Patterns of alcohol consumption and ischaemic heart disease in culturally divergent countries: the Prospective Epidemiological Study of Myocardial Infarction (PRIME)
BMJ 2010; 341 doi: https://doi.org/10.1136/bmj.c6077 (Published 24 November 2010) Cite this as: BMJ 2010;341:c6077All rapid responses
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Ruidavets et al(1) confirm that consumption of low levels of alcohol
is associated with reduced cardiovascular mortality, but importantly, also
suggest that this effect only results in those with regular moderate
consumption, and that the effect is probably through an anti-thrombotic
action(2). Yet in spite of this, and much other evidence, there is still a
lot of resistance to this idea in the clinical and research community(3).
Perhaps it is difficult to understand why alcohol, a substance that
clearly causes harm in excess, could be beneficial in low doses.
A population genetics perspective may help. In the evolution of
thrombosis, a balance is to be achieved between the risk of early death
from traumatic haemmorhage, and the risk of later death from intramural
thrombosis of a critical artery. Whereas our species evolved in an
environment where there was a significant risk of trauma, that is no
longer true, and so the regular intake of an anti-thrombotic agent will
adjust our thrombotic tendency to the adaptive peak of our current milieu.
Low dose alcohol may not be much different to taking aspirin or
warfarin in adjusting our physiology to the new adaptive peak, but alcohol
may have fewer side-effects. Given the complexities of promoting sensible
consumption of alcohol in its currently available forms, should we not be
exploring the potential benefits of a low-dose ethanol pill for widespread
human consumption?
Mahmood Bhutta
Research Fellow, University of Oxford
1.Ruidavets JB, Ducimetiere P, Evans Aet al. Patterns of alcohol
consumption and ischaemic heart disease in culturally divergent countries:
the Prospective Epidemiological Study of Myocardial Infarction (PRIME).
BMJ (Clinical research ed;341:c6077.
2.Salem RO, Laposata M. Effects of alcohol on hemostasis. Am J Clin Pathol
2005;123 Suppl:S96-105.
3.Fillmore KM, Stockwell T, Chikritzhs T, Bostrom A, Kerr W. Moderate
alcohol use and reduced mortality risk: systematic error in prospective
studies and new hypotheses. Ann Epidemiol 2007;17:S16-23.
Competing interests: No competing interests
That is the headline that should have been picked up by the world
media but was not.
There is no question that the Ruidavets et al. study was interesting,
and consistent with past observational studies on the topic. And although
repeated alcohol assessments over time and adjustment for additional
confounders would have been better, it was not an unreasonable design for
assessing harm, which it found. And the authors drew very appropriate
conclusions from their data, including their discussion of public health
and policy implications.
But its results related to regular moderate use should not be
confused with what one might find in a randomized trial, the sorts of
studies that are required for determining preventive benefits, and for
good reason. In recent decades we have seen many examples of drugs
thought to have benefit based on numerous consistent observational studies
that were later found to be either not beneficial or even harmful in
randomized trials. This is a particular concern with observational
studies of alcohol use because low-dose average alcohol consumption is
associated with social advantage, numerous other healthy behaviors, and
markers of good health and health care which are unlikely to be able to be
fully adjusted for in statistical analyses.
Imagine if a pharmaceutical company submitted an application for new
drug approval for a preventive therapy for one of the most common causes
of death. The indication was prevention for all adults. The data in the
application would say: Drug X is a recognized carcinogen even at low
levels for some conditions (like breast cancer), an addictive substance, a
common cause of preventable death, and a substance that people often take
in doses known to be harmful and in excess of low-risk guidelines. In
addition to reams of similar observational studies, we have now proven,
based on self report by people who chose to take a wide variety of dosages
and frequencies and formulations, that daily use of Drug X for one week
reduced ischemic heart disease over the next ten years.
Any respected drug approval agency in the world would not accept
observational data as sufficient for recommending a pharmacological agent
for preventive use, for obvious reasons. There is no reason why alcohol
should receive special treatment in this regard.
Clearly, it would be unethical to do a clinical trial of doses of
alcohol associated with increased risk based on existing studies. But if
we are confident that the preventive benefits of "moderate" drinking
outweigh its risks, let's do the appropriate closely supervised trial
randomizing carefully selected never-drinkers to drink. This would be far
more ethical than promoting -- intentionally or otherwise - behaviors that
are informed by the current substandard evidence base characterizing the
sequelae of low-dose ethanol consumption.
Competing interests: No competing interests
The article states that cholesterol was assayed with reagents from
Boehringer Ingelheim.
Boehringer Ingelheim is a pharmaceutical company that, as far as I know,
doesn't make reagents.
Apparently, there is confusion with Boehringer Mannheim, acquired by
Hitachi some 25 years ago, resold to Roche, a few years later.
Of course, this doesn't diminish the quality of the information on
the subject of the article.
Competing interests: No competing interests
Depression and stress: Possible link between coronary artery disease and binge drinking
Dear Editor,
We congratulate Ruidavets et al on their comprehensive study which
highlights the strong association of binge drinking with adverse cardiac
events.
It is well known that depression and stress are factors directly related
with binge drinking [1, 2]. These factors are also independently linked to
coronary artery disease as well [3]. This may imply that the link of binge
drinking to coronary artery disease might be an indirect one. The authors
probably needed to consider this bias (psychological status) to further
validate their study. We believe psychological questionnaire could have
been used to match both population group (Northern Irish and French). This
could have potentially reduced this bias.
Over-all, this epidemiological study proves the point that binge drinking
has adverse cardio-vascular outcomes.
References
1. Bazargan-Hejazi S, Ani C, Gaines T, Ahmadi A, Bazargan M. Alcohol
misuse and depression symptoms among males and females. Arch Iran Med.
2010 Jul;13(4):324-32.
2. Choi NG, Dinitto DM. Heavy/binge drinking and depressive symptoms
in older adults: gender differences. Int J Geriatr Psychiatry. 2010 Oct 1.
3. Whang W, Shimbo D, Kronish IM, Duvall WL, Julien H, Iyer P, Burg
MM, Davidson KW. Depressive symptoms and all-cause mortality in unstable
angina pectoris (from the Coronary Psychosocial Evaluation Studies
[COPES]). Am J Cardiol. 2010 Oct 15;106(8):1104-7.
Competing interests: No competing interests