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Etiology

Review: Modest alcohol consumption lowers risk for coronary heart disease irrespective of the type of drink

ACP J Club. 1996 Sept-Oct;125:50. doi:10.7326/ACPJC-1996-125-2-050


Source Citation

Rimm EB, Klatsky A, Grobbee D, Stampfer MJ. Review of moderate alcohol consumption and reduced risk of coronary heart disease: is the effect due to beer, wine, or spirits? BMJ. 1996 Mar 23;312:731-6.


Abstract

Objective

To qualitatively review the association between specific alcoholic drinks and the reduction of risk for coronary heart disease (CHD).

Data sources

Studies were identified by searching MEDLINE for epidemiologic investigations of alcohol and CHD published after 1965. Additional studies were identified by scanning references in review articles, proceedings of meetings and symposia, and journals dedicated to tracking alcohol-related research.

Study selection

Studies were selected if they provided specific information on consumption of beer, wine, or spirits in relation to the risk for CHD. Ecological, case-control, and cohort studies were included in the review.

Data extraction

Data were extracted on study design, participant characteristics, type and amount of consumption, and risk for CHD.

Main results

12 ecological studies were included in the review. These studies generally showed a strong inverse association between consumption of wine and mortality from CHD, whereas the association was variable or nonexistent for spirits and beer. 3 case-control studies were reviewed. Taken together, the association was inconsistent and the results do not suggest that one type of drink is more cardioprotective than the others. 10 separate cohort studies were included in the review. 4 of the studies found a significant inverse association between wine consumption and CHD, 4 reported a similar association for beer, and 4 reported a similar association for spirits. 2 studies reported no association with any type of alcoholic drink. From all the cohort studies, with data collected from > 350 000 men and women followed for > 1.8 million person-years, it appears that if any type of drink provides extra cardiovascular benefit apart from its alcohol content, the benefit is likely to be modest at best or possibly restricted to certain subpopulations of patients.

Conclusion

Results from case-control and cohort studies provide evidence that all alcoholic drinks (beer, wine, and spirits) may be associated with a lower risk for coronary heart disease, which indicates that a substantial portion of the benefit is associated with alcohol content and not with other components of the drink.

Source of funding: International Life Sciences Institute (ILSI Europe Alcohol Task Force).

For article reprint: Dr. E.B. Rimm, Harvard School of Public Health, Department of Nutrition, Boston, MA 02115, USA. FAX 617-432-2435.


Commentary

Inverse association between alcohol intake and risk for ischemic heart disease depended on the LDL cholesterol level

Numerous studies over the past few decades have evaluated the association between alcohol consumption and mortality from CHD. Most studies have shown that there is a J-shaped association; that is, persons who drink moderately live longer than those who drink heavily and those who drink rarely or not at all. Increased mortality among abstainers was initially thought to be because of higher mortality among recovering alcoholics; however, well-designed studies have shown that this is not the case.

One of the most interesting and controversial questions about the benefits of moderate alcohol consumption is whether some types of alcohol are more beneficial than others. A perception exists among many, perhaps aided by the popular press, that wine, particularly red wine, is the drink responsible for all the benefit. As Rimm and colleagues document, this is far from clear. They systematically reviewed ecological, case-control, and cohort studies to determine the effect of consumption of beer, wine, and spirits. In ecological studies, the average alcohol intake per capita is compared with the mortality rate from CHD across many countries and regions. Because the results of these studies are based on population averages and not on individual measurements, they are subject to bias and are best used for generating hypotheses. Many ecological studies suggest that wine is most effective in reducing the risk for mortality from CHD, perhaps accounting for this popular view. The 10 prospective cohort studies showed quite different results—it is more likely that the benefit is caused by the alcohol and not by the individual type of liquor. Thus, at this point, there is no evidence that patients (and physicians) who drink beer or spirits should switch to wine.

Another important question is: What mechanism is responsible for the beneficial effect of moderate alcohol consumption? Approximately half the benefit is caused by the rise in high-density lipoprotein cholesterol levels produced by moderate alcohol consumption. Recent evidence has shown that moderate al-cohol consumption increases levels of tissue plasminogen activator, thereby decreasing the risk for thrombosis (1). LDL cholesterol levels are not considered to be an important factor in the decrease in mortality from moderate alcohol consumption.

Hein and colleagues followed nearly 3000 Danish men for 6 years. They found that the association between alcohol consumption and risk for CHD depended highly on LDL cholesterol levels. In multivariate analysis, an association between alcohol consumption and the rate of CHD was only present with higher LDL cholesterol levels (> 5.25 mmol/L). Hein and colleagues do not imply that alcohol intake decreases LDL cholesterol levels; rather, they conclude that the association between moderate alcohol consumption and decreased risk for ischemic heart disease occurs only among persons with higher LDL cholesterol levels. This is an important clinical distinction because it implies that persons with low LDL cholesterol levels will not benefit from moderate alcohol consumption. This needs to be confirmed in additional studies, particularly in different populations.

So, what can we tell our patients? We can advise them that moderate alcohol consumption (up to 1 to 2 drinks/d) lowers the rate of CHD and overall mortality and that the type of alcohol consumed does not matter. For each patient, we need to weigh his or her risk for heart disease with the risk for alcohol abuse. For women, we must also consider the risk for developing breast cancer, which increases with increased alcohol consumption (2).

Scott E. Sherman, MD, MPH
Department of Veterans Affairs Medical CenterSepulveda, California, USA


References

1. Ridker PM, Vaughan DE, Stampfer MJ, Glynn RJ, Hennekens CH. Association of moderate alcohol consumption and plasma concentration of endogenous tissue-type plasminogen activator. JAMA. 1994; 272: 929-33.

2. Willett WC, Stampfer, MJ, Colditz GA, et al. Moderate alcohol consumption and the risk of breast cancer. N Engl J Med. 1987;316:1174-80.