Review
Alcohol and Cardiovascular Health: The Dose Makes the Poison…or the Remedy

https://doi.org/10.1016/j.mayocp.2013.11.005Get rights and content

Abstract

Habitual light to moderate alcohol intake (up to 1 drink per day for women and 1 or 2 drinks per day for men) is associated with decreased risks for total mortality, coronary artery disease, diabetes mellitus, congestive heart failure, and stroke. However, higher levels of alcohol consumption are associated with increased cardiovascular risk. Indeed, behind only smoking and obesity, excessive alcohol consumption is the third leading cause of premature death in the United States. Heavy alcohol use (1) is one of the most common causes of reversible hypertension, (2) accounts for about one-third of all cases of nonischemic dilated cardiomyopathy, (3) is a frequent cause of atrial fibrillation, and (4) markedly increases risks of stroke—both ischemic and hemorrhagic. The risk-to-benefit ratio of drinking appears higher in younger individuals, who also have higher rates of excessive or binge drinking and more frequently have adverse consequences of acute intoxication (for example, accidents, violence, and social strife). In fact, among males aged 15 to 59 years, alcohol abuse is the leading risk factor for premature death. Of the various drinking patterns, daily low- to moderate-dose alcohol intake, ideally red wine before or during the evening meal, is associated with the strongest reduction in adverse cardiovascular outcomes. Health care professionals should not recommend alcohol to nondrinkers because of the paucity of randomized outcome data and the potential for problem drinking even among individuals at apparently low risk. The findings in this review were based on a literature search of PubMed for the 15-year period 1997 through 2012 using the search terms alcohol, ethanol, cardiovascular disease, coronary artery disease, heart failure, hypertension, stroke, and mortality. Studies were considered if they were deemed to be of high quality, objective, and methodologically sound.

Section snippets

Americans’ Drinking Habits

Among all American adults, about two-thirds report that they at least on occasion consume alcohol, and 44% are regular drinkers, defined as someone who has at least 1 drink per week.6 These regular drinkers consume an average of 4.2 alcoholic drinks per week. While a similar proportion of men and women consume alcohol, men on average ingest 6.2 alcoholic beverages per week compared with 2.2 drinks per week for women. Whites are more likely to consume alcohol than nonwhites, and on average,

What Constitutes a Drink?

By definition, a standard drink, regardless of the variety, contains 14 g of ethanol (0.6 fl oz of pure alcohol).7, 8 This equates to 12 oz of beer (about 5% ethanol), 5 oz of table wine (about 12% ethanol), or 1.5 oz of hard liquor or distilled spirits (about 40% ethanol).7, 8 Alcohol consumption can also be quantitated in units, whereby 1 U equals 10 mL or 8 g of ethanol, which corresponds to the amount of alcohol an average adult can metabolize in 1 hour. Thus, for example, 25 mL of whiskey,

Primary Prevention

The health effects of drinking are determined by the quantity and pattern of ethanol consumption.5 Observational studies consistently report that light to moderate drinkers are at lower risk for CV diseases than abstainers, and heavy drinkers are at the highest risk. A meta-analysis involving 1 million individuals reported that light to moderate alcohol consumption was associated with highly significant decreases in death during follow-up, with maximum protection noted at one-half to 1 drink

Secondary Prevention

Light to moderate alcohol intake has also been shown to improve outcomes in patients with established CV disease. In a recent meta-analysis of 8 prospective studies involving 16,351 patients with a history of CV disease, the familiar J-shaped curve was observed with maximal protection by alcohol at approximately 26 g/d (or about 2 drinks daily).16 Studies evaluating alcohol’s effects on patients who have had a myocardial infarction (MI) also report the typical J-shaped relationship between

Alcohol and Arrhythmias

Decades ago, the moniker “holiday heart” was suggested for acute cardiac arrhythmias, typically atrial fibrillation (AF), observed commonly in individuals drinking heavily during times of celebration.24 Unquestionably, heavy alcohol use, whether short-term or long-term, can precipitate arrhythmias.25 In the Copenhagen City Heart Study, consumption of more than 35 drinks per week correlated with higher risk of AF in men.26 Above a “safe” threshold of about 1 drink per day, the relative risk of

