Physiological Reactivity to Alcohol Cues and the Awareness of an Alcohol Effect in a Double-Blind Placebo Design*

Skin conductance level (SCL) was recorded during the presentation of a beer drink in 16 alcoholic patients. The instructions to subjects stated that the ‘beer’ that was to be consumed‘may or may not contain alcohol. ‘Following consumption of either real beer or placebo (non-alcoholic malt beverage) the subjects were asked if they thought they had just consumed an alcoholic drink. SCL increases to the presentation of beer stimuli prior to consumption were highest among alcoholics who perceived the drink as ‘real beer’ following consumption. Perception of the drink as‘real bee' was not related to receiving real beer. The data suggest that autonomic reactivity to alcohol-related cues can facilitate and/or interact with the expectations surrounding alcohol consumption in alcohol dependent individuals.     

Alcohol use and congestive heart failure: incidence, importance, and approaches to improved history taking

Alcohol use, abuse, and dependence have the potential to result in alcoholic cardiomyopathy (ACM). This distinct form of congestive heart failure (CHF) is responsible for 21–36% of all cases of nonischemic dilated cardiomyopathy in Western society. Without complete abstinence, the 4-year mortality for ACM approaches 50%. Therefore, accurate and detailed assessment of alcohol use in congestive heart failure is essential. The prevalence of problematic alcohol use is unrecognized by many clinicians. Clinical assessment of alcohol intake is often reduced to a simple question such as, “Do you drink?” Denial and minimization are hallmarks of alcohol abuse, with many individuals underreporting their use of alcohol. Clinicians can overcome these hurdles by implementing practical history taking measures to improve the accuracy of self-reported alcohol use. The data regarding the dangers of ongoing alcohol use in individuals with ACM make attempts to engage individuals in treatment to support abstinence essential. Suggestions for detailed and accurate assessment are discussed.     

Alcohol abuse in patients with dilated cardiomyopathy. Laboratory vs clinical detection

Detection of alcohol abuse is of utmost importance in the diagnosis and management of alcoholic cardiomyopathy. The ability of laboratory tests and clinical signs to detect alcohol abuse was compared in 31 patients with severe heart failure due to underlying dilated cardiomyopathy. Alcoholic cardiomyopathy was diagnosed in 13 patients and a variety of nonalcoholic cardiomyopathies were diagnosed in the remaining 18 patients. At the time of hospital admission, all patients received a complete cardiovascular examination as well as routine hematologic and biochemical tests. Details concerning past and recent alcohol intake were obtained by an individual who was unaware of the diagnostic status of the patients. The two groups of patients did not differ with respect to clinical presentation, self-report of recent drinking patterns, or clinical signs and medical history items that have been found to be associated with chronic alcohol abuse. However, the group with alcoholic cardiomyopathy had significantly higher values for mean corpuscular volume and gamma-glutamyltranspeptidase. Our results suggest that a combination of routine laboratory tests may be effective in the detection of alcohol abuse in patients with dilated cardiomyopathy.     

To drink or not to drink? That is the question

Numerous studies have used a J-shaped or U-shaped curve to describe the relationship between alcohol use and total mortality. The nadir of the curves based on recent meta-analysis suggested optimal benefit at approximately half a drink per day. Fewer than 4 drinks per day in men and fewer than 2 per day in women appeared to confer benefit. Reductions in cardiovascular death and nonfatal myocardial infarction were also associated with light to moderate alcohol intake. Although some studies suggested that wine had an advantage over other types of alcoholic beverages, other studies suggested that the type of drink was not important. Heavy drinking was associated with an increase in mortality, hypertension, alcoholic cardiomyopathy, cancer, and cerebrovascular events, including cerebrovascular hemorrhage. Paradoxically, light-to-moderate alcohol use actually reduced the development of heart failure and did not appear to exacerbate it in most patients who had underlying heart failure. Numerous mechanisms have been proposed to explain the benefit that light-to-moderate alcohol intake has on the heart, including an increase of high-density lipoprotein cholesterol, reduction in plasma viscosity and fibrinogen concentration, increase in fibrinolysis, decrease in platelet aggregation, improvement in endothelial function, reduction of inflammation, and promotion of antioxidant effects. Controversy exists on whether alcohol has a direct cardioprotective effect on ischemic myocardium. Studies from our laboratory do not support the concept that alcohol has a direct cardioprotective effect on ischemic/reperfused myocardium. Perhaps the time has come for a prospectively randomized trial to determine whether 1 drink per day (or perhaps 1 drink every other day) reduces mortality and major cardiovascular events.     

