Alcohol and the Heart

Can a drink a day keep the cardiologist away? Does alcohol decrease the risk for heart attack and cardiac death or is it harmful to the heart?

Before tackling this question, some definitions are in order. Moderate drinking is defined as two or less drinks per day for men and one or less for women.  A drink is 12 ounces of regular beer or 5 ounces of wine or 1.5 ounces of spirits.

In large studies looking at alcohol and cardiac mortality there appears to be a J shaped curve. Patients with moderate alcohol consumption were at the bottom of the curve (the lowest mortality) with 16% reduction in deaths for men and 12% reduction for women compared to nondrinkers. Nondrinkers had an intermediate mortality rate. Patients with heavy alcohol use, greater than 4 drinks per day, had the highest mortality. The possible heart protective effect of alcohol was even given a name, “the French Paradox”, based on the observation that people in France have low levels of heart disease despite diets high in saturated fat.  In 1991, 60 Minutes aired a show on the paradox, and it was suggested that the high French intake of alcohol, particularly red wine, was responsible for the effect and the lower cardiac mortality. After the show, red wine consumption in the US increased by 44%.

How does alcohol decrease cardiac disease?  While the answer to this question is still not known, it had been theorized that resveratrol, an antioxidant found in the skin of grapes, was the mechanism. Resveratrol, which is found in red wine, is purported to have anti-inflammatory properties and to increase longevity. However, it has been found that the amount of resveratrol in wine is rather low and cannot explain any protective benefits.  Alcohol itself, it seems, may provide benefit by increasing HDL (“good cholesterol”) and decreasing inflammation.  Alcohol, especially after meals, increases insulin sensitivity and sugar metabolism, keeping weight down and diabetes risk low.  On the other hand, heavy alcohol consumption can cause liver disease and cancer as well as having adverse effects on the heart, such as hypertension (elevated blood pressure), atrial fibrillation (an irregular rhythm from the upper chambers of the heart), congestive heart failure and stroke.

Alcohol is a well-known heart toxin. In patients who drink and are susceptible, alcohol can weaken the heart muscle (a condition called cardiomyopathy), decreasing the heart’s pumping ability and causing congestive heart failure, with fluid filling up in the lungs and leading to shortness of breath.  If the heart’s ability to pump blood continues to worsen, the body is deprived of oxygen, several organ systems fail (for example the kidneys stop working) and death follows. In extreme cases, alcoholic cardiomyopathy can lead to heart transplantation. Fortunately abstaining from alcohol once the diagnosis is made can lead to recovery of the function of the heart muscle.  The amount of alcohol needed to cause cardiomyopathy is not known. Women need lower amounts than men and the same consumption in one person may cause no adverse effect while in another person it may cause heart failure. Alcohol is implicated in atrial fibrillation as well. Atrial fibrillation is dangerous in that it can lead to heart failure or blood clots and stroke. Drinking less than 2 drinks per day was not associated with an increased risk for atrial fibrillation. However, for those who drink more than two per day, the risk of atrial fibrillation increases 8% for each drink above two. The more alcohol consumed, the greater the risk for atrial fibrillation. In addition, binge drinking can lead to atrial fibrillation, a phenomenon termed “Holiday Heart Syndrome”  (due to excess consumption of alcohol on weekends or on holidays).  Lastly, for some people, even moderate alcohol consumption can be dangerous, including patients on blood thinners or those with uncontrolled high blood pressure.

Clearly, alcohol is a double-edged sword and the scientific community is still split over whether it is beneficial or not.  There are several factors to keep in mind regarding the data on alcohol’s cardiac protective effects. In almost all of the studies, patients are asked about their alcohol consumption rather than having it measured. This certainly can lead to inaccurate data, as many people will not be truthful about their alcohol use.  It is not known whether moderate drinking is truly protective or whether it is a marker of a healthy lifestyle (moderate drinkers tend to have better over all health, watch a better diet and exercise more than heavy drinkers).  It had been thought that wine was better than other types drinks, however, it seems that the type of alcoholic beverage is less important than the amount and pattern of usage.  In addition, more recent data has shown that the death rates between moderate drinkers and nondrinkers are not that different. In fact, it has been suggested that no amount of alcohol is safe for the heart.

