicated stroke events through September 2015 (n = 27,265). We calculated Cox proportional hazard models for stroke, adjusting for demographic, socioeconomic, behavioral, and health characteristics.

Results

Participants, mean age 64.7 years, consumed on average 2.2 drinks/week and experienced 1,140 first-time stroke events over median 9.1 years follow-up. Nondrinkers had a 12% higher risk of stroke than current drinkers; the risk of stroke among nondrinkers largely reflected high risks among past drinkers; these differences were explained by socioeconomic characteristics. Among current drinkers, light drinkers had significantly lower stroke risks than moderate drinkers after accounting for demographic, socioeconomic, behavioral, and health characteristics. Implications of alcohol did not differ between blacks and whites but did differ by sex: Especially among women, nondrinkers, and specifically past drinkers, had higher risks; these differences were largely explained by health characteristics and behaviors. Alcohol did not explain race and sex differences in stroke incidence.

Discussion

Among older adults, those who used to, but no longer, drink had higher risks of stroke, especially among women; current light drinkers had the lowest risk of stroke.

Alcohol and Acute Myocardial Infarction

A number of studies from different countries and several large-scale meta-analyses have reported reduced coronary heart disease rates among those regularly consuming mild to moderate amounts of alcohol compared with those abstaining from alcohol. In contrast, various studies have also reported that heavy alcohol consumption promotes the progression of atherosclerosis and that binge drinking might trigger embolic stroke and acute myocardial infarction. We discuss the association between alcohol consumption and acute myocardial infarction on the basis of evidence from literature published recently. Alcohol consumption has both favourable and unfavourable effects on metabolism, lipid profile, blood coagulation and fibrinolysis, blood pressure and vascular tone depending on the amount of alcohol consumed and the way that it is drunk (i.e. drinking habits). We conclude that it is extremely important to warn people of the risks associated with binge drinking and to encourage them to remain within the recommended safe limits for alcohol consumption.

Beyond Ischemic Heart Disease: Are There other Health Benefits from Drinking Alcohol?

Evidence is growing that alcohol consumption confers health benefits beyond protection from ischemic heart disease. We review this evidence with regard to cerebrovascular disease, peripheral vascular disease, diabetes, cholelithiasis (gallstones), cognitive functioning, and stress reduction and subjective psychosocial benefits. Other possible benefits are briefly considered. The weight of evidence suggests that low-level alcohol consumption offers some protection against ischemic stroke. The evidence that moderate alcohol consumption protects against diabetes and gallstones is also fairly strong. The possibility of other health benefits cannot be dismissed. For all the conditions considered, more research is indicated. The application of more appropriate statistical techniques, studies of patterns of drinking, and experimental approaches to delineating underlying mechanisms should enable firmer conclusions to be drawn. A better understanding of both the benefits and the risks of alcohol use for individuals and populations will facilitate the development of appropriate program and policy interventions to promote health.

Alcohol consumption and cardiovascular mortality among U.S. adults, 1987 to 2002

OBJECTIVES

The aim of this study was to determine the association of alcohol consumption and cardiovascular mortality in the U.S. population.

BACKGROUND

Alcohol consumption has been associated with a lower risk of cardiovascular disease in cohort studies, but this association has not been prospectively examined in large, detailed, representative samples of the U.S. population.

METHODS

We analyzed 9 iterations of the National Health Interview Survey, an annual survey of a nationally representative sample of U.S. adults between 1987 and 2000. Exposures of interest included usual volume, frequency, and quantity of alcohol consumption and binge drinking. Mortality was ascertained through linkage to the National Death Index through 2002. Relative risks were derived from random-effects meta-analyses of weighted, multivariable-adjusted hazard ratios for cardiovascular mortality from individual survey administrations.

RESULTS

Light and moderate volumes of alcohol consumption were inversely associated with cardiovascular mortality. Compared with lifetime abstainers, summary relative risks were 0.95 (95% confidence interval [CI]: 0.88 to 1.02) among lifetime infrequent drinkers, 1.02 (95% CI: 0.94 to 1.11) among former drinkers, 0.69 (95% CI: 0.59 to 0.82) among light drinkers, 0.62 (95% CI: 0.50 to 0.77) among moderate drinkers, and 0.95 (95% CI: 0.82 to 1.10) among heavy drinkers. The magnitude of lower risk was similar in subgroups of sex, age, or baseline health status. There was no simple relation of drinking pattern with risk, but risk was consistently higher among those who consumed >or=3 compared with 2 drinks/drinking day.

