Alcoholic Cardiomyopathy

Alcoholic cardiomyopathy is a condition resulting from long-term excessive alcohol intake. This cardiac muscle disease causes an impaired heart performance that leads to cardiac failure.

The disorder is the result of the following process: Poison.

Presentation

The clinical presentation is dependent on the stage of the heart muscle disease. In the early ACM, patients are typically asymptomatic [11]. In more advanced disease, individuals manifest with congestive heart failure. Therefore, a clinical picture develops secondary to CHF and pulmonary edema. A majority will experience dyspnea on exertion. As ACM progresses, patients can develop orthopnea. Furthermore, some will have paroxysmal nocturnal dyspnea and episodic coughs that produce frothy sputum. Another common sign of CHF is peripheral edema which is enhanced in patients with cirrhosis. Patients with arrhythmias may feel palpitations

Sudden cardiac death may occur in individuals with dilated cardiomyopathy [12].

Other

Since alcohol affects many organs and systems, alcoholics will typically display signs of thiamine and other vitamin deficiencies. Of importance, liver cirrhosis is prevalent in this group. Therefore, these patients will likely have other sequelae in addition to cardiovascular involvement. 

Liver, Gall & Pancreas
  • Hepatomegaly Abdominal examination revealed a tender hepatomegaly, and a non tender suprapubic mass of about 18wks size. [source] Patients indulging in alcohol and having symptoms of myocarditis, have worse prognosis, because coexistence of these two factors intensifies the signs of left and right ventricular heart failure: tachycardia, supraventricular and ventricular arrhythmias, hepatomegaly [source] Jugular venous distention, peripheral edema, and hepatomegaly are evidence of elevated right heart pressures and right ventricular dysfunction. [source]
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Entire body system
  • Congestive Heart Failure In more advanced disease, individuals manifest with congestive heart failure[source] Laboratory test B-type natriuretic peptide (BNP) levels are sensitive for congestive heart failure[source] Structural changes have been noted in autopsies of chronic alcoholics without congestive heart failure .  [source]
  • Fatigue These symptoms can include the following: Ankle, feet, and leg swelling (edema) Overall swelling Loss of appetite Shortness of breath (dyspnea), especially with activity Breathing difficulty while lying down Fatigue, weakness, faintness Decreased alertness [source] Symptoms are the result of heart failure and include fatigue , shortness of breath, swelling, and cough . [source] Symptoms are the result of heart failure and include fatigue, shortness of breath, swelling, and cough. [source]
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cardiovascular
  • Cardiomegaly This is called cardiomegaly[source] The long-term effects of cardiomegaly are not good. [source] Cardiomegaly sometimes leads to abnormal heart rhythms (called arrhythmias). [source]
  • Distended Neck Veins There may be distended neck veins, enlarged liver, swelling of the arms and legs, and signs of pleural effusion (fluid around the lungs). [source]
  • Gallop Rhythm 21,22 Table 5: Predictors of Poor Outcome in Dilated Cardiomyopathy Test Features Clinical findings Increased age, male gender, ischemic heart disease, diabetes, syncope, right heart failure symptoms, symptomatic ventricular arrhythmias, persistent gallop [source] rhythm, persistent jugular venous distention, systemic hypotension, peripheral vascular disease Laboratory findings Hyponatremia, persistently elevated B-type natriuretic peptide and A-type natriuretic peptide levels, elevated norepinephrine and renin [source]
  • Heart Disease Understand Your Risk for Cardiomyopathy Symptoms and Diagnosis of Cardiomyopathy Prevention and Treatment of Cardiomyopathy Cardiomyopathy in Children Learn more: Family History and Heart Disease Alcohol and Heart Disease Cocaine, Marijuana and Other [source] Drugs and Heart Disease Source: National Heart, Lung, and Blood Institute, National Institutes of Health, U.S. [source] (A term used when overuse of alcohol causes the disease) Congestive cardiomyopathy Diabetic cardiomyopathy Familial dilated cardiomyopathy Idiopathic cardiomyopathy Ischemic cardiomyopathy (A term used when coronary heart disease , also called coronary [source]
  • Heart Murmur Diagnosis Heart murmurs, EKG changes, enlarged heart by imaging. [source] These simple tests allow your doctor to identify potential signs of alcoholic cardiomyopathy or heart failure, including: an enlarged heart sounds of a heart murmur from valve damage sounds of congestion in the heart and lungs swelling of the jugular [source] I must admit though i do drink very heavily on occations , (binge drink episodes) I have recently been for an annual check up and everything was fine except for i had a heart murmur[source]
  • Nocturnal Paroxysmal Dyspnea paroxysmal dyspnea and other symptoms, can also have jugular vein engorgement, liver congestion, lower limbs Edema and pleural effusion, mild condition can often improve after drinking, but then the disease can be worsened again. 3. [source] patients may have no symptoms, or only showed palpitations, chest tightness, fatigue and so on, severe congestion Sexual heart failure for the outstanding performance, usually for heart failure, but mainly to left heart failure, dyspnea, orthopnea and nocturnal [source]
  • Tachycardia lying down Fatigue, weakness, faintness Decreased alertness or concentration Cough containing mucus, or pink, frothy material Decreased urine output (oliguria) Need to urinate at night (nocturia) Heart palpitations (irregular heart beat) Rapid pulse (tachycardia [source] Tachycardia-induced cardiomyopathy Pregnancy Peripartum cardiomyopathy 2003 The Cleveland Clinic Foundation. [source] Tachycardia-Induced Cardiomyopathy Prolonged exposure to rapid heart rates can induce myocardial dysfunction. [source]
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Workup

