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The Health Professionals Follow-up Study (HPFS) is a prospective cohort study of 51,529 US male health professionals.

During the follow up of these men between 1986 to 2006, published in the European Heart Journal, 1,818 men were confirmed with incident non-fatal myocardial infarction (MI) – a non fatal heart attack. Among heart attack survivors, 468 deaths were documented during up to 20 years of follow up. Repeated reports were obtained on alcohol consumption every four years. Average alcohol consumption was calculated prior to and then following the MI.

The overall results show that, in comparison with no alcohol consumption, the pre-MI and the post-MI intakes of light (0.1-9.9 g/day of alcohol, or up to one small typical drink) and moderate (10.0-29.9 g/d, or up to about 2 ½ to 3 drinks) amounts of alcohol were both associated with lower risk of all-cause mortality and cardiovascular morality among these men.

The significant reductions in all-cause mortality risk (22% lower for 0.1-9.9 g/day and 34% lower for 10.0 – 29.9 g/day, in comparison with non-drinkers) were no longer present for those who drank more than 30 g/day; for this highest consumer group, the adjusted hazard ratio was 0.87 with 95% CI of 0.61-1.25.

There are a number of other informative and interesting results described from this study. First, there was little change in reported alcohol intake prior to and following the MI: drinkers tended to remain drinkers of similar amounts. Few non-drinkers began to drink after their heart attack; among heavier drinkers, there was a tendency to reduce drinking (but very few stopped drinking completely). Further there were no significant differences in outcome according to type of beverage consumed although, interestingly, lower hazard ratios were seen for consumers of beer and liquor than of wine. While the authors state that the effects of alcohol were stronger for the association with non-anterior MI’s, the relative risk (versus non-drinkers) for all-cause mortality were little different: among the moderately drinking men the relative risks were 0.58 for anterior MI and 0.51 for other types of MI.

Even though exposures (such as alcohol) for cardiovascular events (such as MI) may be different after a person has an event than it was before the event, in this study the reductions in risk were almost the same. For example, both for alcohol intake reported prior to a MI, and that after a non-fatal MI, the risk of mortality was about 30% lower for moderate drinkers than it was for abstainers. This suggests that, in terms of reducing cardiovascular disease, alcohol may have relatively short-term effects, suggesting that frequent but moderate consumption (of under 30g a day for men) may result in the best health outcomes.

Reference: Pai JK, Mukamal KJ, Rimm EB. Long-term alcohol consumption in relation to all-cause and cardiovascular mortality among survivors of myocardial infarction: the Health Professionals Follow-up Study. European Heart Journal 2012; doi:10.1093/eurheartj/ehs047

Research published in the European Journal of Epidemiology by Costanzo S, Di Castelnuovo de Gaetano G et al has sought to separate the effects of wine, beer or spirit drinking in relation to fatal and non-fatal cardiovascular events. The Italian authors carried out an updated meta-analysis on the relationship between wine, beer or spirit consumption and cardiovascular outcomes, using state-of-the-art statistical techniques.

From 16 studies, results confirmed a J-shaped relationship between wine intake and reduced vascular risk, with maximal protection — an average 31% (95% confidence interval (CI): 19%) was observed at 21 g/day of alcohol. Similarly, from 13 studies a J-shaped relationship was apparent for beer (maximal protection: 42% (95% CI: 19%) at 43 g/day of alcohol). From 12 studies reporting separate data on wine or beer consumption, two closely overlapping dose–response curves were obtained suggesting maximal protection of 33% at 25 g/day of alcohol approximately (2 drinks/day by US standards and 3 units for the UK) for vascular diseases. A statistically significant association between spirits intake and vascular disease was not found.

A major problem with all meta-analyses is the inability to control for variables that were not included in the original reports. While there were adequate data to adjust for most of the usual confounders, there was no way to evaluate effects of the pattern of drinking (frequency, binge drinking, etc.) on the cardiovascular outcomes.

Limited data were available about the association of spirits intake and cardiovascular risk. While the trend was for a decrease in such risk with increasing spirits consumption, there was not a statistically significant relation in the meta-analysis based on 10 independent relationships using random models.

