Correspondence

Ethanol and Hypertrophic Cardiomyopathy

N Engl J Med 1997; 336:878March 20, 1997

Article

To the Editor:

Paz et al. (Sept. 26 issue)1 studied the effects of ethanol on obstruction of the left ventricular outflow tract in hypertrophic cardiomyopathy. They noted an increase of 63 percent in the mean outflow tract gradient in response to 50 ml of 40 percent ethanol and stated, “Patients with this disorder should be cautioned about the potentially harmful effects of this commonly used substance.” Should patients with this condition abstain from alcohol on the basis of this finding?

I would like to point out that the most common cause of death in such patients is sudden death from cardiac causes. The risk of sudden death from cardiac causes is increased for patients with syncope or sustained ventricular tachycardia during electrophysiologic study, but the severity or presence of an outflow tract gradient is not an independent risk factor.2 In addition, similar increases in outflow tract gradients have been noted during and after symptom-limited exercise.3 I believe that further studies are required before it is suggested that patients with this condition abstain from alcohol consumption simply because it may temporarily increase their outflow tract gradient.

John J. Allan, M.D.
University of Iowa, Iowa City, IA 52246

3 References

1. 1

   Paz R, Jortner R, Tunick PA, et al. The effect of the ingestion of ethanol on obstruction of the left ventricular outflow tract in hypertrophic cardiomyopathy. N Engl J Med 1996;335:938-941
   Full Text | Web of Science | Medline

2. 2

   Fananapazir L, Chang AC, Epstein SE, McAreavey D. Prognostic determinants in hypertrophic cardiomyopathy: prospective evaluation of a therapeutic strategy based on clinical, Holter, hemodynamic, and electrophysiological findings. Circulation 1992;86:730-740
   Web of Science | Medline

3. 3

   Klues HG, Leuner C, Kuhn H. Left ventricular outflow tract obstruction in patients with hypertrophic cardiomyopathy: increase in gradient after exercise. J Am Coll Cardiol 1992;19:527-533
   CrossRef | Web of Science | Medline

Author/Editor Response

The authors reply:

To the Editor: Dr. Allan has suggested that our recommendation that patients with hypertrophic obstructive cardiomyopathy should be cautioned about the possible harmful effects of ethanol is premature. However, our study shows a clear increase in outflow tract obstruction caused by ethanol in these patients. A recent thorough review suggested that “outflow obstruction is also a risk factor for sudden death.”1 This may be related to the fact that obstruction may cause myocardial ischemia.2 The mechanism for this is not only increased left ventricular pressure; outflow tract obstruction also leads to a decreased gradient for coronary perfusion3 and may be responsible for the compression of intramyocardial vessels such as septal perforators.

Another complication associated with an increased gradient is mitral regurgitation (which varies in severity directly with the outflow gradient4). This may lead to pulmonary congestion and to poorly tolerated atrial fibrillation. In addition, several large series show that the relief of outflow tract obstruction after surgical myomectomy results in a significant decrease in annual mortality rates.1

It is well accepted that drugs such as vasodilators, which increase the gradient in hypertrophic cardiomyopathy, are relatively contraindicated in patients with this condition, and our results show that ethanol (another vasodilator) also increases the gradient. On the basis of these data, we believe that it is prudent to caution patients with hypertrophic cardiomyopathy about the possible deleterious effects of ethanol.

Rami Paz, M.D.
Paul A. Tunick, M.D.
Itzhak Kronzon, M.D.
New York University Medical Center, New York, NY 10016

4 References

1. 1

   Wigle ED, Rakowski H, Kimball BP, Williams WG. Hypertrophic cardiomyopathy: clinical spectrum and treatment. Circulation 1995;92:1680-1692
   Web of Science | Medline

2. 2

   Dilsizian V, Bonow RO, Epstein SE, Fananapazir L. Myocardial ischemia detected by thallium scintigraphy is frequently related to cardiac arrest and syncope in young patients with hypertrophic cardiomyopathy. J Am Coll Cardiol 1993;22:796-804
   CrossRef | Web of Science | Medline

3. 3

   Cannon RO III, Rosing DR, Maron BJ, et al. Myocardial ischemia in patients with hypertrophic cardiomyopathy: contribution of inadequate vasodilator reserve and elevated left ventricular filling pressures. Circulation 1985;71:234-243
   CrossRef | Web of Science | Medline

4. 4

   Tunick PA, Lampert R, Perez JL, Kronzon I. Effect of mitral regurgitation on the left ventricular outflow pressure gradient in obstructive hypertrophic cardiomyopathy. Am J Cardiol 1990;66:1271-1273
   CrossRef | Web of Science | Medline

Citing Articles (1)

Citing Articles

1. 1

   Nozomi Watanabe, Susumu Nakagawa, Takashi Fukunaga, Shuji Fukuoka, Kinta Hatakeyama, Tohru Hayashi. (2001) Acute Necrotizing Eosinophilic Myocarditis Successfully Treated by High Dose Methylprednisolone. Japanese Circulation Journal 65:10, 923-926
   CrossRef