The workup consists of a detailed history including assessment of amount and duration of alcohol use. Also, a thorough physical exam should be performed to determine the complete clinical picture. Of importance, there are pertinent studies to help achieve the diagnosis of ACM. Early diagnosis and treatment may reverse some of the cardiac damage. Hence, it is important to recognize and address the overall health of the alcoholic patient. 

Laboratory test

B-type natriuretic peptide (BNP) levels are sensitive for congestive heart failure. The levels of BNP can be elevated as this substance is released from the stressed ventricles.

Imaging

Echocardiography is essential as it provides measurements of the wall thickness, which are normal or reduced. Additionally, this modality yields information about the systolic and valvular function and contractility, which are usually impaired [11].

A chest radiograph may reveal evidence of heart failure [11], such as cardiomegaly, alveolar edema, pleural effusions, Kerley B lines, and other signs as well.

Cardiac catheterization evaluates systolic and diastolic performance in addition to the hemodynamic status [13]. Another technique, thallium scintigraphy, may show ischemic areas [13].

Electrocardiography (ECG)

This study identifies structural changes such as left ventricular hypertrophy [11] and any present arrhythmias. 

Other

Since alcoholics are predisposed to other organ and system involvement, more tests may be warranted depending on the overall clinical picture of the patient. Additionally, testing for vitamin deficiencies and electrolyte imbalance are indicated as well. These especially include thiamine, potassium, phosphorus, and magnesium levels.

Test Results

Cardiac Catheterization

ECG

QRS Wave
QT, RR, ST Intervals
T Wave
Blocks
Hypertrophy
Other ECG Findings

Imaging

X-ray
Ultrasound
PET, SPECT

Treatment

The primary therapy of ACM is the withdrawal of the source. Hence, the patient should be aided and encouraged to cease and abstain from alcohol. This includes providing the patient with education, counseling, and resources to guide the challenging process. Alcohol cessation in the early stages of ACM may reverse the damage. In fact, it is also beneficial to abstain in later stages as well.  

Medical treatment involves the same approach as in heart failure secondary to other causes. The main cardiovascular drugs are vasodilators, digoxin, and diuretics [11] [13]. The vasodilators ACE inhibitors and angiotensin receptor blockers may even prevent the development of ACM [14]. Digoxin is useful for those with symptomatic left ventricular dysfunction while diuretics are helpful for symptomatic relief. Beta blockers could be beneficial for stable cases while intravenous inotropic drugs may be indicated for certain patients. Heart transplantation may be necessary for those with advanced disease. 

Another therapeutic aspect is the cautious use of anticoagulants in patients with left ventricular impairment and atrial fibrillation

Since patients with prolonged abuse of alcohol are prone to vitamin insufficiencies, treatment with thiamine, vitamin B-12, folate, and mineral supplementation is advised. Any electrolyte imbalance should be treated early to help prevent the occurrence of an arrhythmia and sudden death

Prognosis

The prognosis for recovery depends on the length and amount of alcohol use. If the heart is damaged, then full recovery is highly unlikely. However, if patients with early disease cease consumption of alcohol. Then the damage is reversible to a certain degree.   