Alcoholic cardiomyopathy

Alcohol is the most frequently consumed toxic substance in the world. Low to moderate daily intake of alcohol has been shown to have beneficial effects on the cardiovascular system. In contrast, exposure to high levels of alcohol for a long period could lead to progressive cardiac dysfunction and heart failure. Cardiac dysfunction associated with chronic and excessive alcohol intake is a specific cardiac disease known as alcoholic cardiomyopathy(ACM). In spite of its clinical importance, data on ACM and how alcohol damages the heart are limited. In this review, we evaluate available evidence linking excessive alcohol consumption with heart failure and dilated cardiomyopathy. Additionally, we discuss the clinical presentation, prognosis and treatment of ACM.     

Alcoholic cardiomyopathy: a review

Alcohol abuse can cause cardiomyopathy indistinguishable from other types of dilated nonischemic cardiomyopathy. Most heavy drinkers remain asymptomatic in the earlier stages of disease progression, and many never develop the familiar clinical manifestations that typify heart failure. We review the current thinking on the pathophysiology, clinical characteristics, and treatments available for alcoholic cardiomyopathy. The relationship of alcohol to heart disease is complicated by the fact that in moderation, alcohol has been shown to afford a certain degree of protection against cardiovascular disease.     

Alcoholic cardiomyopathy: incidence,clinical characteristics,and pathophysiology

In the United States, in both sexes and all races, long-term heavy alcohol consumption (of any beverage type) is the leading cause of a nonischemic, dilated cardiomyopathy, herein referred to as alcoholic cardiomyopathy (ACM). ACM is a specific heart muscle disease of a known cause that occurs in two stages: an asymptomatic stage and a symptomatic stage. In general, alcoholic patients consuming > 90 g of alcohol a day (approximately seven to eight standard drinks per day) for > 5 years are at risk for the development of asymptomatic ACM. Those who continue to drink may become symptomatic and develop signs and symptoms of heart failure. ACM is characterized by an increase in myocardial mass, dilation of the ventricles, and wall thinning. Changes in ventricular function may depend on the stage, in that asymptomatic ACM is associated with diastolic dysfunction, whereas systolic dysfunction is a common finding in symptomatic ACM patients. The pathophysiology of ACM is complex and may involve cell death (possibly due to apoptosis) and changes in many aspects of myocyte function. ACM remains an important cause of a dilated cardiomyopathy, and in latter stages can lead to heart failure. Alcohol abstinence, as well as the use of specific heart failure pharmacotherapies, is critical in improving ventricular function and outcomes in these patients.     

Alkoholische Kardiomyopathie

Long-term alcohol abuse is the leading cause of a secondary cardiomyopathy. In general, alcoholic patients consuming >90 g alcohol per day for more than 5 years are at risk for developing an alcoholic cardiomyopathy (ACM). The underlying pathophysiology is complex and involves many aspects of cardiomyocyte function, such as impaired intracellular energy generation, calcium homeostasis and myofibrillar force generation. Clinical data suggest that there are interindividual differences in the susceptibility to alcohol-induced myocardial damage, which emphasizes the importance of genetic and environmental traits in the pathogenesis of ACM. Since there are no specific signs of ACM, diagnosis remains difficult and basically relies on the coincidence of alcohol abuse and dilated cardiomyopathy. Alcohol abstinence, as well as the use of specific heart failure pharmacotherapies, is critical in improving ventricular function and outcomes in these patients.     

Effects of alcohol on the heart: current views

Chronic and heavy alcohol consumption has deleterious effects upon the cardiovascular system and may cause congestive cardiomyopathy. Evidence of cardiac malfunction has been found in chronic alcoholics without overt heart failure by invasive and noninvasive methods. Ethanol is the incriminated factor having a direct cardiotoxic effect. Electron microscopy and cardiac muscle biopsies show that ethanol may cause changes on plasmalemmal, mitochondrial, and sarcoplasmic membranes. The clinical picture and general management of alcoholic cardiomyopathy do not differ substantially from those of congestive cardiomyopathies of any type. It has, however, been demonstrated that cessation of alcohol consumption may lead to an improved prognosis, even to restoration of normal cardiac function, in individuals with preclinical and mild manifestations of cardiac dysfunction. The literature on the possible association of coronary heart disease with alcohol seems to be ambiguous. It has, however, been postulated recently that moderate alcohol intake may have a protective role against coronary heart disease, in contrast to alcoholic intemperance, which may be a factor favoring coronary heart disease.     

