The association of alcohol consumption and incident heart failure: the Cardiovascular Health Study

Alcoholic cardiomyopathy: an update

Alcohol-induced cardiomyopathy (AC) is an acquired form of dilated cardiomyopathy (DCM) caused by prolonged and heavy alcohol intake in the absence of other causes. The amount of alcohol required to produce AC is generally considered as >80 g/day over 5 years, but there is still some controversy regarding this definition. This review on AC focuses on pathogenesis, which involves different mechanisms. Firstly, the direct toxic effect of ethanol promotes oxidative stress in the myocardium and activation of the renin-angiotensin system. Moreover, acetaldehyde, the best-studied metabolite of alcohol, can contribute to myocardial damage impairing actin-myosin interaction and producing mitochondrial dysfunction. Genetic factors are also involved in the pathogenesis of AC, with DCM-causing genetic variants in patients with AC, especially titin-truncating variants. These findings support a double-hit hypothesis in AC, combining genetics and environmental factors. The synergistic effect of alcohol with concomitant conditions such as hypertension or liver cirrhosis can be another contributing factor leading to AC. There are no specific cardiac signs and symptoms in AC as compared with other forms of DCM. However, natural history of AC differs from DCM and relies directly on alcohol withdrawal, as left ventricular ejection fraction recovery in abstainers is associated with an excellent prognosis. Thus, abstinence from alcohol is the most crucial step in treating AC, and specific therapies are available for this purpose. Otherwise, AC should be treated according to current guidelines of heart failure with reduced ejection fraction. Targeted therapies based on AC pathogenesis are currently being developed and could potentially improve AC treatment in the future.

Alcohol and Heart Failure

Alcohol is the most frequently consumed toxic substance in the world and remains a major global public health issue, with one in three adults consuming it worldwide. Alcohol use is a leading risk factor for disease, contributing to over 60 acute and chronic health conditions, with a particularly complex association with cardiovascular disease. Chronic excessive alcohol consumption is associated with a range of cardiac complications, including decreased myocardial contractility, hypertension, arrhythmias, MI and heart failure. However, low-level alcohol consumption is believed to have a protective effect against ischaemic heart disease and diabetes. In most cohort studies, small to moderate amounts of alcohol consumption have not been linked to heart failure, indicating a threshold effect of alcohol with individual (possibly genetic) predisposition rather than a continuous effect of exposure. This review article explores the potential benefits of alcohol on the heart, the association between alcohol use and alcoholic cardiomyopathy and the epidemiology, clinical correlates and management of alcoholic cardiomyopathy.

Complementary and Alternative Medicines in the Management of Heart Failure: A Scientific Statement From the American Heart Association

Complementary and alternative medicines (CAM) are commonly used across the world by diverse populations and ethnicities but remain largely unregulated. Although many CAM agents are purported to be efficacious and safe by the public, clinical evidence supporting the use of CAM in heart failure remains limited and controversial. Furthermore, health care professionals rarely inquire or document use of CAM as part of the medical record, and patients infrequently disclose their use without further prompting. The goal of this scientific statement is to summarize published efficacy and safety data for CAM and adjunctive interventional wellness approaches in heart failure. Furthermore, other important considerations such as adverse effects and drug interactions that could influence the safety of patients with heart failure are reviewed and discussed.

Alcohol consumption and the risk of heart failure: the Suita Study and meta-analysis of prospective cohort studies

BACKGROUND

Alcohol consumption is a modifiable lifestyle, but its role in heart failure (HF) development is controversial. Herein, we investigated the prospective association between alcohol consumption and HF risk.

METHODS

A total of 2,712 participants (1,149 men and 1,563 women) from the Suita Study were followed up every two years. Cox regression was applied to calculate the hazard ratios (HRs) and 95% confidence intervals (95% CIs) of HF risk for heavy drinking (≥46 g/day in men or ≥23 g/day in women) and never drinking compared to light drinking (<23 g/day in men or <11.5 g/day in women). Then, we combined the results of the Suita Study with those from other eligible prospective cohort studies in a meta-analysis using the random-effects model.

RESULTS

In the Suita Study, within a median follow-up period of 8 years, 319 HF cases (162 in men and 157 in women) were detected. In men, but not women, never and heavy drinking carried a higher risk of HF than light drinking: HRs (95% CIs) = 1.65 (1.00, 2.73) and 2.14 (1.26, 3.66), respectively. Alike, the meta-analysis showed a higher risk of HF among heavy drinkers: HR (95% CI) = 1.37 (1.15, 1.62) and abstainers: HR (95% CI) = 1.18 (1.02, 1.37).

CONCLUSION

We indicated a J-shaped association between alcohol consumption and HF risk among Japanese men. The results of the meta-analysis came in line with the Suita Study. Heavy-drinking men should be targeted for lifestyle modification interventions.

Changes in Alcohol Consumption and Risk of Heart Failure: A Nationwide Population-Based Study in Korea

Background: The association between alcohol intake and newly developed heart failure remains unclear. We aimed to measure the change in alcohol intake between two timepoints to evaluate the association of alcohol consumption with incident heart failure using a population-based study in Korea. Methods: Using the Korean National Health Insurance database, participants who underwent two subsequent national health examinations in 2009 and 2011 were included. Participants were classified into four groups according to total alcohol intake (none: 0 g alcohol/day; light: <15 g alcohol/day; moderate: 15−30 g alcohol/day; and heavy: ≥30 g alcohol/day), and changes in alcohol consumption between the two health exams were grouped into the following five categories: abstainers, sustainers (those who maintained their first examination drinking level), increasers, reducers, and quitters. After adjustment for age, sex, smoking status, regular exercise, socioeconomic information, and comorbidities, the Charlson Comorbidity Index, systolic blood pressure, and laboratory results, a Cox proportional hazards model was used to find the risk of newly diagnosed heart failure (according to ICD-10 code I50 from claims for the first hospitalization) as the primary endpoint. A subgroup analysis among those with a third examination was conducted to reflect further changes in alcohol consumption. Results: Among 3,842,850 subjects, 106,611 (3.0%) were diagnosed with heart failure during the mean follow-up period of 6.3 years. Increasers to a light level of drinking had a lower HF risk compared with abstainers (aHR = 0.91, 95% CI: 0.89−0.94). Those who increased their alcohol intake to a heavy level had a higher HF risk (from light to heavy (aHR = 1.19, 95% CI: 1.12−1.26) and from a moderate to heavy level (aHR = 1.13, 95% CI: 1.07−1.19). Reducing alcohol from a heavy to moderate level was associated with lower HF risk (aHR = 0.90, 95% CI: 0.86−0.95). Conclusion: This study found that light and moderate sustainers had lower incident heart failure risk compared with abstainers. Increased alcohol consumption from light to moderate to heavy was associated with a higher incident heart failure risk.

Alcohol Intake in Patients With Cardiomyopathy and Heart Failure: Consensus and Controversy

Alcohol is often cited to be a common cause of cardiomyopathy and heart failure. However, in most available population-based studies, a modest-to-moderate alcohol consumption has been associated with favorable effects on the cardiovascular system, including a lowered risk of heart failure, compared with no alcohol consumption. Available genetic epidemiological data have not supported a causal association between alcohol consumption and heart failure risk, suggesting that alcohol may not be a common cause of heart failure in the community. Data linking alcohol intake with cardiomyopathy risk are sparse, and the concept of alcoholic cardiomyopathy stems mainly from case series of selected patients with dilated cardiomyopathy, where a large proportion reported a history of excessive alcohol intake. This state-of-the-art paper addresses the current knowledge of the epidemiology of alcoholic cardiomyopathy and the role of alcohol intake in patients with non-alcohol-related heart failure. It also offers directions to future research in the area. The review questions the validity of current clinical teaching in the area. It is not well known how much alcohol is needed to cause disease, and the epidemiological pathways linking alcohol consumption to cardiomyopathy and heart failure are not well understood. Until more evidence becomes available, caution is warranted before labeling patients as having alcoholic cardiomyopathy due to a risk of neglecting other contributors, such as genetic causes of cardiomyopathy. In non-alcohol-related heart failure, it is unknown whether total abstinence is improving outcomes (compared with moderate drinking). Ideally, randomized clinical trials are needed to answer this question.