Chronic alcohol intake can result in congestive heart failure (CHF), arrhythmias, and sudden cardiac death

Complications

  • Atrial Fibrillation The pathogenesis of atrial fibrillation has not been fully established.  [source] The most frequent sequel in acute and chronic alcoholics is atrial fibrillation .  [source] Another therapeutic aspect is the cautious use of anticoagulants in patients with left ventricular impairment and atrial fibrillation.  [source]
  • Atrial Flutter Arrhythmia Arrhythmia can also be the early manifestations of the disease, the most common for atrial fibrillation, followed by atrial flutter, frequent ventricular contraction, premature ventricular contraction and cardiac conduction block; arrhythmia [source] It has been associated with arrhythmia (eg, atrial fibrillation, atrial flutter, other supraventricular arrhythmia, premature ventricular contractions), hypertension, stroke, and sudden death. [ 2 ] In addition, the literature reports alcohol withdrawal [source]
  • Cardiac Arrest This can cause serious complications, including Heart failure Abnormal heart rhythms Heart valve problems Sudden cardiac arrest Heart attacks, high blood pressure, infections, and other diseases can all cause cardiomyopathy. [source] The implantable cardioverter defibrillator (ICD) is similar, but it is geared toward controlling severe arrhythmias that could cause sudden cardiac arrest[source] The specific treatment methodologies aside, the primary goals of treatment for cardiomyopathy include: Lessening the risk of sudden cardiac arrest Stopping the disease from worsening Managing any conditions that influence and complicate the disease Controlling [source]
  • Cardiac Arrhythmia Complications congestive heart failure cardiac arrhythmias, including lethal arrhythmias Calling your health care provider Call your health care provider if symptoms of heart failure or cardiomyopathy develop. [source] Cardiac Arrhythmia Management in Women Heart Disease Facts Panic Attack or Heart Attack Three Women from New Jersey Noreen Back to top Disclaimer Donate Now Contact Us Site Map Store 1999-2000; updates: 2002, 2004, 2005, 2007 Women's Heart Foundation, [source]
  • Cardiomyopathy Alcoholic cardiomyopathy is a type of dilated cardiomyopathy[source] Therefore, the symptoms have a lot in common with other forms of cardiomyopathy[source] Alcoholic cardiomyopathy is a disease in which the chronic long-term abuse of alcohol (i.e., ethanol) leads to heart failure. [source]
  • Dilated Cardiomyopathy What causes dilated cardiomyopathy[source] How common is dilated cardiomyopathy[source] What happens in dilated cardiomyopathy[source]
  • Edema In '08 - I was airlifted to a major hospital in Maine for Respiratory Failure and Pulmonary Edema - combined with Heart Failure because of smoking. [source] The more frequently he has episodes of Heart Failure, Pulmonary Edema - the more frequent the visits to the ER - and the more stress on his heart because of this abuse................he is on the slippery slope - to death. ************ Tell us what medications [source] Therefore, a clinical picture develops secondary to CHF and pulmonary edema[source]
  • Left Ventricular Hypertrophy Electrocardiography (ECG) This study identifies structural changes such as left ventricular hypertrophy  and any present arrhythmias.  [source] Electrocardiogram Can have a variety of ECG abnormalities, the most common left ventricular hypertrophy with ST-T abnormalities, also see low voltage, atrial fibrillation, ventricular premature contraction, atrial contraction, atrioventricular block and [source] ventricular hypertrophy with isolated diastolic dysfunction and preserved systolic function, as assessed by conventional echocardiographic techniques. [source]
  • Myocardial Fibrosis rquez A. 201125 Tenascin-x facilitates myocardial fibrosis and cardiac remodeling through transforming growth factor-I 1 and peroxisome proliferator-activated receptor I in alcoholic cardiomyopathy. ( 21362339 ) Jing L.... [source] The combination of myocyte injury and necrosis associated with myocardial fibrosis results in impaired mechanical function. [source] In valvular disease, excess hemodynamic demands result in myocyte hypertrophy, subsequent chamber enlargement, and myocardial fibrosis[source]
  • Nonsustained Ventricular Tachycardia Common abnormalities seen on Holter monitoring include premature ventricular complexes, premature atrial complexes, atrial fibrillation (either sustained or paroxysmal), nonsustained ventricular tachycardia, and first- or second-degree atrioventricular [source]
  • Pulmonary Edema In '08 - I was airlifted to a major hospital in Maine for Respiratory Failure and Pulmonary Edema - combined with Heart Failure because of smoking. [source] The more frequently he has episodes of Heart Failure, Pulmonary Edema - the more frequent the visits to the ER - and the more stress on his heart because of this abuse................he is on the slippery slope - to death. ************ Tell us what medications [source] Therefore, a clinical picture develops secondary to CHF and pulmonary edema[source]
  • Ventricular Tachycardia ., it turned out that frequency of atrial arrhythmias and also ventricular tachycardias does not differ significantly both in patients with idiopathic and alcoholic cardiomyopathy. [source] During that time there were 14 sudden deaths, 10 sustained ventricular tachycardias and ventricular fibrillation in 3 groups of patients, but the risk of sudden death and arrhythmias was comparable to the group of patients with idiopathic and alcoholic [source] Cardiac sarcoid is associated with ventricular tachycardia and conduction abnormalities (especially complete heart block) that can cause syncope and sudden cardiac death. [source]
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Etiology