The key result of this meta-analysis is the finding of a very similar inverse association between the consumption of beer and the consumption of wine in relation to cardiovascular outcomes. While a similar association was not seen for spirits consumption, the data presented do not permit the conclusion that the key effects on cardiovascular disease are primarily due to the polyphenols in beer and wine. Similarly, the results do not permit the conclusion that the effect on cardiovascular disease is due primarily to the alcohol in these beverages. The lack of a similar J-shaped association for spirits may have been due to different drinking patterns (e.g., more binge drinking among consumers of spirits), as the pattern of drinking was not included as a confounder in the analyses.

Reference: Costanzo S, Di Castelnuovo A, Donati MB, Iacoviello L, de Gaetano G. Wine, beer or spirit drinking in relation to fatal and non-fatal cardiovascular events: a meta-analysis. Eur J Epidemiol 2011;DOI 10.1007/s10654-011-9631-0

Source: Eurekalert November 22 2011

For the first time, new research shows that patterns of alcohol consumption – a drink or two every night, or several cocktails on Friday and Saturday nights only – may be more important in determining alcohol’s influence on heart health than the total amount consumed.

In the journal Atherosclerosis, scientists found that daily moderate drinking – the equivalent of two drinks per day, seven days a week – decreased atherosclerosis in mice, while binge drinking – the equivalent of seven drinks a day, two days a week – increased development of the disease. Atherosclerosis, or the hardening and narrowing of arteries, is a serious condition that can lead to a heart attack or stroke.

While population studies support an association between alcohol and cardiovascular disease, they’ve relied on self-reported data, which is not always accurate or reliable. According to study authors, this is the first study to provide concrete evidence linking drinking patterns to the development of vascular disease, and the nearly 15 percent of Americans who binge drink – as estimated by the Centers for Disease Control and Prevention – should take note.

“People need to consider not only how much alcohol they drink, but the way in which they are drinking it,” said lead study author John Cullen, Ph.D., research associate professor in the Department of Surgery at the University of Rochester Medical Center. “Research shows that people have yet to be convinced of the dangers of binge drinking to their health; we’re hoping our work changes that.”

Scientists don’t yet understand how moderate alcohol consumption benefits cardiovascular health or how heavy drinking episodes hurt it.

The National Institute on Alcohol Abuse and Alcoholism defines binge or “at-risk” drinking as consuming more than four drinks on any day for men, and more than three drinks on any day for women. Understanding how much alcohol is in a “standard” drink is also critical, something the institute is promoting through its new “Rethinking Drinking” campaign.

Health care professionals also need to be aware that drinking style matters and should address the issue when discussing alcohol consumption with patients, especially those who are at higher risk of atherosclerosis or who have suffered a heart attack in the past, added Cullen.

“This evidence is very interesting because it supports a pattern of drinking that is emerging in clinical studies as both safe and seemingly most protective against heart disease – frequent consumption of limited amounts of alcohol. This certainly backs up widespread clinical guidelines that limit drinking to one drink daily for non-pregnant women and two drinks daily for men,” said Kenneth Mukamal, M.D., M.P.H., Associate Professor of Medicine at Harvard Medical School who studies the role of dietary and lifestyle factors, particularly alcohol consumption, on the incidence of cardiovascular and neurovascular disease.

In the study, mice in the “daily-moderate” group were fed ethanol equivalent to two drinks every day of the week, mice in the “weekend-binge” group were fed approximately seven drinks on two days of the week and mice in the control group were fed a non-alcoholic cornstarch mix. All mice were put on an atherogenic diet, which Cullen equates to a high-fat Western diet – think fried food every day – to encourage the development of atherosclerosis, which forms when fatty deposits or plaque collect on the inner walls of the arteries, causing them to narrow.

Levels of LDL or “bad” cholesterol plummeted 40 percent in the daily-moderate drinking mice, but rose 20 percent in the weekend-binge drinking mice, compared to the no-alcohol controls. High levels of bad cholesterol increase the risk of heart disease, and past studies show that every 10 percent increase in LDL results in a 20 percent increase in atherosclerosis risk.

Surprisingly, levels of HDL or “good” cholesterol went up in both the moderate and binge drinking groups, which Cullen speculates is an acute or short-term effect.

The volume of plaque, as well as the accumulation of immune cells that promote inflammation and consequently contribute to the narrowing of arteries, decreased in the moderate mice compared to no-alcohol mice. The opposite occured in the binge-drinking mice: Plaque volume and the number of inflammatory immune cells grew.