Characterization of myocardial oxidative metabolism and myocardial external efficiency in high-risk alcohol cardiotoxicity and alcoholic cardiomyopathy via dynamic 11C-Acetate positron emission tomography

INTRODUCTION

The purpose of this study was to evaluate subjects with high-risk alcohol cardiotoxicity and patients with alcoholic cardiomyopathy (ACM) via dynamic 11C-Acetate positron emission tomography (PET) imaging as a myocardial oxidative metabolic probe.

METHODS AND RESULTS

We recruited 37 subjects with chronic alcohol consumption [18 with moderate consumption (MC), 19 with heavy consumption (HC)], 5 ACM patients, and 12 healthy controls to receive dynamic 11C-Acetate PET scans. PET imaging data were analyzed to calculate kinetic parameters (e.g., Kmono, K1 and k2) based on the mono-exponential and one-tissue compartmental models. Myocardial oxygen consumption (MVO2) and myocardial external efficiency (MEE) were then derived from these kinetic parameters. MVO2 was significantly lowered in the HC group and in ACM patients (0.121± 0.018 and 0.111 ± 0.017 mL·g-1·min-1, respectively) compared with those in healthy controls and MC subjects (0.144 ± 0.023 and 0.146 ± 0.027 mL·g-1·min-1, respectively; P < .01). MEE was significantly reduced in ACM patients (13.0% ± 4.3%) compared with those of healthy controls (22.4% ± 4.6%, P < .01), MC subjects (20.1% ± 4.5%, P < .05), and HC subjects (22.3% ± 4.5%, P < .001).

CONCLUSION

Functional assessment via dynamic 11C-Acetate PET imaging may represent a clinically feasible probe for identifying cohorts with high-risk cardiotoxicity due to addictive alcohol consumption and ACM.

Drugs of Abuse and Heart Failure

Substance use is common among those with heart failure (HF) and is associated with worse clinical outcomes. Alcohol, tobacco, cannabis, and cocaine are commonly abused substances that can contribute to the development and worsening of HF. Heavy alcohol consumption can lead to dilated cardiomyopathy, whereas moderate intake may decrease incident HF. Tobacco increases the risk of HF through coronary artery disease and coronary artery disease-independent mechanisms. Continued smoking worsens outcomes for those with HF and cessation is associated with an improved risk of major adverse cardiac events. Cannabis has complex interactions on the cardiovascular system depending on the method of consumption, amount consumed, and content of cannabinoids. Delta-9-tetrahydrocannabinol can increase sympathetic tone, cause vascular dysfunction, and may increase the risk of myocardial infarction. Cannabidiol is cardioprotective in preclinical studies and is a potential therapeutic target. Cocaine increases sympathetic tone and is a potent proarrhythmogenic agent. It increases the risk of myocardial infarction and can also lead to a dilated cardiomyopathy. The use of beta-blockers in those with HF and cocaine use is likely safe and effective. Future studies are needed to further elucidate the impact of these substances both on the development of HF and their effects on those who have HF.

A Review of Nutritional Requirements of Adults Aged ≥65 Years in the UK

Appropriate dietary choices in later life may reduce the risk of chronic diseases and rate of functional decline, however, there is little well-evidenced age-specific nutritional guidance in the UK for older adults, making it challenging to provide nutritional advice. Therefore, the aim of this critical review was to propose evidence-based nutritional recommendations for older adults (aged ≥65 y). Nutrients with important physiological functions in older adults were selected for inclusion in the recommendations. For these nutrients: 1) recommendations from the UK Scientific Advisory Committee for Nutrition (SACN) reports were reviewed and guidance retained if recent and age-specific, and 2) a literature search conducted where SACN guidance was not sufficient to set or confirm recommendations for older adults, searching Web of Science up to March 2020. Data extracted from a total of 190 selected publications provided evidence to support age-specific UK recommendations for protein (1.2 g·kg-1·d-1), calcium (1000 mg·d-1), folate (400 μg·d-1), vitamin B-12 (2.4 μg·d-1), and fluid (1.6 L·d-1 women, 2.0 L·d-1 men) for those ≥65 y. UK recommendations for carbohydrates, free sugars, dietary fiber, dietary fat and fatty acids, sodium, and alcohol for the general population are likely appropriate for older adults. Insufficient evidence was identified to confirm or change recommendations for all other selected nutrients. In general, significant gaps in current nutritional research among older adults existed, which should be addressed to support delivery of tailored nutritional guidance to this age group to promote healthy aging.

Clarifying the neurobehavioral sequelae of moderate drinking lifestyles and acute alcohol effects with aging

Epidemiological estimates indicate not only an increase in the proportion of older adults, but also an increase in those who continue moderate alcohol consumption. Substantial literatures have attempted to characterize health benefits/risks of moderate drinking lifestyles. Not uncommonly, reports address outcomes in a single outcome, such as cardiovascular function or cognitive decline, rather than providing a broader overview of systems. In this narrative review, retaining focus on neurobiological considerations, we summarize key findings regarding moderate drinking and three health domains, cardiovascular health, Type 2 diabetes (T2D), and cognition. Interestingly, few investigators have studied bouts of low/moderate doses of alcohol consumption, a pattern consistent with moderate drinking lifestyles. Here, we address both moderate drinking as a lifestyle and as an acute event. Review of health-related correlates illustrates continuing inconsistencies. Although substantive reductions in risk for cardiovascular and T2D events are reported, robust conclusions remain elusive. Similarly, whereas moderate drinking is often associated with enhanced cognition and lower dementia risk, few benefits are noted in rates of decline or alterations in brain structure. The effect of sex/gender varies across health domains and by consumption levels. For example, women appear to differentially benefit from alcohol use in terms of T2D, but experience greater risk when considering aspects of cardiovascular function. Finally, we observe that socially relevant alcohol doses do not consistently impair performance in older adults. Rather, older drinkers demonstrate divergent, but not necessarily detrimental, patterns in neural activation and some behavioral measures relative to younger drinkers. Taken together, the epidemiological and laboratory studies reinforce the need for greater attention to key individual differences and for the conduct of systematic studies sensitive to age-related shifts in neurobiological systems.

Relation of Alcohol Consumption to Left Ventricular Fibrosis Using Cardiac Magnetic Resonance Imaging

Light-to-moderate regular alcohol consumption has been associated with reduced mortality, heart failure, and sudden death, with a well described "U-shaped" relationship. We sought to determine whether markers of diffuse ventricular fibrosis as assessed by cardiac magnetic resonance imaging (CMR) T₁ mapping differ between nondrinkers and regular drinkers. We prospectively recruited 165 participants to undergo 3T CMR ventricular T1 mapping which included 120 regular light-to-moderate drinkers (7 to 28 standard drinks per week for >12 months) and 45 age and gender-matched nondrinking controls (1 standard drink ∼12 g alcohol). Diffuse ventricular fibrosis was assessed using ShMOLLI T1 mapping sequences performed in mid-short axis. Native T1, postcontrast T1 times and extracellular volume were compared in the left ventricle between regular drinkers and lifelong nondrinkers. In total 165 participants (mean age 59 ± 12 years, 70% male, 36% hypertension, mean LVEF 58 ± 11%) underwent CMR. Moderate alcohol intake (mean alcohol intake 16 ± 6 SDs/week) was associated with lower markers of diffuse ventricular fibrosis: native T1 time 1140 ± 47 vs 1173 ± 39 ms, p < 0.001; postcontrast T1 time 470 ± 47 vs 445 ± 43 ms, p = 0.01; extracellular volume 25.0 ± 2.7% vs 27.0 ± 2.8%, p = 0.003 despite similar LV size (p = 0.55) and mass compared with nondrinkers (p = 0.78). Quantity of alcohol intake and beverage type did not predict lower native T1 times. In conclusion, light-to-moderate or "social" alcohol consumption is associated with T1 changes on CMR suggestive of a reduction in diffuse ventricular fibrosis. These preliminary findings may provide some insights into the association between modest alcohol intake and reduction in sudden death and heart failure.

