Alcohol Awareness Month: The Link Between Alcohol Use and Atrial Fibrillation

Atrial fibrillation (AF) affects up to 6.1 million individuals in the United States, and the Centers for Disease Control and Prevention anticipates that this number will reach 12.1 million by the year 2030.^1,2 These estimates illuminate the critical need to target modifiable risk factors for AF. Alcohol has long been cited as a top trigger for AF development and recurrence, and newer studies add further support to this relationship.

“In a phenomenon often referred to as ‘holiday heart,’ excessive alcohol consumption has been associated with incident atrial fibrillation, but the relationship between the exact quantity of consumption and risk for atrial fibrillation has been investigated more recently,” said Maryann A. McLaughlin, MD, associate professor of both cardiology and population health science and policy at the Icahn School of Medicine at Mount Sinai in New York, and medical director of the Cardiac Health Program at Mount Sinai Health System. “Importantly, the ‘dose’ of alcohol that predicts atrial fibrillation is still debated.”

In a 2021 community-based cohort study of 107,845 individuals (48.3% men; median age, 47.8 years), Csengeri et al found a non-linear and positive association between alcohol consumption and incident AF over a median follow-up period of 13.9 years, with a hazard ratio (HR) of 1.16 (95% CI, 1.11-1.22; P <.001) for 1 12-gram drink per day.³ This observation was similar across common types of alcohol (beer, wine, and spirits) and “independent of classical pathophysiological pathways including those related to myocardial wall stress and injury reflected by NT-proBNP and hsTnI,” as described in the paper.

Another study published in 2021 examined data pertaining to 403,281 middle-aged adults (52.4% women) from a prospective cohort study and found a J-shaped association between total alcohol consumption and AF risk over a median follow-up period of 11.4 years (IQR, 10.7-12.3 years).The lowest risk for AF was observed with intake of less than 4 standard US drinks per week, with beer and cider showing increased risk at any level of consumption while red wine, white wine, and spirits were not associated with increased risk up to roughly 6 US drinks per week.⁴

In addition to the general links between AF and alcohol consumption over time, studies published in 2022 demonstrated that acute alcohol exposure increased the risk for AF events, as well as the risk for emergency department visits for AF events and new-onset AF.^5,6

Conversely, emerging findings suggest that abstinence from alcohol reduces both the risk for AF recurrence and AF-related stroke. In an open-label randomized controlled trial published in 2020 in the New England Journal of Medicine, Voskoboinik et al observed AF recurrence in 53% of regular drinkers assigned to an abstinence group compared to 73% in the control group.⁷ The abstinence group also showed longer durations of time before AF recurrence vs controls (HR, 0.55; 95% CI, 0.36-0.84; P =.005).

A 2021 study revealed a lower 5-year risk for stroke in patients who were non-drinkers at the time of AF diagnosis and those who stopped drinking after diagnosis compared with current drinkers.⁸

While the evidence implicating alcohol intake of any amount as an AF risk factor continues to accumulate, other research has found conflicting results. In a 2021 prospective cohort study of 9,411 patients with AF, heavy alcohol consumption was associated with an elevated risk for adverse outcomes (adjusted HR [aHR], 1.32; 95% CI, 1.06-1.66) compared with abstinence or rare drinking, while light alcohol intake (aHR, 0.88; 95% CI, 0.68-1.13) and moderate intake (aHR, 0.91; 95% CI, 0.63-1.33) were not linked to an increased risk for adverse outcomes.⁹

Similarly, in a 2020 study of 3,852 patients with AF, no significant association was noted between low to moderate alcohol consumption and the risk for stroke or cardiovascular events.¹⁰

A meta-analysis of 16 observational cohort studies (n=13,044,007) found that heavy drinking (>168 g/week) increased the risk for incident AF (logarithm of the odds ratio [logOR], 0.14; 95% CI, 0.01-0.2; I2, 98.13%) compared with light drinking (<14 g/week), while moderate drinking (<168 g/week) reduced the risk for incident AF compared with abstinence (logOR, -0.20; 95% CI, -0.28 to -0.12; I2, 96.71%) and heavy drinking (logOR, -0.28; 95% CI, -0.37 to -0.18; I2, 95.18%).¹¹