CONCLUSIONS

In 9 nationally representative samples of U.S. adults, light and moderate alcohol consumption were inversely associated with CVD mortality, even when compared with lifetime abstainers, but consumption above recommended limits was not.

Screening for hazardous drinking using the Michigan Alcohol Screening Test-Geriatric Version (MAST-G) in elderly persons with acute cerebrovascular accidents

BACKGROUND

Effective and valid screening methods are needed to identify hazardous drinking in elderly persons with new onset acute medical illness. The goal of the current study was to examine the effectiveness of the Michigan Alcohol Screening Test-Geriatric Version (MAST-G) in identifying hazardous drinking among elderly patients with acute cerebrovascular accidents (CVA) and to compare the effectiveness of 2 shorter versions of the MAST-G with the full instrument.

METHODS

The study sample included 100 men and women who averaged 12 days posthemorrhagic or ischemic CVA admitted to a rehabilitation unit and who were at least 50 years of age and free of substance use other than alcohol. This cross-sectional validation study compared the 24-item full MAST-G, the 10-item Short MAST-G (SMAST-G), and a 2-item regression analysis derived Mini MAST-G (MMAST-G) to the reference standard of hazardous drinking during the past 3 months. Alcohol use was collected using the Timeline Followback (TLFB). Recent and lifetime alcohol-related consequences were collected using the Short Inventory of Problems (SIP).

RESULTS

Nearly one-third (28%) of the study sample met the World Health Organization (WHO) criteria for hazardous drinking. Moderately strong associations were found for the MAST-G, SMAST-G, and MMAST-G with alcohol quantity and frequency and recent and lifetime alcohol consequences. All 3 MAST-G versions could differentiate hazardous from nonhazardous drinkers and had nearly identical area under the curve characteristics. Comparable sensitivity was found across the 3 MAST-G measures. The optimal screening threshold for hazardous drinking was 5 for the MAST-G, 2 for the SMAST-G, and 1 for the MMAST-G.

CONCLUSIONS

The 10-item SMAST-G and 2-item MMAST-G are brief screening tests that show comparable effectiveness in detecting hazardous drinking in elderly patients with acute CVA compared with the full 24-item MAST-G. Implications for research and clinical practice are discussed.

Alcohol Consumption and Abnormalities of Brain Structure and Vasculature

Research on how alcohol consumption influences the structure and blood supply of the brain has generally focused on two primary areas of interest: the atrophic effect of heavy drinking on brain structure and the effects of moderate and heavy drinking on the risk of stroke. Heavy alcohol consumption results in atrophy of gray and white matter, particularly in the frontal lobes, cerebellum, and limbic structures. Heavy drinking also raises the risk of ischemic and hemorrhagic stroke, while light drinking is associated with a lower risk of ischemic stroke. Recently, the author and his colleagues studied alcohol consumption and prevalence of subclinical abnormalities detected by magnetic resonance imaging of the brain among 3376 older adults enrolled in the Cardiovascular Health Study. They found that alcohol consumption was positively associated with measures of brain atrophy and inversely associated with subclinical infarcts in a dose-dependent manner. Alcohol consumption and white matter lesions had a U-shaped relationship, with the lowest prevalence among those who consumed 1-6 drinks per week. Further research is needed to determine how these associations interact to influence overall brain function.

Cerebral blood flow velocity and erythrocyte deformability in heavy alcohol drinkers at the acute stage and two weeks after withdrawal

OBJECTIVE

The aim of the study was to measure changes in blood flow velocity (V(mean)) and erythrocyte deformability (ED) in heavy alcohol drinkers after withdrawal and the relationship between them.

METHODS

The subjects were 32 heavy alcohol drinkers, mean age 47 years (22 men and 10 women). V(mean) was determined by a transcranial 2 MHz pulsed Doppler probe. ED was estimated by the method of cation-osmotic haemolysis (COH). The results were compared with those for 20 healthy volunteers.

