Association between clinically recorded alcohol consumption and initial presentation of 12 cardiovascular diseases: population based cohort study using linked health records
To investigate the association between alcohol consumption and cardiovascular disease at higher resolution by examining the initial lifetime presentation of 12 cardiac, cerebrovascular, abdominal, or peripheral vascular diseases among five categories of consumption.
Population based cohort study of linked electronic health records covering primary care, hospital admissions, and mortality in 1997-2010 (median follow-up six years).
CALIBER (Clinical research using Linked Bespoke studies and Electronic health Records).
1 937 360 adults (51% women), aged ≥30 who were free from cardiovascular disease at baseline.
Main outcome measures
12 common symptomatic manifestations of cardiovascular disease, including chronic stable angina, unstable angina, acute myocardial infarction, unheralded coronary heart disease death, heart failure, sudden coronary death/cardiac arrest, transient ischaemic attack, ischaemic stroke, intracerebral and subarachnoid haemorrhage, peripheral arterial disease, and abdominal aortic aneurysm.
114 859 individuals received an incident cardiovascular diagnosis during follow-up. Non-alcohol use was associated with an increased risk of unstable angina (hazard ratio 1.33, 95% confidence interval 1.21 to 1.45), myocardial infarction (1.32, 1.24 to1.41), unheralded coronary death (1.56, 1.38 to 1.76), heart failure (1.24, 1.11 to 1.38), ischaemic stroke (1.12, 1.01 to 1.24), peripheral arterial disease (1.22, 1.13 to 1.32), and abdominal aortic aneurysm (1.32, 1.17 to 1.49) compared with moderate alcohol intake (consumption within contemporaneous UK weekly/daily guidelines of 21/3 and 14/2 units for men and women, respectively).
Heavy alcohol use (exceeding guidelines) conferred an increased risk of presenting with unheralded coronary death (1.21, 1.08 to 1.35), heart failure (1.22, 1.08 to 1.37), cardiac arrest (1.50, 1.26 to 1.77), transient ischaemic attack (1.11, 1.02 to 1.37), ischaemic stroke (1.33, 1.09 to 1.63), intracerebral haemorrhage (1.37, 1.16 to 1.62), and peripheral arterial disease (1.35; 1.23 to 1.48), but a lower risk of myocardial infarction (0.88, 0.79 to 1.00) or stable angina (0.93, 0.86 to 1.00).
Heterogeneous associations exist between level of alcohol consumption and the initial presentation of cardiovascular diseases. This has implications for counselling patients, public health communication, and clinical research, suggesting a more nuanced approach to the role of alcohol in prevention of cardiovascular disease is necessary.
What is already known about the topic
Moderate alcohol consumption is thought to be associated with a lower risk of developing cardiovascular disease compared with abstinence or heavy alcohol intake. There are ongoing debates about the role of combining different types of current non-alcohol users in producing this apparent protective effect. Specifically, former or occasional alcohol users might have reduced or ceased alcohol consumption because of ill health, making the aggregated non-alcohol using group artificially seem to have a higher risk of cardiovascular disease and mortality
Less is known about the role of alcohol consumption in the aetiology of specific cardiovascular diseases; where studies exist they are often few in number, small in size, have combined different types of non-alcohol users, and have not excluded all forms of cardiovascular disease before the primary event.
Added value of this study
This large scale study of 1.93 million adults without cardiovascular disease at baseline showed that moderate alcohol use is associated with a lower risk of initial presentation with several, but not all, cardiovascular diseases, even after separation of groups of non-alcohol users.
Though higher levels of alcohol intake are associated with a lower risk of initial presentation with myocardial infarction, this is off set by heavier alcohol users having a greater risk of initially presenting with several other cardiovascular diseases as well as mortality from non-cardiovascular causes.
Data on clinically recorded alcohol consumption can be validly used in research and practice.