Critique 025: Pattern of drinking and type of beverage affect the relation of alcohol intake to coronary heart disease 1 December 2010

Ruidavets J-B, Ducimetièere P, Evans A, Montaye M, Haas B, Bingham A, Yarnell J, Amouyel P, Arveiler D, Kee F, Bongard V, Ferrières J.   Patterns of alcohol consumption and ischaemic heart disease in culturally divergent countries: the Prospective Epidemiological Study of Myocardial Infarction (PRIME).  BMJ 2010;341:c6077 doi:10.1136/bmj.c6077

Authors’ Abstract

Objective  To investigate the effect of alcohol intake patterns on ischaemic heart disease in two countries with contrasting lifestyles, Northern Ireland and France.

Design  Cohort data from the Prospective Epidemiological Study of Myocardial Infarction (PRIME) were analysed.  Weekly alcohol consumption, incidence of binge drinking (alcohol >50 g on at least one day a week), incidence of regular drinking (at least one day a week, and alcohol <50 g if on only one occasion), volume of alcohol intake, frequency of consumption, and types of beverage consumed were assessed once at inclusion.  All coronary events that occurred during the 10 year follow up were prospectively registered.  The relation between baseline characteristics and incidence of hard coronary events and angina events was assessed by Cox’s proportional hazards regression analysis.

Setting One centre in Northern Ireland (Belfast) and three centres in France (Lille, Strasbourg, and Toulouse).

Participants 9,778 men aged 50-59 free of ischaemic heart disease at baseline, who were recruited between 1991 and 1994.

Main outcome measures Incident myocardial infarction and coronary death (“hard” coronary events), and incident angina pectoris.

Results A total of 2,405 men from Belfast and 7,373 men from the French centres were included in the analyses, 1,456 (60.5%) and 6,679 (90.6%) of whom reported drinking alcohol at least once a week, respectively.  Among drinkers, 12% (173/1,456) of men in Belfast drank alcohol every day compared with 75% (5,008/6,679) of men in France.  Mean alcohol consumption was 22.1 g/ day in Belfast and 32.8 g/day in France.  Binge drinkers comprised 9.4% (227/2,405) and 0.5% (33/7,373) of the Belfast and France samples, respectively.  A total of 683 (7.0%) of the 9,778 participants experienced ischaemic heart disease events during the 10 year follow up: 322 (3.3%) hard coronary events and 361 (3.7%) angina events.  Annual incidence of hard coronary events per 1000 person years was 5.63 (95% confidence interval 4.69 to 6.69) in Belfast and 2.78 (95% CI 2.41 to 3.20) in France.  After multivariate adjustment for classic cardiovascular risk factors and centre, the hazard ratio for hard coronary events compared with regular drinkers was 1.97 (95% CI 1.21 to 3.22) for binge drinkers, 2.03 (95% CI 1.41 to 2.94) for never drinkers, and 1.57 (95% CI 1.11 to 2.21) for former drinkers for the entire cohort.  The hazard ratio for hard coronary events in Belfast compared with in France was 1.76 (95% CI 1.37 to 2.67) before adjustment, and 1.09 (95% CI 0.79 to 1.50) after adjustment for alcohol patterns and wine drinking.  Only wine drinking was associated with a lower risk of hard coronary events, irrespective of the country.

Authors’ Conclusions  Regular and moderate alcohol intake throughout the week, the typical pattern in middle-aged men in France, is associated with a low risk of ischaemic heart disease, whereas the binge drinking pattern more prevalent in Belfast confers a higher risk.

Forum Comments

While a strong inverse association between moderate alcohol consumption and coronary heart disease (CHD) has been demonstrated for decades, more recent research has emphasized the importance of the pattern of drinking (regular moderate versus episodic or binge drinking).  Further, there continues to be debate about the potential greater effect of wine versus other beverages containing alcohol.  This study provides important data contrasting patterns of drinking and type of beverage usually consumed in Northern Ireland and in France, and the purported effects on the risk of CHD.

