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Alcohol and Cardiovascular Health: The Dose Makes the Poison…or the Remedy

      Abstract

      Habitual light to moderate alcohol intake (up to 1 drink per day for women and 1 or 2 drinks per day for men) is associated with decreased risks for total mortality, coronary artery disease, diabetes mellitus, congestive heart failure, and stroke. However, higher levels of alcohol consumption are associated with increased cardiovascular risk. Indeed, behind only smoking and obesity, excessive alcohol consumption is the third leading cause of premature death in the United States. Heavy alcohol use (1) is one of the most common causes of reversible hypertension, (2) accounts for about one-third of all cases of nonischemic dilated cardiomyopathy, (3) is a frequent cause of atrial fibrillation, and (4) markedly increases risks of stroke—both ischemic and hemorrhagic. The risk-to-benefit ratio of drinking appears higher in younger individuals, who also have higher rates of excessive or binge drinking and more frequently have adverse consequences of acute intoxication (for example, accidents, violence, and social strife). In fact, among males aged 15 to 59 years, alcohol abuse is the leading risk factor for premature death. Of the various drinking patterns, daily low- to moderate-dose alcohol intake, ideally red wine before or during the evening meal, is associated with the strongest reduction in adverse cardiovascular outcomes. Health care professionals should not recommend alcohol to nondrinkers because of the paucity of randomized outcome data and the potential for problem drinking even among individuals at apparently low risk. The findings in this review were based on a literature search of PubMed for the 15-year period 1997 through 2012 using the search terms alcohol, ethanol, cardiovascular disease, coronary artery disease, heart failure, hypertension, stroke, and mortality. Studies were considered if they were deemed to be of high quality, objective, and methodologically sound.

      Abbreviations and Acronyms:

      AF (atrial fibrillation), BP (blood pressure), CAC (coronary artery calcium), CAD (coronary artery disease), CV (cardiovascular), DM (diabetes mellitus), HDL (high-density lipoprotein), HF (heart failure), HTN (hypertension), MI (myocardial infarction)
      It is true, that even then, it was known and acknowledged, that many were greatly injured by it; but none seemed to think the injury arose from the use of a bad thing, but from the abuse of a very good thing.Abraham Lincoln
      • Lincoln A.
      Temperance Address, February 22, 1842.
      Article Highlights
      • Habitual light to moderate alcohol intake is associated with lower rates of death, coronary artery disease, diabetes mellitus, congestive heart failure, and stroke.
      • Excessive alcohol intake is the third leading cause of premature death in the United States; alcohol abuse is the single strongest risk factor for premature death among males aged 15 to 59 years.
      • Excessive alcohol consumption, in a dose-dependent fashion, commonly causes both reversible hypertension and atrial fibrillation and accounts for one-third of all cases of nonischemic dilated cardiomyopathy.
      • The risk-to-benefit ratio of light to moderate drinking is more favorable for people older than age 50 compared with those younger than age 50.
      • The ideal drinking pattern for reducing risk of adverse cardiovascular outcomes is daily consumption of one 5- to 6-oz glass of red wine immediately before or during the evening meal.
      • The cardioprotective effects of light to moderate drinking have not been apparent in most epidemiological studies of populations from India and China.
      • People who abstain from alcohol should not be advised to begin light to moderate drinking because of the paucity of randomized outcome data and the potential for escalation into problem drinking.
      The consumption of alcohol (specifically ethanol), which is commonly referred to as “drinking,” has been an integral part of many cultures since the beginning of recorded human history. Yet, alcohol is analogous to the proverbial double-edged sword: perhaps no other health or lifestyle factor can cut so deeply in either direction—toxic or beneficial—depending on how it is used. According to the World Health Organization, alcohol kills approximately 2.5 million people each year worldwide, causing 4% of all deaths—more than violence, AIDS, or tuberculosis.
      World Health Organization Management of Substance Abuse Team
      Global Status Report on Alcohol and Health.
      The harmful use of alcohol is the world's leading risk factor for death among males between ages 15 and 59 years, mainly due to injuries, violence, and cardiovascular (CV) diseases.
      World Health Organization Management of Substance Abuse Team
      Global Status Report on Alcohol and Health.
      Excessive drinking has been linked to cirrhosis, seizures, stroke, poisonings, accidents, violence, and many malignancies including cancers of the colon and rectum, breast, larynx, and liver.
      World Health Organization Management of Substance Abuse Team
      Global Status Report on Alcohol and Health.
      The yearly health care and economic costs associated with alcohol are staggering, exceeding $234 billion in the United States alone.
      • Rehm J.
      • Mathers C.
      • Popova S.
      • Thavorncharoensap M.
      • Teerawattananon Y.
      • Patra J.
      Global burden of disease and injury and economic cost attributable to alcohol use and alcohol-use disorders.
      In stark contrast to the devastation wrought by excessive alcohol consumption are the benefits associated with light to moderate drinking, including substantial reductions in CV disease—the leading cause of death in the United States.
      • Heidenreich P.A.
      • Trogdon J.G.
      • Khavjou O.A.
      • et al.
      American Heart Association Advocacy Coordinating CommitteeStroke CouncilCouncil on Cardiovascular Radiology and InterventionCouncil on Clinical CardiologyCouncil on Epidemiology and PreventionCouncil on ArteriosclerosisThrombosis and Vascular BiologyCouncil on Cardiopulmonary, Critical Care, Perioperative and ResuscitationCouncil on Cardiovascular NursingCouncil on the Kidney in Cardiovascular DiseaseCouncil on Cardiovascular Surgery and Anesthesia; and Interdisciplinary Council on Quality of Care and Outcomes Research
      Forecasting the future of cardiovascular disease in the United States: a policy statement from the American Heart Association.
      Responsible habitual alcohol use also appears to be linked to lower risks for diabetes mellitus (DM), stroke, heart failure (HF), and total mortality.
      • O'Keefe J.H.
      • Bybee K.A.
      • Lavie C.J.
      Alcohol and cardiovascular health: the razor-sharp double-edged sword.
      The purposes of this review article are to (1) outline the CV risks and benefits associated with alcohol, (2) detail the mechanisms of action whereby alcohol confers protection and/or causes harm, and (3) make recommendations regarding ideal drinking patterns, beverages, and quantities for maximizing the likelihood of benefit while minimizing the risk of harm from alcohol consumption. The findings in this review were based on a literature search of PubMed for the 15-year period 1997 through 2012 using the search terms alcohol, ethanol, cardiovascular disease, coronary artery disease, heart failure, hypertension, stroke, and mortality. Studies were considered if they were deemed to be of high quality, objective, and methodologically sound.

      Americans’ Drinking Habits

      Among all American adults, about two-thirds report that they at least on occasion consume alcohol, and 44% are regular drinkers, defined as someone who has at least 1 drink per week.

      Saad L. Majority in U.S. drink alcohol, averaging four drinks a week: beer edges out wine by 39% to 35% as drinkers' beverage of choice. GALLUP Well-Being website. http://www.gallup.com/poll/156770/majority-drink-alcohol-averaging-four-drinks-week.aspx. Published August 17, 2012. Accessed October 18, 2013.

      These regular drinkers consume an average of 4.2 alcoholic drinks per week. While a similar proportion of men and women consume alcohol, men on average ingest 6.2 alcoholic beverages per week compared with 2.2 drinks per week for women. Whites are more likely to consume alcohol than nonwhites, and on average, white drinkers also consume more drinks—4.5 per week compared with 3.3 among nonwhites.

      Saad L. Majority in U.S. drink alcohol, averaging four drinks a week: beer edges out wine by 39% to 35% as drinkers' beverage of choice. GALLUP Well-Being website. http://www.gallup.com/poll/156770/majority-drink-alcohol-averaging-four-drinks-week.aspx. Published August 17, 2012. Accessed October 18, 2013.

      The favorite drink for men is beer, whereas most women prefer wine. One in 5 drinkers admits to sometimes ingesting too much alcohol, with rates of excessive drinking higher among men and younger adults.

      Saad L. Majority in U.S. drink alcohol, averaging four drinks a week: beer edges out wine by 39% to 35% as drinkers' beverage of choice. GALLUP Well-Being website. http://www.gallup.com/poll/156770/majority-drink-alcohol-averaging-four-drinks-week.aspx. Published August 17, 2012. Accessed October 18, 2013.

      What Constitutes a Drink?

      By definition, a standard drink, regardless of the variety, contains 14 g of ethanol (0.6 fl oz of pure alcohol).

