When should alcohol cardiomyopathy be suspected?

All patients with dilated cardiomyopathy should be asked about alcohol consumption. In addition, macrocytosis is a good indicator of chronic alcohol abuse, even when liver function tests are normal. Susceptibility to the adverse effects of alcohol on the heart is apparently individual. Susceptibility is demonstrated by the presence of immunoglobin A on the sarcolemma and muscle of small blood vessels at biopsy of patients with alcoholic cardiomyopathy.

Does the type of alcoholic drink influence the effect on the heart?

No. Studies show no difference in the abnormalities observed in patients using predominantly wine, beer, or whiskey. Moreover, no consistent pattern of drinking is associated with heart failure. Possible additives in home brew and/or moonshine alcoholic substances may cause additional toxic damage.

Describe the presentation of patients who develop myocardial damage secondary to chronic alcoholism.

Alcohol abuse causes the diffuse myocardial damage seen in other primary myocardial diseases. However, fewer than one-half of patients present with symptoms of congestive heart failure (CHF), whereas in other primary myocardial diseases CHF is the predominant feature. A significant number of patients with alcoholic cardiomyopathy present with arrhythmias and chest pain.

Are specific electrocardiographic (ECG) changes associated with alcoholic cardiomyopathy?

The ECG of patients with alcohol cardiomyopathy may be normal or display nonspecific changes. As disease of the ventricle progresses, poor R wave progression is common, reflecting conduction delay. In addition, enlargement of the left ventricle and left and/or right atrium is common, whereas left or right bundle branch block is seen in 10% of patients.

What common arrhythmias are associated with alcohol ingestion?

Supraventricular arrhythmias predominate in patients without overt cardiomyopathy and in patients with acute intoxication; atrial fibrillation is the most prominent. The etiology appears to be moderate delays in conduction, which cause acute arrhythmias or holiday heart. Acute arrhythmias are seen in heavy, binge drinking, in chronic abuse, or in special circumstances (e.g., prolonged sleeplessness) without chronic abuse. The risk of supraventricular arrhythmias with 6 or more drinks/day is increased by 2.6.

Are the arrhythmias seen during withdrawal the same as acute intoxication arrhythmias?

During withdrawal concentrations of plasma catecholamines are high, and patients may have frequent ventricular ectopy. Ventricular ectopy may help to explain the sudden deaths in young and middle-aged alcoholics without coronary artery disease. The threshold for ventricular fibrillation is reduced, and moderate alcohol levels suggest a declining blood level at the time of cardiac arrest.

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