Alcohol Heart

8/3/2019 Alcohol Heart

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DOMMRDOMMR12/1412/14--12/1712/17

Lesley Dawravoo


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ObjectivesObjectivesy Be able to recognize Holiday Heart

Syndrome and how to distinguish it fromother cardiac disorders

y Understand the current philosophy onalcohol and atrial fibrillation

y Understand alcoholic cardiomyopathy andbe able recognize its uniquecharacteristics


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y Holiday Heart Syndrome

y Alcohol and Atrial Fibrillation

y Alcoholic Cardiomyopathy


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Holiday Heart SyndromeHoliday Heart Syndromey Originally described in 1978 by Ettinger et aly Evaluated 32 dysrhythmia episodes in 24 patients

who drank heavily, but had especially heavy

ingestion prior to the arrhythmiay Most often, symptoms occur immediately after

the drinking, although some occur whileintoxicated

y In most cases, serum alcohol levels were elevatedat time of evaluation


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Holiday Heart SyndromeHoliday Heart Syndromey 19 occurred between Sunday-Tuesday

Monday admission most commony 6 /13 of the arrhythmias occuring from Wed-Sat were

seen between 12/24-1/1y 25/32 episodes occurred on a holidayy Coined the term Holiday Heart Syndrome

y Why doesnt this occur during the 4 th of July or Labor day?Maybe because consumption of other liquids dilutesprevents rapid absorption, preventing excessive bloodalcohol levels


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Holiday Heart SyndromeHoliday Heart Syndromey Acute cardiac rhythm and/or conduction disturbance

associated with heavy ethanol consumptiony Patients consumed alcohol heavily and regularly but also

took part in a weekend or holiday binge beforeevaluation

y Supraventricular tachyarrhythmiasx Most common is atrial fibrillationx A.flutter, PAT, junctional tachycardia, PVCs, v.tach

y Disappears with abstinenceN o residual heart disease


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Holiday Heart SyndromeHoliday Heart Syndromey See more often in younger subjects with new

onset atrial fibrillation and no structural heartdisease

y Can see similar events with the use of marijuana


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Why does Holiday Heart occur?Why does Holiday Heart occur?y Alcohol as a toxin

May affect atrial structure and sizey Alcohol has proarrhythmic effects

y Increases secretion of epi/norepinephriney Increases sympathetic output

y Heavy drinkers are more prone to bingeswhich may trigger a single episode of atrialfibrillation

y May be due to a preexisting atrial pathologiccondition

Increase in intra-atrial conduction time inducedby acute alcohol exposure


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Holiday Heart SyndromeHoliday Heart Syndromey N eed to check electrolytes, echo,

consider exercise stress testy Should refrain from alcohol, caffeine,

significant exertion (catecholamineincrease)

y Young patient with no structural heartdisease or co-morbidities can often bedischarged from ED after arrhythmia hasresolved


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Alcohol and the HeartAlcohol and the Hearty Low to moderate levels of alcohol intake

have been shown to reduce the risks of cardiovascular disease and may even beprotective against development of heartfailure

Maximum recommended is 7 drinks/week for

females and 14 drinks/week for malesy Long term, heavy alcohol use leads to

alcoholic heart disease


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Alcohol andAlcohol and atrialatrial fibrillationfibrillationy Historically, there has been much discrepancy

about the relationship of alcohol and atrialfibrillation

Some studies have shown heavy drinking as a triggerof atrial fibrillationThe Cardiovascular Health study found alcoholconsumption reduced the risk of atrial fibrillation in adose related mannerSeveral cohort studies have found no relationshipbetween alcohol consumption and the risk of atrialfibrillation


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The Copenhagen City Heart StudyThe Copenhagen City Heart Studyy 16 ,000 patients

1071 diagnosed with atrial fibrillationy With age and multivariable-adjusted analysis, found that

episodes atrial fibrillation was similar between abstainers and

those who consumed up to 14 drinks/week y In those that drank >35 drinks/week

Men were at a higher risk of atrial fibrillation

Did not find similar results with women

~5% of men who drank >35 drinks/week would develop atrialfibrillation due to alcohol

y HT N , CAD, and CHF all independent risk factors fordevelopment of atrial fibrillation