Although the heterogeneity of studies precludes firm conclusions, these “results suggest that the association between alcohol consumption and incident AF is far from being a straightforward dose-response effect,” the authors wrote.¹¹ Other research has indicated that the relationship between alcohol intake and AF risk may vary between patients based on factors such as sex, race, and polygenic predisposition to AF.^12,13

Along with the range of studies exploring associations between AF risk and the amount of alcohol intake, researchers have investigated the degree of atrial remodeling associated with alcohol consumption in patients with AF. In a 2019 study using high-density electroanatomic mapping, for example, Voskoboinik et al showed that moderate drinkers had more atrial electrical and structural changes compared to mild drinkers.¹⁴

“It is important to educate patients who present with AF on the risk of alcohol causing physiologic changes of the heart and potentially recurrence of AF,” Dr McLaughlin advised. “Further studies are warranted to identify the ‘threshold’ of alcohol consumption for reduction in AF recurrence and to evaluate the impact of mitigating factors, such as blood pressure reduction, that could contribute to the effects of alcohol reduction on AF.”

We learned more about the AF-alcohol connection in an interview with Gregory M. Marcus, MD, MAS, professor of medicine in residence, associate chief of cardiology for research, and Endowed Professor of Atrial Fibrillation Research at the University of California, San Francisco, School of Medicine.

What does the available evidence suggest about associations between alcohol intake and atrial fibrillation?

Dr Marcus: There is now compelling and consistent evidence that alcohol consumption is causally related to an enhanced risk for AF. The more one drinks, the higher the risk they will develop AF. Recent evidence has objectively demonstrated that, among those with a diagnosis of AF, even 1 drink can trigger an acute AF episode within the following few hours.⁵

What are believed to be the mechanisms driving this link?  

Dr Marcus: We recently demonstrated in a randomized trial that ethanol acutely changes the electrical properties of the heart, most specifically it reduced the atrial effective refractory periods in the pulmonary veins.¹⁵ Precisely how alcohol acts on the heart remains poorly understood, but it does appear to have direct effects on ion channels, with variable results observed among different animal models. There may also be delayed effects either related to alcohol metabolites or perhaps changes in autonomic tone.

What are recommendations for clinicians about how to advise patients on alcohol consumption as a risk factor for AF?

Dr Marcus: When it comes to evidence-based advice regarding alcohol and the heart, there are some fairly clear recommendations but some critical unknowns deserving of rigorous research to inform the public, patients, and clinicians. For those who have a diagnosis of AF that are interested in doing everything they can to minimize the risk of a recurrent AF episode, minimizing or eliminating alcohol intake would be a wise move.

For everyone, avoiding drinking in excess, which can be broadly defined as more than 2 standard drinks in 24 hours, should definitely be avoided given clear evidence of multiple adverse consequences.

What should be the focus of future research investigating this association?

Dr Marcus: We still do not know if a standard drink a day such as a glass of wine, a 12-ounce can or bottle of beer, or a shot of spirits on a regular basis is overall better or worse for overall health. While alcohol as a risk factor for AF is now quite well-established, there is also compelling evidence that regular, light drinking may be associated with some health benefits regarding diabetes, coronary disease, and perhaps even overall mortality.¹⁶ The problem is that most of the research on the topic is observational, which is clearly prone to confounding.

AF is 1 rare area where we now actually have both randomized trial data supporting this association, as well as real-time data using wearable sensors. We are now actively seeking funding support to perform the first major and long-term randomized trial to test whether a drink a day versus near-abstinence leads to overall improved or decreased health and what the actual consequences are, and hopefully to help identify individual-level characteristics that might influence various health effects.