Another unexpected yet noteworthy finding was that the binge drinking mice gained significantly more weight than the moderate and control mice. Though all mice started at approximately the same weight and consumed similar amounts of food over the course of the study, the binge mice gained more than three times as much weight as the moderate mice and about twice as much weight as the control mice.

Building on this study, Cullen is investigating genes that are turned on or off following moderate and binge drinking episodes to determine if they influence outcomes.

The research was supported in part by the Founders Affiliate of the American Heart Association, which supports research exploring new ideas to combat cardiovascular disease. Founders Affiliate research committee chair Lucy Liaw, Ph.D. said these first-time findings could have far-reaching public health implications. “The discoveries of Dr. Cullen’s group show that binge drinkers may have increased risk of developing atherosclerosis and experiencing weight gain. Because obesity is also a risk factor for disease, binge drinking may have a strong negative impact on cardiovascular health,” said Liaw, who is also a member of the AHA national research committee.

The study was also funded by the National Institute on Alcohol Abuse and Alcoholism at the National Institutes of Health. In addition to Cullen, Weimin Liu, M.D., Ph.D., Eileen Redmond, Ph.D. and David Morrow, Ph.D. from the Medical Center contributed to the research.

Effect of alcohol consumption on biological markers associated with risk of coronary heart disease: systematic review and meta-analysis of interventional studies.

Brien SE, Ronksley PE, Turner BJ, Mukamal KJ, Ghali WA.
BMJ. 2011 Feb 22;342:d636. doi: 10.1136/bmj.d636.

Calgary Institute for Population and Public Health, Department of Community Health Sciences, Faculty of Medicine, University of Calgary, Alberta, Canada T2N 4Z6.

Drinking alcohol in moderation protects against heart disease

Research: Association of alcohol consumption with selected cardiovascular disease outcomes: a systematic review and meta-analysis

Research: Effect of alcohol consumption on biological markers associated with risk of coronary heart disease: systematic review and meta-analysis of interventional studies

Individuals who drink alcohol in moderation (about one drink a day or less) are 14-25% less likely to develop heart disease compared to those who drink no alcohol at all, finds research led by Professor William Ghali from the University of Calgary, published on bmj.com today.

The first paper, led by Paul Ronksley from the University of Calgary, emphasises that a balance needs to be found between the public health message that consuming large amounts of alcohol is bad for you, and the one that drinking in moderation can have health benefits.

An accompanying paper led by Dr Susan Brien, also from the University of Calgary, finds that moderate consumption of alcohol (up to one drink or 15 g alcohol per day for women and up to two drinks or 30 g alcohol per day for men) is good for health. They say moderate amounts of alcohol significantly increase the levels of ‘good’ cholesterol circulating in the body and this has a protective effect against heart disease.

Brien and colleagues argue that their study strengthens the case that there is a causal link between alcohol consumption and reduced heart disease.

The authors of both papers acknowledge that a number of previous studies have concluded that moderate alcohol consumption has been associated with a decrease in heart disease. However, they say that the research was out-of-date and there was a need for new material. Professor Ghali says his team’s research is the most comprehensive to date.

Ghali and colleagues reviewed 84 studies of alcohol consumption and heart disease. They compared alcohol drinkers with non-drinkers and their outcomes in relation to heart disease, death from heart disease, incidences of stroke and death from having a stroke.

In the companion study, Brien and colleagues reviewed 63 studies and investigated alcohol consumption with known physical markers for heart disease such as cholesterol, levels of inflammation, fat cells and the condition of blood vessels. They also assessed the impact of the type of alcohol consumed (wine, beer and spirits).

Interestingly, Brien’s research concludes that it is the alcohol content that provides the health benefits not the type of alcoholic beverage (wine, beer or spirits) that is drunk.

Professor Ghali concludes that the debate between the impact of alcohol on heart disease should now centre “on how to integrate this evidence into clinical practice and public health messages”.

He adds “with respect to public health messages there may now be an impetus to better communicate to the public that alcohol, in moderation, may have overall health benefits that outweigh the risks in selected subsets of patients … any such strategy would need to be accompanied by rigorous study and oversight of impacts”.

http://www.bmj.com/cgi/doi/10.1136/bmj.d671