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Alcohol andAlcohol and atrialatrial fibrillationfibrillationy Increased catecholamines

Maki et al. compared controls to those that wereprone to atrial fibrillation after alcohol consumptionIn those that are prone to atrial fibrillation, there wasan increase in plasma catecholamines

y Changed conduction and refractory timesEKGS performed after resolution of arrhythmiasshowed prolongation of PR, QRS, and QT intervals

compared to patients with similar arrhythmias in theabsence of alcoholy Vagal reflexes - increase vagal toney Myocardial damage


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Alcoholic Cardiomyopathy (ACM)Alcoholic Cardiomyopathy (ACM)y The leading cause of secondary dilated

cardiomyopathy in the Western worldy More common in men vs women

Women may be more vulnerable to theeffects of alcoholDevelop ACM with less cumulative lifetime

alcohol exposureFemale gender may be a risk factor for thedevelopment of ACM


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Alcoholic Cardiomyopathy (ACM)Alcoholic Cardiomyopathy (ACM)

y Effects on the heart is due to:Amount one drinksDuration of drinking>80-90g/day for >5yrsx A liter of winex 8 beersx pint of hard liquor


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Alcoholic Cardiomyopathy (ACM)Alcoholic Cardiomyopathy (ACM)

y Early stage AsymptomaticDiastolic dysfunctionIncreased LV massLV dilation

y Late stage SymptomaticSystolic dysfunction symptoms of HF

Wall thinningPronounced LV dilation


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ACMACM -- EtiologyEtiologyy Ethanol induced apoptosis of myocytes

Leads to inotropic incompetencehypertrophy (early) compensatory LV

dilation (late)y Toxic effect of alcohol metabolites

Acetyldehyde, fatty acid ethyl esters

Leads to impaired contraction of themyocardium (through calcium alteration)y N utritional deficienciesy Genetic


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ACMACM -- ACEACEy Angiotensin Converting Enzyme (ACE) levels dependent

on ACE geney May manifest as insertion (I) or deletion (D) with 3

genotypes (DD, II, ID)y DD genotype associated with increased ACE levelsy DD genotype associated with increased incidence of

LVH, alcoholic cardiomyopathyy Study looking at alcoholic men with and without

cardiomyopathyDD genotype in 57% with CM vs 7% in those without


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ACMACM -- Presentation/DiagnosisPresentation/Diagnosisy Present similarly to those with dilated

cardiomyopathyy Insidious onsety N arrow pulse pressure, cardiomegaly, S3,

S4, evidence of heart failure (later stage)y Diagnose with echocardiography


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ACMACM -- TreatmentTreatmenty Abstinencey If begun early enough, considerable

improvement can be seen

May even be able to see improvement if alcoholintake is controlled (20- 6 0g/day)y If begun after fibrosis occurs, may not see

improvementy May also require pharmacologic Tx

Improves ventricular function in those whoabstain and those who dontMortality benefit seen in only those who abstain


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Copyright 2002 by the American College of Chest Physicians. Published by American College of Chest Physicians. 3

Figure 1Alcoholic Cardiomyopathy*: Incidence, ClinicalCharacteristics, and Pathophysiology.Piano, Mariann

Chest. 121(5):1638-1650, May 2002.

Figure 1 . Survival curves of cardiac deaths in male patients with ACMand IDCM. The solid line indicates patients with ACM and alcoholabstinence, the small dashed line indicates IDCM, and the largedashed line indicates patients with ACM without abstinence. Usedwith permission from Fauchier et al.5


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ReviewReviewy Alcoholic Cardiomyopathy

>80-90g/day for >5yrsEarly stage Asymptomatic/Diastolicx LV dilation, increased LV mass

Late stage Symptomatic/Systolicx Wall thinning, pronounced LV dilation

Treatment: abstinenceWill see improvement if fibrosis hasntoccurred yet


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Patient follow upPatient follow upy Echocardiogram normal LVEF, no

valvular disease, no structuralabnormalities

y N o further trips to the ED

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Alcohol Heart