What then is the recommendation for alcohol use? No health agency or major medical group recommends drinking for health purposes. The American Heart Association suggests that if you don’t drink, then don’t start. If you choose to drink alcohol, do so in moderation, without binge drinking. Further, if your moderate drinking is wine with meals, then the benefit seems to be the greatest.

Does the Agony of Defeat include Having a Heart Attack?

Can a fan be so caught up in World Cup soccer that they have a heart attack? Can watching your football team in a tough, hard-fought, closely contested Super Bowl lead to sudden cardiac arrest? There are well known triggers to major cardiac events, but are sporting events one of them?

Many studies have shown that there is an increased risk for a cardiac event immediately after a trigger or stressor occurs. Triggers can be physical, chemical, psychosocial or environmental. Stressors typically will increase the heart rate and blood pressure, increasing the oxygen demand of the heart and leading to a heart attack. Stressors can cause the heart arteries to spasm (the artery closes down, reducing blood flow to the heart). A trigger will result in the release of several stress hormones including catecholamines (adrenaline) and cortisol, in addition to inflammatory proteins and procoagulants (substances which increase blood clotting in a heart artery). In addition, stress reactions destabilize the electrical activity of the heart, which can lead to deadly irregular rhythms and sudden cardiac arrest.

One trigger is physical activity. In general physical activity protects against heart disease. However in patients who are sedentary, a sudden burst of physical activity can lead to acute cardiac events.  For example, consider someone who doesn’t exercise and who has to suddenly run for a bus on a hot humid day or who is out shoveling snow on a cold winter day. That person is at a higher risk for a heart attack than someone who exercises regularly. In fact studies have shown that the risk for a heart attack is 6 times higher in patients who exercise less than once per week, compared to patients who exercise 5 or more times per week.  Many studies have documented that specific physical activities, such as skiing, snow shoveling and sexual activity, can trigger acute heart events.

Caffeine, alcohol, cocaine, and cigarette smoke are all chemical triggers which can cause an acute heart attack, sudden cardiac arrest and stroke.  Caffeine and alcohol can cause these events if consumed in excess, or in greater than usual quantities, for example binge drinking. Patients who don’t regularly use these beverages are more susceptible than those whose consume moderate amounts. Cocaine and cigarette smoke may cause spasm of the heart arteries, cutting off oxygen to the heart muscle leading to heart attacks or malignant irregular heart rhythms. As opposed to caffeine and alcohol, even a single cigarette or snort of cocaine can lead to an acute cardiac event.

Environmental triggers include pollution and changes in temperature.  Many studies have shown an increased risk for acute cardiac events in areas of high pollution.  Heart patients are very susceptible to changes in temperature.  Usually the extremes of temperature, very cold or very hot, are a stressor for heart patients and can trigger an event, especially if combined with physical activity.

Psychosocial triggers include anger, depression, anxiety, work stress, natural disasters, war, and terrorist attacks.  Fits of anger result in the same bad physiological responses as a physical stressor. Patients who were angry, enraged, or furious face a two to nine times higher risk for a heart attack within hours of the episode. Acute episodes of anxiety or depression may trigger events as well. In patients who experienced an episode of severe emotional upset, the risk for a heart attack was 2.5 times higher within 24 hours. Work stress is well known to cause heart attacks.  For example, there is a six-fold increase in the risk for a heart attack within 24 hours of having a high-pressure deadline at work.

Natural disasters are certainly triggers which can precipitate an acute cardiac event. This was first described in a study that showed an excess of cardiac deaths in the days surrounding a major earthquake which struck Athens Greece in 1981.  There were no excess deaths from cancer or from other causes in the days after the earthquake.  These findings were confirmed in a study examining deaths after the Northridge earthquake, which struck the Los Angeles area in January 1994.  There was an excess of cardiac deaths in the six days following the earthquake with the death rate returning to baseline levels after one week. Most of the victims died or had chest pain within one hour of the initial tremor. Japanese researchers looked at heart attacks after the major earthquake and tsunami which struck in March 2011. They found that heart attacks increased from 9 per week before the disaster to 22 in the week following the catastrophe. The heart attack rate slowly declined to the baseline rate over the subsequent 6 weeks. Similar to earthquakes or tsunamis, a war or terrorist attack exposes an entire population to a stressful environment. Studies done after the September 11 2011 terrorist attack on the World Trade Center showed an increase in heart attacks and arrhythmias. In addition, it was shown that there was an increase in cardiac events far from New York City. All of these studies suggest that psychosocial stress, rather than the living conditions at the site of the disaster, precipitated these cardiac events in those who are vulnerable.  