The association between alcohol consumption and left ventricular diastolic function and geometry change in general Korean population

Aims

The adverse effect of heavy alcohol intake on cardiovascular disease is well established. However, there is only limited information about the risk of subclinical left ventricular (LV) abnormality according to alcohol consumption. Thus, this study was to investigate the association between alcohol consumption and LV functional and structural abnormality.

Methods and results

Study participants were 49 714 Korean adults received echocardiogram as an item of health check-up program. They were stratified into 6 groups according to alcohol consumption; non (life time never drinker), occasional (<1 g/day), light (1-15 g/day), moderate (15-30 g/day), heavy (30-60 g/day), and very heavy (>60 g/day) drinker. Multiple logistic regression analysis was used to assess the odd ratios (ORs) for LV hypertrophy (LVH), increased relative wall thickness (RWT) and impaired LV diastolic (LVD) function with a reference of non-drinker. Additionally, the adjusted mean values of echocardiographic parameters were evaluated to assess LV diastolic function and structure. In logistic regression analysis, very heavy alcohol drinker had the highest adjusted ORs for LVH, increased RWT and impaired LVD function in all participants and male subgroup (P < 0.05). The dose dependent relationship was found between alcohol consumption and impaired LVD function in all participants and gender subgroups. There was no specific pattern of relationship to suggest the favourable effect of light alcohol drinking on heart.

Conclusion

Increased alcohol intake had the adverse effect on LV function and structure. However, potential favourable effect of light alcohol intake was not observed. Prospective studies are required to investigate long-term effect of alcohol consumption on subclinical LV change.

Association of Alcohol Consumption After Development of Heart Failure With Survival Among Older Adults in the Cardiovascular Health Study

IMPORTANCE

More than 1 million older adults develop heart failure annually. The association of alcohol consumption with survival among these individuals after diagnosis is unknown.

OBJECTIVE

To determine whether alcohol use is associated with increased survival among older adults with incident heart failure.

DESIGN, SETTING, AND PARTICIPANTS

This prospective cohort study included 5888 community-dwelling adults aged 65 years or older who were recruited to participate in the Cardiovascular Health Study between June 12, 1989, and June 1993, from 4 US sites. Of the total participants, 393 individuals had a new diagnosis of heart failure within the first 9 years of follow-up through June 2013. The study analysis was performed between January 19, 2016, and September 22, 2016.

EXPOSURES

Alcohol consumption was divided into 4 categories: abstainers (never drinkers), former drinkers, 7 or fewer alcoholic drinks per week, and more than 7 drinks per week.

PRIMARY OUTCOMES AND MEASURES

Participant survival after the diagnosis of incident heart failure.

RESULTS

Among the 393 adults diagnosed with incident heart failure, 213 (54.2%) were female, 339 (86.3%) were white, and the mean (SD) age was 78.7 (6.0) years. Alcohol consumption after diagnosis was reported in 129 (32.8%) of the participants. Across alcohol consumption categories of long-term abstainers, former drinkers, consumers of 1-7 drinks weekly and consumers of more than 7 drinks weekly, the percentage of men (32.1%, 49.0%, 58.0%, and 82.4%, respectively; P < .001 for trend), white individuals (78.0%, 92.7%, 92.0%, and 94.1%, respectively, P <. 001 for trend), and high-income participants (22.0%, 43.8%, 47.3%, and 64.7%, respectively; P < .001 for trend) increased with increasing alcohol consumption. Across the 4 categories, participants who consumed more alcohol had more years of education (mean, 12 years [interquartile range (IQR), 8.0-10.0 years], 12 years [IQR, 11.0-14.0 years], 13 years [IQR, 12.0-15.0 years], and 13 years [IQR, 12.0-14.0 years]; P < .001 for trend). Diabetes was less common across the alcohol consumption categories (32.1%, 26.0%, 22.3%, and 5.9%, respectively; P = .01 for trend). Across alcohol consumption categories, there were fewer never smokers (58.3%, 44.8%, 35.7%, and 29.4%, respectively; P < .001 for trend) and more former smokers (34.5%, 38.5%, 50.0%, and 52.9%, respectively; P = .006 for trend). After controlling for other factors, consumption of 7 or fewer alcoholic drinks per week was associated with additional mean survival of 383 days (95% CI, 17-748 days; P = .04) compared with abstinence from alcohol. Although the robustness was limited by the small number of individuals who consumed more than 7 drinks per week, a significant inverted U-shaped association between alcohol consumption and survival was observed. Multivariable model estimates of mean time from heart failure diagnosis to death were 2640 days (95% CI, 1967-3313 days) for never drinkers, 3046 days (95% CI, 2372-3719 days) for consumers of 0 to 7 drinks per week, and 2806 (95% CI, 1879-3734 days) for consumers of more than 7 drinks per week (P = .02). Consumption of 10 drinks per week was associated with the longest survival, a mean of 3381 days (95% CI, 2806-3956 days) after heart failure diagnosis.

CONCLUSIONS AND RELEVANCE

These findings suggest that limited alcohol consumption among older adults with incident heart failure is associated with survival benefit compared with long-term abstinence. These findings suggest that older adults who develop heart failure may not need to abstain from moderate levels of alcohol consumption.

Relation of Alcohol Consumption to Risk of Heart Failure in Patients Aged 65 to 84 Years With Hypertension

Although a high level of alcohol consumption is associated with cardiomyopathy, the benefit or risk of moderate alcohol consumption on incident heart failure (HF) is unknown. This study examined the association between alcohol consumption and risk for HF in older adults with hypertension. The study analyzed data from a cohort of 6,083 participants aged 65 to 84 years at baseline (1995 to 2001) followed for a median of 10.8 years during and after the Second Australian National Blood Pressure Study. Frequency and amount of alcohol consumption were self-reported at baseline and during the clinical trial. The percentages of current drinkers, former drinkers, and never-drinkers at baseline were 4,400 (72%), 394 (6%), and 1,289 (21%), respectively. Incident HF was diagnosed in 183 men and 136 women. After adjustment for multiple confounders, alcohol consumption was not significantly associated with HF. Compared with never-drinkers, the adjusted hazard ratios (95% confidence interval) for those who consume 1 to 7, 8 to 14, and >14 drinks/week at baseline were 0.87 (0.59 to 1.30), 0.96 (0.57 to 1.60), and 0.71 (0.25 to 2.02), respectively in women, and 0.81 (0.47 to 1.38), 0.77 (0.43 to 1.38), and 1.04 (0.59 to 1.84), respectively in men. The findings of lack of an association between alcohol consumption and risk of HF persisted in the analyses comparing the risk of HF across each level of drinking at baseline or at follow-up with never-drinkers. In the present study, there was no evidence for benefit or risk of alcohol consumption, reported at baseline or at follow-up, in relation to incident HF in both men and women.