RESULTS

The study revealed a significant decrease in V(mean) and ED after admission. V(mean) in the left middle cerebral artery (MCA) was 45.1+/-10.2 cm/s as compared with 59.1+/-7.5 cm/s in controls; in the right MCA, it was 46.8+/-11.3 cm/s as compared with 59.0+/-7.6 cm/s in controls (p < 0.001 in each case). But while V(mean) was significantly increased after 14 days withdrawal (54.4+/-10.4 cm/s in the left MCA, p < 0.001, and 54.3+/-12.1 cm/s in the right MCA, p < 0.01), ED showed only small change. A significant difference between V(mean) in men and women was found.

CONCLUSION

The changes in V(mean) after withdrawal are more influenced by plasma composition than by changes in ED.

Moderate Alcohol Consumption Reduces Risk of Ischemic Stroke

Background and Purpose— Moderate alcohol consumption is protective against coronary disease, but its relationship to ischemic stroke (IS) is controversial.

Methods— Stroke-free participants ≥40 years of age identified by random-digit dialing were enrolled in a prospective cohort study between 1993 and 2001. Alcohol consumption was assessed through in-person interview and categorized as none in the past year, ≥1 drink in past month to ≤2 per day (moderate drinkers), and >2 drinks daily. Lifetime drinking was also assessed. Cox proportional hazard regression modeling was used to assess hazard ratios and their 95% CIs for the association of drinking with risk of stroke and vascular events.

Results— Mean age among participants (n=3176) was 69.1±10.3 years; 62.8% were women, 20.8% were non-Hispanic white, 24.5% non-Hispanic black, and 52.4% were Hispanic. No alcohol in the previous year was present in 62.3%, and 32.5% drank moderately. After adjusting for other risk factors compared with those who did not drink in the past year, moderate drinkers had a reduced risk of IS (0.67; 95% CI, 0.46 to 0.99) and IS, myocardial infarction, or vascular death (0.74; 95% CI, 0.59 to 0.94). Results were similar when never-drinkers were used as referent group. Reduction in risk was seen for nonatherosclerotic IS subtypes, and results stratified by age, sex, and race–ethnicity were similar.

Conclusion— Moderate alcohol consumption is associated with decreased risk of IS in a multiethnic population. This effect is independent of other risk factors and holds for nonatherosclerotic stroke subtypes.

Alcohol consumption and platelet activation and aggregation among women and men: the Framingham Offspring Study

BACKGROUND

Alcohol intake has been associated with lower platelet activity; however, few large-scale studies have included women, and to our knowledge, the relationship of alcohol intake with measures of platelet activation has not been studied.

METHODS

We performed a cross-sectional analysis of adults free of cardiovascular disease enrolled in the Framingham Offspring Study. Study physicians assessed alcohol consumption with a standardized questionnaire. We measured platelet activation in response to 1 and 5 microm of adenosine diphosphate (ADP) with a P-selectin assay among 1037 participants and platelet aggregability in response to ADP, epinephrine, and collagen among 2013 participants.

RESULTS

Alcohol consumption was inversely associated with P-selectin expression in response to 1 microm ADP (p = 0.007) and 5 microm ADP (p = 0.02) among men but not women. Alcohol consumption was also inversely associated with platelet aggregation induced by ADP among both women (p = 0.04) and men (p trend = 0.008) and by epinephrine among men (p = 0.03)

CONCLUSIONS

Alcohol consumption is inversely associated with both platelet activation and aggregation, particularly in men. Additional research is needed to determine whether these findings contribute to the contrasting associations of alcohol consumption with risk of thrombotic and hemorrhagic cardiovascular events.

Alcohol consumption and risk of stroke: a meta-analysis

CONTEXT

Observational studies suggest that heavy alcohol consumption may increase the risk of stroke while moderate consumption may decrease the risk.

OBJECTIVE

To examine the association between alcohol consumption and relative risk of stroke.