Can watching a sporting match trigger an acute cardiac event? The two arenas where this issue has been studied, World Cup soccer and the Super Bowl, involve football. A study was published in the New England Journal of Medicine comparing heart attacks among German fans during the 2006 World Cup tournament with cardiac emergencies in Germany at other times the same year.

The study showed that when the German team played, acute cardiac events were 2.6 times more likely to occur (3.2 times more likely in men, 1.8 times more likely in women). Interestingly, 47% of the victims had underlying heart disease and the risk rose during the knockout stage (when the stakes and the pressure are higher). Similarly, the risk for hospital admission for heart attack increased 25% in England on the day in 1998 that England lost to Argentina on a penalty shoot out. No excess admissions occurred for other diagnoses or on the days of England's other matches.

Is the Super Bowl a trigger for acute cardiac events? To answer this question, researchers examined death certificates in Los Angeles County for 2 weeks after the Rams Super Bowl loss in 1980. They found that heart related deaths increased 15% in men and 27% in women during that period.  A more recent study showed that cardiac deaths increased by 20% in Massachusetts following the Patriots loss to the Giants in the 2008 Super Bowl, as dramatic and intense a game as there has been in recent memory.

It seems that the psychosocial stress of watching a high stakes match can trigger an acute cardiac event. In addition, watching sporting matches is associated with adverse behaviors, such as cigarette smoking and binge drinking, which are triggers unto themselves. Clearly fans can get excited and succumb while watching their favorite sporting event, especially if they are male, have underlying heart disease, engaging in risky behavior and if it is a high-stress, pressure-packed event. So sit back and enjoy the game, but don't smoke, don't let the emotions of the game overwhelm you and take it easy on the beer.

How to Live to One Hundred

“Tell me doctor, how do I live to be one hundred years old?” This question was posed to me in a kitchen in a small village in the mountains of southern Greece. The year was 1988 and I was visiting Greece for the first time. I traveled with my cousin to our ancestral home, the village of Mavromati, where two of my grandparents and several aunts and uncles were born. The village was located on the side of a mountain, surrounded by olive groves and sheep pastures. We met my grandmother’s sister, my great aunt, who showed us the homes where my grandparents were born. We then hiked about 1000 feet down the side of the mountain to an archeological site where an ancient city was being unearthed.  My great aunt, who I guessed was about 80 years old, was quite spry, likely from the daily routine of walking with the sheep up and down the mountain. As we went back up the mountain to the village, I huffed and puffed as I tried to keep up with her. Back in her kitchen, we enjoyed a splendid meal of local fruits and vegetables, home made yogurt and fresh mountain water, obtained from the spring in the center of village a few feet from where we were sitting. She described her life in the village, surrounded by many family members and friends.  When she found out that I was a doctor, she asked me her famous question, “Tell me doctor, how do I live to be one hundred years old?” I looked around, noted her lifestyle, and replied to her, “Just keep doing what you are doing”

I returned to Greece in 2009 with my wife and our three children and of course our trip included a pilgrimage to the village. The village had changed, but the mountain spring in the village center was still providing water and I was able to find my great aunt’s house.  The house looked abandoned. In the village center the proprietor of  the coffee house told me that my great aunt had passed away a few months earlier, at the age of 98! I guess she followed my advice.