Alkoholkonsum bei Frauen und Senioren

The association between alcohol consumption and the etiology and prognosis of cardiovascular diseases has been the focus of attention and also the subject of controversial discussions for many years. This is particularly true for heart failure, which can be induced by coronary artery disease (CAD), arterial hypertension, atrial and ventricular arrhythmias and cardiomyopathies. Acute effects of high doses of alcohol can lead to impairment of the cardiac contraction strength with rhythm disturbances (holiday heart syndrome), transient ischemic attacks and in rare cases to sudden cardiac death. The chronic effects of high alcohol consumption include in particular, ventricular dysfunction, chronic rhythm disturbances, alcoholic cardiomyopathy and CAD. In contrast, light to moderate consumption of alcohol is associated with a reduced risk of CAD and ischemic stroke; however, even moderate alcohol drinking is associated with a greater risk for atrial fibrillation. The unfavorable effects of alcohol occur at much lower levels of acute or chronic consumption in women than in men. In the elderly just as in young people, a moderate alcohol consumption is associated with a lower risk of heart failure.     

The alcoholic cardiomyopathies--genuine and pseudo.

Two types of genuine alcoholic cardiomyopathies can produce congestive heart failure, an acute fulminate hyperkinetic type with high cardiac output and a hypokinetic type with a low cardiac output, both of which respond to thiamine. When the chronic alcoholic develops a dilated cardiomyopathy with congestive heart failure without a history of significant malnutrition, then they do not respond to thiamine. This may be explained by a study in which mice given a myotropic virus plus alcohol developed more frequent and severe viral cardiomyopathies than those not fed alcohol. This suggests that a chronic dilated cardiomyopathy in an alcoholic may not be the direct result of the alcohol but secondary to a viral myocarditis. This suggests that the preferred terminology for a dilated cardiomyopathy in an alcoholic who does not respond to thiamine and good nutrition should simply be a dilated cardiomyopathy in an alcoholic. We should assume that the cardiomyopathy is possibly of viral etiology.     

Alcoholic cardiomyopathy

Summary Clinical observations over the past two decades have pointed to the relationship between heart disease and alcohol abuse, usually without evident malnutrition or cirrhosis. While the prevalence of heart failure in the alcoholic population is now known, subclinical abnormalities of left ventricular function in noncardiac alcoholics who were normotensive have a high prevalence with or without some degree of ventricular hypertrophy by echocardiogram. This is frequently a diastolic rather than systolic abnormality. Congestive cardiomyopathy is not infrequently associated with high diastolic arterial blood pressures. Intoxication itself may contribute to blood pressure elevation. Angina pectoris in the absence of significant coronary disease is another presentation. Although the history may not be readily obtained, the major diagnostic feature in this entity is the history of ethanol ingestion in intoxicating amounts for at least 10 years, often marked by periods of spree drinking. While the course of congestive cardiomyopathy may be progressively downhill in individuals who continue to be actively alcoholic after the onset of heart failure, in one series one third of the patients became abstinent. These patients had a 4 year mortality that was persistently one-sixth of the alcoholic group. Management of heart failure is traditional in these patients. Atrial arrhythmias have been shown to occur during the early ethanol withdrawal phase in patients without other clinical evidence of heart disease. Sudden death in a segment of the alcoholic population is considered arrhythmia related and is commonly associated with cigarette use. Identification of the addicted individual is the essential element to management.     

Alcoholic cardiomyopathy: What is known and what is not known

Excessive alcohol consumption represents one of the main causes of non-ischemic dilated cardiomyopathy. Alcoholic cardiomyopathy is characterized by dilation and impaired contraction of one or both myocardial ventricles. It represents the final effect of alcohol-induced toxicity to the heart. Several pathophysiological mechanisms have been proposed at the basis of alcohol-induced damage, most of which are still object of research. Unfortunately, symptoms of alcoholic cardiomyopathy are not specific and common to other forms of heart failure and appear when dilatation and systolic dysfunction are consolidated. Thus, early diagnosis is mandatory to prevent the development and progression to heart failure.Although physicians are aware of this disease, several pitfalls in the diagnosis, natural history, prognosis and treatment are still present. The aim of this narrative review is to describe clinical characteristics of alcoholic cardiomyopathy, highlighting the areas of uncertainty.     

