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Effects of Alcoholism on Coronary Artery Disease and Left Ventricular Dysfunction in Male Veterans

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Effects of Alcoholism on Coronary Artery Disease and Left Ventricular Dysfunction in Male Veterans Original Contribution Effects of Alcoholism on Coronary Artery Disease and Left Ventricular Dysfunction in Male Veterans Spyros Kokolis, MD, Jonathan D. Marmur, MD, Luther T. Clark, MD, John Kassotis, MD, Rodamanthos Kokolis, MD, Erdal Cavusoglu, MD, Reuven Lapin, PA-C, *Sheldon Breitbart, MD, Jason M. Lazar, MD ABSTRACT: Background. Heavy alcohol consumption is a well- and nonhemorrhagic stroke.3 The coronary protective effects of known cause of dilated cardiomyopathy and hypertension, but its effects heavy alcohol consumption have not been well studied. Chronic on coronary atherosclerosis are less well understood. The objective of this heavy alcohol consumption is a well-known cause of dilated car- study was to compare coronary anatomy and left ventricular dysfunction diomyopathy. The deleterious effects of heavy alcohol on left ven- in patients with and without alcoholism associated with heavy consump- tricular function and on arrythmogenesis may counterbalance any tion. Methods. We studied 100 consecutive alcoholic male patients pre- 4 senting with chest pain to the Department of Veterans Affairs New York potential coronary benefits. Few studies have addressed both Harbor Healthcare System (VA) between 1994 and 2002. Alcoholism CAD and left ventricular function in patients chronically con- was defined as a history of either chronic alcohol-related pancreatitis or suming large quantities of alcohol. Accordingly, the objective of liver cirrhosis. Patients were compared to age-matched controls (n = 200) this study was to assess the associations between alcoholism, that were known to be nonalcoholic. All patients underwent coronary CAD severity and left ventricular systolic dysfunction. angiography. Results. Baseline demographic characteristics were simi- lar between the two groups. The prevalence of significant coronary Methods artery disease (CAD) (defined as coronary arterial luminal diameter The local institutional review board of the Department of stenosis > 50%) was lower in the alcoholic group than in the control Veterans Affairs New York Harbor Healthcare System approved group (42% vs. 58%; p = 0.013). Among patients with CAD, those the study (VA). The VA internal medicine healthcare database with a history of alcoholism had fewer vessels with stenoses (1.6 ± 0.6 vs. 2.3 ± 0.7; p < 0.001) than the control group, and were more likely to was queried for patients admitted between 1994 and 2002 who have single-vessel CAD (64% vs. 8%; p < 0.05). The alcoholic group also underwent cardiac catheterization and had a history of chronic had lower mean left ventricular ejection fraction (LVEF) compared to alcoholic pancreatitis or chronic alcoholic liver cirrhosis (diag- the control group (43 ± 13% vs. 49 ± 9%; p < 0.001), and a higher nosed by ICD-9 codes 303.91, 577.1 and 571.2, respectively). prevalence of left ventricular dysfunction (LVEF < 40%; 37% vs. 13%; p < All of these patients had presented to the emergency room 0.05). In the alcoholic group, there was a lower prevalence of CAD in because of chest pain and subsequently had a positive stress test. patients with left ventricular dysfunction as compared to those without The stress test was considered positive if the results of the test left ventricular dysfunction (21% vs. 49%; p = 0.006). Conclusions. In on the chart were documented as “positive”, “equivocal” or a group of male VA patients presenting with chest pain, alcoholism was “nondiagnostic”. Therefore, the patient had this stress test result associated with a lower incidence and a lesser severity of angiographically- defined CAD, but had greater left ventricular dysfunction. There appears followed up with a cardiac angiogram in the VA system. During to be an inverse relationship between CAD and left ventricular function the index admission, all patients underwent echocardiography in patients with a history of heavy alcohol consumption. and had blood drawn for liver function testing. The patients were then subsequently compared to the first 200 consecutive J INVASIVE CARDIOL 2006;18:304–307 age-matched controls without alcoholism between 1994 and 2002 from the VA internal medicine healthcare database. These Light-to-moderate alcohol consumption has been associated patients were defined as nonalcoholic according to the history 1 with a decreased risk of ischemic cardiac events and stroke. The and physical exams conducted by their outpatient internal med- cardioprotective effects of alcohol have been attributed to favor- icine physicians that were documented in the computers of the able lipid changes, including lower LDL, increased HDL choles- VA internal medicine healthcare. Similar to the alcoholic terol and higher apolipoprotein AI and AII levels, antiplatelet, patients, these nonalcoholic patients were admitted