      Rethinking drinking: alcohol and your health. National Institutes of Health, National Institute on Alcohol Abuse and Alcoholism website. http://rethinkingdrinking.niaaa.nih.gov/toolsresources/DrinkSizeCalculator.asp. Accessed October 18, 2013.

      MyDrinkaware: alcohol unit and calorie calculator. Drinkaware website. www.drinkaware.co.uk. Published 2012. Accessed October 18, 2013.

      This equates to 12 oz of beer (about 5% ethanol), 5 oz of table wine (about 12% ethanol), or 1.5 oz of hard liquor or distilled spirits (about 40% ethanol).

      Rethinking drinking: alcohol and your health. National Institutes of Health, National Institute on Alcohol Abuse and Alcoholism website. http://rethinkingdrinking.niaaa.nih.gov/toolsresources/DrinkSizeCalculator.asp. Accessed October 18, 2013.

      MyDrinkaware: alcohol unit and calorie calculator. Drinkaware website. www.drinkaware.co.uk. Published 2012. Accessed October 18, 2013.

      Alcohol consumption can also be quantitated in units, whereby 1 U equals 10 mL or 8 g of ethanol, which corresponds to the amount of alcohol an average adult can metabolize in 1 hour. Thus, for example, 25 mL of whiskey, or 6 oz of beer, or one-half of a standard (5-6 oz) glass of wine would each contain about 1 U of alcohol.

      Rethinking drinking: alcohol and your health. National Institutes of Health, National Institute on Alcohol Abuse and Alcoholism website. http://rethinkingdrinking.niaaa.nih.gov/toolsresources/DrinkSizeCalculator.asp. Accessed October 18, 2013.

      MyDrinkaware: alcohol unit and calorie calculator. Drinkaware website. www.drinkaware.co.uk. Published 2012. Accessed October 18, 2013.

      Primary Prevention

      The health effects of drinking are determined by the quantity and pattern of ethanol consumption.
      • O'Keefe J.H.
      • Bybee K.A.
      • Lavie C.J.
      Alcohol and cardiovascular health: the razor-sharp double-edged sword.
      Observational studies consistently report that light to moderate drinkers are at lower risk for CV diseases than abstainers, and heavy drinkers are at the highest risk. A meta-analysis involving 1 million individuals reported that light to moderate alcohol consumption was associated with highly significant decreases in death during follow-up, with maximum protection noted at one-half to 1 drink daily for women (18% decrease in total mortality; 99% CI, 13%-22%).
      • Di Castelnuovo A.
      • Costanzo S.
      • Bagnardi V.
      • Donati M.B.
      • Iacoviello L.
      • de Gaetano G.
      Alcohol dosing and total mortality in men and women: an updated meta-analysis of 34 prospective studies.
      For men, maximal benefit was seen at 1 to 2 drinks daily, with a total mortality decrease of 17% (95% CI, 15%-19%) (Figure 1). However, intakes above 2.5 drinks per day in women and 4 drinks per day in men were associated with progressively higher death rates in a dose-dependent relationship. In another large and statistically rigorous study of 245,000 US adults, alcohol intakes of both light (3 drinks per week or less) and moderate (4 to 7 drinks per week for women, 4 to 14 drinks per week for men) levels were associated with lower CV mortality compared with either heavy users (>7 drinks per week in women or >14 drinks per week in men) or lifetime abstainers (Figure 2).
      • Mukamal K.J.
      • Chen C.M.
      • Rao S.R.
      • Breslow R.A.
      Alcohol consumption and cardiovascular mortality among U.S. adults, 1987 to 2002.
      Figure thumbnail gr1
      Figure 1Alcohol intake and total mortality.
      Data from Arch Intern Med.
      • Di Castelnuovo A.
      • Costanzo S.
      • Bagnardi V.
      • Donati M.B.
      • Iacoviello L.
      • de Gaetano G.
      Alcohol dosing and total mortality in men and women: an updated meta-analysis of 34 prospective studies.
      Figure thumbnail gr2
      Figure 2Adjusted risks for cardiovascular (CV) disease as a function of alcohol intake. CHD = coronary heart disease; HR = hazard ratio. Error bars indicate 95% CIs.
      Data from Journal of the American College of Cardiology.
      • Mukamal K.J.
      • Chen C.M.
      • Rao S.R.
      • Breslow R.A.
      Alcohol consumption and cardiovascular mortality among U.S. adults, 1987 to 2002.
      The risk-benefit ratio of habitual moderate alcohol intake appears to be more favorable for middle-aged and older people compared with younger individuals. In a pooled analysis of 8 prospective studies from North America and Europe including 192,067 women and 74,919 men, an inverse association was found between alcohol intake and risk of coronary artery disease (CAD) events.
      • Hvidtfeldt U.A.
      • Tolstrup J.S.
      • Jakobsen M.U.
      • et al.
      Alcohol intake and risk of coronary heart disease in younger, middle-aged, and older adults.
      However, the absolute reductions in CAD were not clinically significant for people younger than 50 years of age (Figure 3). Additionally, in a cohort study of 2074 young (aged 25 to 39 years) healthy adults, the carotid intima-media thickness (a surrogate CV risk marker) increased directly in proportion to amount of alcohol ingested.
      • Juonala M.
      • Viikari J.S.
      • Kähönen M.
      • et al.
      Alcohol consumption is directly associated with carotid intima-media thickness in Finnish young adults: the Cardiovascular Risk in Young Finns Study.
      Younger individuals are at a much lower risk for CAD but are more likely to engage in excessive and/or binge drinking and accordingly are at higher risk of alcohol-related accidents, violence, and overdoses.
      World Health Organization Management of Substance Abuse Team
      Global Status Report on Alcohol and Health.
      • Rehm J.
      • Mathers C.
      • Popova S.
      • Thavorncharoensap M.
      • Teerawattananon Y.
      • Patra J.
      Global burden of disease and injury and economic cost attributable to alcohol use and alcohol-use disorders.
      Thus, the risks of regular drinking may outweigh the benefits for many younger men and women. In contrast, studies focusing on middle-aged and older individuals generally show larger absolute CV risk reductions associated with light to moderate drinking.
      • Rizzuto D.
      • Orsini N.
      • Qiu C.
      • Wang H.X.
      • Fratiglioni L.
      Lifestyle, social factors, and survival after age 75: population based study.
      Figure thumbnail gr3
      Figure 3Fully adjusted incidence rates of coronary artery disease according to age and alcohol intake.
      From Circulation,
      • Hvidtfeldt U.A.
      • Tolstrup J.S.
      • Jakobsen M.U.
      • et al.
      Alcohol intake and risk of coronary heart disease in younger, middle-aged, and older adults.
      with permission.
      The alcohol-related CAD benefit in primary prevention was also seen in low-risk men. In the Health Professionals Follow-Up Study, a subgroup of participants was identified as being at low risk for CAD by virtue of meeting all 4 of the following criteria: normal weight, physically active, being a nonsmoker, and eating a healthy diet (Figure 4).
      • Mukamal K.J.
      • Chiuve S.E.
      • Rimm E.B.
      Alcohol consumption and risk for coronary heart disease in men with healthy lifestyles.
      Another study reported that moderate alcohol intake was identified as the single strongest contributor to the longevity conferred by the traditional Mediterranean diet,
      • Trichopoulou A.
      • Bamia C.
      • Trichopoulos D.
      Anatomy of health effects of Mediterranean diet: Greek EPIC prospective cohort study.
      accounting for 25% of the total mortality benefit associated with the Mediterranean cuisine and being more important than vegetable intake, fruit and nut consumption, olive oil use, and fish intake.
      Figure thumbnail gr4
      Figure 4Alcohol intake and risk of myocardial infarction in 8867 middle-aged men already following healthy lifestyle recommendations.
      Adapted from Archives of Internal Medicine,
      • Mukamal K.J.
      • Chiuve S.E.
      • Rimm E.B.
      Alcohol consumption and risk for coronary heart disease in men with healthy lifestyles.
      with permission.

