Left ventricular performance in alcoholic patients without chronic liver disease

Abstinence from alcohol consumption and exercise capacity: A pre and post intervention cohort study

The benefits or harm associated with moderate levels of alcohol consumption on cardiorespiratory fitness are unclear. We hypothesised that in moderate drinkers, four weeks of abstinence could improve cardiorespiratory fitness. This was a single centre, prospective, pre and post intervention, experimental cohort study. Participants were recruited from healthy volunteers among hospital staff, who were non-smokers, over 25 years of age and regularly consumed ≥3 units of alcohol a day, ≥4 times a week for > 1 month. Cardiopulmonary exercise test was used to provide objective, quantifiable and reproducible data. In all, 30 participated, and data were analysed for 22 participants. Mean (SD) peak oxygen consumption and oxygen consumption at anaerobic threshold were similar before and after alcohol abstinence: 37.55 (10.89) and 39.66 (11.48) (P = 0.21) and 18.52 (5.43) and 16.82 (5.19) ml/kg/min (P = 0.1), respectively. It is concluded that this preliminary study did not establish a correlation between four weeks alcohol abstinence and cardiopulmonary fitness as measured by cardiopulmonary exercise test, among healthy volunteers self-reporting moderate alcohol consumption.

Impact of alcohol & smoking on the surgical management of gastrointestinal patients

Alcohol and smoking are repeatedly described as modifiable risk factors in clinical studies across all surgical specialities. These lifestyle choices impart a sub-optimal physiology via multiple processes and play an important role in the surgical management of the gastrointestinal patient. Cessation is imperative to optimise the patient's fitness for surgery with surgery itself being a prime opportunity for sustained cessation. A consistent, planned and integrated management involving surgical, anaesthetic, medical, and primary care facets will aid in successful cessation and perioperative care. This review highlights the pathological processes which contribute to perioperative complications and details the current practices to detect, predict and appropriately manage the perioperative gastrointestinal patient who smokes and consumes alcohol.

Peculiar characteristics of portal-hepatic hemodynamics of alcoholic cirrhosis

Alcohol-related cirrhosis is a consequence of heavy and prolonged drinking. Similarly to patients with cirrhosis of other etiologies, patients with alcoholic cirrhosis develop portal hypertension and the hepatic, splanchnic and systemic hemodynamic alterations that follow. However, in alcoholic cirrhosis, some specific features can be observed. Compared to viral cirrhosis, in alcohol-related cirrhosis sinusoidal pressure is generally higher, hepatic venous pressure gradient reflects portal pressure better, the portal flow perfusing the liver is reduced despite an increase in liver weight, the prevalence of reversal portal blood flow is higher, a patent paraumbilical vein is a more common finding and signs of hyperdynamic circulations, such as an increased cardiac output and decreased systemic vascular resistance, are more pronounced. Moreover, alcohol consumption can acutely increase portal pressure and portal-collateral blood flow. Alcoholic cardiomyopathy, another pathological consequence of prolonged alcohol misuse, may contribute to the hemodynamic changes occurring in alcohol-related cirrhosis. The aim of this review was to assess the portal-hepatic changes that occur in alcohol-related cirrhosis, focusing on the differences observed in comparison with patients with viral cirrhosis. The knowledge of the specific characteristics of this pathological condition can be helpful in the management of portal hypertension and its complications in patients with alcohol-related cirrhosis.

Smoking and alcohol intervention before surgery: evidence for best practice

Smoking and hazardous drinking are common and important risk factors for an increased rate of complications after surgery. The underlying pathophysiological mechanisms include organic dysfunctions that can recover with abstinence. Abstinence starting 3-8 weeks before surgery will significantly reduce the incidence of several serious postoperative complications, such as wound and cardiopulmonary complications and infections. However, this intervention must be intensive to obtain sufficient effect on surgical complications. All patients presenting for surgery should be questioned regarding smoking and hazardous drinking, and interventions appropriate for the surgical setting applied.

