Unrecognized left ventricular dysfunction in an apparently healthy alcohol abuse population

Vitamin D deficiency, cardiothoracic ratio, and long-term mortality in hemodialysis patients

Hemodialysis patients are a special group of patients with higher mortality rates. Hemodialysis patients with vitamin D deficiency {plasma levels of 25-hydroxyvitamin D [25(OH)D] below 20 ng/mL} are associated with even higher mortality rates. The prognostic importance of vitamin D deficiency in hemodialysis patients with different cardiothoracic ratios (CTRs) is still unclear. This prospective study was performed in a single hemodialysis center, and 186 patients were included. This study analyzed the prognostic importance of vitamin D deficiency in hemodialysis patients with different CTRs. Vitamin D deficiency patients had a significantly higher prevalence of stroke and diabetic mellitus than those without vitamin D deficiency. In addition, the CTR was higher in patients with vitamin D deficiency than in those without vitamin D deficiency. After multivariate logistic regression, we found that CTR was the solitary factor that was independently significantly associated with vitamin D deficiency [odds ratio: 1.07, 95% confidence internal (CI): 1.01–1.13, p = 0.02]. Additionally, vitamin D deficiency was associated with all-cause mortality in patients with higher CTR after adjustment in hierarchical regression models. In conclusion, we reported that vitamin D deficiency was independently significantly associated with a higher CTR. We additionally revealed that vitamin D deficiency was an independent predicator for all-cause mortality in higher CTR hemodialysis patients.

Association between cardiothoracic ratio, left ventricular size and systolic function in patients undergoing computed tomography coronary angiography

The present study aimed to investigate the association between cardiothoracic ratio (CTR) and left ventricular (LV) systolic function parameters in patients with or without preserved LV ejection fraction (LVEF). A total of 203 subjects suspected with coronary artery disease underwent chest radiography and dual source computed tomography coronary angiography (DSCT-CA). The LV systolic function parameters: LV end-diastolic volume index (LVEDVI), LV end-systolic volume index (LVESVI), and LVEF were measured from the DSCT-CA. The association between CTR and LV systolic function parameters was analyzed according to LVEF value (<55%, depressed LVEF group; versus ≥55%, preserved LVEF group) and CTR value (<0.5, normal range CTR group; versus ≥0.5, larger CTR group). The LVEDVI and LVESVI were higher in the depressed LVEF group compared with the preserved LVEF group (108.56±57.15 vs. 67.52±14.56 ml/m², P<0.001; and 64.07±37.81 vs. 20.23±7.23 ml/m², P<0.001, respectively) and lower in the normal range CTR group compared with the larger CTR group (67.10±15.00 vs. 77.30±34.32 ml/m², P=0.009 and 21.94±8.96 vs. 28.97±26.54 ml/m², P=0.017, respectively). Significant correlations were found between CTR and LVEDVI, and LVESVI and LVEF in the depressed LVEF group (r=0.66, P<0.001; r=0.65, P<0.001; and r=−0.46, P=0.018, respectively). However, there was no significant association detected between CTR and LV systolic function parameters in the other subgroups. The LVEDVI and LVESVI showed an inverse correlation with the LVEF in each group. Although the CTR was not a reliable indicator of LV size and systolic function in patients with preserved LVEF, it was correlated with LV size and LVEF in patients with depressed LVEF.

Natural history and prognostic factors in alcoholic cardiomyopathy

OBJECTIVES

This study sought to determine the natural history of contemporary alcoholic cardiomyopathy (ACM), to compare it with that of idiopathic dilated cardiomyopathy (IDCM), and to identify risk factors for poor outcome.

BACKGROUND

ACM is a common cause of dilated cardiomyopathy (DCM), but little is known about its natural history or the effect of reducing alcohol intake on disease progression.

METHODS

We studied the clinical characteristics and outcomes of 94 consecutive patients with ACM and 188 with IDCM, evaluated over the period between 1993 and 2011.

