Correspondence
Alcohol and Coronary Heart Disease
N Engl J Med 2003; 348:1719-1722April 24, 2003
- Article
To the Editor:
Mukamal et al. (Jan. 9 issue)1 report on the roles of drinking pattern and type of alcohol consumed in coronary heart disease in men. Although alcohol consumption reduces mortality from coronary heart disease, it has not been shown to have a benefit in terms of overall mortality in some epidemiologic studies,2 so we are very interested in the data on total mortality from the study by Mukamal et al.
The accompanying editorial by Goldberg3 raises an important question about conducting a controlled trial of alcohol consumption. Recognizing the detrimental effects of alcohol, one might legitimately raise ethical questions about randomly assigning participants to exposure to alcohol. An analysis by White et al. with the use of published systematic reviews and population-based data showed a U-shaped relation between alcohol consumption and overall mortality.4 This investigation suggested a favorable risk–benefit ratio in terms of overall mortality in the subgroups of the population it studied. Thus, we concur that a randomized trial of alcohol as a cardioprotective agent, in selected populations in which the benefits most likely outweigh the risks, is justifiable. Such an investigation would not only tally known epidemiologic associations but would also help clinicians make definitive recommendations.
4 ReferencesMurali K. Duggirala, M.D.
Claude M. Bridges, M.D.
Thomas G. McLeod, M.D.
Mayo Clinic, Rochester, MN 55905
duggirala.murali@mayo. edu 1
Mukamal KJ ,Conigrave KM ,Mittlemen MA , et al. Roles of drinking pattern and type of alcohol consumed in coronary heart disease in men. N Engl J Med 2003;348:109-118
Full Text | Web of Science | Medline2
Criqui MH ,Ringel BL . Does diet or alcohol explain the French paradox? Lancet 1994;344:1719-1723
CrossRef | Web of Science | Medline3
Goldberg IJ . To drink or not to drink? N Engl J Med 2003;348:163-164
Full Text | Web of Science | Medline4
White IR ,Altmann DR ,Nanchahal K . Alcohol consumption and mortality: modelling risks for men and women at different ages. BMJ 2002;325:191-194
CrossRef | Web of Science | Medline
To the Editor:
Goldberg's editorial, like an earlier one in the Journal, 1 mentions the lack of compelling evidence of beneficial effects of moderate drinking and proposes that patients with cardiovascular disease be assigned to a study of alcohol treatment. However, a nondrinker who begins to consume alcohol in order to “protect” his or her coronary arteries incurs the unpredictable risk of a disastrous loss of control if he or she happens to be predisposed to alcohol dependence. Furthermore, some previous large studies, generally interpreted as demonstrating beneficial effects of one to two drinks per day, also revealed a positive effect of occasional drinking,2 with a reduction in mortality associated with the consumption of as little as one beer or one glass of wine per month.3 Obviously, such amounts are too small to be effective, and it is not plausible to attribute the improved outcome to the alcohol. Confounding factors (such as lifestyle) are more likely to be responsible, and this is also the interpretation of the National Institute on Alcohol Abuse and Alcoholism.4 Thus, introducing long-term drinking as a therapeutic measure is not justified — a conclusion that has also been reached by others, even with regard to middle-aged persons.5
This conclusion, of course, does not preclude moderate consumption for gustatory reasons. When the question is raised in that context, one's past capacity to keep consumption within socially and medically acceptable bounds is probably the most useful guide in individual decisions about whether “to drink (moderately) or not to drink,” as was already concluded in 1984.1 In persons for whom such evidence is lacking, the introduction of moderate alcohol consumption is not advisable.
5 ReferencesCharles S. Lieber, M.D.
Bronx Veterans Affairs Medical Center, Bronx, NY 10468
liebercs@aol.com 1
Lieber CS . To drink (moderately) or not to drink? N Engl J Med 1984;310:846-848
Full Text | Web of Science | Medline2
Boffetta P ,Garfinkel L . Alcohol drinking and mortality among men enrolled in an American Cancer Society prospective study. Epidemiology 1990;1:342-348
CrossRef | Medline3
Gronbaek M ,Deis A ,Sorensen TIA ,Becker U ,Schnohr P ,Jensen G . Mortality associated with moderate intakes of wine, beer, or spirits. BMJ 1995;310:1165-1169
CrossRef | Web of Science | Medline4
Alcohol and coronary heart disease. In: Alcohol Alert. No. 45. Rockville, Md.: National Institute on Alcohol Abuse and Alcoholism, October 1999.
