Alcohol and cardiovascular disease

The subject of alcohol and heart attacks is important because the major cause of death in many countries is cardiovascular disease.

Research indicates that moderate drinkers are less likely to suffer heart attacks than are abstainers or heavy drinkers [Hennekens, C.H. Alcohol and risk of coronary events. In: Zakhari, S., and Wassef, M., eds." Alcohol and the Cardiovascular System" [http://pubs.niaaa.nih.gov/publications/monograp.htm NIAAA Research Monograph No. 31. NIH Pub. No. 96-4133] Washington, DC: U.S. Govt. Print. Off., 1996. pp. 15-24.] [Umed A. Ajani, MBBS, MPH; J. Michael Gaziano, MD, MPH; Paulo A. Lotufo, MD, DrPH; Simin Liu, MD, ScD; Charles H. Hennekens, MD, DrPH; Julie E. Buring, ScD; JoAnn E. Manson, MD, DrPH [http://circ.ahajournals.org/cgi/content/abstract/102/5/500 Alcohol Consumption and Risk of Coronary Heart Disease by Diabetes Status] "Circulation", 2000;102:500-505] [Jorg Muntwyler,Prof Charles H Hennekens, Prof Julle E Buring, and Dr J Michael Gaziano [http://www.thelancet.com/journals/lancet/article/PIIS014067369806351X/abstract Mortality and light to moderate alcohol consumption after myocardial infarction] "The Lancet" 1998; 352:1882-1885 DOI:10.1016/S0140-6736(98)06351-X] [Kenneth J. Mukamal; Malcolm Maclure; James E. Muller; Jane B. Sherwood; Murray A. Mittleman [http://jama.ama-assn.org/cgi/content/full/285/15/1965 Prior Alcohol Consumption and Mortality Following Acute Myocardial Infarction] "Journal of the American Medical Association", 2001, "285(15)", 1965-1970.] [National Institute on Alcohol Abuse and Alcoholism. [http://pubs.niaaa.nih.gov/publications/aa45.htm "Alcohol Alert", No. 45] October, 1999.] [Rimm EB, Giovannucci EL, Willett WC, Colditz GA, Ascherio A, Rosner B, Stampfer MJ. [http://www.ncbi.nlm.nih.gov/pubmed/1678444 Prospective study of alcohol consumption and risk of coronary disease in men] "The Lancet". 1991, 1991 Aug 24;338(8765):464-8] Howard D. Sesso; Meir J. Stampfer; Bernard Rosner; Charles H. Hennekens; JoAnn E. Manson; J. Michael Gaziano [http://archinte.ama-assn.org/cgi/content/full/160/17/2605 Seven-Year Changes in Alcohol Consumption and Subsequent Risk of Cardiovascular Disease in Men] "Archives of Internal Medicine", 2000;160:2605-2612] [Leon A Simons, John McCallum, Yechiel Friedlander, Michael Ortiz and Judith Simons [http://www.mja.com.au/public/issues/173_03_070800/simons/simons.html Moderate alcohol intake is associated with survival in the elderly: the Dubbo Study] "The Medical Journal of Australia" 2000; 173: 121-124] [Craig R. Walsh; Martin G. Larson; Jane C. Evans; Luc Djousse; R. Curtis Ellison; Ramachandran S. Vasan; and Daniel Levy [http://www.annals.org/cgi/content/abstract/136/3/181 Alcohol Consumption and Risk for Congestive Heart Failure in the Framingham Heart Study] "Annals of Internal Medicine", 5 February 2002, Volume 136 Issue 3, Pages 181-191] The first scientific study of the relationship between alcohol consumption and atherosclerosis was published in the "Journal of the American Medical Association" in 1904 [Cabot, R.C. "The relation of alcohol to arterioscleroisis" "Journal of the American Medical Association", 1904, "43", 774-775.] . Public awareness of the supposed French Paradox in the early 1990s stimulated increased interest in the subject of alcohol and heart disease.

A paper stated, "The results indicated that moderate consumers (1 to 2 drinks/day) were at a lower risk of coronary heart disease than nonconsumers or heavy consumers." [LaPorte RE, Cauley JA, Kuller LH, Flegal K, Gavaler JS, Van Thiel D [http://www.ncbi.nlm.nih.gov/pubmed/3975449 Alcohol, coronary heart disease, and total mortality] "Recent developments in Alcoholism" 1985;3:157-63]

Debate over research methods

Ex-drinkers versus never-drinkers

A logical possibility is that some of the alcohol abstainers in research studies previously drank excessively and had undermined their health, thus explaining their high levels of risk. To test this hypothesis, some studies have excluded all but those who had avoided alcohol for their entire lives. The conclusion remained the same in some studies: moderate drinkers are less likely to suffer heart disease. A paper concludes, "In this population of light to moderate drinkers, alcohol consumption in general was associated with decreased MI [myocardial infarction ] risk in women; however, episodic intoxication was related to a substantial increase in risk." [Dorn, Joan M.; Hovey, Kathleen; Williams, Brent A.; Freudenheim, Jo L.; Russell, Marcia; Nochajski, Thomas H.; Trevisan, Maurizio [http://www.ingentaconnect.com/content/bsc/add/2007/00000102/00000005/art00011 Alcohol drinking pattern and non-fatal myocardial infarction in women] "Addiction" Volume 102, Number 5, May 2007 , pp. 730-739(10)]