References

1. Burns RB, Zimetbaum P, Lubitz SA, Smetana GW. Should this patient be screened for atrial fibrillation?: Grand rounds discussion from Beth Israel Deaconess Medical Center. Ann Intern Med. Published online December 3, 2019. doi:10.7326/M19-1126
2. Centers for Disease Control and Prevention. Atrial Fibrillation. Last reviewed September 27, 2021. Accessed March 22, 2022.
3. Csengeri D, Sprünker NA, Di Castelnuovo A, et al. Alcohol consumption, cardiac biomarkers, and risk of atrial fibrillation and adverse outcomes. Eur Heart J. Published online March 21, 2021. doi:10.1093/eurheartj/ehaa953
4. Tu SJ, Gallagher C, Elliott AD, et al. Risk thresholds for total and beverage-specific alcohol consumption and incident atrial fibrillation. JACC Clin Electrophysiol. Published online December 7, 2021. doi:10.1016/j.jacep.2021.05.013
5. Marcus GM, Modrow MF, Schmid CH, et al. Individualized studies of triggers of paroxysmal atrial fibrillation: The I-STOP-AFib randomized clinical trial JAMA Cardiol. Published online November 14, 2022. doi:10.1001/jamacardio.2021.5010
6. Aung S, Nah G, Vittinghoff E, et al. Population-level analyses of alcohol consumption as a predictor of acute atrial fibrillation episodes. Nat Cardiovasc Res. Published online January 12, 2022. doi:10.1038/s44161-021-00003-7
7. Voskoboinik A, Kalman JM, De Silva A, et al. Alcohol abstinence in drinkers with atrial fibrillation. N Engl J Med. Published online January 2, 2020. doi:10.1056/NEJMoa1817591
8. Lee SR, Choi EK, Jung JH, Han KD, Oh S, Lip GYH. Lower risk of stroke after alcohol abstinence in patients with incident atrial fibrillation: a nationwide population-based cohort study. Eur Heart J. Published online June 7, 2021. doi:10.1093/eurheartj/ehab415
9. Lim C, Kim TH, Yu HT, et al. Effect of alcohol consumption on the risk of adverse events in atrial fibrillation: from the COmparison study of Drugs for symptom control and complication prEvention of Atrial Fibrillation (CODE-AF) registry. Europace. Published online November 23, 2021. doi:10.1093/europace/euaa340
10. Reddiess P, Aeschbacher S, Meyre P, et al. Alcohol consumption and risk of cardiovascular outcomes and bleeding in patients with established atrial fibrillation. CMAJ. Published online January 25, 2021. doi:10.1503/cmaj.200778
11. Giannopoulos G, Anagnostopoulos I, Kousta M, Vergopoulos S, Deftereos S, Vassilikos V. Alcohol consumption and the risk of incident atrial fibrillation: A meta-analysis. Diagnostics (Basel). Published online February 13, 2022. doi:10.3390/diagnostics12020479
12. Halford JL, Weng LC, Choi SH, et al. Associations between alcohol intake and genetic predisposition with atrial fibrillation risk in a national biobank. Circ Genom Precis Med. Published online November 6, 2020. doi:10.1161/CIRCGEN.120.003111
13. Yang L, Chen H, Shu T, Pan M, Huang W. Risk of incident atrial fibrillation with low-to-moderate alcohol consumption is associated with gender, region, alcohol category: a systematic review and meta-analysis. Europace. Published online December 4, 2021. doi:10.1093/europace/euab266
14. Voskoboinik A, Wong G, Lee G, et al. Moderate alcohol consumption is associated with atrial electrical and structural changes: Insights from high-density left atrial electroanatomic mapping. Heart Rhythm. Published online January 19, 2019. doi:10.1016/j.hrthm.2018.10.041
15. Marcus GM, Dukes JW, Vittinghoff E, et al. A randomized, double-blind, placebo-controlled trial of intravenous alcohol to assess changes in atrial electrophysiology. JACC Clin Electrophysiol. Published online January 27, 2021. doi:10.1016/j.jacep.2020.11.026
16. Chiva-Blanch G, Badimon L. Benefits and risks of moderate alcohol consumption on cardiovascular disease: Current findings and controversies. Nutrients. 2019;12(1):108. doi:10.3390/nu12010108