5
Wannamethee SG ,Shaper AG . Taking up regular drinking in middle age: effect on major coronary heart disease events and mortality. Heart 2002;87:32-36
CrossRef | Web of Science | Medline
To the Editor:
Mukamal and coauthors, in a detailed article based on a large cohort of healthy male professionals, report on an alcohol-associated reduction in the risk of coronary heart disease. The average age of persons in the cohort at the beginning of the study was about 53 years. Yet, as most physicians know, the detrimental effects of alcohol usually occur at an earlier age. For example, in 2000, more than 75 percent of the deaths from alcohol-related motor-vehicle accidents in the United States occurred in persons younger than 50 years of age.1 These persons died before reaching an age at which they might have benefited from consuming alcohol.
How will our patients interpret this report? They are likely to make the risky assumption that consuming alcohol offers an overall health benefit. But as Goldberg points out in the accompanying editorial, the overall health benefit is uncertain, and the risk of addiction is unpredictable. Physicians should encourage heavy drinkers to drink less, rather than recommend alcohol to the nearly 40 percent of adults who are nonconsumers.
1 ReferencesAlbert B. Lowenfels, M.D.
New York Medical College, Valhalla, NY 10595
lowenfel@nymc.edu To the Editor:
Mukamal et al. show that moderate alcohol consumption is associated with a decreased risk of myocardial infarction in a population of men in the United States. Although no significant differences were found among different types of alcoholic beverages, the association appeared to be stronger for spirits or beer than for wine.
In a recent meta-analysis,1 we found a significant reduction in vascular risk associated with drinking wine. In the seven studies conducted in the United States, the relative risk of vascular disease among wine drinkers as compared with nondrinkers was 0.59 and was further reduced to 0.46 when only the five studies that enrolled both sexes were considered. No protective effect of wine was apparent in the two studies in which only men were enrolled (Table 1Table 1
Relative Risk of Vascular Disease among Wine Drinkers as Compared with Nondrinkers.). No significant sex-related difference was observed for the risk reduction associated with beer consumption. A possible sex-related difference in the protective effect of wine on vascular risk might explain apparently conflicting results in different epidemiologic studies.1 ReferencesAugusto Di Castelnuovo, Phys.D.
Licia Iacoviello, M.D., Ph.D.
Consorzio Mario Negri Sud, 66030 Santa Maria Imbaro, Italy
iaco@negrisud.it Giovanni de Gaetano, M.D., Ph.D.
Catholic University, 86100 Campobasso, Italy1
Di Castelnuovo A ,Rotondo S ,Iacoviello L ,Donati MB ,de Gaetano G . Meta-analysis of wine and beer consumption in relation to vascular risk. Circulation 2002;105:2836-2844
CrossRef | Web of Science | Medline
Author/Editor Response
We agree with Dr. Duggirala and colleagues that the relation between alcohol consumption and total mortality is of great import. We may be able to assess this relation with additional follow-up in the future, although the study of mortality from cardiovascular causes may be limited by the low case fatality rate for myocardial infarction in this population. Large, well-designed studies have shown lower mortality among men who consume alcohol in moderation but have not specifically assessed the frequency and quantity of consumption.1 We encourage investigators in future studies of alcohol and mortality to include measures of drinking patterns.
As Dr. Lowenfels notes, the absolute risks and benefits of alcohol consumption vary according to age. Younger persons have lower absolute risks of coronary heart disease and higher rates of binge drinking.2 We reiterate our stated position that adults, both younger and older, should discuss alcohol use with their physicians and together make personalized decisions about appropriate consumption. For adults who consume alcohol excessively, we hope these discussions will lead to healthier drinking habits.
Dr. Di Castelnuovo and colleagues suggest that the apparent benefits of wine consumption may be specific to women. If it is accurate, this finding may relate more to the importance of the frequency of alcohol consumption than to the specific beverage consumed. Women are more likely to consume wine than other alcoholic beverages3,4 and therefore may consume wine more frequently than beer or spirits. As we reported, study participants who consumed alcohol at least three days per week were at the lowest risk of myocardial infarction, regardless of the average amount consumed weekly or the choice of beverage. Studies of drinking patterns and coronary heart disease among women may clarify this issue.
We apologize for the inadvertent omission of mention of pharmacists as one of the groups of health professionals enrolled in this study. An attentive pharmacist and study participant brought this error to our attention, for which we are grateful. The Health Professionals Follow-up Study includes dentists, optometrists, pharmacists, osteopaths, podiatrists, and veterinarians, as noted in our original report on alcohol use and coronary heart disease.5
5 ReferencesKenneth J. Mukamal, M.D., M.P.H.
Eric B. Rimm, Sc.D.
