Alcohol consumption linked to increased risk of heart disease, says study
wellhealthorganic.com:alcohol-consumption-good-for-heart-health-new-study-says-no : A new study has found a link between alcohol consumption and an increased risk of developing heart disease. The research, published in the European Heart Journal, analyzed data from over 100,000 people in 14 countries and found that those who drank more alcohol had a higher risk of developing cardiovascular disease, such as heart attacks and stroke. The study also found that even moderate alcohol consumption can be harmful, with the risk increasing for every additional drink per day. The findings highlight the importance of limiting alcohol intake to promote heart health and reduce the risk of cardiovascular disease.
INTRODUCTION
Biologic sex is an important determinant of health and disease. Over the past several decades, research has revealed sex differences in the epidemiology, risk, clinical manifestations, pathophysiology, and progression of many diseases, including cardiovascular disease (CVD) and alcohol-induced pathologies. CVD is the leading cause of morbidity and mortality for women.1 Therefore, understanding the potential interaction between sex and alcohol consumption on the cardiovascular system is important. This review presents the effects of alcohol consumption on the cardiovascular system in women, focusing on prevalent cardiovascular conditions such as hypertension, coronary heart disease (myocardial infarction), stroke, and peripheral arterial disease. The cardiovascular disorders are briefly defined, sex differences in the prevalence and prognosis of the disorders are discussed, followed by examination of the sex differences in alcohol’s effects on those conditions. This review also reports on the sex differences in the prevalence, clinical manifestations, and outcomes associated with alcoholic cardiomyopathy.
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METHODS
The relationship between alcohol consumption and CVD has been extensively investigated, and women have been included in many of these studies. However, results for women and men often have not been presented separately. Studies have been experimental, such as short-term clinical trials, and longitudinal, using participants from ongoing population cohorts such as the Nurses’ Health Study and the Framingham Heart Study. Data from these studies have allowed for the completion of several comprehensive systematic reviews and meta-analyses of alcohol use and its relationships with hypertension, myocardial infarction, stroke, and peripheral arterial disease.
This review summarizes data from meta-analyses and from longitudinal studies. Results were included in this discussion if they were reported for men and women separately. Data were summarized from studies that examined alcohol consumption by either standard drinks or by grams per unit of ethanol per day or week. Studies varied in the way they measured and categorized alcohol consumption, making comparisons sometimes challenging. Most studies reviewed reported alcohol consumption in grams of ethanol per day or week and defined a standard drink as 12 to 15 grams of alcohol.
Drinking patterns, particularly binge drinking, have emerged as an important modifier of the relationship between alcohol and cardiovascular risk. For a review of the sex differences in binge drinking on cardiovascular function, see the 2017 review by Piano and colleagues.2
BLOOD PRESSURE AND HYPERTENSION
The current blood pressure guidelines published in 2018 define hypertension as systolic blood pressure (SBP) greater than 130 mm Hg or diastolic blood pressure (DBP) greater than 80 mm Hg.3 In many of the studies reviewed for this article, hypertension was defined as SBP greater than 140 mm Hg or DBP greater than 90 mm Hg. The effects of alcohol consumption on blood pressure in women are important to consider, because hypertension is a leading cause of cardiovascular morbidity and mortality.1 From 2015 to 2016, the overall prevalence of hypertension (SBP > 140 mm Hg) among adults was 29.0% and was similar for men (30.2%) and women (27.7%).4 For adults ages 18 to 59, hypertension prevalence is greater for men than for women. However, women older than age 60 have greater prevalence (66.8%) of hypertension than men older than age 60 (58.5%). In the United States, experts have estimated that alcohol consumption accounts for 10% of the population burden of hypertension.3 wellhealthorganic.com:alcohol-consumption-good-for-heart-health-new-study-says-no
The effects of single episodes of alcohol consumption have not been investigated in women. Studies that included men have reported that consuming alcohol (1 to 2 standard drinks) in a single episode was associated with transient blood pressure increases that ranged from 4 to 7 mm Hg SBP and from 4 to 6 mm Hg DBP.5–7 In healthy women, an episode of low to moderate alcohol consumption (1 to 2 standard drinks, or 12 to 14 grams of ethanol) more than likely would have no appreciable effect on blood pressure.
Clinical studies and randomized clinical trials have been designed to examine the short-term effects of alcohol consumption, but only one study included women.8–12 In a crossover study, Mori and colleagues examined the effects of different levels of alcohol consumption on ambulatory, 24-hour blood pressure levels among healthy, premenopausal women ages 20 to 45 (N = 24).12 Blood pressure was measured after a 4-week period during which participants consumed different amounts of red wine: 42 to 73 grams of alcohol per week (0.5 to 1.0 drink per day) vs. 146 to 218 grams of alcohol per week (2 to 3 drinks per day). Awake SBP was 2.3 mm Hg higher and DBP was 1.3 mm Hg higher for women who consumed more alcohol (2 to 3 drinks per day) than for women who consumed less (0.5 to 1.0 drink per day) or no alcohol. For the women who consumed less, the red wine showed no effect on blood pressure. These findings suggest 2 to 3 drinks per day have a mild pressor effect on blood pressure in women.