      Secondary Prevention

      Light to moderate alcohol intake has also been shown to improve outcomes in patients with established CV disease. In a recent meta-analysis of 8 prospective studies involving 16,351 patients with a history of CV disease, the familiar J-shaped curve was observed with maximal protection by alcohol at approximately 26 g/d (or about 2 drinks daily).
      • Costanzo S.
      • Di Castelnuovo A.
      • Donati M.B.
      • Iacoviello L.
      • de Gaetano G.
      Alcohol consumption and mortality in patients with cardiovascular disease: a meta-analysis.
      Studies evaluating alcohol’s effects on patients who have had a myocardial infarction (MI) also report the typical J-shaped relationship between drinking and adverse events or total mortality.
      • Marfella R.
      • Cacciapuoti F.
      • Siniscalchi M.
      • et al.
      Effect of moderate red wine intake on cardiac prognosis after recent acute myocardial infarction of subjects with Type 2 diabetes mellitus.
      • Carter M.D.
      • Lee J.H.
      • Buchanan D.M.
      • et al.
      Comparison of outcomes among moderate alcohol drinkers before acute myocardial infarction to effect of continued versus discontinuing alcohol intake after the infarct.
      A large study involving 45 US hospitals with a median follow-up of 3.8 years found a reduced risk-adjusted post-MI total mortality rate for patients who were drinkers before their MI when compared with nondrinkers.
      • Mukamal K.J.
      • Maclure M.
      • Muller J.E.
      • Sherwood J.B.
      • Mittleman M.A.
      Prior alcohol consumption and mortality following acute myocardial infarction.
      Light to moderate drinking has also been correlated with less atherosclerotic progression within coronary artery bypass grafts
      • Mukamal K.J.
      • Girotra S.
      • Mittleman M.A.
      Alcohol consumption, atherosclerotic progression, and prognosis among patients with coronary artery bypass grafts.
      and lower risk of peripheral arterial disease and its complications.
      • Camargo Jr., C.A.
      • Stampfer M.J.
      • Glynn R.J.
      • et al.
      Prospective study of moderate alcohol consumption and risk of peripheral arterial disease in US male physicians.
      • Athyros V.G.
      • Liberopoulos E.N.
      • Mikhailidis D.P.
      • et al.
      Association of drinking pattern and alcohol beverage type with the prevalence of metabolic syndrome, diabetes, coronary heart disease, stroke, and peripheral arterial disease in a Mediterranean cohort.
      • Vliegenthart R.
      • Geleijnse J.M.
      • Hofman A.
      • et al.
      Alcohol consumption and risk of peripheral arterial disease: the Rotterdam study.

      Alcohol and Arrhythmias

      Decades ago, the moniker “holiday heart” was suggested for acute cardiac arrhythmias, typically atrial fibrillation (AF), observed commonly in individuals drinking heavily during times of celebration.
      • Ettinger P.O.
      • Wu C.F.
      • De La Cruz Jr., C.
      • Weisse A.B.
      • Ahmed S.S.
      • Regan T.J.
      Arrhythmias and the “Holiday Heart”: alcohol-associated cardiac rhythm disorders.
      Unquestionably, heavy alcohol use, whether short-term or long-term, can precipitate arrhythmias.
      • Menezes A.R.
      • Lavie C.J.
      • DiNicolantonio J.J.
      • et al.
      Atrial fibrillation in the 21st century: a current understanding of risk factors and primary prevention strategies.
      In the Copenhagen City Heart Study, consumption of more than 35 drinks per week correlated with higher risk of AF in men.
      • Mukamal K.J.
      • Tolstrup J.S.
      • Friberg J.
      • Jensen G.
      • Grønbaek M.
      Alcohol consumption and risk of atrial fibrillation in men and women: the Copenhagen City Heart Study.
      Above a “safe” threshold of about 1 drink per day, the relative risk of AF increases approximately 10% for each drink per day (Figure 5).
      • Samokhvalov A.V.
      • Irving H.M.
      • Rehm J.
      Alcohol consumption as a risk factor for atrial fibrillation: a systematic review and meta-analysis.
      • Kodama S.
      • Saito K.
      • Tanaka S.
      • et al.
      Alcohol consumption and risk of atrial fibrillation: a meta-analysis.
      Figure thumbnail gr5
      Figure 5Dose-response relationship between alcohol consumption and risk of atrial fibrillation (AF). At 10 drinks/day, the risk of AF is doubled. Confidence interval is marked by dashes.
      Adapted from European Journal of Cardiovascular Prevention and Rehabilitation,
      • Samokhvalov A.V.
      • Irving H.M.
      • Rehm J.
      Alcohol consumption as a risk factor for atrial fibrillation: a systematic review and meta-analysis.
      with permission.
      Excessive alcohol intake, whether acutely from binge drinking or from long-term heavy drinking, can also occasionally stimulate ventricular arrhythmias and rarely even sudden cardiac death.
      • Di Castelnuovo A.
      • Costanzo S.
      • Bagnardi V.
      • Donati M.B.
      • Iacoviello L.
      • de Gaetano G.
      Alcohol dosing and total mortality in men and women: an updated meta-analysis of 34 prospective studies.
      • Albert C.M.
      • Manson J.E.
      • Cook N.R.
      • Ajani U.A.
      • Gaziano J.M.
      • Hennekens C.H.
      Moderate alcohol consumption and the risk of sudden cardiac death among US male physicians.
      The proarrhythmic effects of excessive alcohol consumption may be due to its tendency to cause QT interval prolongation and shortening of the atrial effective refractory period.
      • Rossinen J.
      • Sinisalo J.
      • Partanen J.
      • Nieminen M.S.
      • Viitasalo M.
      Effects of acute alcohol infusion on duration and dispersion of QT interval in male patients with coronary artery disease and in healthy controls.
      Acute alcohol intoxication and withdrawal are both associated with the development of hypomagnesemia and hypokalemia.
      • George A.
      • Figueredo V.M.
      Alcohol and arrhythmias: a comprehensive review.
      Alcohol withdrawal also increases cardiac sympathetic activity and reduces both heart rate variability and baroreflex sensitivity; these autonomic disturbances are all strongly linked to cardiac arrhythmias.
      • Bär K.J.
      • Boettger M.K.
      • Koschke M.
      • et al.
      Increased QT interval variability index in acute alcohol withdrawal.

      Alcohol and HF

      Ethanol at higher doses is a cardiotoxin. Habitual heavy alcohol consumption can result in a specific cardiac disease known as alcoholic cardiomyopathy, which accounts for about one-third of all cases of nonischemic dilated cardiomyopathy in the United States.
      • Laonigro I.
      • Correale M.
      • Di Biase M.
      • Altomare E.
      Alcohol abuse and heart failure.
      Individuals who consume more than 90 g of alcohol per day, which corresponds to about 7 drinks per day, for at least 5 years are at risk for the development of alcoholic cardiomyopathy and HF. Without complete abstinence, the 4-year mortality rate for alcoholic cardiomyopathy can be as high as 50%, and it is a common cause of death among long-term heavy drinkers.
      • Sidorenkov O.
      • Nilssen O.
      • Nieboer E.
      • Kleshchinov N.
      • Grjibovski A.M.
      Premature cardiovascular mortality and alcohol consumption before death in Arkhangelsk, Russia: an analysis of a consecutive series of forensic autopsies.
      Importantly, cessation of alcohol consumption and treatment of HF dramatically improve both cardiac function and prognosis.
      • Laonigro I.
      • Correale M.
      • Di Biase M.
      • Altomare E.
      Alcohol abuse and heart failure.
      Paradoxically, long-term mild to moderate alcohol consumption appears to be associated with a significantly reduced risk of HF.
      • Djoussé L.
      • Gaziano J.M.
      Alcohol consumption and risk of heart failure in the Physicians' Health Study I.
      This decrease in risk of HF is independent of other factors, including CAD, and is seen even among older cohorts and hypertensive patients.
      • Abramson J.L.
      • Williams S.A.
      • Krumholz H.M.
      • Vaccarino V.
      Moderate alcohol consumption and risk of heart failure among older persons.
      • Djoussé L.
      • Gaziano J.M.
      Alcohol consumption and heart failure in hypertensive US male physicians.
      In a recent meta-analysis, moderate drinking reduced the risk of HF by as much as 10% to 20%.
      • Padilla H.
      • Michael Gaziano J.
      • Djoussé L.
      Alcohol consumption and risk of heart failure: a meta-analysis.

      Alcohol and Hypertension

      Habitual alcohol consumption raises blood pressure (BP) in a dose-dependent fashion. Long-term heavy drinking is one of the most common reversible causes of hypertension (HTN); excessive alcohol intake is responsible for approximately 16% of cases of HTN worldwide.
      • Puddey I.B.
      • Beilin L.J.
      Alcohol is bad for blood pressure.
      The American Society of Hypertension warns that consuming more than 2 alcoholic drinks per day increases the risk for high BP.

      Hypertension ASo. HTN Risks. Vol 2012; 2012.