What do people who live a long life, people from villages in Greece, from Japan, Switzerland and San Marino, have in common? Beyond having good genetics, there seem to be several recurring themes when the lives of nonagenarians and centenarians are researched. First, there is diet and exercise. Jack LaLanne, who passed away at age 96, said, “Exercise is king. Nutrition is queen. Put them together and you have a kingdom”.  Following a Mediterranean diet, which is rich in olive oil, fruits and vegetables, as well as fish, has been shown to decrease heart attacks, improve overall heart health and increase longevity. People who follow a Mediterranean diet can live up to 15 years longer compared to those who don’t. Diets high in tree nuts, like walnuts and almonds, can increase life span. Patients who ate three servings of nuts per week were less likely to have heart disease or cancer.   Fiber, especially fiber from grains, is important as well. Patients who met their daily recommended doses of fiber, 25 grams for women and 38 grams for men, had a lower risk of dying over a nine year period.  Diets high in omega-3 fatty acids, found in fish, can increase longevity by 2.2 years. Moderate alcohol consumption, such as one glass of red wine per day, can increase longevity as well. On the other hand, what foods should we avoid? Diets high in processed meats increase the risk for cancer and heart disease. Processed sugars and sugary drinks should be avoided due to the risk for diabetes and obesity. Lastly, how we eat seems to make a difference in how long we live. Cultures where emphasis is placed on preparing and cooking meals and where sitting and savoring the food rather than rushing through the meal as if it is another task are cultures with some of the best longevity data. For example, think French cuisine and the whole French dining experience.

Exercise is clearly another factor in longevity.  It has been shown that Olympic medalists and elite cyclists live longer. A recent study showed that Tour de France winners outlived their appropriately matched French counterparts. However, you don’t have to be a world-class athlete to live a long life. Moderate walking every day will increase lifespan by one and a half years while more vigorous walking will increase it by three years. A daily regimen of walking reduces the risk for heart attack, stroke, atrial fibrillation, colon cancer, hypertension, diabetes, depression, obesity and Alzheimer’s disease. Walking lowers total cholesterol levels, raises good cholesterol levels (HDL), maintains healthy bones and lowers stress levels. On the other hand, being sedentary is detrimental to health. For example, every hour of TV watching after the age of 25 can decrease life span by 22 minutes.

Another factor in living a long life includes getting the proper amount of sleep.  People who get less than six hours per night or more than nine hours tend to die younger than people who get seven to eight hours of sleep.  Just as important as the amount of sleep is the quality of sleep. Patients with obstructive sleep apnea are at increased risk for high blood pressure and heart disease. In addition, waking up naturally, ie waking up when one has had enough sleep and not with an alarm, improves the quality of sleep and adds to longevity.

Stress, or rather how a person perceives stress, is a factor in living a long life. Clearly a less stressful life is optimal, but resilience- the ability to cope with stress rather than being beaten down by stress, has been shown to improve longevity. Social support is a major factor as well in reducing stress and in improving longevity.  Having supportive friends and family can make life easier by providing emotional support, providing help when needed and giving a purpose to life.  When analyzed, people with adequate social relationships, including friends, family and community involvement, tended to live nearly four years longer than those without support. Often, the trifecta of socializing, food and exercise are bound together in cultures with longevity. Entire towns will be out walking before or after the evening meal and food is enjoyed over several hours, both being shared with others.

Lastly, people who marry, who have families, who have a pet, who laugh at least once per day, who are well educated, who are optimistic, who are generally “happy people” tend to live longer than those who do not possess these qualities.

It is easy to see how many of these factors for a long life are incorporated into life in a in a small, tightly knit community like my grandparent’s village, but these factors occur in many other places in Europe and throughout the world. So how does one live to one hundred years in the modern, western world? It may be impossible to incorporate all of these factors into our current life style, but with some effort, many of the ideals can be achieved. Alternatively, find yourself a nice Greek island.

            

New Advances in Atrial Fibrillation

Atrial fibrillation is a rapid, irregular heart rhythm in the upper chambers of the heart (the atria).  Instead of having a regular, coordinated beat, the atria are rapid and disorganized. When the atria are not beating in a coordinated fashion, the blood in these chambers does not drain effectively into the lower chambers of the heart (the ventricles). When blood is not draining well, it sits in the atria and can form a blood clot. A clot, or a small part of a clot, can break loose, go to the brain and cause a stroke. 

