The Prognostic Factors of Alcoholic Cardiomyopathy: A single-center cohort study

BACKGROUND

Alcoholic cardiomyopathy (ACM) is considered one of the main causes of left ventricular dysfunction and is the leading cause of nonischemic dilated cardiomyopathy (DCM) in developed countries. However, very few studies have investigated the relationship between clinical characteristics and prognosis in ACM.

AIMS

This study aimed to identify risk factors related to a poor outcome in ACM patients.

STUDY DESIGN

Retrospective cohort study.

METHODS

This study included 321 patients with ACM admitted to our hospital between 2003 and 2013. This study aimed to investigate the clinical characteristics and outcomes of the patients with ACM, and the primary endpoint of the study was all-cause mortality, which was assessed through patient medical records (review of patient hospital records and periodic examination of patients in the outpatient clinic) and medical follow-up calls with trained personnel. All-cause mortality was assessed using Kaplan-Meier survival curves, and the risk factors were assessed using Cox regression. A receiver operating characteristic (ROC) curve analysis was performed to optimize the cutoff point for discriminating between the 2 risk groups.

RESULTS

After a median follow-up period of 3.78 years (interquartile range: 2.08-6.52 years), 83 (27.7%) patients were dead. The independent predictors of all-cause mortality due to ACM were the QRS duration (HR: 1.014; 95% CI: 1.004-1.019; P = .003), systolic blood pressure (HR: 0.980; 95% CI: 0.963- 0.997; P = .020), and New York Heart Association classification (HR: 1.595; 95% CI: 1.110-2.290; P = .011) at admission.

CONCLUSION

Our study indicated that the QRS duration, systolic blood pressure, and New York Heart Association classification at admission provided independent prognostic information in patients with ACM.

[Significance of changes in the myocardium for the forensic-medical diagnosis of death as a result of alcoholic cardiomyopathy]

Significance, of the weight and dimensions of heart as well as of fat dystrophy of cardiomyocytes and of the related detection methods is demonstrated for the diagnosis of alcoholic cardiomyopathy (ACMP). When such patients die in a state of alcoholic intoxication, the diagnosis should be death of acute alcoholic intoxication. Lethality of ACMP can be diagnosed only in those who die in the sober condition or with an insignificant level of alcohol.

[Alcohol, the heart and cardiovascular system]

Any advice about the consumption of alcohol must take into account not only the relation between alcohol and cardiovascular disease but also the well-known association of heavy consumption of alcohol with a large number of health risks. Numerous observational studies have consistently demonstrated a reduction of coronary heart disease with moderate consumption of alcohol. Consumption of 1 or 2 drinks per day is associated with a reduction in risk of dying from coronary heart disease of approx. 30-50%. A drink equivalent amounts to a 12-ounce bottle of beer, a 4-ounce glass of wine, and a 1.5-ounce shot of 80-proof spirits. It has been repeatedly demonstrated that there is a J-shaped relation between alcohol consumption and total mortality. The lowest mortality occurs in those who consume 1 or 2 drinks per day. A stepwise decline in coronary heart disease death occurs with increasing drinks per day. Because coronary heart disease accounts for 1/3 or more of total death, people with no alcohol consumption have higher total mortality than those drinking 1 to 2 drinks per day. Conversely, mortality due to a large number of other diseases increases with an increasing number of drinks consumed per day. The protective effects of alcoholic against coronary heart disease are mainly related to an increase in HDL cholesterol. A number of other mechanisms have been proposed including effects of alcohol on blood clotting and non-alcoholic components of alcoholic beverages, particularly in red wine and dark beer, which may have antioxidant properties. Harmful effects of alcohol on the cardiovascular system include congestive cardiomyopathy, systemic hypertension and cerebral vascular incidents. There is a direct correlation between the amount of alcohol consumed during lifetime and a reduction in left ventricular ejection fraction.

Comparison of long-term outcome of alcoholic and idiopathic dilated cardiomyopathy

AIMS

The outcome of alcoholic cardiomyopathy is thought to be better than idiopathic dilated cardiomyopathy if patients abstain from alcohol. The aim of this study was to compare the long-term clinical outcome of alcoholic and idiopathic dilated cardiomyopathy.

METHODS AND RESULTS

Of 134 patients with dilated cardiomyopathy and normal coronary angiography, 50 had alcoholic cardiomyopathy; they were compared serially to 84 patients with idiopathic dilated cardiomyopathy. Left ventricular end-diastolic diameter, left ventricular ejection fraction and cardiac index, severity of ventricular arrhythmias, measurement of heart rate variability and results of signal-averaged ECG were similar in both groups. Although alcohol withdrawal was strongly recommended but observed in only 70% of patients with alcoholic cardiomyopathy, both groups had similar outcome in terms of cardiac death after follow-up treatment of 47+/-40 months. Multivariate analysis in the entire cohort demonstrated that increased pulmonary capillary wedge pressure (P=0. 003), alcoholism and lack of abstinence during follow-up (P=0.006) and decreased standard deviation of all normal-to-normal RR intervals (P=0.02) were independent predictors of cardiac death.