      Beyond the first 1 or 2 drinks per day, each additional alcoholic drink will increase BP by approximately 1.5 mm Hg. Within 2 to 4 weeks of abstinence or substantial reduction of intake, the alcohol-induced HTN usually resolves.
      A meta-analysis involving studies from the United States, Japan, and Korea reported a linear dose-response relationship between alcohol and BP whereby the relative risk for HTN was 1.7 for 50 g of ethanol per day (about 4 drinks per day) and 2.5 at 100 g/d (8 drinks per day).
      • Taylor B.
      • Irving H.M.
      • Baliunas D.
      • et al.
      Alcohol and hypertension: gender differences in dose-response relationships determined through systematic review and meta-analysis.
      The consumption of alcohol in amounts above 14 drinks per week is an independent risk factor for HTN, and among the US population, black men appear to be the group at highest risk.
      • Fuchs F.D.
      • Chambless L.E.
      • Whelton P.K.
      • Nieto F.J.
      • Heiss G.
      Alcohol consumption and the incidence of hypertension: the Atherosclerosis Risk in Communities Study.
      People living in Asia have also been noted to be particularly prone to BP increases with excessive alcohol intake.
      • Taylor B.
      • Irving H.M.
      • Baliunas D.
      • et al.
      Alcohol and hypertension: gender differences in dose-response relationships determined through systematic review and meta-analysis.
      A study of 28,848 women from the Women’s Health Study and 13,455 men from the Physicians’ Health Study followed up for an average of 11 and 22 years, respectively, assessed the associations of incremental doses of alcohol with BP over time.
      • Sesso H.D.
      • Cook N.R.
      • Buring J.E.
      • Manson J.E.
      • Gaziano J.M.
      Alcohol consumption and the risk of hypertension in women and men.
      In women, a J-shaped association was observed, whereas in men, increasing doses of alcohol were linearly associated with BP. The threshold above which alcohol significantly increased the risk of HTN in women was 4 or more drinks per day, whereas the increased risk of HTN appeared in men even with doses of 1 or more drinks per day.
      • Sesso H.D.
      • Cook N.R.
      • Buring J.E.
      • Manson J.E.
      • Gaziano J.M.
      Alcohol consumption and the risk of hypertension in women and men.
      In a study of a Mediterranean population, the consumption of beer or spirits, but not wine, was associated with a higher risk of HTN (Figure 6).
      • Núñez-Cordoba J.M.
      • Martínez-González M.A.
      • Bes-Rastrollo M.
      • Toledo E.
      • Beunza J.J.
      • Alonso A.
      Alcohol consumption and the incidence of hypertension in a Mediterranean cohort: the SUN study.
      Although red wine has been reported to modestly increase brachial BP, it lowers central aortic BP.
      • Karatzi K.N.
      • Papamichael C.M.
      • Karatzis E.N.
      • et al.
      Red wine acutely induces favorable effects on wave reflections and central pressures in coronary artery disease patients.
      • Stranges S.
      • Wu T.
      • Dorn J.M.
      • et al.
      Relationship of alcohol drinking pattern to risk of hypertension: a population-based study.
      Furthermore if the wine is consumed with a meal, the increase in BP appears to be largely eliminated.
      • Stranges S.
      • Wu T.
      • Dorn J.M.
      • et al.
      Relationship of alcohol drinking pattern to risk of hypertension: a population-based study.
      Figure thumbnail gr6
      Figure 6Hypertension as a function of type and number of drinks consumed. Error bars indicate risk of hypertension.
      Data from Revista Española de Cardiología.
      • Núñez-Cordoba J.M.
      • Martínez-González M.A.
      • Bes-Rastrollo M.
      • Toledo E.
      • Beunza J.J.
      • Alonso A.
      Alcohol consumption and the incidence of hypertension in a Mediterranean cohort: the SUN study.

      Alcohol and Stroke

      Heavy drinking and chronic alcoholism are strong independent risk factors for stroke.
      • Gill J.S.
      • Zezulka A.V.
      • Shipley M.J.
      • Gill S.K.
      • Beevers D.G.
      Stroke and alcohol consumption.
      • Hillbom M.
      • Numminen H.
      • Juvela S.
      Recent heavy drinking of alcohol and embolic stroke.
      • Klatsky A.L.
      • Armstrong M.A.
      • Friedman G.D.
      • Sidney S.
      Alcohol drinking and risk of hospitalization for ischemic stroke.
      Even so, most studies reveal a J-shaped association between alcohol and ischemic stroke, with a protective effect from light to moderate drinking and an elevated risk of stroke with heavy drinking
      • Sacco R.L.
      • Elkind M.
      • Boden-Albala B.
      • et al.
      The protective effect of moderate alcohol consumption on ischemic stroke.
      • Berger K.
      • Ajani U.A.
      • Kase C.S.
      • et al.
      Light-to-moderate alcohol consumption and risk of stroke among U.S. male physicians.
      • Iso H.
      • Baba S.
      • Mannami T.
      • et al.
      Alcohol consumption and risk of stroke among middle-aged men: the JPHC Study Cohort I.
      (Figure 7). A recent study of 47,000 Japanese women followed for an average of 17 years found that ethanol consumption of 300 g/wk or more (21 or more drinks per week) increased total stroke by approximately 2-fold.
      • Ikehara S.
      • Iso H.
      • Yamagishi K.
      • et al.
      JPHC Study Group
      Alcohol consumption and risk of stroke and coronary heart disease among Japanese women: the Japan Public Health Center-based prospective study.
      Figure thumbnail gr7
      Figure 7Fully adjusted statistical association between daily alcohol intake and ischemic stroke. OR = odds ratio.
      From JAMA,
      • Sacco R.L.
      • Elkind M.
      • Boden-Albala B.
      • et al.
      The protective effect of moderate alcohol consumption on ischemic stroke.
      with permission.
      The American Stroke Association guidelines recommend that heavy drinkers with ischemic stroke or transient ischemic attack should eliminate or reduce their alcohol consumption. They also defined “reasonable” alcohol consumption as no more than 2 drinks per day for men and 1 drink per day for women.
      • Furie K.L.
      • Kasner S.E.
      • Adams R.J.
      • et al.
      American Heart Association Stroke Council, Council on Cardiovascular Nursing, Council on Clinical Cardiology, and Interdisciplinary Council on Quality of Care and Outcomes Research
      Guidelines for the prevention of stroke in patients with stroke or transient ischemic attack: a guideline for healthcare professionals from the American Heart Association/American Stroke Association.

      Alcohol and DM

      Consistent data indicate that regular light to moderate drinking is associated with substantial reductions in type 2 DM of 30% to 40%, irrespective of the alcoholic beverage consumed.
      • Djoussé L.
      • Biggs M.L.
      • Mukamal K.J.
      • Siscovick D.S.
      Alcohol consumption and type 2 diabetes among older adults: the Cardiovascular Health Study.
      • Baliunas D.O.
      • Taylor B.J.
      • Irving H.
      • et al.
      Alcohol as a risk factor for type 2 diabetes: a systematic review and meta-analysis.
      • Liu C.
      • Yu Z.
      • Li H.
      • et al.
      Associations of alcohol consumption with diabetes mellitus and impaired fasting glycemia among middle-aged and elderly Chinese.
      In the Physicians’ Health Study, light to moderate alcohol consumption was associated with a decreased risk of type 2 DM during 12 years of follow-up.
      • Ajani U.A.
      • Hennekens C.H.
      • Spelsberg A.
      • Manson J.E.
      Alcohol consumption and risk of type 2 diabetes mellitus among US male physicians.
      However, the protection that moderate drinking provides against new-onset diabetes is attenuated or abolished with higher doses (more than 4 drinks per day)
      • Koppes L.L.
      • Dekker J.M.
      • Hendriks H.F.
      • Bouter L.M.
      • Heine R.J.
      Moderate alcohol consumption lowers the risk of type 2 diabetes: a meta-analysis of prospective observational studies.
      (Figure 8). As in the general population, moderate alcohol intake seems to protect against CAD in diabetic individuals.
      • Tanasescu M.
      • Hu F.B.
      • Willett W.C.
      • Stampfer M.J.
      • Rimm E.B.
      Alcohol consumption and risk of coronary heart disease among men with type 2 diabetes mellitus.
      Figure thumbnail gr8
      Figure 8Alcohol intake and incidence of new-onset type 2 diabetes mellitus. Error bars indicate 95% CI.
      From Journal of the American College of Cardiology.
      • O'Keefe J.H.
      • Bybee K.A.
      • Lavie C.J.
      Alcohol and cardiovascular health: the razor-sharp double-edged sword.
      This J-shaped relationship is also apparent for risk of metabolic syndrome,
      • Husemoen L.L.
      • Jørgensen T.
      • Borch-Johnsen K.
      • Hansen T.
      • Pedersen O.
      • Linneberg A.
      The association of alcohol and alcohol metabolizing gene variants with diabetes and coronary heart disease risk factors in a white population.
      whereby a lower prevalence of metabolic syndrome is seen in people who regularly consume light to moderate amounts of alcohol.
      • Djoussé L.
      • Arnett D.K.
      • Eckfeldt J.H.
      • Province M.A.
      • Singer M.R.
      • Ellison R.C.
      Alcohol consumption and metabolic syndrome: does the type of beverage matter?.
      These results were replicated in an elderly Italian population
      • Buja A.
      • Scafato E.
      • Sergi G.
      • et al.
      ILSA Working Group
      Alcohol consumption and metabolic syndrome in the elderly: results from the Italian Longitudinal Study on Aging.
      and were confirmed by a meta-analysis that reported favorable metabolic effects in women consuming less than 20 g/d and men with less than 40-g/d intake.
      • Alkerwi A.
      • Boutsen M.
      • Vaillant M.
      • et al.
      Alcohol consumption and the prevalence of metabolic syndrome: a meta-analysis of observational studies.
      The American Diabetes Association suggests limits of not more than 2 drinks per day for diabetic men and not more than 1 drink per day for diabetic women.

