Contemporary Appraisal of Sex Differences in Prevalence, Correlates, and Outcomes of Alcoholic Cardiomyopathy

Clinical Trajectories and Long-Term Outcomes of Alcoholic Versus Other Forms of Dilated Cardiomyopathy

BACKGROUND

Alcoholic cardiomyopathy (ACM) is a form of dilated cardiomyopathy (DCM) occurring secondary to long-standing heavy alcohol use and is associated with poor outcomes, but the cause-specific risks are insufficiently understood.

METHOD

Between 1997 and 2018, we identified all patients with a first diagnosis of ACM or DCM. The cumulative incidence of different causes of hospitalisation and mortality in the two groups was calculated using the Fine-Gray and Kaplan-Meier methods.

RESULTS

A Total of 1,237 patients with ACM (mean age 56.3±10.1 years, 89% men) and 17,211 individuals with DCM (mean age 63.6±13.8 years, 71% men) were identified. Diabetes (10% vs 15%), hypertension (22% vs 31%), and stroke (8% vs 10%) were less common in ACM than DCM, whereas obstructive lung disease (15% vs 12%) and liver disease (17% vs 2%) were more prevalent (p<0.05). Cumulative 5-year mortality was 49% in ACM vs 33% in DCM, p<0.0001, multivariable adjusted hazards ratio 2.11 (95% confidence interval 1.97-2.26). The distribution of causes of death was similar in ACM and DCM, with the predominance of cardiovascular causes in both groups (42% in ACM vs 44% in DCM). 5-year cumulative incidence of heart failure hospitalisations (48% vs 54%) and any somatic cause (59% vs 65%) were also similar in ACM vs DCM. At 1 year, the use of beta blockers (55% vs 80%) and implantable cardioverter defibrillators (3% vs 14%) were significantly less often used in ACM vs DCM.

CONCLUSIONS

Patients with ACM had similar cardiovascular risks and hospitalisation patterns as other forms of DCM, but lower use of guideline-directed cardiovascular therapies and greater mortality.

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.

Global, regional and national burden of alcohol cardiomyopathy from Global Burden of Disease Study 2019

This study aimed to provide up-to-date and comprehensive estimates on the global alcohol cardiomyopathy (ACM) from 1990 to 2019. Detailed data on the prevalence, disability-adjusted life-years (DALYs), deaths,percentage change in the number of cases and estimated annual percentage change (EAPC) of ACM worldwide from 1990 to 2019 were obtained or calculated from the Global Burden of Disease Study (GBD) 2019. Globally, the estimated prevalent cases of ACM in 2019 were 707,652 [95% uncertainty interval (UI): 545,182-924,392], with a 35.4% (28.2-44.2) increase from 522,616 (95% UI: 394,118-683,206) in 1990, while the age-standardized prevalence rate (ASPR) was slightly decreased with an overall EAPC of - 1.30 (- 1.38 - - 1.22). Similar to ASPR, the global age-standardized DALYs rate and age-standardized death rate (ASDR) also declined, with an EAPC of - 1.12(- 2.09 - - 0.14) and - 1.53(- 2.36 - - 0.70) from 1990 to 2019, respectively. Conversely, the number of ACM-related DALYs cases in 2019 was 2,441,108 (95% UI: 2,046,734-2,782,542), with an increase of 38.8%(2.8-59.9) over the past 30 years, and the number of ACM-related deaths in 2019 was 71,723 (95% UI: 60,167-81,995), with an increase of 33.1% (0.5- 51.9) compared with 1990. A significant variation in the burden of ACM was observed between different regions and countries. Although the ASPR, age-standardized DALYs rate and ASDR slightly decreased from 1990 to 2019, the absolute number of prevalent cases, DALYs cases and deaths significantly increased. This showed that the burden of ACM remains an important global public health concern. Public health policy and decision-makers should develop and implement more effective strategies specific to geographical location to combat and reduce the burden of ACM in the future.

The burden of alcoholic cardiomyopathy in China and different regions around the world

Background

Alcoholic cardiomyopathy (ACM) remains a significant public health issue with a growing global burden. The burden of ACM in China and different regions remains poorly understood.

Methods

Data on ACM deaths, disability-adjusted life years (DALYs), the corresponding global age-standardized death rate (ASDR), age-standardized DALY rate and estimated annual percentage change (EAPC) were analysed based on age, sex, socio-demographic index (SDI) quintiles, different regions and in China from the Global Burden of Disease (GBD) study 2019.

Results

Globally, the death rate and DALYs due to ACM were 71 723 and 2 441 108 in 2019, 33.06% and 38.79% increase from 1990, respectively. The corresponding ASDR and age-standardized DALY rate decreased with EAPC of -1.52 (95% uncertainty interval (UI) = -2.39, -0.65) and -1.12 (95% UI = -2.14, -0.10). The high-middle SDI regions, especially Eastern Europe, showed the highest number of ACM-related deaths and DALYs. The ACM-related deaths and DALYs were 2545 and 87823 in China in 2019, 171.03% and 147.17% increase from 1990, respectively. Unlike the world level, ASDR and age-standardized DALY rate also increased in China. The ACM burden is higher in men, and people with 50 to 69 years old accounted for the most.