DATA SOURCES

Studies published in English-language journals were retrieved by searching MEDLINE (1966-April 2002) using Medical Subject Headings alcohol drinking, ethanol, cerebrovascular accident, cerebrovascular disorders, and intracranial embolism and thrombosis and the key word stroke; Dissertation Abstracts Online using the keywords stroke and alcohol; and bibliographies of retrieved articles.

STUDY SELECTION

From 122 relevant retrieved reports, 35 observational studies (cohort or case control) in which total stroke, ischemic stroke, or hemorrhagic (intracerebral or total) stroke was an end point; the relative risk or relative odds and their variance (or data to calculate them) of stroke associated with alcohol consumption were reported; alcohol consumption was quantified; and abstainers served as the reference group.

DATA EXTRACTION

Information on study design, participant characteristics, level of alcohol consumption, stroke outcome, control for potential confounding factors, and risk estimates was abstracted independently by 3 investigators using a standardized protocol.

DATA SYNTHESIS

A random-effects model and meta-regression analysis were used to pool data from individual studies. Compared with abstainers, consumption of more than 60 g of alcohol per day was associated with an increased relative risk of total stroke, 1.64 (95% confidence interval [CI], 1.39-1.93); ischemic stroke, 1.69 (95% CI, 1.34-2.15); and hemorrhagic stroke, 2.18 (95% CI, 1.48-3.20), while consumption of less than 12 g/d was associated with a reduced relative risk of total stroke, 0.83 (95%, CI, 0.75-0.91) and ischemic stroke, 0.80 (95% CI, 0.67-0.96), and consumption of 12 to 24 g/d was associated with a reduced relative risk of ischemic stroke, 0.72 (95%, CI, 0.57-0.91). The meta-regression analysis revealed a significant nonlinear relationship between alcohol consumption and total and ischemic stroke and a linear relationship between alcohol consumption and hemorrhagic stroke.

CONCLUSIONS

These results indicate that heavy alcohol consumption increases the relative risk of stroke while light or moderate alcohol consumption may be protective against total and ischemic stroke.

Ischemia-induced glutamate release in rat frontoparietal cortex after chronic alcohol and withdrawal

High doses of ethanol increase stroke risk: in this context, a role for excitatory amino acids has been proposed. The present results show that, in frontoparietal cerebral cortex, chronic ethanol treatment (10% v/v in drinking water for 28 days) was able to slightly reduce glutamate release (evaluated through transdialysis coupled with high-pressure liquid chromatography) following focal ischemia as regards non-treated ischemic rats. This reduction was, however, not associated with decreased cerebral damage. In 24-h withdrawing rats, histological and morphometric analyzes showed an exacerbated cerebral damage coupled with higher glutamate and aspartate release compared to controls. These results suggest that adaptive changes following chronic ethanol consumption lead to an increased excitotoxicity that is particularly evident during the withdrawal condition.

Alcohol intake, type of beverage, and the risk of cerebral infarction in young women

BACKGROUND AND PURPOSE

The relationship between alcohol consumption and cerebral infarction remains uncertain, and few studies have investigated whether the relationship varies by alcohol type or is present in young adults. We examined the relationship between alcohol consumption, beverage type, and ischemic stroke in the Stroke Prevention in Young Women Study.

METHODS

All 59 hospitals in the greater Baltimore-Washington area participated in a population-based case-control study of stroke in young women. Case patients (n=224) were aged 15 to 44 years with a first cerebral infarction, and control subjects (n=392), identified by random-digit dialing, were frequency matched by age and region of residence. The interview assessed lifetime alcohol consumption and consumption and beverage type in the previous year, week, and day. ORs were obtained from logistic regression models controlling for age, race, education, and smoking status, with never drinkers as the referent.

RESULTS

Alcohol consumption, up to 24 g/d, in the past year was associated with fewer ischemic strokes (<12 g/d: OR 0.57, 95% CI 0. 38 to 0.86; 12 to 24 g/d: OR 0.38, 95% CI 0.17 to 0.86; >24 g/d: OR 0.95, 95% CI 0.43 to 2.10) in comparison to never drinking. Analyses of beverage type (beer, wine, liquor) indicated a protective effect for wine consumption in the previous year (<12 g/wk: OR 0.58, 95% CI 0.35 to 0.97; 12 g/wk to <12 g/d: OR 0.55, 95% CI 0.28 to 1.10; >/=12 g/d: OR 0.92, 95% CI 0.23 to 3.64).