CONCLUSION

In contrast with previous studies, patients with alcoholic cardiomyopathy did not have a better outcome than patients with idiopathic dilated cardiomyopathy. Alcoholism without abstinence was a strong predictor of cardiac death. This suggests that a more aggressive approach to alcohol cessation is needed in these patients.

Differences of disease progression in congestive heart failure due to alcoholic as compared to idiopathic dilated cardiomyopathy

In patients with alcoholic cardiomyopathy there is evidence that mild heart failure is reversible if patients abstain from alcohol, but there is no consensus whether the disease is progressive once structural myocardial dilation has evolved. The aim of the present study was to compare the long-term course of congestive heart failure due to alcoholic and idiopathic dilated cardiomyopathy. Of 75 patients with overt congestive heart failure, 23 had alcoholic cardiomyopathy and were compared to 52 patients with idiopathic cardiomyopathy. The mean age was 48 +/- 12 years. Despite medical therapy, heart failure class New York Heart Association III-IV was present in 52% of patients with alcoholic and 47% of patients with idiopathic cardiomyopathy (not significant). Their mean left ventricular ejection fraction was 30 +/- 12% vs 28 +/- 12% and left ventricular end-diastolic volumes were 264 +/- 125 ml and 254 +/- 100 ml respectively (not significant). Overall survival at 1, 5 and 10 years was 100%, 81% and 81% for the group with alcoholic dilated cardiomyopathy and 89%, 48% and 30% for the group with idiopathic cardiomyopathy, respectively (P = 0.041), and the difference was even greater for transplant-free survival P = 0.005). Clinical and invasive signs of left and right heart failure as well as left ventricular dimensions were predictive of a fatal outcome; however, symptom duration and left ventricular volumes were only predictive in patients with idiopathic cardiomyopathy, suggesting that in the two patient groups different mechanisms may lead to death. Mortality in patients with severe congestive heart failure and left ventricular dilatation due to alcoholic cardiomyopathy is significantly lower than that in patients with idiopathic cardiomyopathy and similar degrees of heart failure. Thus, despite structural changes inherent in marked left ventricular dilatation, disease progression in alcoholic dilated cardiomyopathy is different from that in idiopathic cardiomyopathy and thus may have implications for the choice of therapy.

Hearts from donors with chronic alcohol use: a possible risk factor for death after heart transplantation

BACKGROUND

Careful donor and recipient selection are important factors for the success of heart transplantation. Currently, donors with a history of alcohol use are routinely accepted despite the potential deleterious effects of alcohol on the heart.

METHODS

We examined the frequency of chronic alcohol use (> 2 ounces of pure alcohol daily for > or = 3 months) among organ donors and the outcome of the receipients after heart transplantation. Of 99 consecutive patients who underwent transplantation between December 1988 and August 1993 with an adequate donor history, 17 (17%) had a history of chronic alcohol use (alcohol group), and 82 (83%) did not (nonalcohol group). All recipients received triple-drug immunosuppression, and 10 to 14 days of OKT3.

RESULTS

Survival rates at 1 and 2 years were significantly lower in the alcohol group (61% +/- 13% and 61$ +/- 13%) than in the nonalcohol group (95% +/- 3% and 91% +/-4%, p = 0.0001). Most deaths in the alcohol group occurred within 3 months after transplantation. The incidence of rejection episodes did not differ significantly. Fatal rejection occurred more frequently in the alcohol group and was associated with severe ventricular dysfunction before death. Cox multiple regression analysis identified donor alcohol use as an independent risk factor for death after heart transplantation.

CONCLUSIONS

A substantial proportion (17%) of heart donors have a history of chronic alcohol use. The unfavorable early outcome of patients receiving hearts from alcoholic donors suggests the presence of a subclinical alcoholic cardiomyopathy before transplantation and poor tolerance of rejection episodes after transplantation. Larger prospective studies are needed to determine the mechanism of fatal rejection and whether such hearts can be used safely for transplantation.