Nutrients, Nutraceuticals, and Xenobiotics Affecting Renal Health

Chronic kidney disease (CKD) affects 8–16% of the population worldwide. In developed countries, the most important risk factors for CKD are diabetes, hypertension, and obesity, calling into question the importance of educating and acting on lifestyles and nutrition. A balanced diet and supplementation can indeed support the maintenance of a general health status, including preservation of renal function, and can help to manage and curb the main risk factors for renal damage. While the concept of protein and salt restriction in nephrology is historically acknowledged, the role of some nutrients in renal health and the importance of nutrition as a preventative measure for renal care are less known. In this narrative review, we provide an overview of the demonstrated and potential actions of some selected nutrients, nutraceuticals, and xenobiotics on renal health and function. The direct and indirect effects of fiber, protein, fatty acids, curcumin, steviol glycosides, green tea, coffee, nitrates, nitrites, and alcohol on kidney health are reviewed here. In view of functional and personalized nutrition, understanding the renal and systemic effects of dietary components is essential since many chronic conditions, including CKD, are related to systemic dysfunctions such as chronic low-grade inflammation.

Ethanol-induced cardiomyocyte toxicity implicit autophagy and NFkB transcription factor

Chronic ethanol (EtOH) consumption causes early detrimental consequences in many tissues including the myocardium, though the molecular mechanisms leading to the alcoholic cardiomyopathy (ACM) still remain to be elucidated. Here, we studied several biomolecular changes occurring in cardiomyoblasts after their exposure to sublethal concentrations of EtOH and the potential synergistic effect with methylmercury (MM) or doxorubicin (DOXO), which are known to produce direct myocardial dysfunction. In addition, the possible role of autophagic responses and Nuclear Factor kappa-B (NFkB) modulation in early post-alcoholic myocardial damage has been investigated. H9c2 rat cardiomyoblasts were incubated for fifteen days with a sub-lethal concentrations of EtOH (1-1000 μM). In particular, treatment of H9c2 cells with EtOH produced an increase of reactive oxygen species (ROS) and the activation of autophagy. Furthermore, chronic exposure to EtOH, was accompanied by a translocation of NFkB into the nucleus dose-dependently. Finally, co-incubation of EtOH (1-1000 μM) with sublethal concentrations of MM or DOXO showed a prominent apoptotic death of cardiomyoblasts accompanied by ROS overproduction, autophagy activation and by an increased nuclear translocation of NFkB as compared to untreated cells. Thus, EtOH produces early changes in cardiomyoblasts characterized by oxidative stress, reactive autophagy and NFkB modulation at concentrations unable to produce direct cell death. Combination of EtOH with cardiotoxic pollutants or drugs makes the cardiomyocyte vulnerable to exogenous insults leading to apoptosis. These data contribute to better identify molecular mechanisms underlying early stages of alcoholic cardiomyopathy and suggest novel strategies to counteract integrated risk of cardiotoxicity in chronic alcohol consumption.

Effect of Alcohol Consumption on Cardiovascular Health

PURPOSE OF REVIEW

This review aims to discuss the effect of alcohol consumption on various cardiovascular (CV) diseases and CV mortality.

RECENT FINDINGS

Alcohol intake has consistently shown a J- or U-shaped relationship with several cardiovascular diseases. Light to moderate alcohol intake has been associated with lower risk of coronary artery disease, heart failure (HF), as well as CV mortality. On the other hand, heavy consumption has been associated with deleterious CV outcomes including increased mortality. However, the evidence is based from observational and population-based studies where risk of confounding cannot be excluded even after meticulous methodological approaches. This is compounded by conflicting data such as higher risk of certain CV diseases like HF in former drinkers compared to abstainers. Further, Mendelian randomization studies using genetic polymorphisms in enzymes have recently questioned the beneficial association of low-moderate drinking with CV system. There has been substantial and consistent evidence that light to moderate alcohol consumption have beneficial effect on overall cardiovascular profile and mortality. However, there are considerable limitations in the reported literature to determine a strong causality of a protective effect of moderate alcohol consumption by itself. Further robust studies or possibly a well-structured randomized controlled could bring an end to this debate.

Alcohol Use and Cardiovascular Disease Risk in Patients With Nonalcoholic Fatty Liver Disease

BACKGROUND & AIMS

Cardiovascular disease (CVD) is the leading cause of death among patients with nonalcoholic fatty liver disease (NAFLD). Moderate drinking (vs abstinence) is associated with lower risk of CVD in the general population. We assessed whether alcohol use is associated with CVD risk in patients with NAFLD.

METHODS

We analyzed data from participants in the Coronary Artery Risk Development in Young Adults longitudinal cohort study of 5115 black and white young adults, 18-30 years old, recruited from 4 cities in the United States from 1985 through 1986. Participants self-reported alcohol use at study entry and then again after 15, 20, and 25 years. At year 25 (2010-2011), participants underwent computed tomography examination of the thorax and abdomen and tissue Doppler echocardiography with myocardial strain measured by speckle tracking. Coronary artery calcification was defined as an Agatston score above 0. NAFLD was defined as liver attenuation <51 Hounsfield Units after exclusions. Drinkers reported 1-21 (men) or 1-14 (women) standard drinks/week at years 15, 20, or 25. Nondrinkers reported no alcohol use at years 15, 20, and 25.

RESULTS

Of the 570 participants with NAFLD (mean age, 50 years; 54% black; 46% female), 332 (58%) were drinkers; significantly higher proportions of drinkers were white, male, and with higher levels of education compared with nondrinkers (P < .05 for all). Higher proportions of drinkers had obesity, diabetes, and metabolic syndrome compared with nondrinkers (P < .01). There was no difference in liver attenuation between groups (P = .12). After multivariable adjustment, there was no association between alcohol use and CVD risk factors (diabetes, hypertension, hyperlipidemia) or subclinical CVD measures (coronary artery calcification, early transmitral velocity/late (atrial) transmitral velocity (E/A) ratio, global longitudinal strain).

CONCLUSIONS

In a population-based sample of individuals with NAFLD in midlife, prospectively assessed alcohol use is not associated with significant differences in risk factors for CVD or markers of subclinical CVD. In contrast to general population findings, alcohol use may not reduce the risk of CVD in patients with NAFLD.

Therapeutic effects of rapamycin on alcoholic cardiomyopathy

The present study aimed to investigate whether rapamycin has therapeutic potential as a treatment for alcoholic cardiomyopathy. Rats were divided into eight groups (n=7 in each group): The control group; the alcohol group; abstinence in the first week; abstinence in the third week; abstinence in the fourth week; abstinent+rapamycin (AB-RAP) until the first week (AB-RAP 1); AB-RAP until the third week (AB-RAP 3); and AB-RAP until the fourth week (AB-RAP 4). Subsequently, echocardiography, and hematoxylin-eosin and Masson's staining were performed, followed by electron microscopy and terminal deoxynucleotidyl transferase-mediated dUTP nick-end labeling assay. Finally, expression levels of B cell lymphoma-2, Beclin-1 and microtubule-associated protein 1A/1B-light chain 3 were detected by immunohistochemistry and western blot analysis. The levels of left ventricular end-diastolic dimension in AB-RAP 3 (7.00±0.41) and AB-RAP 4 (6.33±0.68) groups were significantly lower when compared with the alcohol group (8.01±0.30; P<0.05). Compared with the alcohol group, the apoptosis rate of left ventricular myocardial tissue in the AB+RAP 3 (37.68±2.15) and AB+RAP 4 (26.97±2.11) groups was significantly reduced (P<0.05). To conclude, rapamycin may be considered as a therapeutic tool to attenuate alcoholic cardiomyopathy and improve cardiac function through increasing autophagy and reducing apoptosis.

[Alcohol consumption in women and the elderly : When does it induce heart failure?]

