Abstract
Evaluation of: Beulens JW, Rimm EB, Ascherio A, Spiegelman D, Hendriks HF, Mukamal KJ. Alcohol consumption and risk for coronary heart disease among men with hypertension. Ann. Intern. Med. 146(1), 10–19 (2007).
Beulens and colleagues evaluated 11,711 men with hypertension in a cohort study and found that moderate alcohol consumption was associated with a decreased risk of myocardial infarction in comparison with subjects who abstained from alcohol consumption. There were no significant differences in death from all causes, death due to cardiovascular disease, total stroke events and ischemic stroke between the two groups.
Moderate alcohol consumption is inversely associated with cardiovascular disease (CVD) and death from all causes. However, intake of more than 30 g of alcohol (i.e., more than two drinks) per day is associated with an increased risk of hypertension. These contradictions may reflect the paucity of information on the relationship between alcohol consumption and risk for CVD among patients with hypertension.
Methods & results
The Health Professionals Follow-up Study (HPFS), a prospective cohort of male health professionals in the USA, followed 51,529 male dentists, veterinarians, optometrists, pharmacists, osteopathic physicians and podiatrists who were 40–75 years of age and who returned a mailed questionnaire regarding their diet and medical history in 1986. Follow-up questionnaires were sent biennially to update information on exposures and newly diagnosed illnesses.
In this 16-year prospective study, 11,711 male health professionals with hypertension reported their average alcohol consumption every 4 years. Compared with men who abstained from alcohol, men who consumed 5.0–9.9, 10.0–14.9, 15.0–29.9, 30.0–49.9 and 50.0 g/day or more of alcohol had decreased risk for myocardial infarction (MI) (hazard ratio [HR] [95% confidence interval (CI)]: 0.75 [0.56–0.99]; 0.65 [0.49–0.86]; 0.65 [0.49–0.86]; 0.60 [0.44–0.82]; and 0.40 [0.22–0.74], respectively). After adjustment for other risk factors, the decreased risk of MI remained significant (alcohol consumption: HR [95% CI], 10.0–14.9 g/day: 0.68 [0.51–0.91]; 15.0–29.9 g/day: 0.72 [0.54–0.97]; 30.0–49.9 g/day: 0.67 [0.48–0.94]; >50.0 g/day: 0.41 [0.22–0.77]).
Conversely, there were no significant differences in death from all causes, death due to CVD, total stroke events and ischemic stroke with alcohol consumption Citation[1].
Discussion & significance
In this prospective analysis of 11,711 men with hypertension, alcohol consumption was associated with a decreased risk for fatal and nonfatal MI but not for death from all causes or death due to CVD. The associations of total and ischemic stroke with moderate alcohol consumption were indeterminate because there were so few cases of stroke.
No previous studies assessed whether alcohol consumption changed after diagnosis of hypertension and, if so, whether this influenced the relationship with death due to CVD. In this analysis, the inverse association with alcohol consumption was similar for fatal and nonfatal events. Kiyohara and colleagues observed a slightly lower risk for ischemic stroke for those who consumed less than 34 g of alcohol per day and an increased risk for those who consumed 34 g or more of alcohol per day in a Japanese general population that had a higher incidence of clinical stroke events than MI events Citation[2]. Limitation of the present study is that alcohol intake and hypertension were self-reported. Few outcomes limited ability to determine precise relationships between alcohol and stroke in the present study.
Expert commentary & conclusion
In this sample of male health professionals, moderate alcohol consumption was associated with a decreased risk for MI among men with hypertension to a degree similar to that of men without hypertension. Despite this, alcohol consumption was not associated with death from all causes or death due to CVD. Recommendations regarding alcohol consumption depend on the individual characteristics of patients with hypertension but, as in the general population, men with hypertension who drink moderately and safely may not need to change their drinking habits.
The relationship between alcohol drinking and hypertension is complicated. Regular alcohol drinking is reported to reduce evening blood pressure level and increase morning blood pressure level, and differences between morning and evening blood pressure increase Citation[3]. Recent data demonstrated that morning blood pressure level has a stronger predictive power for cardiovascular mortality than clinic blood pressure level Citation[4], and morning blood pressure surge is also reported with increased risk for clinical stroke events Citation[5]. In addition, regular alcohol drinkers have an increased risk of masked morning hypertension Citation[6] and masked hypertension is reported to increase the risk of cardiovascular events Citation[7]. Blood pressure variabilities induced by alcohol consumption are reported to be associated with an increased risk for cardiovascular events. The reduction of cardiovascular events by moderate alcohol consumption may be derived from mechanisms other than blood pressure. Mechanisms by which moderate alcohol consumption reduces MI should be clarified.
Five-year view
Moderate alcohol consumption is beneficial to reduce MI; however, this does not indicate that all subjects should drink alcohol. Who should drink alcohol and who should not among hypertensives? Diagnosis of hypertension is usually based on clinic blood pressure; however, over the next 5 years we may need to perform studies using home blood pressure monitoring and/or ambulatory blood pressure monitoring in order to clarify the relationship between alcohol consumption and hypertension to cardiovascular events.
Key issues
| • | Alcohol consumption reduces coronary heart disease among men with hypertension. | ||||
| • | There was no significant difference in total stroke events between alcohol drinkers and nondrinkers. | ||||
| • | Diurnal blood pressure change in alcohol drinking is not evaluated in this study. | ||||
| • | The mechanisms by which alcohol consumption reduces coronary heart disease is not clear. | ||||
References
- Beulens JWJ, Rimm EB, Ascherio A, Spiegelman D, Hendriks HF, Mukamal KJ. Alcohol consumption and risk for coronary heart disease among men with hypertension. Ann. Intern. Med.146, 10–19 (2007).
- Kiyohara Y, Kato I, Iwamoto H et al. The impact of alcohol and hypertension on stroke incidence in a general Japanese population: the Hisayama Study. Stroke26, 368–372 (1995).
- Ishikawa J, Kario K, Hoshide S et al. Determinants of exaggerated difference in morning and evening blood pressure measured by self-measured blood pressure monitoring in medicated hypertensive patients: Jichi Morning Hypertension Research (J-MORE) Study. Am. J. Hypertens.18, 958–965 (2005).
- Ohkubo T, Imai Y, Tsuji I et al. Home blood pressure measurement has a stronger predictive power for mortality than does screening blood pressure measurement: a population-based observation in Ohasama, Japan. J. Hypertens.16, 971–975 (1998).
- Kario K, Pickering TG, Umeda Y et al. Morning surge in blood pressure as a predictor of silent and clinical cerebrovascular disease in elderly hypertensives: a prospective study. Circulation107, 1401–1406 (2003).
- Ishikawa J, Eguchi K, Morinari M et al. Regular alcohol drinking is a determinant of masked morning hypertension detected by home blood pressure monitoring in medicated hypertensive patients with well-controlled clinic blood pressure: the Jichi Morning Hypertension Research (J-MORE) study. Hypertens. Res.29, 679–686 (2006).
- Bobrie G, Chatellier G, Genes N et al. Cardiovascular prognosis of “masked hypertension” detected by blood pressure self-measurement in elderly treated hypertensive patients. JAMA291, 1342–1349 (2004).