Findings from two meta-analyses support an association between alcohol consumption and the risk of developing hypertension (SBP > 140 mm Hg), and that sex is a modifier of this relationship.13,14 In a meta-analysis of 18 cohort studies, Roerecke and colleagues found that for women (with a mean age of 46.7), compared to abstainers, consumption of 1 to 2 drinks per day was not associated with increased hypertension risk.14 However, hypertension risk was elevated for women who consumed 3 or more drinks per day, with a relative risk (RR) of 1.42, 95% confidence interval (CI) [1.22, 1.66]. However, for men, compared to abstainers, any level of alcohol consumption increased the risk for hypertension.
wellhealthorganic.com:alcohol-consumption-good-for-heart-health-new-study-says-no In another meta-analysis conducted several years earlier, Briasoulis and colleagues reported that women ages 30 to 55 who consumed less than 10 grams of alcohol (less than 1 drink) per day, compared to abstainers, showed a significant reduction in RR for hypertension (RR = 0.87, 95% CI [0.82, 0.92]).13 These investigators also reported a “trend toward decreased risk of hypertension” for women participants who consumed 1 to 2 drinks per day (RR = 0.9, 95% CI [0.87, 1.04]). For women, the increased risk for hypertension emerged at alcohol consumption levels of 21 to 30 grams (2 drinks) per day and 31 to 40 grams (2 to 3 drinks) per day. Men who consumed less alcohol showed a trend toward increased risk for hypertension, and a significant increase in risk of hypertension was shown among men who consumed 31 to 40 grams per day (RR = 1.77, CI [1.39, 2.26]) or more than 50 grams (about 4 drinks) per day (RR = 1.62, CI [1.31, 1.87]). Results from another meta-analysis also found a linear relationship for men and a J-shaped relationship for women.15
Roerecke and colleagues also conducted a meta-analysis to examine the effects of a reduction in alcohol consumption on blood pressure.16 Data were analyzed from 36 clinical trials, and the main analysis included men (n = 2,464) and women (n = 401) together, with a subgroup analysis for sex differences. Although trial characteristics (e.g., length of trial and blood pressure assessment method) differed among the studies, for individuals who drank more than 2 drinks per day, a reduction in alcohol consumption was associated with a reduction in blood pressure. Blood pressure reductions were greatest for individuals who consumed 6 or more drinks per day at baseline.
These same authors estimated the reduction in blood pressure that might be achieved by 50% of people in the United Kingdom who consume more than 2 drinks per day.16 Using pooled effect sizes from a subgroup analyses for sex and amount of alcohol, the authors estimated the proportional difference, or the magnitude of SBP reduction, would be a 4.4% reduction for men and a 1.2% reduction for women among men and women with SBP greater than 140 mm Hg.
These results and the examination of daily alcohol consumption indicate the relationship between alcohol and blood pressure is different for men (linear) and for women (J-shaped). For men, all levels of alcohol consumption are associated with increased blood pressure and risk of hypertension.14 For women, the J-shaped relationship indicates that 1 to 2 drinks per day has no effect14 or a lowering effect13 on blood pressure, whereas more than 2 drinks per day increases the risk of hypertension. All these meta-analyses included women before and after menopause; therefore, speculation about the potential effect of hormones on these sex differences is difficult.
CORONARY HEART DISEASE
Coronary heart disease is defined as a disease that results from coronary artery disease or myocardial infarction. The terms “coronary heart disease” and “coronary artery disease” are often used interchangeably. Across all age groups, the prevalence of coronary heart disease and myocardial infarction is greater for men than for women.1 However, the difference in prevalence between men and women narrows with advancing age.1,17 Most women are older when they present with their first myocardial infarction (the mean age is 71.8). Regardless of age, more women than men die within 1 to 5 years after a first myocardial infarction.17
Many epidemiologic studies have examined the relationship between coronary heart disease (and myocardial infarction) and alcohol use. Ronksley and colleagues have conducted the most comprehensive meta-analysis, which incorporated 84 studies over the past 30 years.18 Among those studies, 52% included women. In the analysis, active drinkers were defined using a wide range of alcohol consumption categories, from less than 2.5 grams per day (less than 0.5 drink) to more than 60 grams per day (5 or more drinks). For comparison, the reference group was nondrinkers. These investigators reported that for men and women ages 15 to 90, any amount of alcohol consumption compared to none was associated with a reduced RR for occurrence of coronary heart disease and mortality (for men: RR = 0.71, 95% CI [0.66, 0.77] and RR = 0.77, 95% CI [0.72,0.82], respectively; for women: RR = 0.71, 95% CI [0.66, 0.77] and RR= 0.78, 95% CI [0.64, 0.94], respectively).wellhealthorganic.com:alcohol-consumption-good-for-heart-health-new-study-says-no
In an analysis that used data from the international Interheart case-control study, which included a population of women and men with a mean age of 58, Leong and colleagues examined the relationship between alcohol consumption of 1 drink or more per day during the year before a myocardial infarction.19 Women who had at least 1 drink were less likely to have a myocardial infarction (OR = 0.73, 95% CI [0.61, 0.88]) compared to men who had at least 1 drink (OR = 0.92, 95% CI [0.84, 1.00]). Because alcohol use was defined as the consumption of any alcoholic beverage within the previous 12 months, this analysis did not allow for determining any dose response or specific level of alcohol consumption associated with the reduced risk in women or men.
Collectively, based on these data, there are no sex-related effects of alcohol consumption on the risk for occurrence of coronary heart disease or for coronary heart disease mortality. The results reported by Ronksley and colleagues suggest a wide range of daily alcohol consumption levels are associated with a reduced risk of incidence of coronary heart disease and coronary heart disease mortality in women and men.18 The lack of specific alcohol intake categories in the Interheart study disallows understanding either the lower or upper limits for alcohol consumption associated with myocardial infarction risk.
Neither study’s findings provide specific guidance for understanding the frequency or regularity of consuming different daily levels of alcohol within a designated time period, for example, per week or month. More than likely, more than 2 to 3 drinks per day, every day, may be associated with a different risk profile when compared to consuming 2 to 3 drinks per day, but only 2 to 3 times per week. Finally, consuming 5 or more drinks per day could be considered a binge pattern, which is associated with increased risk of CVD
