Have you ever had a cold beer after a mountain bike ride?

Oh my!

But does such indulgence put one at risk for an arrhythmia? Does alcohol exacerbate an existing arrhythmia? How much, if any, alcohol is acceptable?

These are questions I am asked frequently.  And for those asking, they are very important questions.

I wish the answer was straightforward.  But it is not.

Undoubtedly, excessive alcohol can precipitate an abnormal rhythm.  Look no farther than the well known “holiday heart” syndrome.  It is a not uncommon that a seemingly normal individual can develop atrial fibrillation after partaking in excessive alcohol consumption.

Although it is clear that binge drinking can precipitate AF, it is also known that individuals vary in their susceptibility to alcohol.  Some patients develop arrhythmia after only one drink. We do not understand why this is, just that it is.

As said concisely by DrRich,

Patients who have episodes of paroxysmal atrial fibrillation should carefully examine whether the episodes seem in any way to be related to alcohol consumption. And doctors who treat patients with this condition should be careful to ask about even minor exposure to alcohol. Making the proper diagnosis may spare the patient from inappropriate treatments.

Conflicts

Patients who ask about alcohol intake are most often conflicted.  They hate the idea that their heart is under duress, but forever giving up a beer, a glass of wine, or a cocktail is equally troublesome.

Also, most patients have read conflicting stories on alcohol and heart disease.  We have all heard the notion that the French have less heart disease because of red wine consumption. However, just because two facts are true does not mean they are related. For instance, maybe the French have less heart disease because as a whole they are thinner and they walk much more than the average American.

Doctors are conflicted as well.  The data are not entirely clear.  We know life is short, and since it is generally agreed that alcohol used in moderation is not detrimental, it is hard for us to tell a patient, “yes, that’s it, no more beer or wine for you, forever.”  On the other hand, we are keenly aware of the devastating effects of alcohol overuse.

Living in a state with “dry” counties highlights the moral conflicts of alcohol.  Even though alcohol use is legal, telling patients to stop drinking is not like telling them to quit donuts. A patient has to judge whether a doctor is telling me to stop drinking for moral or medical reasons?

How may alcohol cause AF?

In most new cases of AF, or AF associated with normal hearts, there are specific sites in the atrium which act as triggers–call them initiators.  These sites are often within muscle bundles of the pulmonary veins. (Hence the success of pulmonary vein isolation.)

These nests of irritable cells begin firing for a reason.  In normal hearts particularly, such triggering begins “out of the blue,” often with no easily identifiable reasons.   For some, even small amounts of alcohol can induce firing of these trigger sites.

How alcohol affects the heart is highly varied and the exact mechanisms remain obscure. Along with alcohol’s propensity to induce AF trigger sites, it also induces both an “on alert” state of high adrenaline, as well as impaired sleep.  All these effects create a vulnerable state that favors AF. 

What do I tell patients?

Drinking alcohol is not likely to enhance health.  Used in moderation, it may be neutral, but barely.  The ninety-year old that you know is not likely ninety because of her nightly bourbon habit.

Alcohol is clearly associated with AF.  The threshold amount of alcohol is not known.  A recent study in women suggests that more than two drinks daily is associated with an increased risk of AF.  This is but one study; clearly individuals vary in their susceptibility to alcohol.

Before embarking on potentially toxic AF drugs or an invasive ablation procedure, a trial of abstinence from alcohol seems to be a good idea. (As well as other important lifestyle modifications, like improved sleep and stress reduction.)   If cessation of alcohol intake eliminates or reduces AF episodes, then the answer is obvious.  A delicate choice awaits: alcohol or AF.  I know, it stinks to have to choose.

Here’s a tough question, for thought provoking reasons only

Is it reasonable to do a 50,000 dollar ablation on a patient with AF whose disease could be controlled with lifestyle modifications?  For example, what if alcohol cessation (along with improved sleep and stress reduction) quiets the pulmonary vein triggers, but the patient chooses to persist in consuming alcohol?  Let’s say for the sake of argument, not an excessive amount.  Should a complex, expensive and risky ablation be performed?

To answer this question, we may look to other parallel scenarios for help.  Like the patient with vascular disease who continues to smoke.  In American healthcare, this patient is not denied stents, or bypass surgeries.  Or the obese patient who chooses to keep consuming excessive calories.  We offer them laproscopic banding surgery.  The list goes on and on.

Since I live in the same glass house as my patients, I will not heave the stone too far.  I understand the dilemma.  That pesky gastroesophageal reflux of mine would surely improve with less coffee.  But this has proven a difficult choice thus far.

Choices. Facts.

That’s the point.

John Mandrola is a cardiologist who blogs at Dr John M.

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