through the 2 and anti-inflammatory effects. Low levels of alcohol consump- emergency room because of chest pain and had a stress test that tion have been proven beneficial in providing a protective effect was documented as “positive”, “equivocal”, or “nondiagnostic”, upon the cerebral circulation. However, in heavy alcohol con- thus prompting the hospital to refer the patient for cardiac sumption, there is an increased predisposition to hemorrhagic angiography within the VA system (Figure 3). The following clinical variables were considered in all patients: From the S.U.N.Y. Downstate Medical Center and the *Department of Veter- ans Affairs New York Harbor Healthcare System, Brooklyn, New York. family history of CAD, active smoking, hypertension, previous The authors report no financial relationships or conflicts of interest regarding the myocardial infarction (MI) and diabetes. In both groups of content herein. Manuscript submitted November 29, 2005, provisional acceptance given January patients, the serum laboratory values included: total cholesterol, 3, 2006, manuscript accepted April 3, 2006. triglycerides and high-density lipoproteins (HDL). Low-density Address for correspondence: Jonathan D. Marmur, MD, S.U.N.Y. Downstate lipoproteins (LDL) were determined by the Frederich calcula- Medical Center, Department of Cardiology, Box 1257, 450 Clarkson Avenue, Brook- lyn, NY 11203. E-mail: [email protected] tion in patients whose triglycerides were < 400 mg/dL. 304 The Journal of Invasive Cardiology Effects of Alcoholism on CAD and LV Dysfunction in Male Veterans mean ± standard deviation and 70 P = 0.013 P < 0.001 n were compared using the Stu- o 60 i t dent’s t-test. Categorical vari- 60 c a r ables were expressed as F n D 50 frequencies and percentages and o i A t C c compared using the Fisher’s e f 40 j o 40 E exact test. A p-value of 0.05 was e r c a l considered significant; all tests n u e l c i a 30 were two-sided. Clinical, mor- r v t e n r phological and procedural vari- e P 20 20 V t ables that had demonstrated f e L statistically significant differ- 10 n a ences among the two groups e M were included in the stepwise 0 0 Alcoholic Nonalcoholic Alcoholic Nonalcoholic multivariate logistic analysis to determine the effect of alco- Figure 1. (A) (B) The prevalence of coronary artery disease (CAD) and mean left ventricular ejection fraction in alcoholics versus nonalcoholics. holic status as an independent predictor of CAD, left ventric- ular ejection fraction and vari- 100 ous risk factors. A Alcoholic 100 Nonalcoholic B P = 0.48 P < 0.001 80 80 Results A total of 100 patients were SGPT < 40 IU/L SGPT < 40 IU/L identified as having alcohol- e 60 SGPT > 40 IU/L e SGPT > 40 IU/L g g 60 a a related liver cirrhosis or pancre- t t n n e e atitis and had undergone c c r 40 r e e coronary angiography. The P P 40 mean age was 63 ± 4 years. Ninety-one percent (91%) had 20 20 chronic liver cirrhosis and 9% had a history of alcoholic pan- 0 creatitis. These patients were ≥ 0 EF < 40 EF 40 EF < 40 EF ≥ 40 compared to 200 consecutive Ejection Fraction Ejection Fraction nonalcoholic patients who also Figure 2. The prevalence of SGPT levels and mean left ventricular ejection fraction in alcoholics (A) versus had undergone cardiac catheter- nonalcoholics (B). ization and had a history of chest pain and a positive stress test. Diabetes was more preva- lent in the alcoholic group (59% All coronary angiograms were performed at the VA in Brook- vs. 31%; p < 0.05). Other baseline demographics were similar lyn, New York. CAD was defined visually as an obstructive between both groups (Table 1). However, the prevalence of lesion > 50% stenosis of an epicardial coronary artery. The CAD was lower in the alcoholic group than in the control group branches of major coronary arteries were not assessed in this (42% vs. 58%; p = < 0.05). In patients with CAD, the alcoholic study. The number of stenosed vessels in the major coronary group had fewer mean numbers of stenosed vessels (1.6 ± 0.6 vs. artery distributions — the left main coronary artery, the left 2.3 ± 0.7; p < 0.05), and was more likely to have single-vessel anterior descending artery, the left circumflex artery, and the CAD as compared to the control group (64% vs. 8%; p < 0.05). right coronary artery were visualized to determine if they had an The alcoholic group had a lower mean LVEF compared to obstructive lesion > 50% stenosis to quantify the extent and the control group (43 ± 13 % vs. 49 ± 9 %; p < 0.05), and left severity of CAD in the alcoholic and nonalcoholic patients. ventricular systolic dysfunction was more common (37% vs. LVEF was determined by echocardiography using the Teich- 13%; p < 0.05) than in the nonalcoholic group. In patients holz method. Sensitivities, specificities, positive and negative with left ventricular dysfunction, there was a lower prevalence predictive values of elevated serum SGOT (≥ 40 IU/L) and of CAD in alcoholics as compared to nonalcoholics (38% vs. SGPT (≥ 40 IU/L) values were determined.
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