Noninvasive cardiac evaluation in chronic alcoholic patients with alcohol withdrawal syndrome

Analysis of the factors determining survival of alcoholic withdrawal syndrome patients in a general hospital

AIM

To investigate the clinical variables associated with the risk of dying and the causes of death during the course of alcoholic withdrawal syndrome (AWS) in a general hospital.

METHODS

Cohort study of AWS patients admitted to Xeral Hospital in Lugo, Spain between 1987 and 2003. The characteristics of patients who died were contrasted with those who survived. The different clinical, epidemiological and biochemical variables reflective of alcohol consumption habits, basal health status and presentation features of the syndrome and its complications were all recorded.

RESULTS

There were 539 episodes of hospitalization for AWS in 436 patients (mean age 45.0, SD 12.0, 91.3% males), 71.1% of whom presented with delirium tremens. A total of 29 patients died, yielding a 6.6% mortality rate (95% confidence interval, CI: 4.2-9.1%). Eighteen patients (62%) died after being admitted to the intensive care unit (ICU). The following independent variables were associated with the risk of dying in a multivariate logistic regression model: cirrhosis [odds ratio (OR) 4.8 (95% CI 1.5-14.6), P = 0.006]; presenting with delirium tremens at diagnosis [OR 3.5 (95% CI 1.3-8.9), P = 0.008]; the existence of an underlying chronic pathology other than liver disease [OR 2.5 (95% CI 1-6.1), P = 0.01]; and the need for orotracheal intubation [OR 2.9 (95% CI 1.1-7.9), P = 0.03], especially if pneumonia requiring ICU is added [OR 8 (95% CI 3-21.3), P < 0.001]. Receiver operating characteristic analysis revealed an area under the curve of 0.818 (95% CI 0.742-0.894).

CONCLUSIONS

The factors determining survival after admission to a general hospital for alcoholic withdrawal syndrome depend on the intensity of clinical manifestations (delirium tremens, ICU, orotracheal intubation) and the presence of associated comorbidity.

QT prolongation in the newborn and maternal alcoholism

I discuss a newborn whose mother is addicted to alcohol. On the third day of life, the newborn was found to have ventricular tachycardia. After spontaneous termination of the abnormal rhythm, the duration of the corrected QT interval was 0.48 s. During the next days, the duration of the interval normalized, and has now remained stable for 5 years. I conclude that the so-called "alcohol withdrawal syndrome of the newborn" might cause postnatal prolongation of the QT interval.

Mechanisms of cardiovascular dysregulation during alcohol withdrawal

Alcohol withdrawal (AW) is often accompanied by functional cardiovascular abnormalities which return to normal in few days. However, in some patients, they can predict future alterations in the cardiovascular system, even if they remain in abstinence. These changes are mediated by several central and peripheral mechanisms closely related to AW. The level of activation in the sympathetic nervous system is an important factor regulating the functioning of the cardiovascular system in AW directly and/or indirectly with L-type calcium channels and nitric oxide (NO). Other factors may contribute to cardiovascular alterations in AW including the renin-angiotensin-aldosterone system, vasopressin, cortisol and sodium sensitivity. Monitoring of the cardiovascular system is needed in patients undergoing treatment for AW. The patients with elevated systolic blood pressure (SBP) and diastolic blood pressure (DBP) after resolution of AW may require a fuller work-up of their cardiovascular system.

Influence of increased adrenergic activity and magnesium depletion on cardiac rhythm in alcohol withdrawal

OBJECTIVE

To investigate the prevalence of arrhythmias in alcoholic men during detoxification and its relation to neuroendocrine activation and electrolyte disturbances.

DESIGN

Consecutive case-control study.

SETTING

Primary and secondary care, detoxification ward.

PATIENTS AND CONTROLS

19 otherwise healthy alcoholic men (DSM-III-R) with withdrawal symptoms necessitating detoxification in hospital. 19 age matched, healthy non-alcoholic men as controls for Holter recordings.

INTERVENTIONS

Treatment with chlomethiazole; additional treatment with carbamazepine in patients with previous seizures.

MAIN OUTCOME MEASURES

Computer based analyses of mean heart rate and arrhythmias from 24 hour Holter recordings, 24 hour urinary excretion of adrenaline and noradrenaline, magnesium retention measured by means of intravenous loading test, and serum concentrations of electrolytes.

RESULTS

The 24 hour mean heart rate was higher in the alcoholic men (97.4 beats/minute, 95% confidence interval (CI) 91.2 to 103.6) than in the controls (69.6 beats/minute, 95% CI 65.4 to 73.8, P < 0.001). However, there was no difference in diurnal heart rate variation. The prevalence of premature supraventricular depolarisations was lower in the alcoholic men (P < 0.05). Neither atrial fibrillation nor malignant ventricular arrhythmias occurred. The sinus tachycardia in the alcoholic men correlated with the concomitant urinary excretion of catecholamines (P < 0.05). The mean serum magnesium concentration was 0.78 mmol/l (95% CI 0.73 to 0.83) in the alcoholic men and 0.83 mmol/l (95% CI 0.81 to 0.85) in a reference population of 55 men aged 40. Magnesium depletion (defined as magnesium retention > 30%) was detected in 10 alcoholic men (53%). Three alcoholic men had serum potassium concentrations < or = 3.3 mmol/l on admission.