An analysis by sociologist Kaye Fillmore et al. failed to find significant support. Analyzing 54 prospective studies, the authors found that those studies which were free of the potential error (including former drinkers in the abstaining group) did not demonstrate significant cardiac protection from alcohol, although they continued to exhibit a J-shaped relationship in which moderate drinkers were less likely (but not at a statistically significantly level of confidence) to suffer cardiac disease than lifelong abstainers. [ "Addiction Research & Theory", "14(2)," 2006, 101-132] The instructor of nursing says research is needed that looks at the reasons people abstain, which hers did not do.

Cardiologist Dr. Arthur Klatsky notes that Fillmore’s study, which she freely acknowledges proves nothing but only raises questions, is itself seriously flawed. To overcome the inherent weaknesses of all epidemiological studies, even when properly conducted, he calls for a randomized trial in which some subjects are assigned to abstain while others are assigned to drink alcohol in moderation and the health of all is monitored for a period of years.Fact|date=June 2008

Lifestyle as a possible confounder

Another possibility is that moderate drinkers have more healthful lifestyles (making them healthier), higher economic status (giving them greater access to better foods or better healthcare), higher educational levels (causing them to be more aware of disease symptoms), etc. However, when these and other factors are considered, the conclusion again remains the same: moderate drinkers are less likely to suffer heart disease.Pearson, Thomas A. "Alcohol and Heart Disease." cite web|title="Circulation" 1996;94:3023-3025|url=http://circ.ahajournals.org/cgi/content/full/94/11/3023|accessdate=2006-1-30]

Tests of alternative hypotheses

A study concluded, "Even in men already at low risk on the basis of body mass index, physical activity, smoking, and diet, moderate alcohol intake is associated with lower risk for MI [myocardial infarction] ." [Kenneth J. Mukamal; Stephanie E. Chiuve; Eric B. Rimm [http://archinte.highwire.org/cgi/content/full/166/19/2145 Alcohol Consumption and Risk for Coronary Heart Disease in Men With Healthy Lifestyles] "Archives of Internal Medicine" 2006;166:2145-2150] Other research also addresses this question.

Another study found that when men increased their alcohol intake from very low to moderate, they significantly reduced their risk of coronary heart disease. The study monitored the health of 18,455 males for a period of seven years.

These and similar studies reduce the possibility that it is not alcohol itself that reduces the risk of cardiovascular disease.

Understanding specifically how alcohol improves cardiovascular health and reduces disease also significantly increases scientific confidence in the health benefits of moderate drinking.

The processes whereby alcohol benefits cardiovascular health

Given the epidemiological evidence that moderate drinking reduces heart disease, it becomes important to examine how alcohol might confer its cardiovascular benefits. Can alcohol’s protective affects be explained physiologically? Research suggests that moderate consumption of alcohol improves cardiovascular health in a number of ways [Davidson, Dennis M [http://www.pubmedcentral.gov/picrender.fcgi?artid=1026830&blobtype=pdf Cardiovascular Effects of Alcohol] "Western Journal of Medicine" 1989 October; 151(4): 430–439] [Ely SW, Berne RM [http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=1537125&dopt=Abstract Protective effects of adenosine in myocardial ischemia] "Circulation", 1992 Mar;85(3):893-904 This paper appears to say nothing about alcohol] [Facchini F, Chen YD, Reaven GM [http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=7907975&dopt=Abstract Light-to-moderate alcohol intake is associated with enhanced insulin sensitivity] "Diabetes Care" 1994 Feb;17(2):115-9] [Langer RD, Criqui MH, Reed DM [http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=1537127&dopt=Abstract Lipoproteins and blood pressure as biological pathways for effect of moderate alcohol consumption on coronary heart disease] "Circulation" 1992 Mar;85(3):910-5] Mennen LI, Balkau B, Vol S, Caces E, Eschwege E. [http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?CMD=Display&DB=pubmed Fibrinogen may explain in part the protective effect of moderate drinking on the risk of cardiovascular disease] . "Arteriosclerotic and Thrombodic Vascular Biology" 1999 Apr;19(4):887-92] [Paassilta Marita; Kervinen, Kari; Rantala, Asko O; Savolainen, Markku J; Lilja, Mauno; Reunanen, Antti; Kesäniemi, Y Antero [http://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=28464 Social alcohol consumption and low Lp(a) lipoprotein concentrations in middle aged Finnish men: population based study] "British Medical Journal" 1998 February 14; 316(7131): 594–595] Rimm, Eric B; Williams, Paige; Fosher, Kerry; Criqui, Michael; Stampfer, Meir J [http://bmj.bmjjournals.com/cgi/content/full/319/7224/1523?maxtoshow=&HITS=10&hits=10&RESULTFORMAT=&author1=rimm&searchid=1&FIRSTINDEX=0&resourcetype=HWCIT,HWISS,HWFIG,HWDSUP,HWELTR Moderate alcohol intake and lower risk of coronary heart disease: meta-analysis of effects on lipids and haemostatic factors] "British Medical Journal" 1999;319:1523-1528 (11 December)] [Thun MJ, Peto R, Lopez AD, Monaco JH, Henley SJ, Heath CW Jr, Doll R [http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=9392695&dopt=Abstract Alcohol consumption and mortality among middle-aged and elderly U.S. adults] "New England Journal of Medicine" 1997 Dec 11;337(24):1705-14] Zhang QH, Das K, Siddiqui S, Myers AK [http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=10798590&dopt=Abstract Effects of acute, moderate ethanol consumption on human platelet aggregation in platelet-rich plasma and whole blood] "Alcohol: Clinical and Experimental Research", 2000 Apr;24(4):528-34] [Wang, Zhiqing; Barker, Thomas H; Fuller, Gerald M [http://www.blackwell-synergy.com/doi/abs/10.1111/j.1530-0277.1999.tb04093.x Alcohol at Moderate Levels Decreases Fibrinogen Expression In Vivo and In Vitro] "Alcohol: Clinical and Experimental Research" Volume 23 Page 1927 - December 1999.doi:10.1111/j.1530-0277.1999.tb04093.x] , including the following.