While members agreed with the primary conclusions of the paper, one added that “the data from this paper clearly shows abstention is as risky as binge drinking and that is not mentioned at all in the conclusions.  From a public policy perspective their conclusions suggest the best action would be to reduce access to alcohol, but if the risk of abstention were included, this could hardly be appropriate.”

General comments on the importance of the pattern of drinking

One Forum member states that the evidence on frequency and amount of alcohol consumption should be treated with caution.  The finding of the importance of drinking pattern being the primary determinant in the relation between alcohol and heart disease is mostly applied to men.^1,2  And it is hard to think of a sound, biological mechanism to explain the finding that compared with abstainers, regular heavy drinking is associated with a relative risk of CHD of 0.75 (95% CI  0.64-0.89) while heavy irregular drinking (and binge drinking) is associated with a relative risk of 1.10 (95% CI 1.03-1.17).³  Residual confounding, e.g., socio-economic status⁴ and choice of food,⁵ may partly explain the findings.  

Another member counters: “Laboratory experiments and limited human studies clearly indicate that many of the effects of alcohol and other substances in wine are transitory.  Changes in gene activation affecting fibrinolysis last only hours,⁶ and a decrease in platelet aggregation occurs only for 24 hours or so after drinking (although it may be longer for wine than for other beverages).^7,8  Effects on endothelial function are also transitory.  It would be expected from such research that regular (especially daily) consumption of an alcoholic beverage would lead to a greater reduction in the risk of myocardial infarction and other event related primarily to clot formation than would an irregular pattern of drinking.  As suggested by the present paper, the protection of the French from heart disease may well be due primarily to their consumption of wine on a daily basis.”

A Forum member commented: “I am comfortable that moderate drinking promotes health and longevity and that abstinence and excess, particularly in binges, do the opposite.  It appears that a possible basic biological principle is that life is a J-shaped curve.  Drinking, in my view, should be more to enrich life than to medicate it, and more power to unbiased research to protect us from zealots.”

A member added: “The health promotional aspects of wine is more than just the protection against cardiovascular disease, but has a lot to do with a healthy and enjoyable lifestyle complemented with a Mediterranean – like diet rich in phytochemicals acting synergistically with the wine polyphenols.  Emotional and intellectual aspects of well-being do play an important role in the health benefits of regular and moderate wine consumption, and binge drinking is not part of a holistic approach to a responsible and enjoyable lifestyle.”  Further, it has been shown that wine consumed during a meal provides protection from oxidative products from red meat consumed during the meal.⁹

Do genetics play a role?

“It is also important to note that the wine drinker’s genetic blueprint does play an important role in the potential benefit and harmful effect of alcohol consumption.  Testing for relatively common gene mutations involved in dyslipidaemia may be very useful to identify individuals who may not benefit from alcohol drinking.  While the high-frequency, low-expression gene variations included in the cardiovascular genetic test are not the sole determinants of cardiovascular disease, they may increase the risk imposed by environmental factors such as smoking, physical inactivity, central obesity, stress or unhealthy food choices.  Based on increasing evidence of the role of the Apo E gene in response to alcohol intake, genotyping should in the future be considered before patients with one or more features of the metabolic syndrome are encouraged to consume alcohol to reduce their risk of heart disease.” 

Another member agreed: “I do think as well that genotype may play an important part in the outcome of most diseases.  Indeed, apolipoprotein E (ApoE) genotype is the most widespread known genetic risk factor for cardiovascular disease, with ApoE4 carriers, who represent 25% of Caucasians, having an odds ratio of 1.5 relative to the wild-type E3/E3 genotype.¹⁰   On the other hand, at the present time the genetic factors associated with increased risk of cardiovascular diseases, and especially factors that modify the effects of alcohol, are far from clear.  A recent study from Northern Europe found only “minor effects from selected ADH and ALDH gene variants and did not seem to markedly modify the health effects of alcohol drinking.”¹¹ 

Differences in binge drinking between wine and other beverages?