Relationship between morbidity and mortality due to alcoholic cardiomyopathy and alcohol consumption in Australia

The study was undertaken to determine whether morbidity and mortality rates for alcoholic cardiomyopathy vary with community alcohol consumption levels. The cardiomyopathy mortality comparisons for Australia from 1968 to 1978 showed a positive relationship for both males and females aged 30 to 59 years, and 60 years and over. From 1979 to 1986 a decrease in consumption was associated with a decrease in alcoholic cardiomyopathy mortality for females, and to a lesser extent males, aged 30 to 59 years. The morbidity comparisons for Western Australia from 1971 to 1984 gave similar results to the Australian mortality findings for the males aged 30 to 59 years. It appears that the prevention of alcoholic cardiomyopathy will be facilitated by lowering the overall level of alcohol consumption in the community.

Risk factors in alcoholic cardiomyopathy

Although a relationship has been suggested between abstinence from alcohol and improvement in left ventricular (LV) function, no long-term studies in large groups of patients have been done to confirm this impression or to demonstrate an effect on survival. To address these questions, the authors analyzed the outcome in 105 male patients with alcoholic cardiomyopathy and 64 control male patients with nonalcoholic dilated cardiomyopathy. Survival data were available for all patients. The correlates of survival were assessed via the Cox proportional hazards model. Variables considered were age, race, drinking pattern (current drinker versus former drinker), presence of coronary artery disease (CAD), hypertension, and diabetes, and these echo variables: left atrial (LA) size, posterior wall thickness, LV end diastolic dimension (LVDD), minimal E point septal separation, wall motion, presence of incomplete mitral leaflet closure (IMLC) or low cardiac output, and the ratio of relative wall thickness to LVDD. The two study groups were comparable with respect to all echocardiographic variables. At a mean follow-up of 17.2 months +/- 12.1 months, 42.85% of the alcoholics and 41% of the nonalcoholics had died. Nonsurvival in the alcoholic group was significantly associated with only two factors: an increased LVDD and the presence of IMLC. The drinking pattern was not significantly associated with survival. By contrast, in the nonalcoholics,the variables most closely related to survival were LVDD, low cardiac output, increasing age, and abnormal wall motion. Therefore: (1) the risk factors in alcoholic and nonalcoholic cardiomyopathy are similar although IMLC appears to be a relatively specific prognostic factor for alcoholic cardiomyopathy and (2) abstinence from alcohol does not appear to improve survival.

Factors discriminating survivors and nonsurvivors in alcoholic heart disease

Eighteen patients with dilated cardiomyopathy and a history of excessive ethanol intake were monitored for 3-98 months (mean 23 months). Six patients died (mean age 43.7 +/- 9.2 years) and 12 patients survived (mean age 48.8 +/- 9.5 years). Of the echocardiographic findings taken during heart failure, only the relative wall thickness to the internal dimension of the left ventricle (t/r ratio) differed significantly (survivors 0.33 +/- 0.77 vs. nonsurvivors 0.25 +/- 0.04, P less than 0.05). Of the hemodynamic data obtained after treatment of heart failure, left ventricular end-diastolic pressure differed significantly (survivors 6 +/- 2 vs. nonsurvivors 12 +/- 4 mmHg, P less than 0.001). The two groups could not be differentiated by ejection fraction, cardiac output, end-diastolic or end-systolic volumes, or semi-quantitative analysis of histologic findings obtained by right ventricular endomyocardial biopsy (light microscopy). Only two of six nonsurvivors (33%) succeeded in abstaining from alcohol, while eight of twelve survivors (67%) became teetotalers (P less than 0.05). Total abstinence from alcohol seems to be essential but was not necessarily followed by recovery in the most severe cases. Thus, the absence of adequate hypertrophy and high left ventricular filling pressure may predict the prognosis in alcoholic heart disease.

Alcohol and mortality. Diagnostic considerations

Two hundred fifty of 1289 alcoholics died within eight years of treatment of alcoholism or its complications. Gastrointestinal and cardiovascular disorders were significantly greater among the group who died within one year of treatment. Other sex, age and racial differences were also significant.

Variable prognosis in congestive cardiomyopathy. Role of left ventricular function, alcoholism, and pulmonary thrombosis

Prognosis of 36 patients with congestive cardiomyopathy was studied in relation to various clinical factors. Half life of the survival curve after overt heart failure was about 7 years. Although left ventricular function was a major determinant of clinical course in congestive cardiomyopathy in general, its relation to prognosis was variable according to the type of cardiac involvement. In peripartal cardiomyopathy and in a type of cardiomyopathy named subacute cardiomyopathy with pulmonary thrombosis in this paper, factor(s) other than left ventricular function, possibly including pulmonary thrombosis, may be operative as more important determinant of extremely poor prognosis in these subtypes. Alcoholic cardiomyopathy was also unique in its favorable prognosis in association with reversible cardiomegaly following abstention from alcohol.