The association between alcohol consumption and the etiology and prognosis of cardiovascular diseases has been the focus of attention and also the subject of controversial discussions for many years. This is particularly true for heart failure, which can be induced by coronary artery disease (CAD), arterial hypertension, atrial and ventricular arrhythmias and cardiomyopathies. Acute effects of high doses of alcohol can lead to impairment of the cardiac contraction strength with rhythm disturbances (holiday heart syndrome), transient ischemic attacks and in rare cases to sudden cardiac death. The chronic effects of high alcohol consumption include in particular, ventricular dysfunction, chronic rhythm disturbances, alcoholic cardiomyopathy and CAD. In contrast, light to moderate consumption of alcohol is associated with a reduced risk of CAD and ischemic stroke; however, even moderate alcohol drinking is associated with a greater risk for atrial fibrillation. The unfavorable effects of alcohol occur at much lower levels of acute or chronic consumption in women than in men. In the elderly just as in young people, a moderate alcohol consumption is associated with a lower risk of heart failure.

Alcohol Abuse and Cardiac Disease

BACKGROUND

Understanding the relationship between alcohol abuse, a common and theoretically modifiable condition, and the most common cause of death in the world, cardiovascular disease, may inform potential prevention strategies.

OBJECTIVES

The study sought to investigate the associations among alcohol abuse and atrial fibrillation (AF), myocardial infarction (MI), and congestive heart failure (CHF).

METHODS

Using the Healthcare Cost and Utilization Project database, we performed a longitudinal analysis of California residents ≥21 years of age who received ambulatory surgery, emergency, or inpatient medical care in California between 2005 and 2009. We determined the risk of an alcohol abuse diagnosis on incident AF, MI, and CHF. Patient characteristics modifying the associations and population-attributable risks were determined.

RESULTS

Among 14,727,591 patients, 268,084 (1.8%) had alcohol abuse. After multivariable adjustment, alcohol abuse was associated with an increased risk of incident AF (hazard ratio [HR]: 2.14; 95% confidence interval [CI]: 2.08 to 2.19; p < 0.0001), MI (HR: 1.45; 95% CI: 1.40 to 1.51; p < 0.0001), and CHF (HR: 2.34; 95% CI: 2.29 to 2.39; p < 0.0001). In interaction analyses, individuals without conventional risk factors for cardiovascular disease exhibited a disproportionately enhanced risk of each outcome. The population-attributable risk of alcohol abuse on each outcome was of similar magnitude to other well-recognized modifiable risk factors.

CONCLUSIONS

Alcohol abuse increased the risk of AF, MI, and CHF to a similar degree as other well-established risk factors. Those without traditional cardiovascular risk factors are disproportionately prone to these cardiac diseases in the setting of alcohol abuse. Thus, efforts to mitigate alcohol abuse might result in meaningful reductions of cardiovascular disease.

Alcohol consumption and risk of heart failure: Meta-analysis of 13 prospective studies

BACKGROUND & AIMS

Controversy exists on the association between alcohol consumption and risk of heart failure (HF). We carried out a meta-analysis to summarize available prospective data on alcohol consumption and HF.

METHODS

We searched PubMed for relevant studies published until January 1, 2017. Relative risk (RR) estimates from individual studies were pooled in a random-effects meta-analysis.

RESULTS

A total of 13 prospective studies, with 13,738 HF cases and 355,804 participants, were included in the meta-analysis. Light alcohol drinking (0.1-7 drinks/week) was inversely associated with risk of HF (RR, 0.86; 95% confidence interval, 0.81-0.90). There was no statistically significant association between moderate (7.1-14 drinks/week), high (14.1-28 drinks/week), or heavy (>28 drinks/week) alcohol consumption and HF risk. Former drinking was associated with an increased risk of HF compared with never or occasional drinking (RR, 1.22; 95% confidence interval, 1.11-1.33).

CONCLUSIONS

This meta-analysis found that light alcohol drinking was associated with a lower risk of HF. Former drinking was associated with a higher risk of HF.

Alcohol and cardiovascular disease in the geriatric population

There has been little focus on the effects of alcohol on the elderly. Although the cardiovascular benefits of moderate alcohol consumption could be of the greatest benefit in this group, so might be the detrimental effects of abuse. In this article, we review available data on the effects of alcohol consumption on cardiovascular disease, cardiomyopathy, arrhythmias, hypertension, and vascular function in older adults. Alcohol consumption has increased in the US population age 65 years and older in the last decade, as has monthly heavy episodic drinking in older alcohol consumers. Studies of alcohol consumption in older subjects suggest that consumption in moderation does not increase the risk of heart failure, hypertension, or atrial arrhythmias, and may in fact improve vascular function and reduce cardiovascular disease events. As in younger subjects, heavy consumption, or abuse of alcohol, negates any potential protective cardiovascular effects, increasing the incidence of heart failure and hypertension. Although alcohol consumed in moderation does not appear harmful in the elderly population, heavier consumption exacerbates hypertension and increases the incidence of heart failure.

An investigation into the effect of alcohol consumption on health status and health care utilization in Ireland

This paper presents a study of the effect of alcohol consumption on individual health status and health care utilization in Ireland using the 2007 Slán National Health and Lifestyle Survey, while accounting for the endogenous relationship between alcohol and health. Drinkers are categorized as those who never drank, non-drinkers, moderate drinkers, or heavy drinkers, based on national recommended weekly drinking levels in Ireland. The drinking-status equation is estimated using an ordered probit model. Predicted values for the inverse mills ratio are generated, which are then included in the health and health-care utilization equations. Differences in health status for each category of drinker are examined, and the relationship between both alcohol consumption and health with a host of other personal and socio-economic variables is also identified. Given that the measure of health status available is self-assessed, the effect of alcohol consumption on health-care utilization is also analyzed as an alternative measure of health. Findings show that in Ireland, moderate drinkers enjoy the best health status. More moderate drinkers report having very good or excellent health compared with heavy drinkers, non-drinkers, or those who never drank. While heavy drinkers do not report having as good a health status as moderate drinkers, they are better off in terms of health when compared with non-drinkers and those who are lifetime abstainers.

Contrasting association between alcohol consumption and risk of myocardial infarction and heart failure: Two prospective cohorts

BACKGROUND

The potential cardioprotective effect of light-to-moderate alcohol consumption is disputed, and the association between heavy drinking and heart failure (HF) risk is unclear. We examined the association between alcohol consumption and risk of myocardial infarction (MI) and HF in two prospective cohorts.

METHODS

We analyzed data from the Cohort of Swedish Men (40,590 men) and the Swedish Mammography Cohort (34,022 women). Participants were free of ischemic heart disease and HF at baseline. MI and HF cases were ascertained by linkage with the Swedish National Patient Register. Cox proportional hazards regression model was used to estimate hazard ratios (HRs) with 95% confidence intervals (CIs).

RESULTS

During follow-up (1998-2010), we ascertained 3678 and 1905 cases of MI and HF, respectively, in men and 1500 and 1328 cases of MI and HF, respectively, in women. Alcohol consumption was inversely associated with MI in both men and women (P trend <0.001); compared with light drinkers, the multivariable HRs were 0.70 (95% CI, 0.56-0.87) in men who consumed >28 drinks/week and 0.32 (95% CI, 0.15-0.67) in women who consumed 15-21 drinks/week. Alcohol consumption was not inversely associated with HF risk. However, in men, the risk of HF was higher in never, former, and heavy drinkers (>28 drinks/week; HR=1.45; 95% CI, 1.09-1.93) compared with light drinkers.

CONCLUSIONS

Alcohol consumption has divergent associations with MI and HF, with an inverse association observed for MI but not HF. Heavy drinking was associated with an increased HF risk in men.