Disfunción diastólica en la cirrosis hepática

The presence of a hyperdynamic circulation in cirrhotic liver is currently a well established concept. The first studies of cardiac function in patients with cirrhosis suggested the existence of an alcoholic cardiomyopathy. More recently, altered left ventricular response to physiological and/or pharmacological stimuli in patients with post-viral liver cirrhosis has been established, and clinically insignificant diastolic cardiac function has also been observed. Neurohumoral hyperactivity and hyperdynamic circulation, which are associated with chronic exposure to the cardiodepressant substances present in advanced liver disease, play a decisive role in the genesis of this process. The lack of relaxation of the left ventricle and alteration in the pattern of transmitral flow, both of which are characteristics of this clinical entity, are easily detected by echocardiography. The growing evidence of diastolic dysfunction in liver cirrhosis, particularly in decompensated cirrhosis, suggests the clinical importance of the problem, thus introducing the concept of "cirrhotic cardiomyopathy". Greater insight into this phenomenon could help to decrease cardiovascular risk, especially during maneuvers commonly used in the treatment of the complications of liver cirrhosis, such as paracentesis, transjugular intrahepatic portosystemic shunt stent implantation, and liver transplantation.

Cirrhotic cardiomyopathy: a pathophysiological review of circulatory dysfunction in liver disease

The systemic circulation in patients with cirrhosis is hyperdynamic with an increased cardiac output and heart rate and a reduced systemic vascular resistance as the most pronounced alterations. The concomitant cardiac dysfunction has recently been termed "cirrhotic cardiomyopathy", which is an entity different from that seen in alcoholic heart muscle disease. Clinically, these patients present with sodium fluid retention and strain often unmasks the presence of latent heart failure. No specific treatment can yet be recommended but caution should be used with respect to procedures that may stress the heart such as shunt implantation and liver transplantation.

Preoperative alcoholism and postoperative morbidity

BACKGROUND

Preoperative risk assessment has become part of daily clinical practice, but preoperative alcohol abuse has not received much attention.

METHODS

A Medline search was carried out to identify original papers published from 1967 to 1998. Relevant articles on postoperative morbidity in alcohol abusers were used to evaluate the evidence.

RESULTS

Prospective and retrospective studies demonstrate a twofold to threefold increase in postoperative morbidity in alcohol abusers, the most frequent complications being infections, bleeding and cardiopulmonary insufficiency. Wound complications account for about half of the morbidity. The pathogenic mechanisms include preoperative immune incompetence, subclinical cardiac insufficiency and haemostatic imbalance. In addition, surgical trauma and/or postoperative abstinence result in an exaggerated stress response, which may further contribute to postoperative morbidity.

CONCLUSION

Alcohol consumption should be included in the preoperative assessment of likely postoperative outcome. Reduction of postoperative morbidity in alcohol abusers may include preoperative alcohol abstinence to improve organ function, or perioperative alcohol administration to avoid the abstinence response.

Effect of preoperative abstinence on poor postoperative outcome in alcohol misusers: randomised controlled trial

OBJECTIVE

To evaluate the influence of preoperative abstinence on postoperative outcome in alcohol misusers with no symptoms who were drinking the equivalent of at least 60 g ethanol/day.

DESIGN

Randomised controlled trial.

SETTING

Copenhagen, Denmark.

SUBJECTS

42 alcoholic patients without liver disease admitted for elective colorectal surgery.

INTERVENTIONS

Withdrawal from alcohol consumption for 1 month before operation (disulfiram controlled) compared with continuous drinking.

MAIN OUTCOME MEASURES

Postoperative complications requiring treatment within the first month after surgery. Perioperative immunosuppression measured by delayed type hypersensitivity; myocardial ischaemia and arrhythmias measured by Holter tape recording; episodes of hypoxaemia measured by pulse oximetry. Response to stress during the operation were assessed by heart rate, blood pressure, serum concentration of cortisol, and plasma concentrations of glucose, interleukin 6, and catecholamines.