Atrial fibrillation is the most common heart rhythm disturbance with about 5.6 million diagnosed cases in the United States.  If left untreated, atrial fibrillation leads to stroke in 5 out of 100 people per year. Atrial fibrillation is treated with medications such as beta blockers, calcium channel blockers or digoxin to control the rapid heart rate. If doctors want to return a patient to a normal, regular rhythm then antiarrhythmic agents are used, often with cardioversion (shocking the heart back to normal rhythm).  To prevent blood clots and strokes, Coumadin (warfarin) has been prescribed for many decades. Coumadin will decrease the risk for stroke to less than 1 in 100 patients per year. Coumadin however is difficult to take, requiring frequent blood drawing to ensure that the blood is not “too thin” (leading to bleeding) or “too thick” (leading to stroke). In addition, eating green leafy foods will interfere with the level of blood thinning provided by Coumadin (green leafy foods have Vitamin K which reverses the effect of Coumadin). Many common medications interfere with Coumadin’s effect as well. Lastly, there is a significant risk for major bleeding on Coumadin, especially bleeding in the brain.

One recent break through in the management of atrial fibrillation came with the introduction of novel oral anticoagulants (NOACs).  These agents include Dabigatran (Pradaxa), Rivaroxaban (Xarelto) and Apixaban (Eliquis).  The NOACs are easier to take than Coumadin since there are no dietary restrictions. Their blood thinning effect is consistent, so blood drawing to test levels is not needed. In addition, they have been shown to reduce the risk of stroke to a greater degree than Coumadin and they are generally safer with lower risk for major bleeding and bleeding into the brain.  The major down side to the NOACs is that, to date, there is no antidote which can reverse the effect of these medications if a patient comes to the hospital with bleeding (there is an antidote for Coumadin).  Until a reversing agent becomes available, patents with bleeding on a NOAC are supported with blood transfusions, surgery and time (letting the medication wash out of the system).

Another recent innovation in the treatment of atrial fibrillation is catheter ablation. It is felt that atrial fibrillation is caused when tiny electrical wavelets are conducted from the pulmonary veins to the atria (pulmonary veins are vessels that carry oxygenated blood from the lungs to the heart).  Once in the atria, these wavelets perpetuate and cause the rapid chaotic rhythm.  Catheter ablation entails threading an electrical probe from the leg artery into the heart. The catheter is positioned at the inlet of the pulmonary veins into the atria and small areas of the heart tissue are burned, effectively causing a “circuit breaker”, the burned tissue stops the wavelets from reaching the atria. Catheter ablation has been successful in 84% of patients, allowing them to stop many of the medications, including blood thinners, they were taking to control atrial fibrillation.  Catheter ablation is generally recommended for symptomatic atrial fibrillation patients, especially if they have failed one or more antiarrhythmic agents.

Recently an association has been made between atrial fibrillation and obstructive sleep apnea.  Sleep apnea is a condition where patients stop breathing during the sleep cycle.  When they stop breathing the blood oxygen level decreases. When the oxygen level is low, patients are then aroused and gasp for breath. This cycle continues throughout the night. With frequent arousals, patients can’t enter the deepest phase of sleep, so the body does not get its proper rest. When the body can’t rest, it is perpetually aroused, there are excess catecholamines (adrenaline) and that may predispose to atrial fibrillation. When sleep apnea is successfully treated with a CPAP mask (to keep the airway open, stopping the drop in blood oxygen) episodes of atrial fibrillation are reduced.

It is becoming more apparent that atrial fibrillation is a disease related to life style and systemic disease. It has been known for years that atrial fibrillation can occur with binge drinking of alcohol (the so-called “holiday heart syndrome”).  Reducing alcohol intake can reduce episodes of atrial fibrillation. More recently, it has been shown that obesity is related to atrial fibrillation. Obesity can lead to diabetes, hypertension and sleep apnea, all factors in causing atrial fibrillation. Now, for the first time, it has been shown that obese patients who lost 10 per cent of their body weight achieved freedom from atrial fibrillation without the use of any medication or ablation. The more weight that was lost, the greater the freedom from atrial fibrillation.

Atrial fibrillation used to be thought of as a disease. Now we are beginning to see that the atria are a window on overall health and that atrial fibrillation is an exposure to an excess. Medications and procedures for atrial fibrillation can help manage the acute episode, but then the real work begins, as patients then must address life style issues such as alcohol intake and treating obesity and sleep apnea. Despite the new advances in pharmacology and surgery to treat atrial fibrillation, the future cure of atrial fibrillation will more likely come from identifying the life style causes and treating these causes.