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Last Updated Thursday October 19 2017 11:46 PM IST

Matters of the Heart | Alcohol and coronary artery disease

Dr Roy John Korula
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184874014, Matters of the Heart | Alcohol and coronary artery disease Matters of the Heart | Alcohol and coronary artery disease. Photo: Getty Images

Being a heart surgeon, at many gatherings I attend, the topic of conversation very often veers around to heart diseases. Die-hard smokers always tell me they just can’t give up cigarettes. In jest I tell them, “If you must smoke, then you had better drink a little too”. It is my personal experience and strong conviction (not corroborated by any hard evidence though) that those who smoke and drink live longer than those who only smoke. 

Numerous epidemiological studies have shown that moderate consumption of virtually all types of alcoholic drinks are associated with a lower risk for nonfatal myocardial infarction, and fatal heart attacks as compared to those who completely abstain from alcohol.  One of the major beneficial effects of alcohol is increasing the levels of High-Density Lipoproteins – (HDL, the good cholesterol). HDL removes cholesterol from the arterial wall and transports it back to the liver. It probably also has several other protective effects on the arterial system. But non-drinkers will argue that better increases of HDL can be obtained by regular exercise – without the alcohol. Which is actually true. 

Other studies have found that alcohol intake is especially beneficial to those with high levels of Low-Density Lipoprotein (LDL - the bad cholesterol), and subsequent coronary artery disease. 

Although the evidence of a lower risk of coronary heart disease among moderate drinkers is substantial and consistent, controversy remains about whether the relationship is truly causal - that is, whether moderate alcohol consumption really prevents coronary heart disease.

Matters of the Heart | Alcohol and coronary artery disease

It has been wine, mainly red wine which has been linked to cardioprotection. The “French Paradox” -the arguable and controversial observation that the rate of coronary heart disease in France is relatively low despite high rates of saturated fat intake and cigarette smoking is attributed to their high consumption of wine, especially red wine. This has led to the belief that red wine is particularly beneficial for health. Red wine contains flavanoids and other anti-oxidants like resveratrol and quercetin that are beneficial. These antioxidants are claimed to protect the lining of blood vessels in the heart and prevent cholesterol deposition in its walls. The anti-oxidants also have a beneficial effect on the platelets, which are responsible for aggregating, clumping and causing a clot inside a blood vessel, the initial process leading to a stroke or heart attack. Several studies have suggested that alcohol also causes the blood to clot less avidly through effects on platelets and coagulation factors, or even enhances the ability of the blood to break up clots when they form. 

There is, however, no statistical proof that antioxidants in any form help. Antioxidants like L-carnitine, Vitamin E, Vitamin C, CoQ10 etc. have shown no analytical benefit in the prevention of heart disease. Critics will also argue that instead of drinking wine to get these antioxidants, drinking other fruit juices or red grape juice may indeed provide a person with the same level of antioxidants. Which is also true.

Alcohol may also be involved in a variety of other physiological processes (like lowering levels of markers of inflammation suggesting less likelihood of developing a heart attack, increasing levels of nitric oxide secretion by the blood vessels causing them to relax and dilate etc.) which are related to the development of heart attacks. 

Finally, the relationship between alcohol consumption and heart disease may be modulated by genetic factors - genetic variations in the risk of alcoholism (the so-called “alcoholic gene”), variations in the rate of production of the enzymes that break down alcohol, the genetic disparity in HDL levels, ethnicity, etc. 

Matters of the Heart | Alcohol and coronary artery disease

Consumption of alcohol has its own problems, It is also associated with dangers such as cirrhosis of the liver, pancreatitis, high blood pressure, obesity, stroke, breast cancer, besides a significant morbidity and mortality due to drunken driving and suicide. With chronic alcoholism (or should I be politically right and label them “advanced drinkers”) comes the risk of becoming obese, with its associated complications of developing diabetes and heart failure. Other serious but less common problems of excess alcohol consumption include foetal alcohol syndrome, cardiomyopathy, cardiac arrhythmias and sudden cardiac death.

Because each person has a unique combination of factors such as age, sex, family history and genes, these factors influence that person's risk of specific diseases potentially caused or prevented by alcohol use. Thus the equilibrium of the risks and benefits of alcohol consumption for each person will correspondingly be unique. Accordingly, a young woman with a strong family history of alcoholism should weigh the decision of how much alcohol to drink (if any) differently than should a middle-aged man with no family history of premature heart disease.

The only way to prove the benefits or otherwise of alcohol on heart disease is to conduct a randomized trial between alcohol consumers and abstainers. It is unlikely that a randomized controlled trial of alcohol consumption will ever be ethically sanctioned or performed to establish a direct link between alcohol consumption and reduction in heart disease and to define the risks and benefits of encouraging consumption of alcohol. Further, abstainers are an inappropriate control population because at least some of these people may abstain by choice, religious leanings, because of an unrelated illness or disease, or be themselves former alcohol abusers. In addition, other factors like lifestyle, exercise, and eating habits may differ between voluntary abstainers and drinkers.

In the likely unavailability of this scientific base, and based on present evidence, a number of precise and definitive facts can be accepted and established on the development of recommendations about alcohol consumption. First, the beneficial effects of alcohol are limited to one or two drinks per day. Not more. This beneficial effect is seen especially in the middle aged and elderly. Second, heavier consumption of alcohol is related to a number of health problems mentioned above. Third, it is clear that persons with medical and social conditions made worse by alcohol should not consume any alcohol whatsoever. Persons with a personal or strong family history of alcoholism are at risk for alcohol addiction and should avoid all alcoholic beverages. Fourth, those with prior diagnoses of high lipids (triglycerides), pancreatitis, liver disease, uncontrolled hypertension, congestive heart failure, and a variety of lesser known diseases which contraindicate alcohol ingestion should not ingest it. Pregnant women and persons on certain medications that interact with alcohol should also refrain from its consumption. 

Matters of the Heart | Alcohol and coronary artery disease

To complicate the issue, it is also not possible to predict in which people alcoholism will become a problem. Given these and other risks, the American Heart Association (AHA) cautions people NOT to start drinking, if they do not already drink alcohol. Secondly, although alcohol may be protective, people should not start drinking to derive these presumed potential benefits of alcohol.

The AHA rather recommends that to reduce your risk of heart disease you should consider lowering your cholesterol and high blood pressure, controlling your weight, getting enough physical activity and following a healthy diet. These provide greater benefits than consuming alcohol. 

If you must drink alcohol, do so in moderation. This means not more than two drinks per day for men and one drink per day for women. (A drink is one 12 oz. beer, 4 oz. of wine, 1.5 oz. of 80-proof spirits, or 1 oz. of 100-proof spirits – all containing the same amounts of alcohol.) 

Better still, have an enduring and lifelong check and constraint on alcohol consumption.

Happy alcoholidays. 

(The author is a former head of the department of cardiothoracic surgery at Christian Medical College and Hospital, Vellore. He is currently the chief administrative of icer, and head of the cardiothoracic surgery department at Pushpagiri Heart Institute, Tiruvalla.)

Also read: HealthMatters of the Heart | Should I disclose my error to a patient?



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