Alcohol and cardiovascular disease in the geriatric population

There has been little focus on the effects of alcohol on the elderly. Although the cardiovascular benefits of moderate alcohol consumption could be of the greatest benefit in this group, so might be the detrimental effects of abuse. In this article, we review available data on the effects of alcohol consumption on cardiovascular disease, cardiomyopathy, arrhythmias, hypertension, and vascular function in older adults. Alcohol consumption has increased in the US population age 65 years and older in the last decade, as has monthly heavy episodic drinking in older alcohol consumers. Studies of alcohol consumption in older subjects suggest that consumption in moderation does not increase the risk of heart failure, hypertension, or atrial arrhythmias, and may in fact improve vascular function and reduce cardiovascular disease events. As in younger subjects, heavy consumption, or abuse of alcohol, negates any potential protective cardiovascular effects, increasing the incidence of heart failure and hypertension. Although alcohol consumed in moderation does not appear harmful in the elderly population, heavier consumption exacerbates hypertension and increases the incidence of heart failure.     

Alcohol abuse and heart failure

Alcoholic patients who consume >90 g of alcohol a day for >5 years are at risk of developing asymptomatic alcoholic cardiomyopathy (ACM). Those patients who continue to drink may become symptomatic and develop signs and symptoms of heart failure (HF). This distinct form of congestive HF is responsible for 21–36% of all cases of non‐ischaemic dilated cardiomyopathy in Western Society. Without complete abstinence, the 4 year mortality for ACM is close to 50%. This short review summarizes the experimental and clinical evidence regarding the role of alcohol in the pathophysiology of ACM and HF.     

Prevalence of clinically occult cardiomyopathy in chronic alcoholism

The mean absolute heart weight and mean heart weight to body weight ratio of a group of 43 alcoholics, screened from 1,970 consectuive autopsy reports at the Detroit General Hospital by selecting alcoholics with only ethyl alcohol abuse as an etiology of heart disease, are compared to those of a group of similarly selected age-matched nonalcoholic controls. None of the alcoholics was clinically suspected of having had cardiomyopathy. The statistically significant increased mean absolute heart weight and heart weight to body weight ratio of the alcoholic group reflected the presence of subclinical alcoholic cardiomyopathy. In addition, several of the patients in the alcoholic group displayed gross and microscopic cardiac pathologic changes consistent with alcoholic cardiomyopathy occurring in the absence of cardiomegaly.     

Alcohol and the heart

ALCOHOLISM IN GENERAL: Alcoholism is one of the major health problems in the world. Alcohol consumption has an impact on different body systems like the central nervous system, the gastrointestinal tract, the hematopoetic organs, and the cardiovascular system. Alcohol interferes with other medications, and drinking can exacerbate a variety of medical illnesses. IMPACT ON THE HEART: In the heart, alcohol and its metabolite acetaldehyde confer a toxic effect on mitochondria as well as on the sarcoplasmatic reticulum, which is dependent on both the mean daily consumption and the duration of alcohol intake. A wide range of toxic effects of alcohol in distinct individuals can be observed and modest doses of alcohol can exert beneficial effects on the cardiovascular system probably by an increase in high density lipoprotein cholesterol (HDL) or changes in blood clotting mechanisms. Detrimental effects of alcohol on the heart comprise a decrease in myocardial contractility, hypertension, atrial and ventricular arrhythmias, and secondary non-ischemic dilated cardiomyopathy. After consuming large quantities of alcohol over years, alcoholic cardiomyopathy may develop, which presents with dilation and impaired contractility of the left or both ventricles. Endomyocardial biopsies of patients with alcoholic cardiomyopathy reveal in up to 30% of all cases myocarditis with lymphocytic infiltrates. TREATMENT: Abstinence after development of milder heart failure can stop progression or even reverse symptoms in some cases, otherwise severe heart failure ensues leading to a poor prognosis. Except abstinence, treatment of alcoholic cardiomyopathy is based on the regimen of therapy for heart failure to reduce the size of the dilated heart and to mitigate the symptoms of heart failure.     