      American Diabetes Association. Food & Fitness: Alcohol. http://www.diabetes.org/food-and-fitness/food/what-can-i-eat/alcohol.html. Updated November 11, 2013. Accessed October 18, 2013.

      Cardioprotective Mechanisms of Action

      The main active ingredient of any alcoholic beverage is ethanol, and most evidence indicates that this compound, rather than any other specific component of a drink, is the primary factor for both conferring health benefits and causing toxicity, depending on the pattern of consumption and dosing.
      • Mukamal K.J.
      • Jensen M.K.
      • Grønbaek M.
      • et al.
      Drinking frequency, mediating biomarkers, and risk of myocardial infarction in women and men.
      • Krenz M.
      • Korthuis R.J.
      Moderate ethanol ingestion and cardiovascular protection: from epidemiologic associations to cellular mechanisms.
      Accumulating scientific evidence suggests that light to moderate alcohol intake may enhance insulin sensitivity, elevate high-density lipoprotein (HDL) cholesterol, reduce inflammation, increase adiponectin, and improve endothelial function (Figure 9).
      • Krenz M.
      • Korthuis R.J.
      Moderate ethanol ingestion and cardiovascular protection: from epidemiologic associations to cellular mechanisms.
      • Perissinotto E.
      • Buja A.
      • Maggi S.
      • et al.
      ILSA Working Group
      Alcohol consumption and cardiovascular risk factors in older lifelong wine drinkers: the Italian Longitudinal Study on Aging.
      • Wakabayashi I.
      Associations between alcohol drinking and multiple risk factors for atherosclerosis in smokers and nonsmokers.
      In a linear dose-dependent fashion, alcohol intake increases HDL cholesterol (especially the cardioprotective HDL2 subfraction) and apolipoprotein A-I.
      • De Oliveira e Silva E.R.
      • Foster D.
      • McGee Harper M.
      • et al.
      Alcohol consumption raises HDL cholesterol levels by increasing the transport rate of apolipoproteins A-I and A-II.
      Alcohol intake is also linearly associated with lipoprotein particle size (higher ethanol consumption is linked to larger low-density lipoprotein and HDL particles); however, a U-shaped association is seen with particle number, whereby consumers of 7 to 13 drinks per week had fewer particles than abstainers or heavy drinkers.
      • Mukamal K.J.
      • Mackey R.H.
      • Kuller L.H.
      • et al.
      Alcohol consumption and lipoprotein subclasses in older adults.
      Figure thumbnail gr9
      Figure 9Potential mechanisms of cardiovascular protection associated with moderate drinking. HDL = high-density lipoprotein; LDL = low-density lipoprotein.
      Adapted from Journal of Molecular and Cellular Cardiology,
      • Krenz M.
      • Korthuis R.J.
      Moderate ethanol ingestion and cardiovascular protection: from epidemiologic associations to cellular mechanisms.
      with permission.
      Light to moderate alcohol intake does not appear to protect against coronary artery calcium (CAC) accumulation, and although heavy consumption of hard liquor or beer was reportedly associated with greater CAC accumulation, wine intake was neutral for CAC.
      • McClelland R.L.
      • Bild D.E.
      • Burke G.L.
      • et al.
      Multi-Ethnic Study of Atherosclerosis
      Alcohol and coronary artery calcium prevalence, incidence, and progression: results from the Multi-Ethnic Study of Atherosclerosis (MESA).
      In the Cardiovascular Risk Survey, a multiethnic, community-based, cross-sectional study of 14,618 people, consumption of less than 60 g/d was linked to less peripheral atherosclerosis, whereas consumption of 60 g/d or more was associated with more atherosclerosis.
      • Xie X.
      • Ma Y.T.
      • Yang Y.N.
      • et al.
      Alcohol consumption and ankle-to-brachial index: results from the Cardiovascular Risk Survey.
      In the Pravastatin Inflammation/CRP Evaluation Study, C-reactive protein levels were lower in those with moderate alcohol intake vs no or minimal alcohol intake. This anti-inflammatory effect persisted after adjustment for multiple traditional CV risk factors, suggesting that moderate drinking may confer cardioprotection in part by acting as an anti-inflammatory agent.
      • Albert M.A.
      • Glynn R.J.
      • Ridker P.M.
      Alcohol consumption and plasma concentration of C-reactive protein.
      Importantly, moderate alcohol consumption (1 or 2 drinks) increases insulin sensitivity and glucose metabolism for the ensuing 12 to 24 hours.
      • Greenfield J.R.
      • Samaras K.
      • Hayward C.S.
      • Chisholm D.J.
      • Campbell L.V.
      Beneficial postprandial effect of a small amount of alcohol on diabetes and cardiovascular risk factors: modification by insulin resistance.
      The biological mechanism whereby alcohol improves insulin sensitivity appears to involve suppression of fatty acid release from adipose tissue and elevation of adiponectin levels.
      • Ebrahim S.
      • Lawlor D.A.
      • Shlomo Y.B.
      • et al.
      Alcohol dehydrogenase type 1C (ADH1C) variants, alcohol consumption traits, HDL-cholesterol and risk of coronary heart disease in women and men: British Women's Heart and Health Study and Caerphilly cohorts.
      • Sierksma A.
      • Patel H.
      • Ouchi N.
      • et al.
      Effect of moderate alcohol consumption on adiponectin, tumor necrosis factor-alpha, and insulin sensitivity.
      This reduction in fatty acids decreases substrate competition in the Krebs cycle of skeletal muscles, thereby facilitating glucose metabolism.
      • Greenfield J.R.
      • Samaras K.
      • Jenkins A.B.
      • Kelly P.J.
      • Spector T.D.
      • Campbell L.V.
      Moderate alcohol consumption, estrogen replacement therapy, and physical activity are associated with increased insulin sensitivity: is abdominal adiposity the mediator?.
      One or 2 drinks per day will reduce triglycerides modestly (7%-10%) and decrease abdominal obesity.
      • Davies M.J.
      • Baer D.J.
      • Judd J.T.
      • Brown E.D.
      • Campbell W.S.
      • Taylor P.R.
      Effects of moderate alcohol intake on fasting insulin and glucose concentrations and insulin sensitivity in postmenopausal women: a randomized controlled trial.
      Thereafter, abdominal obesity and triglycerides increase in direct proportion to the amount of alcohol consumed.
      • Greenfield J.R.
      • Samaras K.
      • Jenkins A.B.
      • Kelly P.J.
      • Spector T.D.
      • Campbell L.V.
      Moderate alcohol consumption, estrogen replacement therapy, and physical activity are associated with increased insulin sensitivity: is abdominal adiposity the mediator?.
      • Dorn J.M.
      • Hovey K.
      • Muti P.
      • et al.
      Alcohol drinking patterns differentially affect central adiposity as measured by abdominal height in women and men.
      Red wine is rich in polyphenols, which possess antioxidant, anti-inflammatory, and antiplatelet activities.
      • Li H.
      • Förstermann U.
      Red wine and cardiovascular health [editorial].
      Indeed, multiple small, randomized controlled trials have found that red wine stimulated superior improvements in insulin resistance, lipid profiles, and endothelial function compared with other alcoholic beverages.
      • Li H.
      • Förstermann U.
      Red wine and cardiovascular health [editorial].
      In a recent study, daily ingestion of 275 mL/d of dealcoholized red wine decreased systolic and diastolic BP by increasing nitric oxide levels in the vasculature.
      • Chiva-Blanch G.
      • Urpi-Sarda M.
      • Ros E.
      • et al.
      Dealcoholized red wine decreases systolic and diastolic blood pressure and increases plasma nitric oxide: short communication.
      Another recent study compared the effects of 3 alcoholic beverages—red wine, beer, and vodka—on oxidative stress.
      • Krnic M.
      • Modun D.
      • Budimir D.
      • et al.
      Comparison of acute effects of red wine, beer and vodka against hyperoxia-induced oxidative stress and increase in arterial stiffness in healthy humans.
      Only red wine shielded the vasculature against hyperoxia-induced oxidative stress and transient increase in arterial stiffness.

