Access to alcohol and heart disease among patients in hospital: observational cohort study using differences in alcohol sales lawsBMJ 2016; 353 doi: https://doi.org/10.1136/bmj.i2714 (Published 14 June 2016) Cite this as: BMJ 2016;353:i2714
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Re: Access to alcohol and heart disease among patients in hospital: observational cohort study using differences in alcohol sales laws
I enjoyed reading the research article “Access to alcohol and heart disease among patients in hospital: observational cohort study using differences in alcohol sales laws.” As a student of both Physician Assistant and MPH studies who is interested in rural health and medicine, I find this medical research topic intriguing as cardiac studies intersect with a multitude of regional and cultural considerations with regards to alcohol availability and consumption in Texan counties. As such, I feel that this research study has several limitations that need to be addressed.
This research concludes that there is a significant relationship between “wet” counties (those with alcohol sales) and an increase of atrial fibrillation hospital admissions. Although the approach to research is unique and contributes to the body of literature at large, currently, many previous studies loosely support or outright refute the conclusions made in this study, such as that done by Mukamal et al. (2007). Research by Kodama et al. (2011) asserts that only a correlation was made between habitual heavy (or misuse) alcohol drinking and an increased risk of atrial fibrillation. This research study self-identified several limitations that affected results, including a heterogeneous definition of “heavy drinking,” an inability to validate assessment of alcohol intake, and the racial differences amongst participants. I would suggest that these three limitations be added to limitation considerations in the research study being analyzed. Another study by Djousse et al. (2004) identifies a dose-response association with weak correlation between long-term alcohol use and risk of atrial fibrillation. Moderate alcohol use, defined in the research as consumption of up to 36 g/day, had minimal and non-significant effects on atrial fibrillation risk. Furthermore, this study assessed alcohol abuse by use of a CAGE questionnaire, which did not result to be significantly related to atrial fibrillation in participants, and also failed to show a relation to atrial fibrillation after follow-up intervals of two years at a time.
Additional considerations of limitations, in addition to those mentioned above, could include a more in depth consideration for variance of religious beliefs, access to health care and hospitals with the ability to care for cardiac patients, individual county populations, geographical proximity of “dry” counties to “wet” counties where residents can attain alcohol and then presumably return to their county of residence, and prevalence of abuse of other substances or comorbidities that could contribute to atrial fibrillation cases. While this research is, indeed, groundbreaking in its approach and scope, I would love to see further studies through which more specific analysis amongst more homogenous groupings of counties and participants could be achieved.
Djoussé, L., Levy, D., Benjamin, E. J., Blease, S. J., Russ, A., Larson, M. G., Massaro, J. M., D’Agostino, R. B., Wolf, P. A., and Ellison, R. C. (2004). The American Journal of Cardiology. doi:10.1016/j.amjcard.2003.12.004
Kodama, S., Saito, K., Tanaka, S., Horikawa, C., Saito, A., Heianza, Y., Anasako, Y., Nishigaki, Y., Yachi, Y., Tada Iida, K., Ohashi, Y., Yamada, N., and Sone, H. (2011). Alcohol consumption and risk of atrial fibrillation. Journal of the American College of Cardiology 57(4). doi:10.1016/j.jacc.2010.08.641
Mukamal, K. J., Psaty, B. M., Rautaharju, P. M., Furberg, C. D., Kuller, L. H., Mittleman, M. A., Gottdiener, J. S., and Siscovick, D. S. (2006). Alcohol consumption and risk and prognosis of atrial fibrillation among older adults: The cardiovascular health study. American Heart Journal 153(2). doi:10.1016/j.ahj.2006.10.039
Competing interests: No competing interests