RESULTS

After a median follow-up of 59 months (interquartile range: 25 to 107 months), 14 ACM patients (15%) had died from cardiovascular causes (6 from heart failure and 8 from sudden cardiac death), 14 (15%) underwent heart transplantation, 35 (37%) experienced recovery in left ventricular function, and 31 (33%) remained clinically stable without improvement in systolic function. Transplantation-free survival was higher in ACM patients than in IDCM patients (p = 0.002), and ACM was associated with a favorable outcome on multiple analysis of the entire cohort (odds ratio [OR]: 0.4; 95% confidence interval [CI]: 0.2 to 0.8; p = 0.01). Independent predictors of death or heart transplantation in ACM identified by multiple logistic regression analysis were atrial fibrillation (OR: 9.7; 95% CI: 2.56 to 36.79; p = 0.001); QRS duration >120 ms (OR: 7.2; 95% CI: 2.02 to 26; p = 0.002), and lack of beta-blocker therapy (OR: 4.4; 95% CI: 1.35 to 14.49; p = 0.014). ACM patients who reduced their alcohol intake to moderate levels exhibited similar survival (p = 0.22) and cardiac function recovery (p = 0.8) as abstainers.

CONCLUSIONS

ACM has a better prognosis than IDCM. Atrial fibrillation, QRS width >120 ms, and the absence of beta-blocker therapy identify patients with a poor outcome. Alcohol abstainers and those who reduce intake to a moderate degree show similar clinical outcomes.

Alcohol consumption and risk of heart failure: a meta-analysis

BACKGROUND

Heart failure is highly prevalent among older adults and is associated with high treatment costs. Identifying modifiable determinants of heart failure may help in prevention. Alcohol consumption has emerged as a modifiable risk factor for cardiovascular diseases. Although many studies have suggested a positive association between heavy drinking and cardiomyopathy, the association between infrequent or light-to-moderate drinking and heart failure risk has been less conclusive.

PURPOSE

To examine the relation between various levels of alcohol intake and incident heart failure.

METHODS

We conducted a meta-analysis of 6 studies obtained through a PubMed literature search. Alcohol drinkers were classified as never, former, and current drinkers of 0.1 to 0.9, 1 to 7, 8 to 14, and > 14 drinks per week.

RESULTS

Compared with never drinkers, the pooled relative risks were 1.16 (95% confidence interval [CI], 0.90-1.51) for former drinkers, 0.90 (95% CI, 0.83-0.98), 0.80 (95% CI, 0.73-0.88), 0.78 (95% CI, 0.65-0.95), and 0.77 (95% CI, 0.63-0.95) for current drinkers of 0.1 to 0.9, 1 to 7, 8 to 14, and > 14 drinks per week, respectively, in a random effects model.

CONCLUSION

These data suggest that infrequent and light-to-moderate drinking is associated with a lower risk of heart failure.

Alcohol consumption and heart failure in hypertensive US male physicians

Although alcohol drinking increases blood pressure and heavy drinking has been associated with alcoholic cardiomyopathy, little is known about the association between light to moderate drinking and risk of heart failure (HF) in hypertensive subjects. Thus, the association between light to moderate drinking and incident HF in 5,153 hypertensive male physicians who were free of stroke, myocardial infarction, or major cancers at baseline was prospectively examined. Alcohol consumption was self-reported and classified as <1, 1 to 4, 5 to 7, and >or=8 drinks/week. HF was ascertained using follow-up questionnaires and validated using Framingham criteria. Average age was 58 years, and about 70% of subjects consumed 1 to 7 drinks/week. A total of 478 incident HF cases occurred in this cohort during follow-up. Compared with subjects consuming <1 drink/week, hazard ratios for HF were 0.89 (95% confidence interval [CI] 0.70 to 1.12), 0.72 (95% CI 0.57 to 0.91), and 0.38 (95% CI 0.20 to 0.72) for alcohol consumption of 1 to 4, 5 to 7, and >or=8 drinks/week after adjustment for age, body mass index, smoking, randomization group, use of multivitamins, vegetable consumption, breakfast cereal, exercise, and history of atrial fibrillation, respectively (p for trend <0.001). Similar results were obtained for subjects with HF with and without antecedent myocardial infarction and those without diabetes mellitus. In conclusion, our data suggested that light to moderate alcohol consumption was associated with a lower risk of HF in hypertensive male physicians.