Alcohol use disorders and the heart

Alcohol use is an important preventable and modifiable cause of non‐communicable disease, and has complex effects on the cardiovascular system that vary with dose. Observational and prospective studies have consistently shown a lower risk of cardiovascular and all‐cause mortality in people with low levels of alcohol consumption when compared to abstainers (the ‘J’‐shaped curve). Maximum potential benefit occurs at 0.5 to one standard drinks (7–14 g pure ethanol) per day for women (18% lower all‐cause mortality, 95% confidence interval (CI) = 13–22%) and one to two standard drinks (14–28 g ethanol) per day for men (17% lower all‐cause mortality, 95% CI = 15–19%). However, this evidence is contested, and overall the detrimental effects of alcohol far outweigh the beneficial effects, with the risk of premature mortality increasing steadily after an average consumption of 10 g ethanol/day. Blood pressure (BP) is increased by regular alcohol consumption in a dose‐dependent manner, with a relative risk for hypertension (systolic BP > 140 mm Hg or diastolic > 90 mm Hg) of 1.7 for 50 g ethanol/day and 2.5 at 100 g/day. Important reductions in BP readings can be expected after as little as 1 month of abstinence from alcohol. Heavy alcohol consumption in a binge pattern is associated with the development of acute cardiac arrhythmia, even in people with normal heart function. Atrial fibrillation is the most common arrhythmia associated with chronic high‐volume alcohol intake, and above 14 g alcohol/day the relative risk increases 10% for every extra standard drink (14 g ethanol). Ethanol and its metabolites have toxic effects on cardiac myocytes, and alcoholic cardiomyopathy (ACM) accounts for a third of all cases of non‐ischaemic dilated cardiomyopathy. Screening people drinking alcohol above low‐volume levels and delivering a brief intervention may prevent the development of cardiovascular complications. Although people with established cardiovascular disease show improved outcomes with a reduction to low‐volume alcohol consumption, there is no safe amount of alcohol to drink and patients with ACM should aim for abstinence in order to optimize medical treatment.     

Alkohol und Herz

The cultural and natural scientific ambivalence of the heart and alcohol has long been the subject of philosophical, artistic, intellectual and emotional discussions, not uncommonly in a romanticizing manner. The indulgence of alcoholic beverages in moderation is contrasted by the inestimable risks and dangers of alcohol abuse with many cardiovascular implications, such as cardiac arrhythmia, cardiomyopathy and arterial hypertension. The inspirational mental effects of alcohol have been emphasized in many citations from Classical Antiquity through the Middle Ages and even in modern times. In addition to wine and beer many alcoholic drinks, such as Champagne, sparkling wines, whisky (or whiskey), brandy (Cognac) and fruit brandies have a nearly ritual culture of traditions and customs, without which social life would be unthinkable. The interplay between enjoyment and displeasure is emphasized in the year 2016 with the 500-year jubilee of the German purity requirements for beer with countless events, including the Bavarian State Exhibition 2016. Recently, evidence of a neuroprotective effect of alcohol was reported with an improvement of intellectual capacity, which could counteract the widely occurring dementia syndrome. Millions of people could profit from this effect.     

40例心脏移植术后受体心脏病理诊断与术前临床诊断的对比分析

目的通过比较40例心脏移植前、后诊断的异同来评价终末期心力衰竭患者术前诊断的准确性。方法40例患者术前全部经过询问病史,体格检查,心电图、超声心动图检查。凡有心绞痛症状,超声心动图证实存在节段性室壁运动异常或存在明确的危险因素等条件之一,且病情允许的患者在术前作冠状动脉造影。若≥1支冠状动脉主支的横断面面积减少75％以上被认为是有意义的冠状动脉病变。术前诊断为冠心病的患者全部行双核素检查,评价存活心肌。所有心脏移植术取下的心脏均被称重,测量室壁厚度,并经大体检查和组织学检查。结果心脏移植术前诊断为原发性扩张型心肌病（IDC）占45．0％,酒精性心肌病17．5％,冠心病占17．5％,肥厚型心肌病7．5％。高血压病、瓣膜病、致心律失常性右室心肌病、克山病和心肌致密化不全各1例,各占2．5％。术前诊断为冠心病者,受体心脏均有严重冠状动脉病变。术前诊断为IDC的18例和酒精性心肌病的7例患者,受体心脏病理检查共有8例（占32％）可见严重的冠状动脉病变。术前诊断为高血压心脏病和主动脉瓣换瓣术后心力衰竭的患者各1例,也可见冠状动脉严重病变。术前诊断为IDC和克山病者,6例受体心脏病理诊断为致心律失常性右室心肌病。术前诊断为IDC者1例,在移植取下心脏后被病理诊断为巨细胞心肌炎。结论早期正确诊断心力衰竭的病因,可决定患者不同的治疗方法（血管重建而不是心脏移植）,且能判断移植患者的预后。本研究的结果提示：无论临床表现如何,所有怀疑IDC的患者均应尽早作冠状动脉造影,并尽可能查明其病因。