Alcohol Consumption and Sudden Cardiac Death
Abstract & commentary
Synopsis: Men who consume mild to moderate amounts of alcohol had a reduced risk of SCD as compared to those who consumed less or more.
Source: Albert CM, et al. Circulation 1999;100: 944-950.
Although heavy alcohol consumption is associated with an increased risk of sudden cardiac death (SCD), the risk of more moderate alcohol consumption is unclear. Thus, Albert and associates evaluated the Physician’s Health Study database of more than 22,000 apparently healthy men aged 40 years or older who were followed for an average of 12 years. The purpose of this study was to assess the effects of aspirin and beta-carotene on cardiovascular disease and cancer end points. At enrollment and at 84 months, a questionnaire regarding number of alcoholic drinks consumed was administered. SCD occurred in 141 subjects. Alcohol consumption was evenly distributed between one drink or less per month to one per day, but there were few men who consumed two or more per day. After controlling for confounders, men who consumed 2-4 drinks per week (relative risk 0.40, P = 0.004) or 5-6 drinks/week (RR 0.21, P = 0.002) at baseline had a significantly reduced risk of SCD compared to those who consumed more or less alcohol. In fact, the relationship between alcohol consumption and SCD was "U" shaped. By contrast, the risk of nonfatal cardiac events was linear, with the lowest risk recorded for those who drank 1-2 drinks/day (P = 0.02). Albert et al conclude that men who consume mild to moderate amounts of alcohol (2-6 drinks/week) had a reduced risk of SCD as compared to those who consumed less or more.
Comment by Michael H. Crawford, MD
SCD is the most common cause of death in adults younger than 65 years of age. Out-of-hospital resuscitation is not going to be the answer; thus, prevention makes sense. In this regard, this study is of interest. Prior prospective studies have shown a reduction in coronary events with moderate alcohol consumption, but not in SCD. However, case-controlled studies have shown a reduction in both. It may be that the prospective studies were underpowered for SCD, a deficiency that the Physician’s Health Study did not have with 20,000 participants.
The "U" shape of the curve relating alcohol consumption to SCD contrasts to the linear relation between alcohol intake and other coronary events. Presumably, the difference is that high alcohol intake is arrhythmogenic. The mechanism for the beneficial effect of alcohol is not known, but some studies have suggested that reduced plaque rupture, thrombosis, and autonomic nervous system activity or increased HDL levels may play a role. Clearly more study is needed about mechanisms to develop an approach with the benefits of alcohol, but without the risks of alcohol.
There are several limitations to this study. One is the lack of knowledge of the type of alcohol imbibed. Thus, we cannot accept or refute the red wine hypothesis. Also, we don’t know the pattern of alcohol ingestion, but presumably most physicians do not binge drink and the 5-6 drinks/week is spread out. Obviously, binge drinking has its own risks (i.e., holiday heart syndrome). In addition, there may be confounders that accompany moderate alcohol intake that may explain the results in part. Finally, the study was done on healthy, upper socioeconomic class men and may not be applicable to women and other segments of the U.S. male population. However, for the weary physician who has battled disease and HMOs all day, they should go ahead and have that one cocktail as long as they are not on call or planning to operate heavy machinery.
Which is most correct concerning alcohol consumption and cardiac events?
a. Moderate consumption reduces sudden cardiac death rates.
b. Moderate consumption reduces nonfatal events.
c. Benefits are only seen with red wine intake.
d. a and b.
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