Moderate Alcohol Consumption Is Associated With Left Ventricular Diastolic Dysfunction in Nonalcoholic Hypertensive Patients

Ethanol consumption is associated with left ventricular dysfunction in heavy ethanol drinkers. The effect of moderate ethanol intake on left ventricular function in hypertension, however, is unknown. We investigated the relationship between ethanol consumption and cardiac changes in nonalcoholic hypertensive patients. In 335 patients with primary hypertension, we assessed daily ethanol consumption by questionnaires that combined evaluation of recent and lifetime ethanol exposure and examined cardiac structure and function by echocardiography. Patients with abnormal liver tests, previous cardiovascular events, left ventricular ejection fraction <50%, and creatinine clearance <30 mL/min 1.72 m 2 were excluded. Left ventricular hypertrophy was found in 21% of hypertensive patients and diastolic dysfunction was detected in 50% by tissue-Doppler imaging. Ethanol consumption was comparable in hypertensive patients with and without left ventricular hypertrophy, whereas patients with left ventricular diastolic dysfunction had significantly greater consumption than patients with normal ventricular filling. Left atrial diameter, e′ wave velocity, e′/a′ ratio, and E/e′ ratio changed progressively with increasing levels of ethanol consumption, and prevalence of left ventricular diastolic dysfunction increased with a change that became statistically significant in patients consuming 20 g/d of ethanol or more. The e′ wave velocity was inversely correlated with ethanol consumption, and multivariate logistic regression indicated that ethanol consumption predicted diastolic dysfunction independently of age, body mass index, blood pressure, insulin sensitivity, and left ventricular mass index. In conclusion, ethanol consumption is independently associated with left ventricular diastolic dysfunction in nonalcoholic hypertensive patients and might contribute to development of diastolic heart failure.

Access to alcohol and heart disease among patients in hospital: observational cohort study using differences in alcohol sales laws

OBJECTIVE

 To investigate the relation between alcohol consumption and heart disease by using differences in county level alcohol sales laws as a natural experiment.

DESIGN

 Observational cohort study using differences in alcohol sales laws.

SETTING

 Hospital based healthcare encounters in Texas, USA.

POPULATION

 1 106 968 patients aged 21 or older who were residents of "wet" (no alcohol restrictions) and "dry" (complete prohibition of alcohol sales) counties and admitted to hospital between 2005 and 2010, identified using the Texas Inpatient Research Data File.

OUTCOME MEASURES

 Prevalent and incident alcohol misuse and alcoholic liver disease were used for validation analyses. The main cardiovascular outcomes were atrial fibrillation, acute myocardial infarction, and congestive heart failure.

RESULTS

 Residents of wet counties had a greater prevalence and incidence of alcohol misuse and alcoholic liver disease. After multivariable adjustment, wet county residents had a greater prevalence (odds ratio 1.05, 95% confidence interval 1.01 to 1.09; P=0.007) and incidence (hazard ratio 1.07, 1.01 to 1.13; P=0.014) of atrial fibrillation, a lower prevalence (odds ratio 0.83, 0.79 to 0.87; P<0.001) and incidence (hazard ratio 0.91, 0.87 to 0.99; P=0.019) of myocardial infarction, and a lower prevalence (odds ratio 0.87, 0.84 to 0.90; P<0.001) of congestive heart failure. Conversion of counties from dry to wet resulted in statistically significantly higher rates of alcohol misuse, alcoholic liver disease, atrial fibrillation, and congestive heart failure, with no detectable difference in myocardial infarction.

CONCLUSIONS

 Greater access to alcohol was associated with more atrial fibrillation and less myocardial infarction and congestive heart failure, although an increased risk of congestive heart failure was seen shortly after alcohol sales were liberalized.

Re-feeding syndrome and alcoholic cardiomyopathy: A case of interacting diagnoses

Re-feeding syndrome is an uncommon clinical entity of fluid and electrolyte disorders that typically occurs after re-initiation of enteral nutrition following prolonged fasting. This disorder can be complicated by left ventricular (LV) dysfunction, arrhythmias, and death. Alcohol abuse and anorexia nervosa are independently associated with similar complications. The interaction between these diagnoses can result in significant, but reversible, LV dysfunction. We present the case of a 69-year-old woman with a history of significant alcohol abuse and anorexia nervosa. The patient was admitted to hospital for the management of re-feeding syndrome, which was complicated by significant LV dysfunction. Her LV function normalized following a combination of electrolyte replacement, re-institution of feeding, and abstinence from alcohol. Re-feeding syndrome, anorexia nervosa, and alcohol abuse are conditions that commonly co-exist. These conditions may have a synergistic relationship, potentially resulting in a profound cardiomyopathy. Careful monitoring and aggressive electrolyte replacement may be helpful in identifying this complication and minimizing its potential harm. <Learning objective: Re-feeding syndrome can be complicated by significant myocardial dysfunction, particularly in patients with a history of alcohol abuse or anorexia nervosa, which independently cause cardiac dysfunction. Physicians should be aware of the risk of new cardiomyopathy in patients with these overlapping diagnoses. We review the case of a patient with these conditions who developed a significant reversible cardiomyopathy managed with re-institution of feeding and electrolyte replacement.>.

Chronic plus binge ethanol feeding induces myocardial oxidative stress, mitochondrial and cardiovascular dysfunction, and steatosis

Alcoholic cardiomyopathy in humans develops in response to chronic excessive alcohol consumption; however, good models of alcohol-induced cardiomyopathy in mice are lacking. Herein we describe mouse models of alcoholic cardiomyopathies induced by chronic and binge ethanol (EtOH) feeding and characterize detailed hemodynamic alterations, mitochondrial function, and redox signaling in these models. Mice were fed a liquid diet containing 5% EtOH for 10, 20, and 40 days (d) combined with single or multiple EtOH binges (5 g/kg body wt). Isocalorically pair-fed mice served as controls. Left ventricular (LV) function and morphology were assessed by invasive pressure-volume conductance approach and by echocardiography. Mitochondrial complex (I, II, IV) activities, 3-nitrotyrosine (3-NT) levels, gene expression of markers of oxidative stress (gp91phox, p47phox), mitochondrial biogenesis (PGC1α, peroxisome proliferator-activated receptor α), and fibrosis were examined. Cardiac steatosis and fibrosis were investigated by histological/immunohistochemical methods. Chronic and binge EtOH feeding (already in 10 days EtOH plus single binge group) was characterized by contractile dysfunction (decreased slope of end-systolic pressure-volume relationship and preload recruitable stroke work), impaired relaxation (decreased time constant of LV pressure decay and maximal slope of systolic pressure decrement), and vascular dysfunction (impaired arterial elastance and lower total peripheral resistance). This was accompanied by enhanced myocardial oxidative/nitrative stress (3-NT; gp91phox; p47phox; angiotensin II receptor, type 1a) and deterioration of mitochondrial complex I, II, IV activities and mitochondrial biogenesis, excessive cardiac steatosis, and higher mortality. Collectively, chronic plus binge EtOH feeding in mice leads to alcohol-induced cardiomyopathies (National Institute on Alcohol Abuse and Alcoholism models) characterized by increased myocardial oxidative/nitrative stress, impaired mitochondrial function and biogenesis, and enhanced cardiac steatosis.

Light-to-moderate drinking and incident heart failure--the Norwegian HUNT study

BACKGROUND

We analyzed the association between light-to-moderate alcohol intake and the risk of heart failure (HF).

METHODS AND RESULTS

We studied 60,665 individuals free of HF who provided information on alcohol consumption in a population-based cohort study conducted in 1995-97 in Norway. Sociodemographic factors, cardiovascular risk factors and common chronic disorders were assessed by questionnaires and/or by a clinical examination. The cohort was followed for a first HF event for an average of 11.2 ± 3.0 years. Mean alcohol consumption was 2.95 ± 4.5 g/day; 1588 HF cases occurred during follow-up. The quantity of alcohol consumption was inversely associated with incident HF in this low-drinking population. The risk was lowest for consumption over three but less than six drinks/week; the multivariate hazard ratio when comparing this category to non-drinkers was 0.67 (95% CI: 0.50-0.92). Among problem drinkers based on CAGE questionnaires, total consumption showed no favorable association with HF, even when overall consumption was otherwise moderate. Excluding former drinkers and controlling for common chronic diseases had minimal effect on these associations. Frequent alcohol consumption, i.e. more than five times/month, was associated with the lowest HF risk; the adjusted hazard ratio comparing this group to alcohol intake less than once/month was 0.83 (95% CI: 0.68-1.03). We found no evidence for a differential effect according to beverage type, nor that the competing risks of death from other causes modified the association.