Conclusions

ACM burden in China and across the world increased substantially from 1990 to 2019. The greatest burden was borne by the high-middle SDI regions, especially by men aged 50-69 years old. Geographically and gender-age tailored strategies were needed to prevent ACM.

Chronic Ethanol Exposure Induces Deleterious Changes in Cardiomyocytes Derived from Human Induced Pluripotent Stem Cells

Chronic alcohol consumption in adults can induce cardiomyopathy, arrhythmias, and heart failure. In newborns, prenatal alcohol exposure can increase the risk of congenital heart diseases. Understanding biological mechanisms involved in the long-term alcohol exposure-induced cardiotoxicity is pivotal to the discovery of therapeutic strategies. In this study, cardiomyocytes derived from human pluripotent stem cells (hiPSC-CMs) were treated with clinically relevant doses of ethanol for various durations up to 5 weeks. The treated cells were characterized for their cellular properties and functions, and global proteomic profiling was conducted to understand the molecular changes associated with long-term ethanol exposure. Increased cell death, oxidative stress, deranged Ca²⁺ handling, abnormal action potential, altered contractility, and suppressed structure development were observed in ethanol-treated cells. Many dysregulated proteins identified by global proteomic profiling were involved in apoptosis, heart contraction, and extracellular collagen matrix. In addition, several signaling pathways including the Wnt and TGFβ signaling pathways were affected due to long-term ethanol treatment. Therefore, chronic ethanol treatment of hiPSC-CMs induces cardiotoxicity, impairs cardiac functions, and alters protein expression and signaling pathways. This study demonstrates the utility of hiPSC-CMs as a novel model for chronic alcohol exposure study and provides the molecular mechanisms associated with long-term alcohol exposure in human cardiomyocytes.

Sex Differences in the Brain Transcriptome Related to Alcohol Effects and Alcohol Use Disorder

There is compelling evidence that sex and gender have crucial roles in excessive alcohol (ethanol) consumption. Here, we review some of the data from the perspective of brain transcriptional differences between males and females, focusing on rodent animal models. A key emerging transcriptional feature is the role of neuroimmune processes. Microglia are the resident neuroimmune cells in the brain and exhibit substantial functional differences between males and females. Selective breeding for binge ethanol consumption and the impacts of chronic ethanol consumption and withdrawal from chronic ethanol exposure all demonstrate sex-dependent neuroimmune signatures. A focus is on resolving sex-dependent differences in transcriptional responses to ethanol at the neurocircuitry level. Sex-dependent transcriptional differences are found in the extended amygdala and the nucleus accumbens. Telescoping of ethanol consumption is found in some, but not all, studies to be more prevalent in females. Recent transcriptional studies suggest that some sex differences may be due to female-dependent remodeling of the primary cilium. An interesting theme appears to be developing: at least from the animal model perspective, even when males and females are phenotypically similar, they differ significantly at the level of the transcriptome.

Global, Regional, and National Burden of Myocarditis and Cardiomyopathy, 1990-2017

Objective: To estimate the burden of myocarditis (MC), alcoholic cardiomyopathy (AC), and other cardiomyopathy (OC) for 195 countries and territories from 1990 to 2017. Methods: We collected detailed information on MC, AC, and OC between 1990 and 2017 from the Global Burden of Disease study 2017, which was designed to provide a systematic assessment of health loss due to diseases and injuries in 21 regions, covering 195 countries and territories. Estimates of MC, AC, and OC burden were produced using a standard Cause of Death Ensemble model and a Bayesian mixed-effects meta-regression tool, and included prevalence, deaths, years lived with disability (YLDs), and years of life lost (YLLs). All estimates were presented as counts, age-standardized rates per 100,000 people and percentage change, with 95% uncertainty intervals (UIs). Results: Worldwide, there were 1.80 million (95% UI 1.64-1.98) cases of MC, 1.62 million (95% UI 1.37-1.90) cases of AC and 4.21 million (95% UI 3.63-4.87) cases of OC, contributing to 46,486 (95% UI 39,709-51,824), 88,890 (95% UI 80,935-96,290), and 233,159 (95% UI 213,677-248,289) deaths in 2017, respectively. Furthermore, globally, there were 131,376 (95% UI 90,113-183,001) YLDs and 1.26 million (95% UI 1.10-1.42) YLLs attributable to MC, 139,087 (95% UI 95,134-196,130) YLDs and 2.84 million (95% UI 2.60-3.07) YLLs attributable to AC, and 353,325 (95% UI 237,907-493,908) YLDs and 5.51 million (95% UI 4.95-5.99) YLLs attributable to OC in 2017. At the national level, the age-standardized prevalence rates varied by 10.4 times for MC, 252.6 times for AC and 38.1 times for OC; the age-standardized death rates varied by 43.9 times for MC, 531.0 times for AC and 43.3 times for OC; the age-standardized YLD rates varied by 12.4 times for MC, 223.7 times for AC, and 34.1 times for OC; and the age-standardized YLL rates varied by 38.4 times for MC, 684.8 times for AC, and 36.2 times for OC. Between 1990 and 2017, despite the decreases in age-standardized rates, the global numbers of prevalent cases, deaths, YLDs, and YLLs have increased for all the diseases. Conclusion: Accurate assessment of the burden of MC, AC, and OC is essential for formulating effective preventative prevention and treatment programs and optimizing health system resource allocation. Our results suggest that MC, AC, and OC remain important global public health problems with increasing numbers of prevalent cases, deaths, YLDs, and YLLs over the past decades, and there are significant geographic variations in the burden of these diseases. Further research is warranted to expand our knowledge of potential risk factors and to improve the prevention, early detection and treatment of these diseases.

