moderate alcohol and cardioprotection????

​​I have been one of those occasionally advocating small amounts of alcohol to some of my patients (ie, those with no personal or family history of addictions  and who were resistant to taking statins despite their increased cardiovascular risk) for several reasons. There have been large meta-analyses (for example, see Ronksley P E et al. BMJ 2011;342:bmj.d671  -- meta-analysis of 84 studies with 11 years followup) finding 25% decrease in CAD incidence and mortality and 13% decrease in total mortality in moderate alcohol consumers. And, there was reasonable biological plausibility (reviewed by Brien, et al BMJ 2011) finding increased HDL, slightly decreased LDL, increased apolipoprotein A1, decreased fibrinogen, and increased adiponectin (which is decreased in the setting of insulin resistance/diabetes and negatively correlates with insulin resistance) -- all of which should decrease CAD.  There are many clinicians strongly against our promoting a glass of wine with meals, partly because of the overall devastating effects of excessive alcohol intake (and that we as providers should not suggest a toxic chemical) and partly because of very likely biases in the retrospective and uncontrolled studies on moderate alcohol consumption.  Some of these biases, for example, include the fact that "non-drinkers" in many of the studies included former drinkers (who from several other studies have more depression and increased mortality than "never drinkers"); in addition, those who drink small amounts of wine with dinner might well take care of themselves better (healthier diet, more exercise, other factors??) than those who either drink much more or do not drink at all. In this light, a new BMJ article found minimal benefit of alcohol (see alcohol and mortality bmj 2015 in dropbox, or  BMJ 2015;350:h384). details:

--analyses were done of 10 waves of the Health Survey for England from 1998-2008, in adults >50 yo​.
--the Health Survey is an annual cross sectional survey of the non-institutionalized general English population, which included questions about self-reported average weekly alcohol consumption and consumption on the heaviest day in the past week. the survey assessed "former drinkers" as well as "never drinkers"
--all-cause mortality was based on recorded deaths, with prior consent by the patient to link to the Health Survey database (n=18,368)

results:
--controlling for age (their Model 1), weekly use and use on heaviest day were protective at all levels of consumption and in all age groups except women 50-64 yo (where consumption of >20 units/week was insignificant)
--controlling for age, BMI, economic activity, education, ethnicity, country region, marital status, smoking status, and social class (their Model 2), and not including "former drinkers", the only groups with protection from alcohol were women >65 yo consuming <=10 units/week or up to 3 units on their heaviest consumption day as well as those who consumed at a frequency of <=2 drinking occasions/month, and men 50-64 yo consuming 15-20 units/week or drinking up to 1.5 units on their heaviest consumption day (though the magnitude of protection in men was "minimal").

so, this study adds to others which have found that when "former drinkers" are removed from the non-drinker category, the protective effect of alcohol is either attenuated or nullified. and, i think i'll remove the powerpoint slides i have on the protective effects of alcohol from my lipid presentation....

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