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Moderate Excess Alcohol Consumption and Adverse Cardiac Remodelling Heart failure and cardiomyopathies Original research Heart: first published as 10.1136/heartjnl-2021-319418 on 11 August 2021. Downloaded from Moderate excess alcohol consumption and adverse cardiac remodelling in dilated cardiomyopathy Upasana Tayal ,1,2 John Gregson,3 Rachel Buchan,1,2 Nicola Whiffin,1,2 Brian P Halliday,1,2 Amrit Lota,1,2 Angharad M Roberts,4 A John Baksi,1,2 Inga Voges,2 Julian W E Jarman,1,2 Resham Baruah,2 Michael Frenneaux,2 John G F Cleland,1,5 Paul Barton,1,2 Dudley J Pennell,1,2 James S Ware,1,2,4 Stuart A Cook,4,6 Sanjay K Prasad1,2 ► Additional supplemental ABSTRACT consumption may be associated with a lower risk for material is published online Objective The effect of moderate excess alcohol heart failure.2 However, Mendelian methodolog- only. To view, please visit the ical approaches have raised doubts regarding the journal online (http:// dx. doi. consumption is widely debated and has not been well org/ 10. 1136/ heartjnl- 2021- defined in dilated cardiomyopathy (DCM). There is need cardioprotective effects of low to moderate alcohol 319418). for a greater evidence base to help advise patients. We consumption.3 Guidance on alcohol consumption is frequently requested by patients with no clear 1 sought to evaluate the effect of moderate excess alcohol National Heart and Lung consumption on cardiovascular structure, function and evidence base to advise patients. Institute, Imperial College London, London, UK outcomes in DCM. It is established that chronic excess alcohol 2Royal Brompton Hospital, Methods Prospective longitudinal observational cohort consumption can lead to an alcoholic cardiomy- London, UK study. Patients with DCM (n=604) were evaluated for opathy with adverse outcomes.4 However, the 3 London School of Hygiene and a history of moderate excess alcohol consumption (UK effect of a prior history of moderate excess alcohol Tropical Medicine, London, UK 4 consumption remains an important unanswered Medical Research Council government guidelines; >14 units/week for women, Clinical Sciences Centre, >21 units/week for men) at cohort enrolment, had question for clinicians and patients. Imperial College London, cardiovascular magnetic resonance and were followed In this study, our aim was to determine the effects London, UK of a history of moderate excess alcohol consump- 5 up for the composite endpoint of cardiovascular death, Robertson Centre for heart failure and arrhythmic events. Patients meeting tion on cardiovascular structure, function and Biostatistics, University of Glasgow, Glasgow, UK criteria for alcoholic cardiomyopathy were not recruited. outcomes in a well- characterised cohort of patients 6Duke NUS, Singapore Results DCM patients with a history of moderate with DCM. Notably, no patients with a diagnosis excess alcohol consumption (n=98, 16%) had lower of alcoholic cardiomyopathy were recruited to this Correspondence to biventricular function and increased chamber dilatation study. Dr Upasana Tayal, Imperial of the left ventricle, right ventricle and left atrium, as well http://heart.bmj.com/ College London National Heart as increased left ventricular hypertrophy compared with and Lung Institute, London SW3 METHODS 6NP, UK; u. tayal@ rbht. nhs. uk patients without moderate alcohol consumption. They Data sharing were more likely to be male (alcohol excess group: n=92, The data and analysis methods that support the Received 25 March 2021 94% vs n=306, 61%, p=<0.001). After adjustment Accepted 12 July 2021 findings of this study are available from the corre- for biological sex, moderate excess alcohol was not sponding author (UT) on reasonable request. Data associated with adverse cardiac structure. There was no will be shared after review and approval by our difference in midwall myocardial fibrosis between groups. Biobank scientific board, and terms of collaboration on October 5, 2021 by guest. Protected copyright. Prior moderate excess alcohol consumption did not will be reached together with a signed data access affect prognosis (HR 1.29, 95% CI 0.73 to 2.26, p=0.38) agreement. during median follow-up of 3.9 years. Conclusion DCM patients with moderate excess alcohol consumption have adverse cardiac structure Study population and function at presentation, but this is largely due to The study population comprised 604 patients with biological sex. Alcohol may contribute to sex-specific DCM confirmed by late gadolinium enhancement phenotypic differences in DCM. These findings help to (LGE) cardiovascular magnetic resonance (CMR) inform lifestyle discussions for patients with DCM. prospectively enrolled in the National Institute for Health Research Royal Brompton Hospital Cardio- vascular Biobank project between 2009 and 2015. Patients