      Inconsistency of Cardioprotection Among Various Ethnicities

      The cardioprotective effect of light to moderate drinking has not been consistently replicated among all the ethnicities and nations that have been studied.
      • Núñez-Cordoba J.M.
      • Martínez-González M.A.
      • Bes-Rastrollo M.
      • Toledo E.
      • Beunza J.J.
      • Alonso A.
      Alcohol consumption and the incidence of hypertension in a Mediterranean cohort: the SUN study.
      • Halanych J.H.
      • Safford M.M.
      • Kertesz S.G.
      • et al.
      Alcohol consumption in young adults and incident hypertension: 20-year follow-up from the Coronary Artery Risk Development in Young Adults Study.
      • Roy A.
      • Prabhakaran D.
      • Jeemon P.
      • et al.
      Impact of alcohol on coronary heart disease in Indian men.
      The INTERHEART study,
      • Yusuf S.
      • Hawken S.
      • Ounpuu S.
      • et al.
      INTERHEART Study Investigators
      Effect of potentially modifiable risk factors associated with myocardial infarction in 52 countries (the INTERHEART study): case-control study.
      a landmark 27,000-patient international epidemiological study, found that regular alcohol intake was associated with a decrease in the risk of MI in both sexes and all adult age groups. Individuals from 50 different nations were included in the INTERHEART study, which found that regular alcohol intake reduced the risk of MI by 14%; however, this cardioprotection was not apparent among the cohort from India.
      • Yusuf S.
      • Hawken S.
      • Ounpuu S.
      • et al.
      INTERHEART Study Investigators
      Effect of potentially modifiable risk factors associated with myocardial infarction in 52 countries (the INTERHEART study): case-control study.
      These results were replicated in a study conducted in India involving 4465 participants, in which the cohort of current and/or past alcohol users had a higher risk of CAD compared with alcohol abstainers.
      • Roy A.
      • Prabhakaran D.
      • Jeemon P.
      • et al.
      Impact of alcohol on coronary heart disease in Indian men.
      Similarly, light to moderate drinking has not been consistently associated with cardioprotection in Chinese populations.
      • Ronksley P.E.
      • Brien S.E.
      • Turner B.J.
      • Mukamal K.J.
      • Ghali W.A.
      Association of alcohol consumption with selected cardiovascular disease outcomes: a systematic review and meta-analysis.
      • Schooling C.M.
      • Sun W.
      • Ho S.Y.
      • et al.
      Moderate alcohol use and mortality from ischaemic heart disease: a prospective study in older Chinese people.

      Ideal Drinking Patterns, Doses, and Beverages

      The standard definition of light to moderate alcohol intake is up to 1 drink per day for women and up to 2 drinks per day for men. Among the various alcoholic beverages, red wine, likely owing to its unique array of nonalcoholic components, is generally associated with the best health outcomes, especially for CV issues.
      • Marfella R.
      • Cacciapuoti F.
      • Siniscalchi M.
      • et al.
      Effect of moderate red wine intake on cardiac prognosis after recent acute myocardial infarction of subjects with Type 2 diabetes mellitus.
      • Chiva-Blanch G.
      • Urpi-Sarda M.
      • Ros E.
      • et al.
      Dealcoholized red wine decreases systolic and diastolic blood pressure and increases plasma nitric oxide: short communication.
      • Krnic M.
      • Modun D.
      • Budimir D.
      • et al.
      Comparison of acute effects of red wine, beer and vodka against hyperoxia-induced oxidative stress and increase in arterial stiffness in healthy humans.
      • Chiva-Blanch G.
      • Urpi-Sarda M.
      • Ros E.
      • et al.
      Effects of red wine polyphenols and alcohol on glucose metabolism and the lipid profile: a randomized clinical trial.
      • Di Castelnuovo A.
      • Costanzo S.
      • Donati M.B.
      • Iacoviello L.
      • de Gaetano G.
      Prevention of cardiovascular risk by moderate alcohol consumption: epidemiologic evidence and plausible mechanisms.
      Binge drinking, usually defined as episodic excessive alcohol intake (≥5 drinks within a few hours) often with intent to become intoxicated, is associated with 2-fold higher risk of mortality.
      • Mukamal K.J.
      • Maclure M.
      • Muller J.E.
      • Mittleman M.A.
      Binge drinking and mortality after acute myocardial infarction.
      • Ruidavets J.B.
      • Ducimetière P.
      • Evans A.
      • et al.
      Patterns of alcohol consumption and ischaemic heart disease in culturally divergent countries: the Prospective Epidemiological Study of Myocardial Infarction (PRIME).
      Even occasional binges attenuate the protection offered by otherwise light to moderate consumption. Cultures, such as those following the traditional Mediterranean diet, in which alcohol is consumed before or during the largest daily meal seem to have the most benefit from habitual light to moderate drinking.
      • Trichopoulou A.
      • Bamia C.
      • Trichopoulos D.
      Anatomy of health effects of Mediterranean diet: Greek EPIC prospective cohort study.
      • Bagnardi V.
      • Zatonski W.
      • Scotti L.
      • La Vecchia C.
      • Corrao G.
      Does drinking pattern modify the effect of alcohol on the risk of coronary heart disease? evidence from a meta-analysis.
      The advantages of this pattern of drinking at dinnertime may be due to the effectiveness of low- to moderate-dose alcohol in blunting postprandial glucose spikes and subsequent inflammation
      • O'Keefe J.H.
      • Gheewala N.M.
      • O'Keefe J.O.
      Dietary strategies for improving post-prandial glucose, lipids, inflammation, and cardiovascular health.
      or may possibly be related to enhanced social bonding with an emphasis on moderation generally espoused by this tradition.
      • Trichopoulou A.
      • Bamia C.
      • Trichopoulos D.
      Anatomy of health effects of Mediterranean diet: Greek EPIC prospective cohort study.
      Finally, the health benefits of drinking, like those bestowed by exercise,
      • O'Keefe J.H.
      • Patil H.R.
      • Lavie C.J.
      • Magalski A.
      • Vogel R.A.
      • McCullough P.A.
      Potential adverse cardiovascular effects from excessive endurance exercise [published correction appears in Mayo Clin Proc. 2012;87(7):704].
      are best attained when done daily and in moderation.
      • O'Keefe J.H.
      • Bybee K.A.
      • Lavie C.J.
      Alcohol and cardiovascular health: the razor-sharp double-edged sword.
      • O'Keefe J.H.
      • Patil H.R.
      • Lavie C.J.
      • Magalski A.
      • Vogel R.A.
      • McCullough P.A.
      Potential adverse cardiovascular effects from excessive endurance exercise [published correction appears in Mayo Clin Proc. 2012;87(7):704].
      This is likely due to the fact that many of the benefits of light to moderate drinking are transient, generally dissipating within 24 hours.
      • O'Keefe J.H.
      • Bybee K.A.
      • Lavie C.J.
      Alcohol and cardiovascular health: the razor-sharp double-edged sword.

      Warnings and Precautions

      The Atherosclerosis Risk in Communities (ARIC) study found that among individuals deemed to be at low risk for addiction, moderate alcohol consumption was safe and did not lead to adverse outcomes related to problem drinking.
      • Eigenbrodt M.L.
      • Mosley Jr., T.H.
      • Hutchinson R.G.
      • Watson R.L.
      • Chambless L.E.
      • Szklo M.
      Alcohol consumption with age: a cross-sectional and longitudinal study of the Atherosclerosis Risk in Communities (ARIC) study, 1987-1995.
      However, other studies indicate that among nondrinkers, it is not possible to reliably predict who might be at increased risk for falling into a pattern of dangerously high alcohol intake once they begin drinking.
      • Rehm J.
      • Mathers C.
      • Popova S.
      • Thavorncharoensap M.
      • Teerawattananon Y.
      • Patra J.
      Global burden of disease and injury and economic cost attributable to alcohol use and alcohol-use disorders.
      • O'Keefe J.H.
      • Bybee K.A.
      • Lavie C.J.
      Alcohol and cardiovascular health: the razor-sharp double-edged sword.
      Indeed, habitual alcohol intake appears to be a “slippery slope” that many individuals cannot safely navigate; thus, the American Heart Association cautions people not to start drinking if they do not already consume alcohol.