CONCLUSIONS

Light to moderate alcohol consumption appears to be associated with a reduced risk of ischemic stroke in young women.

Light ethanol consumption enhances liver regeneration after partial hepatectomy in rats

BACKGROUND & AIMS

The effects of "social drinking" on the liver have yet to be fully documented. The aim of this study was to document the effects of daily light, moderate, and heavy ethanol exposure on hepatic regenerative activity in the rat.

METHODS

Adult male Sprague-Dawley rats underwent daily gavages with 1.0 (light), 2. 0 (moderate), or 4.0 (heavy) g/kg of ethanol or tap water (controls) for 30 days before 70% partial hepatectomy (PHx). Hepatic regenerative activity was then documented on days 1, 3, 5, and 7 after PHx.

RESULTS

Compared with controls, restitution of liver mass, [(3)H]thymidine incorporation, and proliferating cell nuclear antigen expression were decreased in the heavy (-10%, -60%, and -36%, respectively), unchanged in the moderate (-4%, -8%, and -16%, respectively), and increased in the light (+6%, +38%, and +29%, respectively) ethanol groups. Messenger RNA differential display of resected livers at PHx identified a band present only in the light ethanol group that encodes a unique 47-kilodalton protein with growth-promoting features designated light ethanol-induced stimulatory protein.

CONCLUSIONS

The results indicate that light ethanol consumption enhances hepatic regenerative activity after PHx in rats. Further studies are required to determine the mechanism involved and whether social drinking has beneficial or adverse effects on the natural history of acute or chronic liver disease in humans.

Serum gamma-glutamyl transferase, self-reported alcohol drinking, and the risk of stroke

BACKGROUND AND PURPOSE

There is still conflicting evidence regarding a link between alcohol drinking and the risk of stroke. In most prospective studies, the assessment of the alcohol drinking has been based on self-reporting, which may be unreliable. The aim of the present study was to examine the relationship between stroke and both the self-reported alcohol drinking and the serum gamma-glutamyl transferase (GGT) concentration, which was regarded as a biological marker of alcohol drinking.

METHODS

A prospective cohort study of 14 874 Finnish men and women aged 25 to 64 years who participated in a cardiovascular risk-factor survey in 1982 or 1987. The following risk factors, determined at baseline, were included in data analyses: self-reported alcohol drinking, GGT, smoking, blood pressure, serum cholesterol, and body mass index. The cohorts were followed until the end of 1994. Stroke events were identified through the national death registry and hospital discharge registry by computerized record linkage.

RESULTS

Serum GGT concentration was associated with the risk of total and ischemic stroke in both genders. There was also a significant association among men between GGT and the risk of intracerebral hemorrhage and among women between GGT and the risk of subarachnoid hemorrhage. The relationships remained statistically significant also after adjustment for other risk factors. Self-reported alcohol drinking did not associate with any type of stroke.

CONCLUSIONS

These results support the hypothesis that excessive alcohol drinking is related to an increased risk of stroke. Biological markers of alcohol drinking, such as serum GGT level, are useful for the assessment of risks related to alcohol drinking.

The effect of acute ingestion of a large dose of alcohol on the hemostatic system and its circadian variation

BACKGROUND AND PURPOSE

Heavy binge drinking may trigger the onset of embolic stroke and acute myocardial infarction, but the underlying mechanisms are unclear. The effects of binge drinking on the hemostatic system and its circadian variation have not been investigated. We investigated the effects of an acute intake of a large dose of alcohol (1.5 g/kg).

METHODS

Twelve healthy, nonsmoking men participated in sessions where they were served ethanol in fruit juice or served fruit juice alone and, lying in a supine position, were followed up for 12 to 24 hours. The treatments were randomized and separated from each other by a 1-week washout period. Blood and urine were collected for hemostatic measurements.