Alcohol consumption and risk of heart failure in the Physicians' Health Study I

BACKGROUND

Heart failure (HF) is the leading cause of hospitalization among the elderly, and 1 in 5 adults aged 40 years will develop HF in their lifetime. Data on the effects of moderate alcohol consumption on the risk of HF have been sparse and inconsistent. This study sought to evaluate the association between moderate alcohol consumption and incident HF.

METHODS AND RESULTS

A total of 21,601 participants of the Physicians' Health Study I who were free of HF and provided data on alcohol intake at baseline were prospectively followed up from 1982 to 2005. Incident HF cases were ascertained through annual follow-up questionnaires and validated with the use of Framingham criteria. During an average follow-up of 18.4 years, 904 incident cases of HF occurred. The crude incidence rates of HF were 25.0, 20.0, 24.3, and 20.6 cases per 10,000 person-years for alcohol categories of <1, 1 to 4, 5 to 7, and >7 drinks per week, respectively. Corresponding hazard ratios (95% CI) were 1.0 (reference), 0.90 (0.76 to 1.07), 0.84 (0.71 to 0.99), and 0.62 (0.41 to 0.96), respectively, with P for trend=0.012 adjusted for age, body mass index, smoking, and history of valvular heart disease. There was no evidence for a strong association between moderate alcohol consumption and HF without antecedent coronary artery disease.

CONCLUSIONS

Although heavy drinking should be discouraged, our data indicate that moderate drinking may lower the risk of HF. The lack of an association between moderate alcohol intake and HF without antecedent coronary artery disease suggests that possible benefits of moderate drinking on HF may be mediated through beneficial effects of alcohol on coronary artery disease.

Alcohol and the myocardium

Structural and functional abnormalities are prominent in alcoholic cardiomyopathy (ACM). Histological features in affected subjects are almost identical to the characteristics of dilated cardiomyopathy. Quantitative morphometry, however, can distinguish between ACM and dilated cardiomyopathy. Biopsies from patients with ACM show increases in the activities of some myocardial enzymes (alpha-hydroxybutyric dehydrogenase, creatine kinase, lactate dehydrogenase, malic dehydrogenase) which are correlated with the bimodal distribution of alcohol intake and may represent an adaptive response. One-third of patients with ACM have serum antibodies against cardiac acetaldehyde-protein adducts. Animal models of ethanol toxicity have shown that acutely, alcohol and acetaldehyde reduce the synthesis of cardiac contractile proteins in vivo. Two-dimensional SDS-PAGE has also shown that in rats chronically fed alcohol, the relative amounts of over 10% of heart muscle proteins are altered. The heat shock proteins (HSP) Hsp60 and Hsp70 are decreased in alcohol-fed rats, as is desmin. Reduction in HSPs may indicate reduced myocardial protection whilst a fall in desmin may indicate structural defects. In conclusion, ACM is a complex process that is due to altered protein synthesis, the formation of acetaldehyde adducts and a reduction of cardiac HSPs and desmin. Both acetaldehyde and alcohol are myocardial perturbants.

