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Moderate Drinking and Reduced Risk of Heart Disease

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Moderate Drinking and Reduced Risk of Heart Disease Moderate Drinking and Reduced Risk of Heart Disease Arthur L. Klatsky, M.D. Although heavier drinkers are at increased risk for some heart diseases, moderate drinkers are at lower risk for the most common form of heart disease, coronary artery disease (CAD) than are either heavier drinkers or abstainers. This association has been demonstrated in large-scale epidemiological studies from many countries. Abstainers may share traits potentially related to CAD risk, such as psychological characteristics, dietary habits, and physical exercise patterns. However, evidence supports a direct protective effect of alcohol, even after data have been adjusted for the presence of these factors. The alcohol-CAD relationship is also independent of the hypothetically increased risk status among abstainers who stopped drinking for medical reasons. All alcoholic beverages protect against CAD, although some additional protection may be attributable to personal traits or drinking patterns among people who share some beverage preferences or to nonalcohol ingredients in specific beverages. Alcohol’s protective effect may result from favorable alterations in blood chemistry and the prevention of clot formation in arteries that deliver blood to the heart muscle. Because CAD accounts for a large proportion of total mortality, the risk of death from all causes is slightly lower among moderate drinkers than among abstainers, but heavier drinkers are at considerably higher total mortality risk. KEY WORDS: moderate AOD use; heavy AOD use; coronary artery disorder; risk factors; protective factors; AODR (alcohol and other drug related) disorder; AODR mortality; alcoholic cardiomyopathy; hypertensive disorder; cardiac arrhythmia; stroke; alcoholic beverage; public health; AOD use frequency; literature review iseases of the heart and blood disorders (i.e., cardiomyopathy), high truth, the relationships between drink- vessels (i.e., cardiovascular blood pressure (i.e., hypertension), brain ing and CVD are both complex and Ddiseases [CVDs]) are a major damage from ruptured blood vessels interconnected (Klatsky 1995a). Discus- cause of illness and disability in the (i.e., hemorrhagic stroke), and heart sions of alcohol’s effects on CVD must United States. Heart disease is the rhythm irregularities (i.e., arrhythmias). clearly differentiate between different leading cause and stroke is the third Lighter drinking is related to lower levels of drinking as well as the specific leading cause of death among adult risk of coronary artery disease (CAD) type of CVD being considered. Americans. Together, these two condi- and of ischemic stroke, which is char- This article briefly reviews the tions account for more than 40 percent acterized by blockage of blood vessels effects of heavier drinking on certain of all deaths annually (Dufour 1996). that supply the brain.1 Researchers have studied extensively Sweeping generalizations circulated ARTHUR L. KLATSKY, M.D., is a senior the role of alcohol in CVD, especially in the popular media have perpetuated consultant in cardiology at the Division in relation to drinking level. Heavier public misconceptions about the effects of Cardiology, Department of Medicine, drinking (see the following section, of moderate drinking on CVD. In and the Division of Research, Kaiser “Definitions of Moderate Drinking”) Permanente Medical Center, Oakland, is related to higher risk of heart muscle 1See glossary, p. 23, for terms not defined in the text. California. Vol. 23, No. 1, 1999 15 CVDs and considers at greater length in drinking patterns. Subjects in popu- guishable either clinically or patholog- the cardiovascular effects of moderate lation studies are generally requested to ically. Thus, alcohol cardiomyopathy drinking. The article concentrates on describe their average total alcohol con- is generally diagnosed when dilated CAD for two major reasons. First, CAD sumption over a given time period (e.g., cardiomyopathy of unknown origin is is the most common type of CVD and 1 week or 1 month). Thus, a person who encountered in a patient with a his- therefore dominates epidemiological habitually consumes 2 drinks each even- tory of long-term heavy drinking. statistics when CVDs are studied as a ing might report the same average weekly The proportion of cardiomyopathy group. Second, alcohol has been reputed consumption as a person who hypothet- attributable to alcohol is unknown. to have a protective effect against CAD. ically consumes 14 drinks within a Although substantial circumstan- The discussion of CAD suggests possi- few hours every Saturday night. The tial evidence implicates alcohol as a ble mechanisms to account for this cause of dilated