RESULTS

The intervention group developed significantly fewer postoperative complications than the continuous drinkers (31% v 74%, P=0.02). Delayed type hypersensitivity responses were better in the intervention group before (37 mm2 v 12 mm2, P=0.04), but not after surgery (3 mm2 v 3 mm2). Development of postoperative myocardial ischaemia (23% v 85%) and arrhythmias (33% v 86%) on the second postoperative day as well as nightly hypoxaemic episodes (4 v 18 on the second postoperative night) occurred significantly less often in the intervention group. Surgical stress responses were lower in the intervention group (P

CONCLUSIONS

One month of preoperative abstinence reduces postoperative morbidity in alcohol abusers. The mechanism is probably reduced preclinical organ dysfunction and reduction of the exaggerated response to surgical stress.

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Key Words Collapse

MESH Headings

• Adult
• Aged
• Alcoholism/complications
• Colonic Diseases/surgery
• Elective Surgical Procedures
• Female
• Humans
• Male
• Middle Aged
• Postoperative Care
• Postoperative Complications/etiology
• Preoperative Care
• Prognosis
• Rectal Diseases/surgery
• Temperance

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Grants Collapse

Affiliation(s)

H Tonnesen Department of Surgical Gastroenterology, Hvidovre Hospital, University of Copenhagen, DK-2650 Hvidovre, Denmark
J Rosenberg
H J Nielsen
V Rasmussen
C Hauge
I K Pedersen
H Kehlet

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Spectrum of alcohol-induced myocardial damage detected by indium-111-labeled monoclonal antimyosin antibodies

OBJECTIVES

We sought to determine the prevalence, intensity and evolving changes of myocardial damage detected by myocardial uptake of antimyosin antibodies in patients with alcohol-induced dilated cardiomyopathy, alcohol addicts attending a detoxification unit and healthy subjects with short-term alcohol consumption.

BACKGROUND

Evidence of alcohol-induced myocardial damage may be provided by myocardial uptake of indium-111-labeled monoclonal antimyosin antibodies. The spectrum of such damage in patients who are heavy drinkers (> 100 g for > 10 years), with or without cardiomyopathy, and the impact of short-term alcohol ingestion on antimyosin antibody uptake have not been adequately explored.

METHODS

One hundred twenty antimyosin studies were performed in 56 patients with dilated cardiomyopathy (group I), 15 alcohol addicts attending a detoxification unit (group II) and 6 volunteers for short-term alcohol ingestion (group III). Estimation of antibody uptake was calculated through a heart/lung ratio (HLR) (normal < 1.55).

RESULTS

The 56 patients in group I (54 men, 2 women; mean [+/-SD] age 46 +/- 11 years) had consumed 123 +/- 60 g/day of alcohol for 21 +/- 9 years, for a cumulative intake of 914 +/- 478 kg. Mean duration of symptoms was 46 +/- 49 months. Mean left ventricular end-diastolic diameter was 71 +/- 10 mm, and mean ejection fraction was 28 +/- 12%. No differences in New York Heart Association functional class, ventricular size or ejection fraction were noted between 28 active and 28 past consumers, except for the prevalence and intensity of antibody uptake (75% vs. 32%, p < 0.001) and HLR (1.75 +/- 0.26 vs. 1.49 +/- 0.17, p = 0.0001). In 19 patients in the active group restudied after alcohol withdrawal, antibody uptake decreased (from 1.76 +/- 0.17 to 1.55 +/- 0.19, p < 0.001), and ejection fraction improved (from 30 +/- 12% to 43 +/- 16%, (p < 0.001). No changes occurred in the 15 past consumers restudied. The 15 male patients in group II (mean age 36 +/- 4 years) had consumed 156 +/- 59 g/day for 17 +/- 5 years, for a cumulative alcohol intake of 978 +/- 537 kg, an amount similar to that in patients in group I, but antimyosin antibody uptake was detected in only 3 (20%) of 15 patients. None of six group III subjects developed antibody uptake after short-term ethanol ingestion. Despite the small sample size, the power to detect clinically relevant differences in most variables that did not reach statistical significance was amply sufficient.