Harvard School of Public Health, Boston, MA 02215
kmukamal@caregroup.harvard. edu 1
Camargo CA Jr ,Hennekens CH ,Gaziano JM ,Glynn RJ ,Manson JE ,Stampfer MJ . Prospective study of moderate alcohol consumption and mortality in US male physicians. Arch Intern Med 1997;157:79-85
CrossRef | Web of Science | Medline2
Naimi TS ,Brewer RD ,Mokdad A ,Denny C ,Serdula MK ,Marks JS . Binge drinking among US adults. JAMA 2003;289:70-75
CrossRef | Web of Science | Medline3
Tjonneland A ,Gronbaek M ,Stripp C ,Overvad K . Wine intake and diet in a random sample of 48763 Danish men and women. Am J Clin Nutr 1999;69:49-54
Web of Science | Medline4
Barefoot JC ,Gronbaek M ,Feaganes JR ,McPherson RS ,Williams RB ,Siegler IC . Alcoholic beverage preference, diet, and health habits in the UNC Alumni Heart Study. Am J Clin Nutr 2002;76:466-472
Web of Science | Medline5
Rimm EB ,Giovannucci EL ,Willett WC , et al. Prospective study of alcohol consumption and risk of coronary disease in men. Lancet 1991;338:464-468
CrossRef | Web of Science | Medline
Author/Editor Response
How is one to make practical use of data such as those presented in the report by Mukamal et al.? Such information is widely disseminated in the popular press; this may lead to the concerns of Drs. Lieber and Lowenfels that it encourages more alcohol intake and hence more complications from alcohol consumption. I agree with them. Physicians should advise their patients to use strategies for the prevention of cardiac disease that are better supported by data from clinical trials and that are associated with a lower incidence of harmful side effects.
The issue is what to do with the wealth of correlative data obtained in these epidemiologic studies. There are two options: One may ignore the data, which is problematic because if the medical literature contains such information, it will undoubtedly be disseminated in the popular press; or one may test the validity of the data by performing a clinical trial. I agree that for primary prevention of cardiac disease, this option would require a large investment, and even if the trial were positive — that is, if alcohol were shown to be beneficial — it would need to show benefits beyond and in addition to those of cholesterol-lowering therapy, antihypertensive treatment, and aspirin, with limited side effects. A more limited study in patients with documented coronary artery disease who are already receiving standard treatments for atherosclerosis might be another option. This is a group in which the risk–benefit ratio might be reasonable. If alcohol showed benefit in such a study, one might consider its use in this population. If not, then one would reconsider whether additional correlative population-based data would be useful.
As Dr. Lieber notes, the data suggest that people who want to drink for “gustatory reasons” should not use health benefits as an excuse. Thus, in almost 20 years, the message, and even the title of the editorial, has hardly changed.
Ira J. Goldberg, M.D.
Columbia University College of Physicians and Surgeons, New York, NY 10032- Citing Articles (5)
Citing Articles
1
Augusto Castelnuovo, Simona Costanzo, Maria Benedetta Donati, Licia Iacoviello, Giovanni Gaetano. (2010) Prevention of cardiovascular risk by moderate alcohol consumption: epidemiologic evidence and plausible mechanisms. Internal and Emergency Medicine 5:4, 291-297
CrossRef2
Augusto Di Castelnuovo, Simona Costanzo, Romina di Giuseppe, Giovanni de Gaetano, Licia Iacoviello. (2009) Alcohol consumption and cardiovascular risk: mechanisms of action and epidemiologic perspectives. Future Cardiology 5:5, 467-477
CrossRef3
A. Di Castelnuovo, L. Iacoviello, K. Furman, M. B. Donati, G. de Gaetano. (2004) Wine, alcohol and cardiovascular risk: open issue. Journal of Thrombosis and Haemostasis 2:11, 2042-2044
CrossRef4
K. Sh. Nadareishvili, I. I. Meskhishvili, D. D. Kakhiani, G. L. Ormrtsadze, M. T. Khvedelidze, E. T. Chitanava. (2004) Effects of low ethanol doses on heart rhythm in rabbits. Bulletin of Experimental Biology and Medicine 138:3, 271-275
CrossRef5
K. Sh. Nadareishvili, I. I. Meskhishvili, D. D. Kakhiani, G. L. Ormrtsadze, M. T. Khvedelidze, E. T. Chitanava. (2004) Effects of low ethanol doses on heart rhythm in rabbits. Bulletin of Experimental Biology and Medicine 138:9, 271-275
CrossRef