RESULTS

The urinary excretion of the platelet thromboxane A(2) metabolite 2, 3-dinor-thromboxane B(2) was significantly (P<0.05) greater during the night after an evening intake of alcohol than during the control night. A smaller increase was observed during the daytime after an intake of alcohol in the morning. The effects on the endothelial prostacyclin metabolite 2,3-dinor-6-ketoprostaglandin F(1alpha) excretion were negligible. A 7-fold increase in plasminogen activator inhibitor 1 activity was observed after both morning (P<0. 05) and evening (P<0.01) intakes of alcohol.

CONCLUSIONS

This is the first study to suggest that acute ingestion of a relatively large but tolerable dose of alcohol transiently enhances thromboxane-mediated platelet activation. The observations also demonstrate alcohol-induced changes in the normal circadian periodicity of the hemostatic system in subjects not accustomed to consumption of alcohol.

Light-to-moderate alcohol consumption and the risk of stroke among U.S. male physicians

BACKGROUND

Several studies have shown U- or J-shaped relations between alcohol consumption and the risk of stroke. We evaluated the effect of light-to-moderate alcohol intake on the risk of stroke, with separate analyses of ischemic stroke and hemorrhagic stroke.

METHODS

Our analyses were based on a prospective cohort study of 22,071 male physicians, 40 to 84 years old, who were participating in the Physicians' Health Study. At base line, the participants reported that they had no history of stroke, transient ischemic attack, or myocardial infarction and were free of cancer. Alcohol intake, reported by 21,870 participants at base line, ranged from none or almost none to two or more drinks per day.

RESULTS

During an average of 12.2 years of follow-up, 679 strokes were reported. As compared with participants who had less than one drink per week, those who drank more had a reduced overall risk of stroke (relative risk, 0.79; 95 percent confidence interval, 0.66 to 0.94) and a reduced risk of ischemic stroke (relative risk, 0.77; 95 percent confidence interval, 0.63 to 0.94). There was no statistically significant association between alcohol consumption and hemorrhagic stroke. The overall relative risks of stroke for the men who had one drink per week, two to four drinks per week, five or six drinks per week, or one or more drinks per day were 0.78 (95 percent confidence interval, 0.59 to 1.04), 0.75 (95 percent confidence interval, 0.58 to 0.96), 0.83 (95 percent confidence interval, 0.62 to 1.11), and 0.80 (95 percent confidence interval, 0.64 to 0.99), respectively, in an analysis in which we controlled for major risk factors for stroke.

CONCLUSIONS

Light-to-moderate alcohol consumption reduced the overall risk of stroke and the risk of ischemic stroke in men. The benefit is apparent with as little as one drink per week. Greater consumption, up to one drink per day, does not increase the observed benefit.

Moderate alcohol consumption: the gentle face of Janus

OBJECTIVES

The regular consumption of alcohol in moderate amounts (defined in North America as up to 2 drinks per day for men and 1 drink per day for females) has been recognized in the last decade as a negative risk factor for atherosclerosis and its clinical sequelae: coronary heart disease (CHD), ischemic stroke, and peripheral vascular disease. Mortality and morbidity attributable to CHD are 40-60% lower in moderate drinkers than among abstainers. Among the mechanisms accounting for these reductions, increased circulating concentrations of HDL-cholesterol and inhibition of blood coagulation appear to be paramount. Additional benefits are, in certain beverages, conferred by the presence of constituents other than alcohol (e.g., flavonoids and hydroxystilbenes), which prevent oxidative damage, free radical formation, and elements of the inflammatory response.

CONCLUSIONS

A number of other diseases appear to be beneficially modulated by moderate alcohol consumption based on epidemiologic surveys and, in some instances, experimental evidence. These include duodenal ulcer, gallstones, enteric infections, rheumatoid arthritis, osteoporosis, and diabetes mellitus (type II). Compared with abstainers, moderate drinkers exhibit improved mental status characterized by decreased stress and depression, lower absenteeism from work, and decreased incidence of dementia (including Alzheimer's disease). Although limits of safe drinking have been conservatively defined, it is regrettable that political considerations are hampering the clinical application of this knowledge and its dissemination to the lay public.