CONCLUSIONS

In alcohol-induced dilated cardiomyopathy, alcohol withdrawal is associated with the reduction or disappearance of myocardial damage and improvement of function. The difference in prevalence of antimyosin antibody uptake in patients with and without cardiac disease who consume similar amounts of alcohol suggests the presence of those with different myocardial susceptibilities to alcohol. Short-term ethanol ingestion in healthy subjects does not induce detectable uptake of antimyosin antibodies.

Prediction of recovery after abstinence in alcoholic cardiomyopathy: role of hemodynamic and morphometric parameters

The aim of the study is to describe the hemodynamic and morphometric characteristics of patients with alcoholic cardiomyopathy (ACM) and to evaluate whether these parameters can identify the subgroup of patients in whom recovery of cardiac function after abstinence will occur. Nineteen male patients (mean age 52.4 years, range 39-64 years) with symptomatic left ventricular dysfunction (LVD) [ejection fraction (EF) <50%] and a history of chronic heavy alcohol intake were submitted to a full invasive work-up including right ventricular endomyocardial biopsy (EMB). Counseling aimed at obtaining abstention and clinical follow-up were regularly performed in all patients. The two requisites necessary to define recovery were (1) an increase in left ventricular EF, and (2) improvement of symptoms. The former was defined as a gain in left ventricular EF > 15% from baseline; the latter, as a gain of at least one New York Heart Association (NYHA) functional class. Using these criteria, 9 alcoholic patients (48%) (Group A) improved significantly, while 10 (52%) (Group B) either stabilized or deteriorated at 2 years' follow-up. Group A patients had significantly lower pulmonary artery mean pressure (27.8 mmHg +/- 13.3 vs. 40.3 mmHg +/- 12.4; p < 0.05) and pulmonary capillary wedge pressure (18.4 mmHg +/- 8.9 vs. 26.5 mmHg +/- 7.7; p < 0.05) compared with Group B. All other hemodynamic data did not show statistically significant differences in the two groups. Quantitative evaluation of myocardial hypertrophy and interstitial fibrosis performed on EMB tissue samples using the morphometric approach was not predictive of recovery. Improvement in cardiac performance and functional class was detected in about one-half of patients with ACM who abstained from alcohol, and occurred even in cases presenting with severe LVD. Recovery is associated with significantly lower pulmonary artery and pulmonary wedge pressures. The morphometric evaluation of EMB does not provide adjunctive prognostic information in these patients.

Relation of left ventricular function to habitual alcohol consumption

Left ventricular (LV) dysfunction is a frequent finding in chronic alcoholic subjects. LV function's relation to alcohol use in the general population, where low and moderate consumption predominate, was studied in this work. A random sample of 120 people born in 1954 was invited to participate in the study, and 93 (42 men and 51 women) enrolled. Ethanol use was studied by 2-month daily recording of all alcoholic drinks; smoking and physical activity were quantified likewise, and salt intake by 7-day food records. Subsequently, subjects underwent an LV examination by M-mode echocardiography, and a transmitral flow velocity study by pulsed Doppler ultrasound. The relations of LV measurements to alcohol use were studied by multiple linear regression adjusting for sex, body size, blood pressure, heart rate, smoking, physical activity and dietary salt intake. No subject had clinical heart disease. The average daily ethanol consumption ranged from 0 to 1.2 g/kg of body weight (median 0.2). Statistically significant associations with square-root daily ethanol use were found for LV end-systolic diameter (regression coefficient [b] +/- SE 4.0 +/- 1.5 mm/square root of g/kg; p < 0.01), fractional shortening (b = -3.9 +/- 1.8%/square root of g/kg; p < 0.05), peak early transmitral velocity (b = -8.9 +/- 3.5 cm/s/square root of g/kg; p < 0.05), and peak atrial transmitral velocity (b = -4.9 +/- 1.9 cm/s/square root of g/kg; p < 0.05). No interactions with sex were observed.(ABSTRACT TRUNCATED AT 250 WORDS)

