ESC 2012: Does alcohol intake increase the risk of AF?

If you counsel patients with atrial fibrillation, one topic that comes up a lot is alcohol.

Is it safe to drink? How much? I heard that alcohol helps prevent heart disease? Is one drink a day okay?

These are questions that AF caregivers hear often. I know I do.

I realize that Trials and Fibrillations is supposed to be a high-tech EP blog, but as a doctor on the front lines of perhaps the least healthy state in the US, I don't dismiss lifestyle factors. There's a reason this disease is running amok.

That's why I went to the session entitled, A drinker, rather than a smoker, is at high risk for atrial fibrillation in the general male population.

Japanese researchers set out to clarify the risk of developing AF in smokers and drinkers in a male population. They studied a community 60 miles outside of Tokyo, analyzing 75 361 men (average age 62) who participated in an annual health exam between the years 2000 and 2007. AF was assessed with 403 000 12-lead ECGs, recorded annually over the study period. Drinking and smoking behaviors were assessed with self-reported questionnaires.

They looked at AF prevalence at study onset then seven years later. The results were interesting.

• 49% of the subjects were drinkers (one or more drinks daily), and 40% were regular smokers.
• At study onset, the AF prevalence overall was 1.55%, with drinkers having a higher likelihood of AF than nondrinkers—1.7% vs 1.4%.
• Over the seven-year period, drinkers were 48% more likely to develop AF, while those who smoked did not see an increased risk.
• The striking finding was that drinking alcohol increased the risk more than hypertension (odds ratio=1.38) and body-mass index (BMI) (OR=1.36) and only slightly less than age (OR=1.8).

These data allowed for provocative conclusions (quoted directly from final slide):

• Drinkers are at a high risk for AF.
• However, smoking is not a risk factor for AF.
• With regard to lifestyle modifications for AF prevention, the risks of drinking should be emphasized more than those of smoking.

These kind of data pose a problem, don't they?

Just yesterday at ESC, there was a session entitled, "Eat, drink, and be merry." The topic of red wine was addressed. The consensus on alcohol's role in the prevention of atherosclerosis is complicated, but at least it seems a threshold of intake might exist—a J-shaped dose-response curve. Specifically, one to two drinks per day might not be harmful. Whether alcohol itself prevents atherosclerosis is debatable.

It's a different story for alcohol and AF. Although today's presentation involved a retrospective database analysis, which has significant limitations, including its evaluation of men only, the data warrant serious consideration.

Three things push me into believing what this study purports:

Consistency with previous trials : Here is a 2011 meta-analysis of 14 studies that concluded not consuming alcohol is most favorable in terms of AF risk reduction. Although statistically heavy, this study indicates that AF risk may increase incrementally with just one drink per day. And yes, there is actually a study (Journal of the American College of Cardiology) proposing that whiskey intake enhances vulnerability to AF in patients without heart failure or cardiomyopathy.

Biologic plausibility : ­­Alcohol is not inert. It may act to increase adrenergic tone, decrease vagal tone, impair inotropy, and alter refractory periods and conduction velocity. Two obvious clinical variables associated with (excess) alcohol intake include sleep disturbance and hypertension.

Anecdotal experience of an AF doctor : Chalk this one up as the weakest of the three. Before there were checklists, quality measures, and tiered levels of evidence, doctors had only their experience and gut feeling to go on. Surely this counts for something? Although it would be foolish to say AF follows rules, it's not a stretch to say there may be trends. Here are a few typical AF vignettes to ponder: the frazzled middle-aged executive who slows his (or her) brain each night with a couple of cocktails; the business traveler who adds nightly drinks to the inflammation of travel; and then there is the retiree who starts with gin and tonics at four o'clock. I could go on. You get the picture. Trends indeed.

How to conclude?

I have been going to EP conferences for almost a decade, and rarely have I ever sat through a lecture on the importance of counseling AF patients on basic lifestyle issues. You may hear lifestyle mentioned in passing, but it's not emphasized. Audiences at EP symposia hear the newest on ablation, anticoagulants, and devices. Electrophysiologists don't often focus on "upstream" things like obesity, sleep disorders, and sadly, yes, alcohol.

Maybe that should change?

Perhaps Europe will not be leading in this charge. Here's an interesting image. Beer and wine sold at the ESC—starting in the morning!