      American Heart Association. Alcohol and heart disease. American Heart Association website. http://www.heart.org/HEARTORG/Conditions/More/MyHeartandStrokeNews/Alcohol-and-Heart-Disease_UCM_305173_Article.jsp. Updated September 20, 2012. Accessed October 18, 2013.

      Furthermore, among the 16 million Americans who meet the diagnostic criteria for alcohol abuse or dependence, only 1.5 million seek and receive formal treatment, usually with discouragingly low rates of long-term abstinence.
      • Schooling C.M.
      • Sun W.
      • Ho S.Y.
      • et al.
      Moderate alcohol use and mortality from ischaemic heart disease: a prospective study in older Chinese people.
      Heavy long-term alcohol use increases the risks for many malignancies, particularly cancers of the gastrointestinal tract and liver.
      • Poli A.
      • Marangoni F.
      • Avogaro A.
      • et al.
      Moderate alcohol use and health: a consensus document.
      Additionally, for women, even light to moderate alcohol intake is associated with increased risk for breast cancer.

      Park SY, Kolonel LN, Lim U, White KK, Henderson BE, Wilkens LR. Alcohol consumption and breast cancer risk among women from five ethnic groups with light to moderate intakes: the Multiethnic Cohort Study [published online ahead of print September 12, 2013]. Int J Cancer. http://dx.doi.org/10.1002/ijc.28476.

      Until we have more randomized outcome data and tools for predicting susceptibility to problem drinking, it would seem prudent to encourage physicians and patients to focus on more innocuous interventions to prevent CV disease.

      Acknowledgments

      We thank Darwish Naji, MD (Saint Luke’s Mid America Heart Institute and University of Missouri-Kansas City) for assistance with data discovery and analysis.

      Supplemental Online Material

      References

        • Lincoln A.
        Temperance Address, February 22, 1842.
        in: Basler R.P. The Collected Works of Abraham Lincoln, Vol. 1: 1824-1848. History Book C edition. Rutgers University Press, Springfield, IL1953: 399
        • World Health Organization Management of Substance Abuse Team
        Global Status Report on Alcohol and Health.
        World Health Organization, Geneva, Switzerland2011: 85
        • Rehm J.
        • Mathers C.
        • Popova S.
        • Thavorncharoensap M.
        • Teerawattananon Y.
        • Patra J.
        Global burden of disease and injury and economic cost attributable to alcohol use and alcohol-use disorders.
        Lancet. 2009; 373: 2223-2233
        • Heidenreich P.A.
        • Trogdon J.G.
        • Khavjou O.A.
        • et al.
        • American Heart Association Advocacy Coordinating Committee
        • Stroke Council
        • Council on Cardiovascular Radiology and Intervention
        • Council on Clinical Cardiology
        • Council on Epidemiology and Prevention
        • Council on Arteriosclerosis
        • Thrombosis and Vascular Biology
        • Council on Cardiopulmonary, Critical Care, Perioperative and Resuscitation
        • Council on Cardiovascular Nursing
        • Council on the Kidney in Cardiovascular Disease
        • Council on Cardiovascular Surgery and Anesthesia; and Interdisciplinary Council on Quality of Care and Outcomes Research
        Forecasting the future of cardiovascular disease in the United States: a policy statement from the American Heart Association.
        Circulation. 2011; 123: 933-944
        • O'Keefe J.H.
        • Bybee K.A.
        • Lavie C.J.
        Alcohol and cardiovascular health: the razor-sharp double-edged sword.
        J Am Coll Cardiol. 2007; 50: 1009-1014
      1. Saad L. Majority in U.S. drink alcohol, averaging four drinks a week: beer edges out wine by 39% to 35% as drinkers' beverage of choice. GALLUP Well-Being website. http://www.gallup.com/poll/156770/majority-drink-alcohol-averaging-four-drinks-week.aspx. Published August 17, 2012. Accessed October 18, 2013.

      2. Rethinking drinking: alcohol and your health. National Institutes of Health, National Institute on Alcohol Abuse and Alcoholism website. http://rethinkingdrinking.niaaa.nih.gov/toolsresources/DrinkSizeCalculator.asp. Accessed October 18, 2013.

      3. MyDrinkaware: alcohol unit and calorie calculator. Drinkaware website. www.drinkaware.co.uk. Published 2012. Accessed October 18, 2013.

        • Di Castelnuovo A.
        • Costanzo S.
        • Bagnardi V.
        • Donati M.B.
        • Iacoviello L.
        • de Gaetano G.
        Alcohol dosing and total mortality in men and women: an updated meta-analysis of 34 prospective studies.
        Arch Intern Med. 2006; 166: 2437-2445
        • Mukamal K.J.
        • Chen C.M.
        • Rao S.R.
        • Breslow R.A.
        Alcohol consumption and cardiovascular mortality among U.S. adults, 1987 to 2002.
        J Am Coll Cardiol. 2010; 55: 1328-1335
        • Hvidtfeldt U.A.
        • Tolstrup J.S.
        • Jakobsen M.U.
        • et al.
        Alcohol intake and risk of coronary heart disease in younger, middle-aged, and older adults.
        Circulation. 2010; 121: 1589-1597
        • Juonala M.
        • Viikari J.S.
        • Kähönen M.
        • et al.
        Alcohol consumption is directly associated with carotid intima-media thickness in Finnish young adults: the Cardiovascular Risk in Young Finns Study.
        Atherosclerosis. 2009; 204: e93-e98
        • Rizzuto D.
        • Orsini N.
        • Qiu C.
        • Wang H.X.
        • Fratiglioni L.
        Lifestyle, social factors, and survival after age 75: population based study.
        BMJ. 2012; 345: e5568
        • Mukamal K.J.
        • Chiuve S.E.
        • Rimm E.B.
        Alcohol consumption and risk for coronary heart disease in men with healthy lifestyles.
        Arch Intern Med. 2006; 166: 2145-2150
        • Trichopoulou A.
        • Bamia C.
        • Trichopoulos D.
        Anatomy of health effects of Mediterranean diet: Greek EPIC prospective cohort study.
        BMJ. 2009; 338: b2337
        • Costanzo S.
        • Di Castelnuovo A.
        • Donati M.B.
        • Iacoviello L.
        • de Gaetano G.
        Alcohol consumption and mortality in patients with cardiovascular disease: a meta-analysis.
        J Am Coll Cardiol. 2010; 55: 1339-1347
        • Marfella R.
        • Cacciapuoti F.
        • Siniscalchi M.
        • et al.
        Effect of moderate red wine intake on cardiac prognosis after recent acute myocardial infarction of subjects with Type 2 diabetes mellitus.
        Diabet Med. 2006; 23: 974-981
        • Carter M.D.
        • Lee J.H.
        • Buchanan D.M.
        • et al.
        Comparison of outcomes among moderate alcohol drinkers before acute myocardial infarction to effect of continued versus discontinuing alcohol intake after the infarct.
        Am J Cardiol. 2010; 105: 1651-1654
        • Mukamal K.J.
        • Maclure M.
        • Muller J.E.
        • Sherwood J.B.
        • Mittleman M.A.
        Prior alcohol consumption and mortality following acute myocardial infarction.
        JAMA. 2001; 285: 1965-1970
        • Mukamal K.J.
        • Girotra S.
        • Mittleman M.A.
        Alcohol consumption, atherosclerotic progression, and prognosis among patients with coronary artery bypass grafts.
        Am Heart J. 2006; 151: 368-372
        • Camargo Jr., C.A.
        • Stampfer M.J.
        • Glynn R.J.
        • et al.
        Prospective study of moderate alcohol consumption and risk of peripheral arterial disease in US male physicians.
        Circulation. 1997; 95: 577-580
        • Athyros V.G.
        • Liberopoulos E.N.
        • Mikhailidis D.P.
        • et al.
        Association of drinking pattern and alcohol beverage type with the prevalence of metabolic syndrome, diabetes, coronary heart disease, stroke, and peripheral arterial disease in a Mediterranean cohort.
        Angiology. 2007; 58: 689-697
        • Vliegenthart R.
        • Geleijnse J.M.
        • Hofman A.
        • et al.
        Alcohol consumption and risk of peripheral arterial disease: the Rotterdam study.
        Am J Epidemiol. 2002; 155: 332-338
        • Ettinger P.O.
        • Wu C.F.
        • De La Cruz Jr., C.
        • Weisse A.B.
        • Ahmed S.S.
        • Regan T.J.
        Arrhythmias and the “Holiday Heart”: alcohol-associated cardiac rhythm disorders.
        Am Heart J. 1978; 95: 555-562
        • Menezes A.R.
        • Lavie C.J.
        • DiNicolantonio J.J.
        • et al.
        Atrial fibrillation in the 21st century: a current understanding of risk factors and primary prevention strategies.
        Mayo Clin Proc. 2013; 88: 394-409
        • Mukamal K.J.
        • Tolstrup J.S.
        • Friberg J.
        • Jensen G.
        • Grønbaek M.
        Alcohol consumption and risk of atrial fibrillation in men and women: the Copenhagen City Heart Study.
        Circulation. 2005; 112: 1736-1742
        • Samokhvalov A.V.
        • Irving H.M.
        • Rehm J.
        Alcohol consumption as a risk factor for atrial fibrillation: a systematic review and meta-analysis.
        Eur J Cardiovasc Prev Rehabil. 2010; 17: 706-712
        • Kodama S.
        • Saito K.
        • Tanaka S.
        • et al.
        Alcohol consumption and risk of atrial fibrillation: a meta-analysis.
        J Am Coll Cardiol. 2011; 57: 427-436
        • Albert C.M.
        • Manson J.E.
        • Cook N.R.
        • Ajani U.A.
        • Gaziano J.M.
        • Hennekens C.H.
        Moderate alcohol consumption and the risk of sudden cardiac death among US male physicians.
        Circulation. 1999; 100: 944-950
        • Rossinen J.
        • Sinisalo J.
        • Partanen J.
        • Nieminen M.S.
        • Viitasalo M.
        Effects of acute alcohol infusion on duration and dispersion of QT interval in male patients with coronary artery disease and in healthy controls.
        Clin Cardiol. 1999; 22: 591-594
        • George A.
        • Figueredo V.M.
        Alcohol and arrhythmias: a comprehensive review.
        J Cardiovasc Med (Hagerstown). 2010; 11: 221-228
        • Bär K.J.
        • Boettger M.K.
        • Koschke M.
        • et al.
        Increased QT interval variability index in acute alcohol withdrawal.
        Drug Alcohol Depend. 2007; 89: 259-266
        • Laonigro I.
        • Correale M.
        • Di Biase M.
        • Altomare E.
        Alcohol abuse and heart failure.
        Eur J Heart Fail. 2009; 11: 453-462
        • Sidorenkov O.
        • Nilssen O.
        • Nieboer E.
        • Kleshchinov N.
        • Grjibovski A.M.
        Premature cardiovascular mortality and alcohol consumption before death in Arkhangelsk, Russia: an analysis of a consecutive series of forensic autopsies.
        Int J Epidemiol. 2011; 40: 1519-1529
        • Djoussé L.
        • Gaziano J.M.
        Alcohol consumption and risk of heart failure in the Physicians' Health Study I.
        Circulation. 2007; 115: 34-39
        • Abramson J.L.
        • Williams S.A.
        • Krumholz H.M.
        • Vaccarino V.
        Moderate alcohol consumption and risk of heart failure among older persons.
        JAMA. 2001; 285: 1971-1977
        • Djoussé L.
        • Gaziano J.M.
        Alcohol consumption and heart failure in hypertensive US male physicians.
        Am J Cardiol. 2008; 102: 593-597
        • Padilla H.
        • Michael Gaziano J.
        • Djoussé L.
        Alcohol consumption and risk of heart failure: a meta-analysis.
        Phys Sportsmed. 2010; 38: 84-89
        • Puddey I.B.
        • Beilin L.J.
        Alcohol is bad for blood pressure.
        Clin Exp Pharmacol Physiol. 2006; 33: 847-852
      4. Hypertension ASo. HTN Risks. Vol 2012; 2012.