Alcohol use in pregnancy and its impact on the mother and child

AIMS

To review the impact of prenatal alcohol exposure on the outcomes of the mother and child.

DESIGN

Narrative review.

SETTING

Review of literature.

PARTICIPANTS

Mothers and infants affected by prenatal alcohol use.

MEASUREMENTS

Outcomes of mothers and children.

FINDINGS

Prenatal alcohol exposure is one of the most important causes of preventable cognitive impairment in the world. The developing neurological system is exquisitely sensitive to harm from alcohol and there is now also substantial evidence that alcohol-related harm can extend beyond the individual person, leading to epigenetic changes and intergenerational vulnerability and disadvantage. There is no known safe level or timing of drinking for pregnant or lactating women and binge drinking (> four drinks within 2 hours for women) is the most harmful. Alcohol-exposure increases the risk of congenital problems, including Fetal Alcohol Spectrum Disorder (FASD) and its most severe form, Fetal Alcohol Syndrome (FAS).

CONCLUSION

The impact of FASD and FAS is enduring and life-long with no current treatment or cure. Emerging therapeutic options may mitigate the worst impact of alcohol exposure but significant knowledge gaps remain. This review discusses the history, epidemiology and clinical presentations of prenatal alcohol exposure, focusing on FASD and FAS, and the impact of evidence on future research, practice and policy directions.

Effects of Alcohol on the Cardiovascular System in Women

Cardiovascular disease (CVD) is a leading cause of morbidity and mortality for women. This review summarizes the relationship between alcohol consumption and common CVDs in women and highlights potential differences from men. Except for risk of hypertension, no sex-related effects of alcohol consumption on the risk for coronary heart disease and stroke have been reported, and data on the sex-related effects on risk for peripheral arterial disease are limited. For women, alcohol consumption has a J-shaped relationship with hypertension. About 1 to 2 standard drinks per day is associated with lower risk for the development of hypertension, whereas for men, the relationship is relatively linear. In the area of alcoholic cardiomyopathy, the prevalence is greater for men, but women may develop alcoholic cardiomyopathy at a lower lifetime level of alcohol consumption. Overall, data support that 1 to 2 standard drinks per day for women and men is associated with a lower risk of CVD, and higher daily amounts may increase the risk of CVD.

The Effects of Ethanol on the Heart: Alcoholic Cardiomyopathy

Alcoholic-dilated Cardiomyopathy (ACM) is the most prevalent form of ethanol-induced heart damage. Ethanol induces ACM in a dose-dependent manner, independently of nutrition, vitamin, or electrolyte disturbances. It has synergistic effects with other heart risk factors. ACM produces a progressive reduction in myocardial contractility and heart chamber dilatation, leading to heart failure episodes and arrhythmias. Pathologically, ethanol induces myocytolysis, apoptosis, and necrosis of myocytes, with repair mechanisms causing hypertrophy and interstitial fibrosis. Myocyte ethanol targets include changes in membrane composition, receptors, ion channels, intracellular [Ca²⁺] transients, and structural proteins, and disrupt sarcomere contractility. Cardiac remodeling tries to compensate for this damage, establishing a balance between aggression and defense mechanisms. The final process of ACM is the result of dosage and individual predisposition. The ACM prognosis depends on the degree of persistent ethanol intake. Abstinence is the preferred goal, although controlled drinking may still improve cardiac function. New strategies are addressed to decrease myocyte hypertrophy and interstitial fibrosis and try to improve myocyte regeneration, minimizing ethanol-related cardiac damage. Growth factors and cardiomyokines are relevant molecules that may modify this process. Cardiac transplantation is the final measure in end-stage ACM but is limited to those subjects able to achieve abstinence.