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Home , Alcoholic cardiomyopathy

Postgrad Med J: first published as 10.1136/pgmj.60.700.151 on 1 February 1984. Downloaded from

Postgraduate Medical Journal (February 1984) 60, 151-154

Reversibility of alcoholic MARKKU KUPARI M.D. First Department ofMedicine, University of Helsinki; and Research Laboratories ofthe State Monopoly (Alko), Helsinki, Finland

Summary Case report A patient with alcoholic cardiomyopathy is described A 32-year-old seaman was admitted to hospital in in whom cardiovascular function capacity and radio- December 1978 because of advancing . logical heart size fluctuated widely with periods of He had been well until 6 weeks earlier when heavy drinking and abstinence. On two occasions, and fatigue on exertion first cessation of drinking resulted in clinical recovery appeared after a 3-week period of exceptionally from severe degrees of congestive failure and in heavy . He admitted to excessive complete reversal of cardiac enlargement. Echocardi- drinking since 1970 and his approximate alcohol

ographic follow-up showed, however, that the true consumption had amounted to 150-200 grams/day by copyright. rapidity of myocardial recovery was much slower than during the last 2 years before admission. He gave no estimated clinically and radiologicaHly and than sug- history of hypertension, chest pain or recent viral gested by the previous reports. illness and was a non-smoker. On examination, the patient appeared well nour- ished and without signs of chronic liver disease. KEY WORDS: cardiac failure, . Heart rate was 102 beats/min and blood pressure was 110/80 mmHg. There was a third heart sound, Introduction marked jugular venous distension and the liver was palpable 3 cm below the right costal margin. The The natural course of congestive alcoholic cardio- showed sinus P-wave electrocardiogram , http://pmj.bmj.com/ is poor: over 40% of such patients died changes indicative of left atrial strain and ST within an average time of 3 years in a prospective segment depression as well as T-wave inversion study (Demakis et al., 1974). By abstention from suggestive of left ventricular strain. The chest roent- alcohol, the patients seemed to benefit so that 61% of genogram disclosed cardiac enlargement; the cardio- abstaining patients were clinically improved in con- thoracic ratio was 0 55 (Fig. la). Apart from macro- trast with only 10% of those who continued heavy cytosis of the red cells, the routine blood tests were drinking. Moreover, three previous case reports non-revealing. Tests for antinuclear antibodies were

(Schwartz, Sample and Wigle, 1975; Baudet et al., negative as were the serologic reactions for syphilis on September 28, 2021 by guest. Protected 1979; Hung et aL, 1979) have objectively shown that and streptococcal, viral, and rickettsial diseases. A even severe degrees of congestive failure due to tentative diagnosis of alcoholic cardiomyopathy was alcoholic heart muscle disease are potentially totally made and the patient was discharged on digoxin and reversible. The recovery from overt failure to normal hydrochlorthiazide and advised to refrain from cardiac function in these patients took from 8-18 drinking. months. The condition of the patient improved rapidly The patient reported in this paper serves to during abstinence and he resumed his professional emphasize the necessity of total and permanent activities 4 months after the discharge from hospital. cessation of drinking for successful treatment of All medications were discontinued in June 1979. In alcoholic heart disease. This case also demonstrates December 1979, 1 year after admission, the patient the usefulness of serial echocardiographic studies was symptom-free and the clinical cardiac examina- in following the restoration of myocardial perform- tion was interpreted normal. The chest X-rays ance. showed a return of heart size to normal; the Postgrad Med J: first published as 10.1136/pgmj.60.700.151 on 1 February 1984. Downloaded from

152 Clinical reports JRSil!:n>s~~~~~~~~~~~~~~~~~~~~~~..' by copyright.

L:,.aVl.tE:,!~~~~ '...... ' ti http://pmj.bmj.com/ on September 28, 2021 by guest. Protected FIG. 1. X-ray studies of the chest: on admission in December 1978 (A), after 1 year of abstinence in December 1979 (B), on readmission in March 1981 (C), and after a 6-month abstinence in September 1981 (D). cardiothoracic ratio was 0-38 (Fig. lb). Though much breathlessness 4 days before admission. On examina- diminished, T-wave inversion still persisted in the tion, there was a summation gallop as well as a leads V4-V6 of the electrocardiogram. The patient murmur of mitral insufficiency. The electrocardiog- was considered almost fully recovered and was ram showed left atrial and left ventricular strain and discharged from follow-up. occasional ventricular premature beats in addition to In March 1981, the patient was readmitted because . The chest roentgenogram revealed of congestive heart failure (Fig. lc). He had been well a recurrence of cardiac enlargement as well as and maintained abstinence until 2 weeks earlier when pulmonary venous engorgement and interstitial ex- he relapsed into alcohol abuse imbibing approxi- travasation. The routine blood tests were normal and mately 3/4 litres of whisky daily till the onset of the antiviral antibodies showed no acute reactions; Postgrad Med J: first published as 10.1136/pgmj.60.700.151 on 1 February 1984. Downloaded from