As the name suggests, this type of cardiomyopathy is caused by alcohol. While there is no set amount of alcohol intake or duration of use correlated with the severity of the disease, asymptomatic alcoholics may exhibit cardiac changes if they use more than 90 grams of alcohol daily for a duration greater than 5 years. Furthermore, symptomatic patients have likely consumed excessive alcohol for a decade or more [2].

The heart is one of many organs affected by alcohol abuse as this substance is toxic to the myocardial cells. Specifically, alcoholic cardiomyopathy causes an impaired contractility [3] resulting in structural changes such as hypertrophy to accommodate the extra blood [4]. Furthermore, the cardiac dysfunction leads to a compensatory increase in blood pressure. The resultant hypertension produces damage to the myocardium, valves and blood vessels.

Epidemiology

ACM occurs in correlation with prolonged and high levels of alcohol intake. However, not all alcoholics develop this condition. The prevalence ranges from 23% to 40% [5]. 

The patient demographic demonstrates a gender preference with men accounting for 86% of all cases. Additionally, mortality is higher in men than women. With regards to race, death rates are greater in African Americans than white people [6]. 

ACM is implicated in approximately 3.8% of all cases of cardiomyopathy [6]. In fact, chronic alcohol abuse is the second most common etiology of dilated cardiomyopathy, a condition observed more in alcoholics than the general population. 

Sex distribution
Age distribution

Pathophysiology

The deterioration of the cardiac function in alcoholics is related to a complex pathophysiology.  In asymptomatic cases, there is cardiac dysfunction, but clinical manifestations such as dyspnea do not emerge until advanced disease. Structural changes have been noted in autopsies of chronic alcoholics without congestive heart failure [7]. 

In a study assessing chronic alcoholics without cardiac symptoms, echocardiography revealed abnormal left ventricular diastolic function with altered early and late diastolic filling velocity. These observations in the early stages of alcohol abuse have been corroborated in other investigations as well. Further findings demonstrate systolic dysfunction as indicated by a prolonged pre-ejection period (PEP) and a diminished left ventricular ejection time (LVET). Specifically, the elevated  PEP/LVET ratio reflects reduced myocardial function [8]. 

Gender variability has been demonstrated in a study evaluating carotid pulse measurements in asymptomatic ACM patients. Men exhibited changes in PEP and LVET while women did not. 

Long-term and heavy alcohol use in men makes them susceptible to arrhythmias and sudden cardiac death. The most frequent sequel in acute and chronic alcoholics is atrial fibrillation [9]. The pathogenesis of atrial fibrillation has not been fully established. It is believed that the weakened cardiac performance and rhythmicity resulting from alcoholism are likely secondary to multiple changes in cellular processes. 

Finally, dilated cardiomyopathy is a consequence of vitamin and nutritional deficiencies such as thiamine [10]. These are attributed to alcoholism. 

Prevention

The primary method of preventing ACM is by avoiding excessive consumption of alcohol. Patients should be educated on what constitutes moderate intake. They should also be counseled on signs of addiction and be made aware of all available resources.

With regards to preventing heart disease, patients should be educated about eating healthy, exercising, maintaining healthy weight, achieving glycemic control, and smoking cessation/abstinence. 

Summary

Alcoholic cardiomyopathy (ACM), a form of dilated cardiomyopathy, develops in individuals with chronic and heavy alcohol consumption [1]. The heart muscle becomes weak and this results in limited contractility and eventually cardiac failure. Other risk factors such as hypertension, smoking, and diabetes mellitus are typically present in these patients.

There are two stages of this disease which are asymptomatic and symptomatic. The pathophysiology involves a process of cardiovascular changes in which the heart pump function becomes diminished causing the compensatory heart enlargement to accommodate for the extra blood. Consequently, diastolic dysfunction is exhibited followed by systolic dysfunction and eventually congestive heart failure. The latter produces symptoms. In men, sudden cardiac death is a risk especially in the setting of fatal arrhythmias.

Diagnosis is achieved through obtaining the medical and social history, physical exam, laboratory studies, and cardiac imaging. The echocardiogram is very important as it provides information on the heart size and overall function. Other imaging techniques are also useful. 