cardiomyopathy, the protective effect, including the poten- absence of specific diagnostic tests tial role of beverage type. Finally, the seriously impedes epidemiological article discusses implications of the study. The most convincing circum- alcohol-CVD relationship in terms of Moderate drinking stantial evidence for alcoholic cardio- total mortality and overall public health. does not appear myopathy is the extensive data, in animals and humans, of nonspecific to increase the cardiac abnormalities related to alco- Definitions of Moderate hol. One key report (Urbano-Marquez Drinking risk of alcoholic et al. 1989) showed a clear relationship cardiomyopathy. in alcoholics between lifetime alcohol Definitions of moderate drinking vary consumption and both structural and widely (see the article by Dufour, pp. functional abnormalities of heart and 5–14). This article defines moderate skeletal muscle. The amounts of alco- drinking as the consumption of fewer hol necessary to produce such evidence than three standard drinks per day. A health risks posed by such widely were large, equivalent to eight or more standard drink is equivalent to approx- varying patterns of consumption may drinks per day over a period of 20 imately 12 ounces (oz) of beer, 5 oz of differ substantially. years. Thus, moderate drinking does wine, or 1.5 oz of distilled spirits, each not appear to increase the risk of alco- of which contains approximately 12 holic cardiomyopathy. grams (0.5 oz) of alcohol. Effects of Heavy Drinking Both clinical observations and exper- Problems inherent to epidemiological imental data (Ballester et al. 1997) sug- studies of alcohol and CVD include gest that alcoholic cardiomyopathy can individual susceptibility and the catego- Alcoholic Cardiomyopathy improve with abstinence, which is there- rization of drinking levels. Individual fore a cornerstone of therapy. factors that influence interpretation of Clinicians and researchers have long rec- study results include sex, age, dietary ognized that alcohol consumption can Hypertension habits, cigarette smoking, the consump- directly damage heart muscle cells inde- tion of caffeinated beverages, and various pendently of any other cardiovascular Although an association between heavy psychosocial factors that are difficult to effect (Klatsky 1995a). Breathlessness alcohol consumption and hypertension characterize and measure. and fatigue may be early signs of such was recognized as early as 1915 (Lian The characterization of drinking lev- heart muscle disease (i.e., cardiomyopa- 1915), the epidemiological significance els is complicated by the use of subjects’ thy). Complications may develop as the of this finding was largely ignored for self-reported estimates. In particular, disease progresses, including heart fail- the next 60 years. Since the mid- heavier drinkers may underestimate ure, embolism, and arrhythmias, possi- 1970s, alcohol has joined obesity and their alcohol consumption. If some bly resulting in sudden death. salt intake as an acknowledged factor proportion of heavy drinkers report Although cardiomyopathies can be potentially contributing to the risk for lighter drinking, then the “lighter” caused by viral infection, exposure to hypertension. Two types of epidemio- drinking group will include some toxic substances and, possibly, genetic logical studies provide evidence for this people who really drink more, and a factors, most cases are considered to relationship. Cross-sectional studies condition related only to heavy drink- be of unknown cause. The type of seek a correlation between reported ing (e.g., alcoholic cardiomyopathy) heart muscle damage produced by alcohol use and blood pressure; pro- may erroneously appear to be related alcohol is called dilated cardiomyopa- spective studies follow subjects over to moderate alcohol consumption thy, because one or more heart cham- time to document the development of (Klatsky 1994). bers are abnormally distended with increased blood pressure in relation to Another potential source of error is blood. Alcoholic and nonalcoholic reported alcohol use. Of the more than failure to consider individual differences cardiomyopathy are not readily distin- 50 cross-sectional and 10 prospective 16 Alcohol Research & Health Moderate Drinking and Heart Disease population studies, almost all have abstention or marked reduction of or more drinks per day as among peo- demonstrated a link between alcohol alcohol consumption (Klatsky 1995b). ple consuming less than one drink per and hypertension in nonhospitalized The association between alcohol con- day. Certain arrhythmias are extremely persons in a number of countries sumption and blood pressure appears common in older persons, and only a (Klatsky 1995b). Studies differ about to be independent of salt intake, small proportion of arrhythmias result whether
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