From Pages to Practice
Chris is a 60-year-old man who visits his primary care physician for an annual physical examination. He has a history of hypertension and paroxysmal atrial fibrillation and takes daily beta-blockers. Since turning 60, Chris has made lifestyle changes, including exercising regularly and improving his diet. Chris’s primary care physician asks about alcohol intake and he reveals he drinks two cans of beer every day.
The harmful effects of alcohol on the body are well known, especially regarding its effects on the liver. Alcohol consumption is also associated with cardiovascular disease, including a strong dose-dependent correlation with incident atrial fibrillation that is not widely appreciated. Management of atrial fibrillation focuses on the prevention of stroke and treatment of the underlying arrhythmia. In addition to medical treatment, weight reduction is another lifestyle modification that can reduce symptom burden in patients with atrial fibrillation.
In a recent randomized-controlled trial published in NEJM, abstinence from alcohol reduced arrhythmia recurrences in patients with atrial fibrillation. The study included 140 regular alcohol drinkers in Australia who were advised to either abstain completely from alcohol or continue consuming alcohol as usual. Although the results indicate that alcohol consumption is another modifiable risk factor in the management of atrial fibrillation, an editorialist notes limitations of the study population due to moderate-to-heavy baseline alcohol consumption and a low burden of atrial fibrillation. In patients such as Chris, modifying alcohol intake is another strategy to help manage atrial fibrillation.
The following NEJM Journal Watch summary explains the study and results in more detail.
Harlan M. Krumholz, MD, SM reviewing Voskoboinik A et al. N Engl J Med 2020 Jan 2 Gillis AM. N Engl J Med 2020 Jan 2
Epidemiological studies report a dose-dependent association between alcohol consumption and the risk for atrial fibrillation (AF) and even for AF recurrence after ablation. Australian investigators randomized 140 patients in sinus rhythm who routinely consumed ≥10 alcoholic drinks weekly, who previously had ≥2 AF episodes, and who were without alcohol use disorder to undergo alcohol abstinence or to consume alcohol per usual (ACTRN12616000256471). The patients were using rhythm control strategies with no planned ablations (mean age, 62; 85% men).
Participants had implantable pacemakers or cardiac rhythm management devices and transmitted electrocardiogram tracings twice daily. The time since the first AF diagnosis was 6.9 years in the abstinence group and 4.9 years in the control group. The two groups had similar use of antiarrhythmic medications. Mean baseline number of drinks weekly was 16.8 in the abstinence group and 16.4 in the control group. Binge drinking (≥5 drinks on one occasion at least monthly) occurred in 29% and 23%, respectively.
The abstinence group reduced its mean intake to 2.1 drinks weekly (control group, 13.2 drinks weekly); 61% achieved complete abstinence. After 2 weeks of stabilization, recurrence of AF lasting >30 seconds occurred in 53% of the abstinence group and 73% of the control group over 6 months, with abstinence showing a significantly longer time to recurrence (hazard ratio, 0.55). Median time in AF was significantly lower in the abstinence group (0.5% vs. 1.2%). Hospital admissions for AF occurred in 9% and 20%, respectively. The abstinence group had better symptom scores.
Comment: This remarkable study, while small, shows a big effect of an abstinence strategy on AF. The editorialist considered this to be a “compelling argument” for an abstinence strategy in AF management. Unless it is proven otherwise, I now consider this to be a strong evidence-based lifestyle recommendation for these patients.