Clinical reports 153

TABLE 1. Non-invasive follow-up of left ventricular performance during abstinence after the second admission Months of abstinence Variable Reference range* 0 6 12 18 Heart rate (beats/min) 94 81 72 66 Blood pressure (mmHg) 100/70 114/70 116/70 116/70 LVEDD (mm) 74 62 67 63 41-57 LVESD (mm) 67 55 58 52 26-41 PWT (mm) 11 13 11 11 7-12 LVM (g) 242 239 216 200 90-192 Fractional shortening (%) 10 12 14 18 24-42 PEP/LVET 0-54 0 57 0-48 0 40 0 26-040 LVEDD and LVESD=left ventricular end-diastolic and end-systolic diameters, respectively, measured by the European standardization (Roelandt and Gibson, 1980); PWT=posterior wall end- diastolic thickness; LVM = left ventricular mass (Troy, Pombo and Rackley, 1972); PEP/LVET-pre- ejection period/left ventricular ejection time ratio, derived from simultaneous recordings of electrocardiogram, phonocardiogram, and carotid arterial pulse tracing (Lewis et al., 1977). *The reference ranges are the 95% confidence intervals in twenty healthy male subjects aged 23-62 ~~~~~~Iyears (mean age, 36 years). a:~~~ by copyright. w~~~~~* - . ¼ic http://pmj.bmj.com/ on September 28, 2021 by guest. Protected

FIG. 2. M-mode echocardiographic studies of the left ventricle on readmission in March 1981 (A) and after a 6-month abstention from alcohol (B). Note the diminution of left ventricular transverse diameters; the depth scales are nearly identical. haemochromatosis was also excluded. A left ventri- tained total abstinence and again rapidly improved. cular echocardiographic study and measurement of All medications were discontinued in June 1981 and the systolic time intervals gave findings typical of the patient resumed his working activities. In Sep- congestive cardiomyopathy (Fig. 2a, Table 1). The tember 1981, 6 months after the readmission, he was patient was started on digoxin and prazosin and a symptom-free apart from slight dyspnoea on effort; small dose of metoprolol was later added to the neither murmurs nor gallop sounds were heard on regimen. auscultation. The chest X-rays revealed again a After discharge from hospital, the patient main- normal-sized heart (Fig. Id). Nevertheless, left ven- Postgrad Med J: first published as 10.1136/pgmj.60.700.151 on 1 February 1984. Downloaded from

154 Clinical reports tricular dilatation and hypokinesia, although dimin- which were acutely exacerbated by the toxic insult ished, still persisted on the echocardiographic study from heavy alcohol intake. Abstention from drinking (Fig. 2b, Table 1) and the electrocardiogram showed must be total and permanent to be curative in negative T-waves in the leads V4-V6. Until Septem- alcoholic heart disease. ber 1982, the patient has maintained abstinence, and repeated echocardiographic studies 12 and 18 months References after the 2nd admission have shown a steady but slow in left ventricular performance (Table BAUDET, M., RIGAUD, M., ROCHA, P., BARDET, J. & BOURDARIAS, improvement J.P (1979) Reversibility of alcoholic cardiomyopathy with absten- 1). tion from alcohol. , 64, 317. DEMAKIS, J.G., PROSKEY, A., RAHIMTOOLA, S.H., JAMIL, M., SUT- Discussion TON, G.C., ROSEN, K.M., GUNNAR, R.M. & TOBIN, J.R. (1974) The natural course of alcoholic cardiomyopathy. Annals of The case presented herein supports the few earlier Internal Medicine, 80, 293. reports on the reversibility of alcoholic cardiomyo- HUNG, J., HARRIS, P.J., KELLY, D.T., RICHMOND, D.R., HUTTON, B.F. & BAUTOVICH, G. (1979) Improvement of left ventricular pathy. On the other hand, this case shows also that, function in alcoholic cardiomyopathy documented by serial gated although the initial clinical improvement can be cardiac pool scanning. Australian and New Zealand Journal of rapid, the restoration of cardiac performance during Medicine, 9, 420. abstinence either may remain incomplete or can take LEWIS, R.P., RITTGERS, S.E., FORESTER, W.F. & BOUDOULAS, H.A. (1977) A critical review of the systolic time intervals. Circulation, a much longer time than suggested by the previous 56, 146. case histories (Schwartz et al., 1975; Baudet et al., ROELANDT, J. & GIBSON, D.G. (1980) Recommendations for 1979; Hung et al., 1979). On clinical grounds alone, standardization of measurements of M-mode echocardiograms. without the use of echocardiography, the rapidity of European Heart Journal, 1, 375. SCHWARTZ, L., SAMPLE, K.A. & WIGLE, E.D. (1975) Severe alco- myocardial recovery would have been greatly over- holic cardiomyopathy reversed with abstention from alcohol. estimated in the present case. The slowness of this American Journal of Cardiology, 36, 963. process helps to explain the surprisingly rapid recur- TROY, B.L., POMBO, J. & RACKLEY, C.E. (1972) Measurement of left rence of congestive failure on resumed heavy drink- ventricular wall thickness and mass by echocardiography. Circula- ing before the 2nd admission. So, although symptom- tion, 45, 602. by copyright. free and having normal function capacity, there were still subclinical manifestations of cardiomyopathy (Accepted 16 March 1983) http://pmj.bmj.com/ on September 28, 2021 by guest. Protected