Chapter 11
The Epidemiology of Alcohol and Cardiovascular Diseases
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Arthur L. Klatsky Kaiser Permanente Medical Center, 280 West MacArthur Boulevard, Oakland, CA 94611
Disparities in the relations of alcohol consumption to various cardiovascular (CV) conditions have become evident. Heavier drinking is related to higher prevalence of cardiomyopathy, hypertension (HTN), hemorrhagic stroke, and cardiac dysthythmias. Lighter drinking is related to lower prevalence of coronary artery disase (CAD), occlusive stroke, and sudden cardiac death. The composite of these relations in several population studies of overall CV mortality is a U-shaped curve (lighter drinkers at lower risk than abstainers or heavier drinkers), although several other studies show a l l drinkers, lighter and heavier, at lower CV mortality risk than abstainers. Increased non-cardiovascular mortality among heavier drinkers is found in a l l studies, with a J-curve for the total alcohol-mortality relation.
Alcoholic Cardiomyopathy (ACM) The concept of an independent direct cardiotoxic effect of alcohol has become accepted. The circumstantial evidence is substantial, but the absence of specific markers continues to impede epidemiologic study. Alcohol-associated CM cannot be distinguished clinically or pathologically from dilated CM of unknown cause(s). Historical episodes suggest synergistic myocardial toxicity of alcohol with arsenic and cobalt; other cofactors in alcoholic heart disease remain speculative. A role for thiamine deficiency in low output chronic heart
© 1997 American Chemical Society Watkins; Wine ACS Symposium Series; American Chemical Society: Washington, DC, 1997.
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failure has never been established, although an i n t e r a c t i o n with a l c o h o l c a r d i o t o x i c i t y might e x i s t i n malnourished persons. The most convincing c i r c u m s t a n t i a l evidence f o r ACM is the extensive data, i n animals and humans, of n o n s p e c i f i c c a r d i a c abnormalities r e l a t e d to a l c o h o l . These i n c l u d e s t r u c t u r a l abnormalities i n autopsy and b i o p s y s t u d i e s and demonstration of acute and chronic functional and metabolic derangements by several techniques. Two recent r e p o r t s deserve s p e c i a l mention: (1) A p o s s i b l e nonoxidative metabolic pathway f o r a l c o h o l has been reported by Lapasota and Lange (1) i n the heart, muscle, pancreas, and b r a i n , r e l a t e d to f a t t y a c i d metabolism. Accumulation of f a t t y a c i d e t h y l e s t e r s was shown to be r e l a t e d to blood a l c o h o l l e v e l s and to mitochondrial metabolism. (2) A report by Urbano-Marqueζ et a l . (2) showed a c l e a r r e l a t i o n i n a l c o h o l i c s of l i f e t i m e alcohol consumption to s t r u c t u r a l and f u n c t i o n a l myocardial and s k e l e t a l muscle abnormalities. The amounts of a l c o h o l Were l a r g e -- the e q u i v a l e n t of 120 grams alcohol/day f o r 20 years. As of 1995, a large proportion (-50%) of a l l cases of CM are considered to be of unknown cause. The p r o p o r t i o n of CM a t t r i b u t e d to a l c o h o l v a r i e s markedly i n r e p o r t s , probably due mostly to d i f f e r e n c e s i n the a l c o h o l h a b i t s of the populations under study. Thus, recent r e p o r t s include a l c o h o l - a t t r i b u t a b l e proportions ranging from 3.4% at Johns Hopkins H o s p i t a l (3) to 41.9% at the P h i l a d e l p h i a VA H o s p i t a l (4). The l a c k of s p e c i f i c markers f o r ACM necessitates exclusion of other CV conditions f o r d i a g n o s i s . However, the probability of synergistic damage includes c a r d i o t o x i t y a d d i t i v e to other myocardial damage. For t h i s reason, persons with heart muscle impairment or major arrhythmias should be e s p e c i a l l y strongly advised to l i m i t a l c o h o l intake to < 3 drinks/day. Hypertension
(HTN)
An a s s o c i a t i o n between heavier alcohol consumption and
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