Alcohol consumption and stroke incidence in male smokers

BACKGROUND

Studies on alcohol consumption and incidences of stroke subtypes have suggested distinct dose-response relationships. Blood pressure and HDL cholesterol mediate the effect of alcohol on coronary heart disease, but similar evidence on cerebrovascular diseases is not available.

METHODS AND RESULTS

We studied the risk of stroke in 26 556 male cigarette smokers 50 to 69 years of age without history of stroke. The men were categorized as nondrinkers, light (</=24 g/d), moderate (25 to 60 g/d), or heavy (>60 g/d) drinkers. A total of 960 men suffered from incident stroke: 83 with subarachnoid and 95 with intracerebral hemorrhage, 733 with cerebral infarction, and 49 with unspecified stroke. The adjusted relative risk of subarachnoid hemorrhage was 1.0 in light drinkers, 1.3 in moderate drinkers, and 1.6 in heavy drinkers compared with nondrinkers. The respective relative risks of intracerebral hemorrhage were 0.8, 0.6, and 1.8; of cerebral infarction, 0.9, 1.2, and 1.5. Systolic blood pressure attenuated the effect of alcohol consumption in all subtypes of stroke, whereas HDL cholesterol strengthened the effect of alcohol in subarachnoid hemorrhage and cerebral infarction but attenuated the effect in intracerebral hemorrhage.

CONCLUSIONS

Alcohol consumption may have a distinct dose-response relationship within each stroke subtype-linear in subarachnoid hemorrhage, U-shaped in intracerebral hemorrhage, and J-shaped in cerebral infarction-but further studies are warranted. Systolic blood pressure and HDL cholesterol seem to mediate the effect of alcohol on stroke incidence, but evidently additional mechanisms are involved.

Intake of beer, wine, and spirits and risk of stroke : the copenhagen city heart study

BACKGROUND AND PURPOSE

Alcohol consumption has been associated with a protective effect on risk of ischemic stroke. There may, however, be differences in the effect of beer, wine, and spirits due to properties other than ethanol, a topic that has gained only little attention in stroke research.

METHODS

Our analysis was a prospective cohort study of 13 329 eligible men and women, aged 45 to 84 years, participating in the Copenhagen City Heart Study. Information on alcohol habits and a number of socioeconomic and health-related factors was obtained at baseline. During 16 years of follow-up, 833 first-ever strokes occurred. Data were analyzed by means of multiple Poisson regression.

RESULTS

We found indications of a U-shaped relation between intake of alcohol and risk of stroke. In analyses adjusted for age, sex, and smoking, intake of wine on a monthly, weekly, or daily basis was associated with a lower risk of stroke compared with no wine intake (monthly: relative risk [RR], 0. 83; 95% CI, 0.69 to 0.98; weekly: RR, 0.59; 95% CI, 0.45 to 0.77; daily: RR, 0.70; 95% CI, 0.46 to 1.00). This effect of wine intake remained after complete adjustment for confounding variables (monthly: RR, 0.84; 95% CI, 0.70 to 1.02; weekly: RR, 0.66; 95% CI, 0.50 to 0.88; daily: RR, 0.68; 95% CI, 0.45 to 1.02). There was no association between intake of beer or spirits on risk of stroke.

CONCLUSIONS

The differences in the effects of beer, wine, and spirits on the risk of stroke suggest that compounds in the wine in addition to ethanol are responsible for the protective effect on risk of stroke.

Socioeconomic inequalities in stroke mortality among middle-aged men: an international overview. European Union Working Group on Socioeconomic Inequalities in Health

BACKGROUND AND PURPOSE

Several studies observed that people from lower socioeconomic groups have higher chances of dying of stroke. There are reasons to expect that these differences are relatively small in southern European countries or in Nordic welfare states. This report therefore presents an international overview of socioeconomic differences in stroke mortality.

METHODS

Unpublished data on mortality by occupational class were obtained from national longitudinal studies or cross-sectional studies. The data refer to deaths among men aged 30 to 64 years in the 1980s. A common occupational class scheme was applied to most countries. The mortality difference between manual classes and nonmanual classes was measured in relative terms (by rate ratios) and in absolute terms (by rate differences).