JMM

Your comments

	ESC 2012: Does alcohol intake increase the risk of AF?
	# 1 of 11	August 29, 2012 05:29 (EDT)
	S Nelson	So what if alcohol slightly promotes AF?  The data are overwhelming that moderate alcohol consumption significantly lowers OVERALL CVD morbidity and mortality and all-cause death. Other, positive CVD effects overwhelm any negative AF effects.  So don't throw the CVD baby out with the AF bathwater.    Unless the alcohol consumption is in the excessive range of the spectrum -- or there are other alcohol-related physical or social things going on -- it would be inappropriate to counsel heart patients to reduce their alcohol intake as part of lifestyle modifications.  Rather, we should be counseling more patients to take up drinking, or to imbibe more.
	# 2 of 11	August 30, 2012 03:10 (EDT)
	dennis	I have come to my own conclusion that alcohol is a trigger for AF in my own situation.   Having HCM throughout my life and going on beta blockers at age 37 I continued to inhibit alcohol, beer or rum was my choice.  At age 66 I suffered my first AF/SVT episode but did not connect alcohol nor did my cardiologist or EP mention the relationship.    At 68 I put two and two together and went clean.    I still have my episodes however I think, no I know that they would be increased or more severe if I were to add alcohol back to the brew...    If you are predisposed for AF, then I would seriously consider finding another pass-time and find a good NA beer.    The Germans make a good one called Clausthaler that I swear is the real thing.... except of course the buzz.
	# 3 of 11	August 30, 2012 07:40 (EDT)
	Dan Hackam	The carbohydrate of most beers are very high - about 18 grams of total carbs for a single pint of Guiness (and none of those carbs can be deducted from the total as representing fibre carbs). Beer is therefore a potent contributor toward metabolic syndrome, dysglycemia and could through that pathway chronically lead toward atrial fibrillation. Just as there are non-alcoholic brews, there are also low carb beers to choose from - Sleeman Clear being one of the nicest.
	# 4 of 11	August 30, 2012 10:50 (EDT)
	Ken Grauer, MD	I agree with the anecdotal experience of an AFib doctor - Alchohol clearly is a risk factor for precipitating AFib. That said - one drink a day for patients without heart problems is probably ok. Would be better that the 1 drink was not every day - but don't know that I could prove that 1 drink per day was bad in patients without heart disease. The Japanese study referred to above did not seem to divide up the drinkers into those who only had 1 drink a day vs those consuming more than 1 drink a day ... so I don't know that their conclusions are equally valid for patients who truly only have 1 drink per day.  More than 1 drink per day is probably bad. IF you have AFib - then you should cut out alcohol entirely. Doing so MAY make a big difference.  The above generalities stated assume that 1 drink = 1 drink (not a reliable assumption in many patients who report drinking "only 1 drink per day Doc ...." ).  Finally - in patients who have had a drinking problem - 1 drink (ever) - is one drink too many.  The above the opinion of a retired family doctor who loves cardiology.
	# 5 of 11	August 31, 2012 04:51 (EDT)
	Paul Kardon	Dennis, I could have written your comment verbatim. While anecdotal, it sure seems to be true for me. Increased alcohol intake, (read any), = increased episodes of AF.
	# 6 of 11	August 31, 2012 06:44 (EDT)
	Bill from Sydney	Alcohol is also a trigger for "pre" atrial fibrillation in my case (slightly labored heart beats, rapidly resolving palpitations), but rarely and only after many drinks. Wine is more a trigger than other forms of alcohol. Over-eating (especially meat) is a trigger. Sickness (with fever) is a trigger. Sustained over-exercise is a trigger. Dehydration is a trigger. So you need to make sure you aren't combining risk factors.  If you have mild / occasional atrial fibrillation like me, and you are otherwise in good health and aren't combining risk factors, then having a drink with friends is perfectly reasonable. When out with friends I might have a light beer, or a half beer mixed with lemonade, and that has never led to an episode. I also like an occasional scotch and that has never led to an episode. But on average, I am careful and wouldn't have more than a few drinks per week.
	# 7 of 11	August 31, 2012 02:06 (EDT)
	leo chan	What are the findings relating to alcohol and permanent AF?  Does alcohol consumption make a difference?
	# 8 of 11	August 31, 2012 07:18 (EDT)
	dennis	Of course there are a number of risk factors for AF. Not withstanding, AGE. Each of us has his or her own chemistry and characteristics to consider. For me, it is no longer worth the risk and I abstain from alcohol, am concientious to hydrate and maintain a good but low key food consuption and enjoy AF free period of time and deal with AF when it comes around. My own 'pill in the box' is a 100 mg tab of instant release cardizem to get the heart rate down and give my pacer a chance at getting ahead of the AF...
	# 9 of 11	September 7, 2012 12:37 (EDT)
	ken	I am not an alcohol drinker, I just never enjoyed it.  i can go a year without an alcoholic drink, I never got a nice "buzz" from any type of drinking, no enjoyable warm feeling or loose tongue and a relaxed happy feeling.  I would drink, and a few hours later get a headach.  Anyway,  my wife had a new job and her boss invited staff over.  I was offered a Rum and Coke and drank 2 within an hour.  A few hours i was in A.Fib  much to my surprise.  I had been in sinus rhythm for years. The folks in the Emergency Room rolled their eyes when I mentioned the alcohol I had consumed for the first time in years.  My Cardiologist showed up in a few hours and politely said he had not heard of that in the past.  They then put the paddles on and shocked me back into sinus rhythm. 11 years later it is lambrusco wine and wine coolers while on a vacation to Florida with a cousin's family.  On an empty stomach   I had wine and 7UP.     I had been symptom free other than an occasional extra beat for the 10 years.  Back comes the atrial fib. Back to the hospital i go, and after trying medicine to convert the heart and failing, out came the paddles the setting was 100 jewels, I was put to sleep and converted back into sinus rhythm. This time the Cardiologist said he had heard a few things about it. Now in my 60s i read that alcohol can indeed contribute to it.  Well, at least i know it is not just me, and my imagination.  I have also found that eating a lot of regular white sugar on an empty stomach in a short period of time can set me off in the last 15 years or so.  (Big piece of white cake on my birthday)  Any thoughts there?
	# 10 of 11	September 17, 2012 11:26 (EDT)
	Enrique Guadiana	A few years back I read an Sandinavian article which conclude the lowest risk for CV disease were in the light drinker, the next were the heavy drinkers and the worst were the non drinkers. Some researchers speculates that all the explanation is not from from the alcohol and you have to take in account the differences in personality and live styles among them. I believe they are conducting a study to address this matter.
	# 11 of 11	September 22, 2012 03:57 (EDT)
	Natalia	Briefly, in my practice about half of all AF cases in men < 60 years are associated with intensive alcohol drinking (with dilatation of the heart chambers or without dilation) in patients without clinically obvious atherosclerotic disease. No doubt such patients need lifestyle modifications with alcohol intake reduction.

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