CONCLUSION

Increased adrenergic activity, magnesium depletion, and hypokalaemia are often seen after heavy drinking, but in alcoholic men without clinical heart disease these changes were not accompanied by arrhythmias other than sinus tachycardia during detoxification in hospital.

Echocardiographic abnormalities in chronic asymptomatic alcoholics

Alcohol abuse is a frequent contributor to elevated blood pressure, but the literature is ambiguous about the role of hypertension in producing left ventricular dysfunction. Fifty asymptomatic male alcoholics admitted for detoxification were studied using echocardiograms and systolic time intervals. Alcoholics were separated into Group I (28 with hypertension) and Group II (22 without hypertension). Forty-four patients had analyzable echocardiograms and were compared to 29 nonalcoholics. Group III consisted of 14 nonalcoholics with hypertension. Group IV consisted of 15 normotensive nonalcoholics (controls). The ejection fraction and shortening fraction were reduced in Group I (p less than 0.05). Hypertensive alcoholics had increased left ventricular mass indices but less than hypertensive nonalcoholics. Left ventricular wall stress was compared to mass as an index of ventricular compensation. The wall stress to mass index for hypertensive alcoholics was 1.65 as compared to 1.43 for the controls. Alcoholics without hypertension had a wall stress to mass ratio of 1.54. Hypertensive patients had a reduced wall stress to mass ratio of 1.38 when compared to controls. These data suggest an inappropriate compensatory response to afterload. Alcohol and hypertension combined may be more harmful to left ventricular function than either disease alone.

Cardiac function in alcohol-associated systemic hypertension

The pathogenesis of alcohol cardiomyopathy is obscure. Because systemic hypertension is observed in one-third of alcoholics, the relation of this finding to left ventricular (LV) function was analyzed in 66 alcoholics (26 with a blood pressure of 160/95 mm Hg or higher) 4 to 5 days after alcohol withdrawal. Hypertensive alcoholics had a more abnormal ratio of preejection period/LV ejection time (PEP/ET) (0.398 +/- 0.01 vs 0.35 +/- 0.01, p less than 0.02) than normotensive alcoholics (matched normal 0.290 +/- 0.01). Hypertensive alcoholics (transitory hypertension) with blood pressures of 120/80 mm Hg or less at time of study also had more abnormal PEP/LVET than matched normotensive alcoholics (0.415 +/- 0.03 vs 0.331 +/- 0.01, p less than 0.05). In both hypertensive (77 +/- 6 dynes/cm2 X 10(3)) and normotensive alcoholics (67 +/- 4 dynes/cm2 X 10(3) LV stress was elevated (normal 46 +/- 3 dynes/cm2 X 10(3), both p less than 0.02). However, LV mass was not increased (hypertensive 96 +/- 4 g/m2; vs normotensive 100 +/- 4 g/m2; (normal 92 +/- 5 g/m2), resulting in a markedly increased stress to mass ratio (hypertensive 0.8 +/- 0.06; Normal 0.05 +/- 0.05, p less than 0.02). Hypertensive alcoholics also had LV "hyperfunction," with an increased stress/LV end-systolic volume ratio (1.7 +/- 0.1 vs 1.3 +/- 0.1 dynes/cm2 X 10(3)/ml, p less than 0.02). Thus, hypertensive alcoholics, even those with transitory hypertension, have more abnormal cardiac function than normotensive alcoholics. Presence of hypertension with hyperdynamic LV features may be a prelude to heart failure.

Special aspects of human alcohol withdrawal

There are still surprising gaps in our knowledge of alcohol withdrawal. While quantitative alcohol consumption accounts for about one third of the variability in severity of acute withdrawal, there is little systematic knowledge about the other factors involved. Thus, we cannot precisely predict the severity of withdrawal in individual patients. Controversy exists as to the role of medical vs. social detoxification approaches to acute withdrawal, the influence of acute withdrawal and its treatment on the long-term outcome of alcoholism, and the importance (or even existence) of chronic withdrawal. There is little systematic data to guide withdrawal treatment in special clinical settings, e.g., with concurrent medical or psychiatric illness or with mixed substance dependence. This chapter reviews the published literature, tries to point out methodological and conceptual problems, and suggests areas for future research.

Cardiac arrhythmias in a population admitted to an acute alcoholic detoxification center

To characterize the relationship between acute alcohol ingestion and its withdrawal with cardiac arrhythmias, we studied 38 patients admitted to an acute community alcoholic detoxification center with 24-hour ambulatory ECGs and serum ethanol levels. We found a mild correlation between the serum ethanol level and the mean rate of ventricular ectopic beats/hour (rs = 0.34, p less than 0.05). Nonsustained ventricular tachycardia and atrial fibrillation were more common in patients found to have evidence of previous underlying organic heart disease. There was no change in the prevalence of cardiac arrhythmias in this population after 2 weeks of ethanol abstinence as judged by repeat 24-hour ambulatory ECG. We conclude that in patients admitted to an acute detoxification center, cardiac arrhythmias are found more commonly in those with underlying organic heart disease, and these arrhythmias do not appear to change after 2 weeks of abstinence from alcohol ingestion.

The effects of alcohol on blood pressure and electrolytes

The interaction between alcohol abuse, changes in blood pressure, and electrolyte abnormalities is complex. Some effects of alcohol are seen only with acute ingestion, some during withdrawal, and some only in chronic drinkers. Careful attention to the interactions between the metabolism of various electrolytes can prevent unnecessary morbidity and mortality in alcoholic patients.