:I. Alcohol improves blood lipid profile. ::A. It increases HDL ("good") cholesterol. ::B. It decreases LDL ("bad") cholesterol.::C. It improves cholesterol (both HDL and LDL) particle size (Mukamal, K. J. et al. Alcohol consumption and lipoprotein subclasses in older adults. Journal of Clinical Endocrinology & Metabolism, 2007, April. PMID: 17440017)

:II. Alcohol decreases thrombosis (blood clotting). ::A. It reduces platelet aggregation. ::B. It reduces fibrinogen (a blood clotter). ::C. It increases fibrinolysis (the process by which clots dissolve).

:III. Alcohol acts through additional ways. ::A. It reduces coronary artery spasm in response to stress. ::B. It increases coronary blood flow. ::C. It reduces blood pressure. ::D. It reduces blood insulin level. ::E. It increases estrogen levels

There is a lack of medical consensus about whether moderate consumption of beer, wine, or distilled spirits has a stronger association with heart disease. Studies suggest that each is effective, with none having a clear advantage. Most researchers now believe that the most important ingredient is the alcohol itselfRimm, Eric B; Klatsky, Arthur; Grobbee, Diederick; Stampfer, Meir J [http://bmj.bmjjournals.com/cgi/content/abstract/312/7033/731?ijkey=c90dc8d3bbf9198b2fc1e2d1e3c171a4a4c19a08&keytype2=tf_ipsecsha Review of moderate alcohol consumption and reduced risk of coronary heart disease: is the effect due to beer, wine, or spirits?] "BMJ" 1996;312:731-736 (23 March)] [John C Barefoot, Morten Grønbæk, John R Feaganes, R Sue McPherson, Redford B Williams and Ilene C Siegler [http://www.ajcn.org/cgi/content/full/76/2/466 Alcoholic beverage preference, diet, and health habits in the UNC Alumni Heart Study] "American Journal of Clinical Nutrition", Vol. 76, No. 2, 466-472, August 2002]

The American Heart Association has reported that "More than a dozen prospective studies have demonstrated a consistent, strong, dose-response relation between increasing alcohol consumption and decreasing incidence of CHD (coronary heart disease). The data are similar in men and women in a number of different geographic and ethnic groups. Consumption of one or two drinks per day is associated with a reduction in risk of approximately 30% to 50%".

Heart disease is the largest cause of mortality in the United States and many other countries. Therefore, some physicians have suggested that patients be informed of the potential health benefits of drinking alcohol in moderation, especially if they abstain and alcohol is not contraindicated. Others, however, argue against the practice in fear that it might lead to heavy or abusive alcohol consumption. Heavy drinking is associated with a number of health and safety problems.

References

Further reading

* "British Medical Journal" [http://bmj.bmjjournals.com/cgi/content/full/332/7552/0-c "Alcohol drinking patterns have different CHD outcomes in men and women"]
* "British Medical Journal" [http://bmj.bmjjournals.com/cgi/content/full/332/7552/1244 "Prospective study of alcohol drinking patterns and coronary heart disease in women and men"]

External links

* [http://www.health.gov/dietaryguidelines/dga2005/document/html/chapter9.htm USDA Dietary Guidelines for Americans 2005: Chapter 9 Alcoholic Beverages]