CONCLUSIONS

Frequent light-to-moderate alcohol consumption without problem drinking was associated with a lower HF risk in this population characterized by a low average alcohol intake.

Alcohol and cardiovascular diseases: where do we stand today?

For centuries, multiple medical risks of heavy alcohol drinking have been evident with simultaneous awareness of a less harmful or sensible drinking limit. The increased risks of heavy drinking, defined as three or more standard-sized drinks per day, are both cardiovascular (CV) and non-CV. The CV risks include the following: (i) alcoholic cardiomyopathy (ACM), (ii) systemic hypertension, (iii) atrial arrhythmias, (iv) haemorrhagic stroke and, probably, ischaemic stroke. By contrast, modern epidemiological studies have shown lower morbidity and mortality amongst light-moderate drinkers, due mostly to a reduced risk of coronary artery disease (CAD), with contributions from ischaemic stroke and heart failure (HF). A low level of alcohol drinking has no clear relation to increased risk of any CV condition, except for haemorrhagic stroke. There is good evidence that supports the existence of mechanisms by which alcohol might protect against CAD, but the mechanisms for other alcohol-CV associations remain unclear. Interrelationships amongst the CV conditions affect the individual alcohol-disease relationships; for example, lower CAD risk in light-moderate drinkers is to a large extent responsible for the reduced HF risk. International comparison data plus the presence of proposed beneficial nonalcohol components in wine (particularly in red wine) suggest that this beverage type might afford extra CAD protection. However, the effect of beverage choice is confounded by a healthier drinking pattern and more favourable risk traits in wine drinkers. Debate persists about methodological and public health issues related to the epidemiology of alcohol-related CV disease.

Perceptions, Information Sources, and Behavior Regarding Alcohol and Heart Health

Despite the equipoise regarding alcohol's cardiovascular effects and absence of relevant rigorous controlled trials, the lay press frequently portrays alcohol as "heart healthy." The public perception of alcohol's heart effects, the sources of those perceptions, and how they may affect behavior are unknown. We performed a cross-sectional analysis of data obtained from March 2013 to September 2014 from consecutive participants enrolled in the Health eHeart Study. Of 5,582 participants, 1,707 (30%) viewed alcohol as heart healthy, 2,157 (39%) viewed it as unhealthy, and 1,718 (31%) were unsure. Of those reporting alcohol as heart healthy, 80% cited lay press as a source of their knowledge. After adjustment, older age (odds ratio 1.11), higher education (odds ratio 1.37), higher income (odds ratio 1.07), US residence (odds ratio 1.63), and coronary artery disease (odds ratio 1.51) were associated with perception of alcohol as heart healthy (all p <0.003). Ever smokers (odds ratio 0.76, p = 0.004) and those with heart failure (odds ratio 0.5, p = 0.01) were less likely to cite alcohol as heart healthy. Those perceiving alcohol as heart healthy consumed on average 47% more alcohol on a regular basis (95% confidence interval 27% to 66%, p <0.001). In conclusion, of >5,000 consecutive Health eHeart participants, approximately 1/3 believed alcohol to be heart healthy, and the majority cited the lay press as the origin of that perception. Those with a perception of alcohol as heart healthy drink substantially more alcohol.

Alcohol consumption and risk of incident heart failure in older men: a prospective cohort study

Aims

Light-to-moderate drinking has been associated with reduced risk of heart failure (HF). We have examined the association between alcohol consumption and incident HF in older British men.

Methods and results

Prospective study of 3530 men aged 60–79 years with no diagnosed HF or myocardial infarction (MI) at baseline and followed up for a mean period of 11 years, in whom there were 198 incident HF cases. Men were divided into 6 categories of alcohol consumption: none, <1, 1–6, 7–13, 14–34 and ≥35 drinks/week. There was no evidence that light-to-moderate drinking is beneficial for risk of HF. Heavy drinking (≥35 drinks/week) was associated with significantly increased risk of HF. Using the large group of men drinking 1–6 drinks/week as the reference group, the relative HRs (95% confidence interval) for HF adjusted for age, lifestyle characteristics, blood pressure, atrial fibrillation and renal dysfunction were 0.97 (0.59 to 1.63), 1.39 (0.86 to 2.25), 1.00, 0.94 (0.64 to 1.43), 1.16 (0.78 to 1.71) and 1.91 (1.02 to 3.56) for the 6 alcohol groups, respectively. The increased risk associated with heavy drinking was attenuated after adjustment for N-terminal pro-brain natriuretic peptide (NT-proBNP) (HR=1.43 (0.76 to 1.69)). Stratified analysis showed heavy drinking was associated with increased HF risk only in those with ECG evidence of myocardial ischaemia.

Conclusions

There was no evidence that light-to-moderate drinking is beneficial for the prevention of HF in older men without a history of an MI. Heavier drinking (≥5 drinks/day), however, was associated with increased risk of HF in vulnerable men with underlying myocardial ischaemia.

Relationship between alcohol consumption and cardiac structure and function in the elderly: the Atherosclerosis Risk In Communities Study

BACKGROUND

Excessive alcohol consumption is associated with cardiomyopathy, but the influence of moderate alcohol use on cardiac structure and function is largely unknown.

METHODS AND RESULTS

We studied 4466 participants from visit 5 of the Atherosclerosis Risk in Communities (ARIC) study (76±5 years and 60% women) who underwent transthoracic echocardiography, excluding former drinkers and those with significant valvular disease. Participants were classified into 4 categories based on self-reported alcohol intake: nondrinkers, drinkers of ≤7, ≥7 to 14, and ≥14 drinks per week. We related alcohol intake to measures of cardiac structure and function, stratified by sex, and fully adjusted for covariates. In both genders, increasing alcohol intake was associated with larger left ventricular diastolic and systolic diameters and larger left atrial diameter (P<0.05). In men, increasing alcohol intake was associated with greater left ventricular mass (8.2±3.8 g per consumption category; P=0.029) and higher E/E' ratio (0.82±0.33 per consumption category; P=0.014). In women, increasing alcohol intake was associated with lower left ventricular ejection fraction (-1.9±0.6% per consumption category; P=0.002) and a tendency for worse left ventricular global longitudinal strain (0.45±0.25% per consumption category; P=0.07).

CONCLUSIONS

In an elderly community-based population, increasing alcohol intake is associated with subtle alterations in cardiac structure and function, with women appearing more susceptible than men to the cardiotoxic effects of alcohol.

Cardiovascular risks and benefits of moderate and heavy alcohol consumption

The heart and vascular system are susceptible to the harmful effects of alcohol. Alcohol is an active toxin that undergoes widespread diffusion throughout the body, causing multiple synchronous and synergistic effects. Alcohol consumption decreases myocardial contractility and induces arrhythmias and dilated cardiomyopathy, resulting in progressive cardiovascular dysfunction and structural damage. Alcohol, whether at binge doses or a high cumulative lifetime consumption-both of which should be discouraged-is clearly deleterious for the cardiovascular system, increasing the incidence of total and cardiovascular mortality, coronary and peripheral artery disease, heart failure, stroke, hypertension, dyslipidaemia, and diabetes mellitus. However, epidemiological, case-control studies and meta-analyses have shown a U-type bimodal relationship so that low-to-moderate alcohol consumption (particularly of wine or beer) is associated with a decrease in cardiovascular events and mortality, compared with abstention. Potential confounding influences-alcohol-dose quantification, tobacco use, diet, exercise, lifestyle, cancer risk, accidents, and dependence-can affect the results of studies of both low-dose and high-dose alcohol consumption. Mendelian methodological approaches have led to doubts regarding the beneficial cardiovascular effects of alcohol, and the overall balance of beneficial and detrimental effects should be considered when making individual and population-wide recommendations, as reductions in alcohol consumption should provide overall health benefits.