were recruited from a network of >30 © Author(s) (or their INTRODUCTION regional hospitals. No patients with a diagnosis of employer(s)) 2021. Re- use permitted under CC BY. The effect of moderate alcohol consumption is alcoholic cardiomyopathy were recruited (alcohol 4 Published by BMJ. widely debated and has not been well defined in consumption in excess of 80 g/day for 5 years. dilated cardiomyopathy (DCM). From a global Patients were enrolled at the time of the first diag- To cite: Tayal U, Gregson J, health perspective, there has been increased recent nostic imaging study. All patients underwent base- Buchan R, et al. Heart Epub ahead of print: interest in the effects of alcohol on the heart, line clinical evaluation, ECG, genetic assessment and [please include Day Month particularly the potentially beneficial effects of low CMR including evaluation for LGE midwall fibrosis Year]. doi:10.1136/ to moderate alcohol consumption on cardiovas- as previously described.5 Socioeconomic status was heartjnl-2021-319418 cular disease.1 Studies indicate that modest alcohol assessed using the Index of Multiple Deprivation Tayal U, et al. Heart 2021;0:1–7. doi:10.1136/heartjnl-2021-319418 1 Heart failure and cardiomyopathies Table 1 Definitions of alcohol consumption and moderate alcohol excess in the UK, Europe and North America Heart: first published as 10.1136/heartjnl-2021-319418 on 11 August 2021. Downloaded from Diagnosis Alcohol consumption Used in this study Notes Alcoholic cardiomyopathy 80 g/day for at least 5 years. No patients with alcoholic cardiomyopathy – were recruited to this study. Moderate alcohol excess according to UK Men: >21 units of alcohol/week. Women: Yes – the basis of the primary analysis. UK 1 unit of alcohol=10 mL or 8 g of pure government guidelines 1987–2016 >14 units of alcohol/week. alcohol, an amount the average adult metabolises in 1 hour. Moderate alcohol excess according to the Men: up to 20 g/day (2 units). Women: up Considered in secondary sensitivity analysis; ESC 1 unit of alcohol=10 g alcohol. European Society of Cardiology (ESC) 2016 to 10 g/day (1 unit). not the basis of the primary analysis. Moderate alcohol excess according to the Men: >2 standard drinks/day. Women: >1 No US ‘standard drink’=∼12 g alcohol. US Centre for Disease Control/US Dietary standard drink/day. Guidelines Moderate alcohol excess according to the >2 standard drinks/day. No WHO ‘standard drink’=10 g alcohol. WHO quintile. All patients provided written informed consent. The events. Cardiovascular mortality and each of the arrhythmic study was approved by the regional ethics committee. and heart failure composites were predefined secondary end- DCM was diagnosed based on established CMR criteria of left points. Major arrhythmic events comprised haemodynamically ventricular dilation and reduced ejection fraction with reference stable and unstable sustained ventricular tachycardia, ventricular to age and gender adjusted nomograms6 in the absence of known fibrillation, appropriate implantable cardiac defibrillator shock coronary artery disease (presence of subendocardial LGE sugges- and aborted sudden cardiac death. Major heart failure events tive of previous myocardial infarction, >50% stenosis in one comprised heart transplantation, left ventricular assist device or more major epicardial coronary arteries or need for previous implantation and unplanned heart failure hospitalisation. percutaneous coronary intervention or coronary artery bypass End- points were defined according to the 2014 American grafting), abnormal loading conditions (uncontrolled hyperten- College of Cardiology (ACC)/American Heart Association sion or significant primary valvular disease), acute myocarditis (AHA) definitions for cardiovascular end- points in clinical trials8 or non- alcohol toxin exposure. A history of well- controlled and the 2006 ACC/AHA/European Society of Cardiology (ESC) hypertension or diabetes was documented as comorbidities. guidelines for management of patients with ventricular arrhyth- mias.9 Follow- up data were collected from primary care and Alcohol history hospital medical records and patient questionnaires. Survival Alcohol consumption prior to the diagnosis of DCM was assessed status was also identified using the UK Health and Social Care by patient interview and review of medical records. Patient Information Service to ensure no deaths were missed. Death interview using a standardised questionnaire was conducted certificates and postmortem reports were obtained where appli- by a research nurse at study enrolment, and patients’ current cable. All primary end- point events were adjudicated by an inde- http://heart.bmj.com/ weekly alcohol consumption as well as previous alcohol history pendent committee of three senior cardiologists with
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