Comparison of the cardiotoxicity of ethanol in women versus men

Subclinical left ventricular (LV) dysfunction is a common occurrence in alcoholic men but has been claimed to be absent or very rare in alcoholic women. M-mode echocardiography was performed to study LV size, mass and systolic function, and Doppler ultrasound to study LV filling in 14 chronic female alcoholics aged 24 to 48 years and in 2 age-matched control groups consisting of 17 healthy women and 22 alcoholic men. Compared with healthy women, female alcoholics had no differences in heart rate or blood pressure but a shorter LV end-diastolic diameter (mean +/- standard deviation, 46 +/- 4 vs 48 +/- 3 mm, p less than 0.05), lower fractional shortening (31 +/- 6 vs 34 +/- 3%, p less than 0.05), increased wall thickness to radius ratio (0.43 +/- 0.08 vs 0.37 +/- 0.05, p less than 0.05), reduced peak early diastolic transmitral velocity (45 +/- 11 vs 68 +/- 7 cm/s, p less than 0.001), reduced deceleration of the early diastolic velocity (-274 +/- 69 vs -572 +/- 107 cm/s2, p less than 0.001), and an increased atrial filling fraction (35 +/- 12 vs 27 +/- 5%, p less than 0.05). Although alcoholic men had a longer duration of heavy drinking than alcoholic women (median 19 vs 5 years, p less than 0.001), and a higher systolic blood pressure (140 +/- 17 vs 120 +/- 17 mm Hg, p less than 0.001), there were no statistically significant differences between the sexes either in LV diameters, wall thickness or mass normalized to body area, or in indexes of systolic or diastolic LV function.(ABSTRACT TRUNCATED AT 250 WORDS)

Left ventricular size, mass and function in relation to the duration and quantity of heavy drinking in alcoholics

Left ventricular (LV) hypertrophy and mild dysfunction are frequently observed in alcoholics but little is known about how they relate to the duration and severity of alcohol abuse. LV size, mass and function were studied using echocardiography and systolic time intervals in 78 middle-aged male alcoholics who also gave detailed accounts of the duration of heavy drinking, the quantity of recent ethanol consumption and the duration of abstinence. Compared with 34 healthy nonalcoholics, alcoholics had a higher LV mass index (85 +/- 2 [mean +/- standard error] vs 77 +/- 2 g/m2, p = 0.001), a thicker posterior wall (11 +/- 0.2 vs 10 +/- 0.2 mm, p = 0.02), a longer end-systolic diameter index (18 +/- 0.3 vs 17 +/- 0.3 mm/m2, p = 0.02), and a higher preejection period/ejection time ratio (0.36 +/- 0.01 vs 0.33 +/- 0.01, p = 0.002). In multivariate linear regression models, these abnormalities proved independent of the drinking history, except that posterior wall thickness was weakly related to the duration of heavy drinking (standardized correlation coefficient 0.36, p = 0.01). Univariate analyses suggested that the LV mass index and systolic time interval ratio had, if anything, a curvilinear relation to the total duration of heavy alcohol consumption. It is concluded that the LV hypertrophy and dysfunction found in alcoholics are poorly related to the duration and severity of self-reported alcohol abuse. Together with other data, this suggests that there is no simple linear dose-injury relation in the long-term cardiotoxicity of ethanol. Factors modifying the myocardial effects of ethanol need to be studies more in the future.

Acute effects of alcohol and food intake on cardiac performance

Alcohol and food intake induce changes in LV performance which can be evaluated by radionuclide cardiographic methods. Alcohol probably exerts its effects by a direct action of ethanol in the blood on the myocardium, while the postprandial hemodynamic changes are related to the effects of food in the intestine. Alcohol intoxication causes a dose-dependent impairment of LV emptying at rest, whereas compensatory mechanisms other than an increased sympathetic nervous activity counterbalance this effect during exercise. In patients with coronary artery disease, alcohol induces only small changes in LV volumes at rest, possibly because of a concomitant vasodilation. Food intake seems to have a considerable influence on central hemodynamics leading to an increase in cardiac output both in healthy subjects and in patients with coronary artery disease. In healthy subjects an increase is recorded in the LVEDV and LVESV after a meal. The autonomic nervous system is probably responsible for most of the hemodynamic changes.