Alcoholic cardiomyopathy

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Overview

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Pathophysiology

Differentiating Alcoholic cardiomyopathy from other Diseases

Epidemiology and Demographics

Natural History, Complications and Prognosis

Diagnosis

History and Symptoms

Physical Examination

Laboratory Findings

Electrocardiogram

Chest X Ray

Echocardiography

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Hardik Patel, M.D.

Overview

Alcoholic cardiomyopathy is a disease in which the excessive use of alcohol use damages the heart muscle causing heart failure. It is characterized by constellation of findings which includes a history of excessive alcohol intake, physical signs of alcohol abuse, heart failure, and supportive findings consistent with dilated cardiomyopathy.

Pathophysiology

Alcoholic cardiomyopathy is a type of dilated cardiomyopathy. Both acute and chronic alcohol consumption, in excessive amounts, has been associated with adverse effects on the myocardium leading to nonischemic dilated cardiomyopathy. The maximum recommended dose of alcohol consumption in US men and women is 14 drinks and 7 drinks respectively. Consumption above these levels has been shown to be associated with the increased risk of alcoholic cardiomyopathy. [1]

Excessive use of alcohol has a direct toxic effect on the heart muscle cells. The heart muscle becomes weakened, subsequently dilates, and cannot pump blood efficiently. The lack of blood flow affects all parts of the body, resulting in damage to multiple tissues and organ systems. Alcohol may also simultaneously be causing direct damage to the liver.[2].

Proposed mechanisms of myocardial injury in alcoholic cardiomyopathy include:

  • Ethanol induced apoptosis
  • Impaired contraction of myocardium due to direct toxicity
  • Inhibition of protein synthesis
  • Activation of renin-angiotensin system (RAS)
  • Inhibition of oxidative phosphorylation
  • Fatty acid ester accumulation
  • Nutritional deficiency of thiamine
  • Free radical damage

Epidemiology and Demographics

Alcoholic cardiomyopathy is more prevalent in middle aged males between the ages of 35-50. However, females may be more sensitive to cardiotoxic effects of alcohol, and may develop alcoholic cardiomyopathy with lesser amounts of alcohol use, than males.

Diagnosis

History and Symptoms

The alcohol history, with attention to daily, maximal, and lifetime intake and the duration of alcohol consumption as well as the nutritional status of the patient should be inquired about.

Symptoms presented by the occurrence of alcoholic cardiomyopathy are the result of the heart failure and usually occur after the disease has progressed to an advanced stage. Therefore the symptoms have a lot in common with other forms of cardiomyopathy. Symptoms may develop acutely or insidiously.

Physical Examination

Appearance of the Patient

The patient may have altered mental status due to chronic alcoholism.

Neck

Extremities

  • Pedal edema
  • Cold extremities with decreased pulse

Lungs

  • Rales may be heard on lung exam due to pulmonary congestion.

Heart

Palpitation
  • Enlargment of the heart with a laterally displaced and diffused point of maximal impulse.
Auscultation

Abdomen

Other sequelae of alcoholic liver disease may also be noted on physical examination.

Electrocardiogram

Chest X Ray

Echocardiography

  • Echocardiography is the most useful initial diagnostic test in the evaluation of patients with heart failure. Because of its noninvasive nature and the ease of the test, it is the test of choice in the initial and follow-up evaluation of most forms of cardiomyopathy. It provides information not only on overall heart size and function, but also on valvular structure and function, wall motion and thickness, and pericardial disease. Possible echocardiographic findings include: [3]
  • LV dilatation (earliest manifestation)[4]
  • Increased LV wall thickness [5]
  • Diastolic and systolic dysfunction[6][7]
  • Reduced ejection fraction [8][9]

Other Diagnostic Studies

Treatment

Treatment for alcoholic cardiomyopathy involves lifestyle changes, including complete abstinence from alcohol use, a low sodium diet, and fluid restriction, as well as medications. If the heart failure is severe, the effectiveness of treatment will be limited.

Medications may include, ACE inhibitors and beta blockers which are commonly used for other forms of cardiomyopathy to reduce the strain on the heart. Diuretics can also be used to help remove the excess fluid from the body. Persons with congestive heart failure may be considered for surgical insertion of an ICD or a pacemaker which can improve the heart function. In cases where the heart failure is irreversible and worsening, a heart transplant may be considered.

Treatment will possibly prevent the heart from further deterioration, and the cardiomyopathy is largely reversible if complete abstinence from alcohol is maintained.

References

  1. Thun MJ, Peto R, Lopez AD; et al. (1997). "Alcohol consumption and mortality among middle-aged and elderly U.S. adults". The New England Journal of Medicine. 337 (24): 1705–14. doi:10.1056/NEJM199712113372401. PMID 9392695. Unknown parameter |month= ignored (help)
  2. Piano MR (2002). "Alcoholic cardiomyopathy: incidence, clinical characteristics, and pathophysiology". Chest. 121 (5): 1638–50. PMID 12006456. Unknown parameter |month= ignored (help)
  3. Orlando E, Gennari P, Boari C (1980). "[Echocardiographic study of the left ventricle in chronic alcoholism]". Minerva Medica (in Italian). 71 (44): 3235–9. PMID 6450342. Unknown parameter |month= ignored (help)
  4. Lazarević AM, Nakatani S, Nesković AN; et al. (2000). "Early changes in left ventricular function in chronic asymptomatic alcoholics: relation to the duration of heavy drinking". Journal of the American College of Cardiology. 35 (6): 1599–606. PMID 10807466. Unknown parameter |month= ignored (help)
  5. Askanas A, Udoshi M, Sadjadi SA (1980). "The heart in chronic alcoholism: a noninvasive study". American Heart Journal. 99 (1): 9–16. PMID 6444262. Unknown parameter |month= ignored (help)
  6. Fernández-Solà J, Nicolás JM, Paré JC; et al. (2000). "Diastolic function impairment in alcoholics". Alcoholism, Clinical and Experimental Research. 24 (12): 1830–5. PMID 11141042. Unknown parameter |month= ignored (help)
  7. Estruch R, Fernández-Solá J, Sacanella E, Paré C, Rubin E, Urbano-Márquez A (1995). "Relationship between cardiomyopathy and liver disease in chronic alcoholism". Hepatology (Baltimore, Md.). 22 (2): 532–8. PMID 7635421. Unknown parameter |month= ignored (help)
  8. Kelbaek H, Eriksen J, Brynjolf I; et al. (1984). "Cardiac performance in patients with asymptomatic alcoholic cirrhosis of the liver". The American Journal of Cardiology. 54 (7): 852–5. PMID 6486037. Unknown parameter |month= ignored (help)
  9. Dancy M, Bland JM, Leech G, Gaitonde MK, Maxwell JD (1985). "Preclinical left ventricular abnormalities in alcoholics are independent of nutritional status, cirrhosis, and cigarette smoking". Lancet. 1 (8438): 1122–5. PMID 2860335. Unknown parameter |month= ignored (help)

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