RESULTS

In all countries, manual classes had higher stroke mortality rates than nonmanual classes. This difference was relatively large in England and Wales, Ireland, and Finland and relatively small in Sweden, Norway, Denmark, Italy, and Spain. Differences were intermediate in the United States, France, and Switzerland. In Portugal, mortality differences were intermediate in relative terms but large in absolute terms. In most countries, inequalities were much larger for stroke mortality than for ischemic heart disease mortality.

CONCLUSIONS

Socioeconomic differences in stroke mortality are a problem common to all countries studied. There are probably large variations, however, in the contribution that different risk factors, such as tobacco and alcohol consumption, make to the stroke mortality excess of lower socioeconomic groups. Medical services can contribute to reducing socioeconomic differences in stroke mortality.

Cardiovascular effects of alcohol

The ingestion of one or two alcoholic drinks can affect heart rate, blood pressure, cardiac output, myocardial contractility, and regional blood flow. These actions generally are not clinically important. In the presence of cardiovascular disease, however, even such small quantities of alcohol might result in transient unfavorable hemodynamic changes. Moreover, alcohol abuse can produce cardiac arrhythmias, hypertension, cardiomyopathy, stroke, and even sudden death. In contrast, moderate alcohol use produces changes that have an overall favorable effect on atherosclerotic-related vascular diseases. Because cardiovascular disease due to atherosclerosis is the leading cause of death in Western society, this desirable effect of alcohol use outweighs its detrimental actions, resulting in favorable findings in population studies. Nevertheless, the body of evidence argues against encouraging alcohol use for its cardiovascular effects.

Effects of moderate alcohol consumption on the central nervous system

The concept of moderate consumption of ethanol (beverage alcohol) has evolved over time from considering this level of intake to be nonintoxicating and noninjurious, to encompassing levels defined as "statistically" normal in particular populations, and the public health-driven concepts that define moderate drinking as the level corresponding to the lowest overall rate of morbidity or mortality in a population. The various approaches to defining moderate consumption of ethanol provide for a range of intakes that can result in blood ethanol concentrations ranging from 5 to 6 mg/dl, to levels of over 90 mg/dl (i.e., approximately 20 mM). This review summarizes available information regarding the effects of moderate consumption of ethanol on the adult and the developing nervous systems. The metabolism of ethanol in the human is reviewed to allow for proper appreciation of the important variables that interact to influence the level of exposure of the brain to ethanol once ethanol is orally consumed. At the neurochemical level, the moderate consumption of ethanol selectively affects the function of GABA, glutamatergic, serotonergic, dopaminergic, cholinergic, and opioid neuronal systems. Ethanol can affect these systems directly, and/or the interactions between and among these systems become important in the expression of ethanol's actions. The behavioral consequences of ethanol's actions on brain neurochemistry, and the neurochemical effects themselves, are very much dose- and time-related, and the collage of ethanol's actions can change significantly even on the rising and falling phases of the blood ethanol curve. The behavioral effects of moderate ethanol intake can encompass events that the human or other animal can perceive as reinforcing through either positive (e.g., pleasurable, activating) or negative (e.g., anxiolysis, stress reduction) reinforcement mechanisms. Genetic factors and gender play an important role in the metabolism and behavioral actions of ethanol, and doses of ethanol producing pleasurable feelings, activation, and reduction of anxiety in some humans/animals can have aversive, sedative, or no effect in others. Research on the cognitive effects of acute and chronic moderate intake of ethanol is reviewed, and although a number of studies have noted a measurable diminution in neuropsychologic parameters in habitual consumers of moderate amounts of ethanol, others have not found such changes. Recent studies have also noted some positive effects of moderate ethanol consumption on cognitive performance in the aging human. The moderate consumption of ethanol by pregnant women can have significant consequences on the developing nervous system of the fetus. Consumption of ethanol during pregnancy at levels considered to be in the moderate range can generate fetal alcohol effects (behavioral, cognitive anomalies) in the offspring. A number of factors--including gestational period, the periodicity of the mother's drinking, genetic factors, etc.--play important roles in determining the effect of ethanol on the developing central nervous system. A series of recommendations for future research endeavors, at all levels, is included with this review as part of the assessment of the effects of moderate ethanol consumption on the central nervous system.