Management involves cessation of alcohol and treatment of heart failure with standard medications such as vasodilators, digoxin, beta blockers, and diuretics. 

Early diagnosis and treatment may reverse the cardiac damage. Additionally, any patient exhibiting signs of alcoholism should prompt studies regarding vitamin deficiencies and electrolyte abnormalities. Also, other risk factors should be addressed and controlled. 

Patient Information

Alcoholic cardiomyopathy is a condition that results from drinking too much alcohol over years. The excessive alcohol causes toxic effects on the heart cells and, therefore, the muscle of the heart becomes too weak to pump blood efficiently. This means that the body receives less blood supply and hence experiences damage to organs and tissues. Over years of heavy abuse, the heart fails and the patients experience symptoms.

In the early stages of the disease, the patients do not have symptoms even though the heart undergoes structural changes. Once it becomes advanced, heart failure symptoms being to manifest. These include:

The diagnosis is determined when the clinician obtains the patient's history and performs a physical exam. Laboratory tests are also helpful. Additionally, imaging techniques such as an echocardiogram will provide beneficial information on the size of the heart, the function of the valves and the pumping function. An EKG will show abnormal heart rhythms (if present) and findings suggestive of an enlarged heart. A chest x-ray can show evidence of heart failure such as fluid buildup in the lungs. 

The main therapy is quitting alcohol and remaining abstinent. This is a challenging task but the patient should be provided with education, counseling, and resources to help. The treatment of heart failure includes medications such as ACE inhibitors, beta blockers, digoxin, diuretics, and others as needed. 

In cases with advanced cardiomyopathy, heart transplantation may be needed. 

Since alcoholics tend to have vitamin and electrolyte deficiencies, these should be treated promptly to help prevent further complications.

Self-assessment

References

  1. McKenna CJ, Codd MB, McCann HA, et al. Alcohol consumption and idiopathic dilated cardiomyopathy: a case control study. American Heart Journal. 1998; 135(5 Pt 1):833.
  2. Mathews EC, Gradin JM, Henry WL, et al. Echocardiographic abnormalities in chronic alcoholics with and without overt congestive heart failure. American Journal of Cardiology. 1981; 47(3):570-578.
  3. Sarma JS, Ikeda S, Fischer R, et al. Biochemical and contractile properties of heart muscle after prolonged alcohol administration. Journal of Molecular and Cellular Cardiology. 1976; 8(12):951–972.
  4. Kupari M, Koskinen P, Suokas A, et al. Left ventricular filling impairment in asymptomatic chronic alcoholics. American Journal of Cardiology. 1990; 66(20):1473–1477.
  5. Fauchier L, Babuty D, Poret P, et al. Comparison of longterm outcome of alcoholic and idiopathic dilated cardiomyopathy. European Heart Journal. 2000; 21(4):306–314.
  6. Hyattsville. Vital and Health Statistics. Department of Health and Human Services. Centers for Disease Control and Prevention. 1995; 13(122).
  7. Skinner HA, Holt S, Sheu WJ, et al. Clinical versus laboratory detection of alcohol abuse: the alcohol clinical index. British Medical Journal (Clinical Research Ed). 1986; 292(6537): 1703-1708.
  8. Levi GF, Quadri A, Ratti S, Basagni M. Preclinical abnormaltiy of left ventricular function in chronic alcoholics. British Heart Journal. 1977; 39: 35-37.
  9. Conen D, Tedrow UB, Cook NR, et al. Alcohol consumption and risk of incident atrial fibrillation in women. Journal of American Medical Association.2008; 300(21): 2489-2496.
  10. Klatsky AL. Alcohol and Cardiovascular Health. Integrative and Comparative Biology. 2004 August; 44(4):324-328.
  11. Wexler RK, Elton T, Pleister A, et al. Cardiomyopathy: an overview. American Family Physician. 2009; 79(9):778-84.
  12. Binham JD, Fredlund V. A case of dilated cardiomyopathy. Rural and Remote Health. 2012; 2143.
  13. Massin EK. Current Treatment of Dilated Cardiomyopathy Texas Heart Institute Journal. 1991; 18(1):41-49.
  14. Cheng CP, Cheng HJ, Cunningham C, Shihabi ZK, Sane DC, Wannenburg T, Little WC.  Angiotensin II type 1 receptor blockade prevents alcoholic cardiomyopathy. Circulation. 2006;114(3):226-36.

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  • Myocardial perfusion patterns in patients with severe left ventricular dysfunction: differences between patients with primary cardiomyopathy, chronic coronary artery - AS Iskandrian, A Hakki, S Kane - American heart journal, 1986 - Elsevier
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