A member asked: “Is there some basic taste factor in different alcoholic beverages that affects the pattern of drinking?  Perhaps the acidity and astringency in wine (especially red wine) mitigate against binge consumption, and tend to promote consumption with meals.  It would be very interesting if we could show that the form of the alcohol actually alters consumption pattern.”  Another member agrees: “It seems to take only a few weeks to acclimate to certain foods, so perhaps persons could be ‘trained’ to consume primarily certain beverages in a healthy pattern.  It is realized, however, that in adults the prior alcohol drinking pattern may be extremely entrenched.”

References from Forum Critique

1. Tolstrup J, et al.  Prospective study of alcohol drinking patterns and coronary heart disease in women and men. BMJ 2006;332:1244-1247.
2. Ruidavets J-B, et al.  Patterns of alcohol consumption and ischemic heart disease in culturally divergent countries: the Prospective Epidemiological Study of Myocardial Infarction (PRIME). BMJ 2010;341:c6077.
3. Bagnardi V, et al.  Does drinking pattern modify the effect of alcohol on the risk of coronary heart disease? Evidence from a meta-analysis. J Epidemiol Community Health 2008;62:615-615.
4. Mäkeä P.  Alcohol related mortality as a function of socio-economic status. Addiction 1999;94:867-886.
5. Johansen D, et al.  Food buying habits of people who buy wine or beer: cross sectional study. BMJ 2006;332:519-522.
6. Booyse FM, Pan W, Grenett HE, Parks DA, Darley-Usmar VM, Bradley KM, Tabengwa EM.  Mechanism by which alcohol and wine polyphenols affect coronary heart disease risk.  Ann Epidemiol 2007;17:S24-S31.
7. Ruf JC, Berger JL, Renaud S.  Platelet rebound effect of alcohol withdrawal and wine drinking in rats. Relation to tannins and lipid peroxidation.  Arterioscler Thromb Vasc Biol 1995;15:140-144.
8. Ruf JC.  Alcohol, wine and platelet function.  Biol Res 2004;37:209-215
9. Gorelik S, Ligumsky M, Kohen R, Kanner J.  The stomach as a “bioreactor”: when red meat meets red wine.  J Agric Food Chem 2008;56:5002-5007.
10. Rimbach G, Minihane AM.  Nutrigenetics and personalised nutrition: how far have we progressed and are we likely to get there? Proceedings of the Nutrition Society 2009;68:162-172.
11. Husemoen LL, Jorgensen T, Borch Johnsen K, Hansen T, Pedersen O, Linneberg A.  The association of alcohol and alcohol metabolizing gene variants with diabetes and coronary heart disease risk factors in a white population.  PLoS One, 2010;5Art No e11735.

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Comments included in this critique by the International Scientific Forum on Alcohol Research were provided by the following:

Pierre-Louis Teissedre, PhD, Faculty of Oenology – ISVV, University Victor Segalen Bordeaux 2, Bordeaux, France.

Erik Skovenborg, MD, Scandinavian Medical Alcohol Board, Practitioner, Aarhus, Denmark.

R. Curtis Ellison, MD, Section of Preventive Medicine & Epidemiology, Boston University School of Medicine, Boston, MA, USA.

David Vauzour, PhD, Dept. of Food and Nutritional Sciences, The University of Reading, UK.

Creina Stockley, clinical pharmacology, Health and Regulatory Information Manager, Australian Wine Research Institute, Glen Osmond, South Australia, Australia.

Harvey Finkel, MD, Hematology/Oncology, Boston University Medical Center, Boston, MA, USA.

David Van Velden, MD, Dept. of Pathology, Stellenbosch University, Stellenbosch, South Africa.

Andrew L. Waterhouse, PhD, Marvin Sands Professor, Department of Viticulture and Enology, University of California, Davis.