Alcohol and incident heart failure among middle-aged and elderly men: cohort of Swedish men

BACKGROUND

Compared with no alcohol consumption, heavy alcohol intake is associated with a higher rate of heart failure (HF) whereas light-to-moderate intake may be associated with a lower rate. However, several prior studies did not exclude former drinkers, who may have changed alcohol consumption in response to diagnosis. This study aimed to investigate the association between alcohol intake and incident HF.

METHODS AND RESULTS

We conducted a prospective cohort study of 33 760 men aged 45 to 79 years with no HF, diabetes mellitus, or myocardial infarction at baseline participating in the Cohort of Swedish Men Study. We excluded former drinkers. At baseline, participants completed a food frequency questionnaire and reported other characteristics. HF was defined as hospitalization for or death from HF, ascertained by Swedish inpatient and cause-of-death records from January 1, 1998, through December 31, 2011. We constructed Cox proportional hazards models to estimate multivariable-adjusted incidence rate ratios. During follow-up, 2916 men were hospitalized for (n=2139) or died (n=777) of incident HF. There was a U-shaped relationship between total alcohol intake and incident HF (P=0.0004). There was a nadir at light-to-moderate alcohol intake: consuming 7 to <14 standard drinks per week was associated with a 19% lower multivariable-adjusted rate of HF compared with never drinking (incidence rate ratio, 0.81; 95% confidence interval, 0.69-0.96).

CONCLUSIONS

In this cohort of Swedish men, there was a U-shaped relationship between alcohol consumption and HF incidence, with a nadir at light-to-moderate intake. Heavy intake did not seem protective.

Alcohol consumption and risk of heart failure: the Atherosclerosis Risk in Communities Study

AIM

Alcohol is a known cardiac toxin and heavy consumption can lead to heart failure (HF). However, the relationship between moderate alcohol consumption and risk for HF, in either men or women, remains unclear.

METHODS AND RESULTS

We examined 14 629 participants of the Atherosclerosis Risk in Communities (ARIC) study (54 ± 6 years, 55% women) without prevalent HF at baseline (1987-89) who were followed for 24 ± 1 years. Self-reported alcohol consumption was assessed as the number of drinks/week (1 drink = 14 g of alcohol) at baseline, and updated cumulative average alcohol intake was calculated over 8.9 ± 0.3 years. Using multivariable Cox proportional hazards models, we examined the relation of alcohol intake with incident HF and assessed whether associations were modified by sex. Overall, most participants were abstainers (42%) or former drinkers (19%), with 25% reporting up to 7 drinks per week, 8% reporting ≥7 to 14 drinks per week, and 3% reporting ≥14-21 and ≥21 drinks per week, respectively. Incident HF occurred in 1271 men and 1237 women. Men consuming up to 7 drinks/week had reduced risk of HF relative to abstainers (hazard ratio, HR 0.80, 95% CI 0.68-0.94, P = 0.006); this effect was less robust in women (HR 0.84, 95% CI 0.71-1.00, P = 0.05). In the higher drinking categories, the risk of HF was not significantly different from abstainers, either in men or in women.

CONCLUSION

In the community, alcohol consumption of up to 7 drinks/week at early-middle age is associated with lower risk for future HF, with a similar but less definite association in women than in men. These findings suggest that despite the dangers of heavy drinking, modest alcohol consumption in early-middle age may be associated with a lower risk for HF.

Alcohol consumption and risk of death in male physicians with heart failure

The 5-year risk of death after onset of heart failure (HF) is about 50%. Although previous studies have shown beneficial effects of light-to-moderate alcohol consumption and risk of cardiovascular diseases and mortality, it is unclear whether moderate alcohol consumption is associated with a lower risk of death in subjects with HF. We investigated whether alcohol consumption and type of alcohol preference are associated with the risk of total mortality in 449 US male physicians with prevalent HF. Alcohol consumption was assessed through food frequency questionnaire, and mortality was ascertained through annual follow-up questionnaires and adjudicated by an Endpoint Committee. The mean age of subjects was 75.7±8.2 years with an average follow-up of 7 years. We found evidence of a J-shaped relation between alcohol consumption and mortality (hazard ratio [95% confidence interval] 1.00 [reference], 0.85 [0.61 to 1.20], 0.60 [0.40 to 0.88], and 0.71 [0.42 to 1.21] for alcohol intake of none, <1 drink/day, 1 to 2 drinks/day, and 3+ drinks/day, respectively [p for quadratic trend=0.058]). There was no relation between beverage preference (beer, wine, or liquor) and mortality. In conclusion, our data showed a J-shaped association between alcohol intake and mortality in patients with HF.

Effects of alcohol consumption on cognition and regional brain volumes among older adults

This study utilized data from the Framingham Heart Study Offspring Cohort to examine the relationship between midlife and late-life alcohol consumption, cognitive functioning, and regional brain volumes among older adults without dementia or a history of abusing alcohol. The results from multiple linear regression models indicate that late life, but not midlife, alcohol consumption status is associated with episodic memory and hippocampal volume. Compared to late life abstainers, moderate consumers had larger hippocampal volume, and light consumers had higher episodic memory. The differences in episodic memory according to late life alcohol consumption status were no longer significant when hippocampal volume was included in the regression model. The findings from this study provide new evidence that hippocampal volume may contribute to the observed differences in episodic memory among older adults and late life alcohol consumption status.

Plasma phospholipid trans-fatty acids levels, cardiovascular diseases, and total mortality: the cardiovascular health study

BACKGROUND

While self-reported trans-fatty acid (TFA) consumption is linked to coronary heart disease (CHD), relationships between objective biomarkers of TFA subtypes (t-16:1n9, total t-18:1, and cis/trans-(c/t-), t/c- and t/t-18:2) and cardiovascular disease (CVD) or total mortality are not well established.

METHODS AND RESULTS

We evaluated 2742 adults in the Cardiovascular Health Study, aged 74±5 years and free of prevalent CVD, with plasma phospholipid TFA measures in 1992. Incident fatal and nonfatal CHD events, CVD and non-CVD mortality, and total mortality were centrally adjudicated through 2010. Risks were assessed using Cox proportional hazards. During 31 494 person-years, 1735 total deaths and 639 total CHD events occurred. In the multivariate model including mutual adjustment for the 5 TFA subtypes, circulating t/t-18:2 was associated with higher total mortality (extreme quintile hazard ratio (HR)=1.23, 95% CI=1.04 to 1.44, P-trend=0.01), CVD mortality (HR=1.40, 95% CI=1.05 to 1.86, P-trend=0.02), and total CHD (HR=1.39, 95% CI=1.06 to 1.83, P-trend=0.01). t/c-18:2 was positively related to total mortality (HR=1.19, P-trend=0.05), total CHD (HR=1.67, P-trend=0.002), and nonfatal CHD (HR=2.06, P-trend=0.002) after mutual adjustment; these associations were insignificant without mutual adjustment. Neither t-16:1n9 nor t-18:1 was significantly associated with total mortality or CVD, nor was c/t-18:2 if we excluded early cases.

CONCLUSIONS

Among circulating TFAs, t/t-18:2 was most adversely associated with total mortality, mainly due to the increased risk of CVD. t/c-18:2 was also positively associated with total mortality and CHD, but only after adjustment for other TFAs. These results highlight the need for further investigation of dietary sources, nondietary determinants, and health effects of specific TFA subtypes, especially t-18:2 isomers.