Ethanol feeding produces deficiencies in left ventricle total RNA, total DNA and mitochondrial ribosomal RNA

Chronic alcoholism causes a variety of ultrastructural, biochemical and functional alterations in the myocardium, but the underlying mechanisms are not well understood. Molecular changes that developed in the left ventricles of rats fed for 1 to 24 weeks on liquid diets containing ethanol as 36% of total calories were analyzed. Total tissue RNA and DNA were chemically extracted and measured by spectroscopic methods; mitochondrial DNA and mitochondrially-coded ribosomal RNA were measured at the 12s rRNA region by a quantitative polymerase chain reaction method; mitochondrial protein and enzyme activities were assayed. Ethanol-fed rats had 83.9 +/- 2.9% (mean +/- S.E.M.) as much DNA/g tissue and 74.7 +/- 3.9% as much total left ventricle DNA as pair-fed controls (P < 0.001). The alcoholics had 71.4 +/- 1.7% as much RNA/g tissue and 64.4 +/- 2.7% as much total left ventricle RNA as controls (P < 0.001). Mitochondrially-coded 12s rRNA was a lower proportion of total left ventricle RNA in all of the alcoholics; it was only 59.9 +/- 4.6% of control values (P < 0.001). Total left ventricle 12s rRNA was < 40% of normal. There was little or no change in mitochondrial DNA levels measured at the 12s location. Mitochondrial cytochrome contents were reduced 26-38% in the ethanol-fed rats, but only after 24 weeks. This study shows that experimental alcoholism produces rapid and sustained decreases in left ventricle total RNA and DNA and mitochondrial ribosomal RNA. The observed effects would be expected to have a major impact on left ventricle structural integrity and functional capacity.

Alcohol and heart muscle disease

Ethanol consumption may induce acute and chronic effects on the myocardium. High-dose acute ethanol intake may induce a decrease in myocardial contraction and produce a variety of rhythm disturbances. These effects are more relevant in patients with underlying cardiomyopathy. Chronic ethanol intake may induce the development of a dilated cardiomyopathy, which is clinically and functionally similar to idiopathic dilated cardiomyopathy. Alcoholic cardiomyopathy is potentially reversible with abstinence. The prognosis depends on the persistence or abstinence of ethanol intake. There is a positive correlation between alcoholic cardiomyopathy and the presence of other ethanol-related diseases, such as skeletal myopathy and cirrhosis. In patients with a specific ethanol-related disease, the possible presence of other complications of alcoholism should be ruled out. Although there are several factors potentially implicated in the pathogenesis of alcohol-related myocardial damage, ethanol itself may induce direct myocardial lesions, which are dose-related and independent of nutrition, protein or ionic deficiencies. The most relevant pathogenic studies on alcoholic cardiomyopathy are based on the disruption of membrane permeability and ionic fluxes mediated by ethanol, inducing a decrease in the calcium transients through the sarcolemma and interfering with the excitation-contraction coupling of myocytes. Cell energy depletion or protein-turnover disruption may contribute to the deleterious effect of ethanol on the myocardium.

Sepsis protects the heart of alcoholic rats from ischemia-reperfusion injury

We have previously shown that administration of Escherichia coli to a rat induces cardiac dysfunction, but also prevents the myocardium from being further damaged by total ischemia. We have also previously shown that induction of sepsis in a rat that has consumed alcohol as 36% of its caloric intake for 8-10 weeks, results in a potentiation of the cardiac depression resulting from sepsis. In this study, we determined if administration of Gram-negative bacteria to a chronically alcoholic rat would still protect the heart from ischemia-reperfusion injury. We tested the protective effect of sepsis using an in vitro, isovolumically contracting heart preparation. Global ischemia was maintained for 35 min, followed by 25-min reperfusion. In the present experiments, sepsis produced a 40% decrease in cardiac performance, but was also protective of hearts made ischemic the next day. Hearts from septic and alcoholic septic rats recovered 100% of preischemic ventricular function after 35-min ischemia, whereas hearts from the control and alcohol groups recovered only 80% of preischemic left ventricular performance. Whereas preischemic function was significantly decreased in the septic groups compared with the two nonseptic groups, postischemic function was no longer significantly different in the four groups. Thus, sepsis resulted in development of protection of the hearts from ischemia-reperfusion injury, even in hearts that were severely compromised by the combination of chronic alcoholism and Gram-negative sepsis.