Alcohol and HF

Ethanol at higher doses is a cardiotoxin. Habitual heavy alcohol consumption can result in a specific cardiac disease known as alcoholic cardiomyopathy, which accounts for about one-third of all cases of nonischemic dilated cardiomyopathy in the United States.33 Individuals who consume more than 90 g of alcohol per day, which corresponds to about 7 drinks per day, for at least 5 years are at risk for the development of alcoholic cardiomyopathy and HF. Without complete abstinence, the 4-year

Alcohol and Hypertension

Habitual alcohol consumption raises blood pressure (BP) in a dose-dependent fashion. Long-term heavy drinking is one of the most common reversible causes of hypertension (HTN); excessive alcohol intake is responsible for approximately 16% of cases of HTN worldwide.39 The American Society of Hypertension warns that consuming more than 2 alcoholic drinks per day increases the risk for high BP.40 Beyond the first 1 or 2 drinks per day, each additional alcoholic drink will increase BP by

Alcohol and Stroke

Heavy drinking and chronic alcoholism are strong independent risk factors for stroke.47, 48, 49 Even so, most studies reveal a J-shaped association between alcohol and ischemic stroke, with a protective effect from light to moderate drinking and an elevated risk of stroke with heavy drinking50, 51, 52 (Figure 7). A recent study of 47,000 Japanese women followed for an average of 17 years found that ethanol consumption of 300 g/wk or more (21 or more drinks per week) increased total stroke by

Alcohol and DM

Consistent data indicate that regular light to moderate drinking is associated with substantial reductions in type 2 DM of 30% to 40%, irrespective of the alcoholic beverage consumed.55, 56, 57 In the Physicians’ Health Study, light to moderate alcohol consumption was associated with a decreased risk of type 2 DM during 12 years of follow-up.58 However, the protection that moderate drinking provides against new-onset diabetes is attenuated or abolished with higher doses (more than 4 drinks per

Cardioprotective Mechanisms of Action

The main active ingredient of any alcoholic beverage is ethanol, and most evidence indicates that this compound, rather than any other specific component of a drink, is the primary factor for both conferring health benefits and causing toxicity, depending on the pattern of consumption and dosing.66, 67 Accumulating scientific evidence suggests that light to moderate alcohol intake may enhance insulin sensitivity, elevate high-density lipoprotein (HDL) cholesterol, reduce inflammation, increase

Inconsistency of Cardioprotection Among Various Ethnicities

The cardioprotective effect of light to moderate drinking has not been consistently replicated among all the ethnicities and nations that have been studied.44, 84, 85 The INTERHEART study,86 a landmark 27,000-patient international epidemiological study, found that regular alcohol intake was associated with a decrease in the risk of MI in both sexes and all adult age groups. Individuals from 50 different nations were included in the INTERHEART study, which found that regular alcohol intake

Ideal Drinking Patterns, Doses, and Beverages

The standard definition of light to moderate alcohol intake is up to 1 drink per day for women and up to 2 drinks per day for men. Among the various alcoholic beverages, red wine, likely owing to its unique array of nonalcoholic components, is generally associated with the best health outcomes, especially for CV issues.17, 82, 83, 89, 90 Binge drinking, usually defined as episodic excessive alcohol intake (≥5 drinks within a few hours) often with intent to become intoxicated, is associated with

Warnings and Precautions

The Atherosclerosis Risk in Communities (ARIC) study found that among individuals deemed to be at low risk for addiction, moderate alcohol consumption was safe and did not lead to adverse outcomes related to problem drinking.96 However, other studies indicate that among nondrinkers, it is not possible to reliably predict who might be at increased risk for falling into a pattern of dangerously high alcohol intake once they begin drinking.3, 5 Indeed, habitual alcohol intake appears to be a

Acknowledgments

We thank Darwish Naji, MD (Saint Luke’s Mid America Heart Institute and University of Missouri-Kansas City) for assistance with data discovery and analysis.

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