        • Taylor B.
        • Irving H.M.
        • Baliunas D.
        • et al.
        Alcohol and hypertension: gender differences in dose-response relationships determined through systematic review and meta-analysis.
        Addiction. 2009; 104: 1981-1990
        • Fuchs F.D.
        • Chambless L.E.
        • Whelton P.K.
        • Nieto F.J.
        • Heiss G.
        Alcohol consumption and the incidence of hypertension: the Atherosclerosis Risk in Communities Study.
        Hypertension. 2001; 37: 1242-1250
        • Sesso H.D.
        • Cook N.R.
        • Buring J.E.
        • Manson J.E.
        • Gaziano J.M.
        Alcohol consumption and the risk of hypertension in women and men.
        Hypertension. 2008; 51: 1080-1087
        • Núñez-Cordoba J.M.
        • Martínez-González M.A.
        • Bes-Rastrollo M.
        • Toledo E.
        • Beunza J.J.
        • Alonso A.
        Alcohol consumption and the incidence of hypertension in a Mediterranean cohort: the SUN study.
        Rev Esp Cardiol. 2009; 62: 633-641
        • Karatzi K.N.
        • Papamichael C.M.
        • Karatzis E.N.
        • et al.
        Red wine acutely induces favorable effects on wave reflections and central pressures in coronary artery disease patients.
        Am J Hypertens. 2005; 18: 1161-1167
        • Stranges S.
        • Wu T.
        • Dorn J.M.
        • et al.
        Relationship of alcohol drinking pattern to risk of hypertension: a population-based study.
        Hypertension. 2004; 44: 813-819
        • Gill J.S.
        • Zezulka A.V.
        • Shipley M.J.
        • Gill S.K.
        • Beevers D.G.
        Stroke and alcohol consumption.
        N Engl J Med. 1986; 315: 1041-1046
        • Hillbom M.
        • Numminen H.
        • Juvela S.
        Recent heavy drinking of alcohol and embolic stroke.
        Stroke. 1999; 30: 2307-2312
        • Klatsky A.L.
        • Armstrong M.A.
        • Friedman G.D.
        • Sidney S.
        Alcohol drinking and risk of hospitalization for ischemic stroke.
        Am J Cardiol. 2001; 88: 703-706
        • Sacco R.L.
        • Elkind M.
        • Boden-Albala B.
        • et al.
        The protective effect of moderate alcohol consumption on ischemic stroke.
        JAMA. 1999; 281: 53-60
        • Berger K.
        • Ajani U.A.
        • Kase C.S.
        • et al.
        Light-to-moderate alcohol consumption and risk of stroke among U.S. male physicians.
        N Engl J Med. 1999; 341: 1557-1564
        • Iso H.
        • Baba S.
        • Mannami T.
        • et al.
        Alcohol consumption and risk of stroke among middle-aged men: the JPHC Study Cohort I.
        Stroke. 2004; 35: 1124-1129
        • Ikehara S.
        • Iso H.
        • Yamagishi K.
        • et al.
        • JPHC Study Group
        Alcohol consumption and risk of stroke and coronary heart disease among Japanese women: the Japan Public Health Center-based prospective study.
        Prev Med. 2013; 57: 505-510
        • Furie K.L.
        • Kasner S.E.
        • Adams R.J.
        • et al.
        • American Heart Association Stroke Council, Council on Cardiovascular Nursing, Council on Clinical Cardiology, and Interdisciplinary Council on Quality of Care and Outcomes Research
        Guidelines for the prevention of stroke in patients with stroke or transient ischemic attack: a guideline for healthcare professionals from the American Heart Association/American Stroke Association.
        Stroke. 2011; 42: 227-276
        • Djoussé L.
        • Biggs M.L.
        • Mukamal K.J.
        • Siscovick D.S.
        Alcohol consumption and type 2 diabetes among older adults: the Cardiovascular Health Study.
        Obesity (Silver Spring). 2007; 15: 1758-1765
        • Baliunas D.O.
        • Taylor B.J.
        • Irving H.
        • et al.
        Alcohol as a risk factor for type 2 diabetes: a systematic review and meta-analysis.
        Diabetes Care. 2009; 32: 2123-2132
        • Liu C.
        • Yu Z.
        • Li H.
        • et al.
        Associations of alcohol consumption with diabetes mellitus and impaired fasting glycemia among middle-aged and elderly Chinese.
        BMC Public Health. 2010; 10: 713
        • Ajani U.A.
        • Hennekens C.H.
        • Spelsberg A.
        • Manson J.E.
        Alcohol consumption and risk of type 2 diabetes mellitus among US male physicians.
        Arch Intern Med. 2000; 160: 1025-1030
        • Koppes L.L.
        • Dekker J.M.
        • Hendriks H.F.
        • Bouter L.M.
        • Heine R.J.
        Moderate alcohol consumption lowers the risk of type 2 diabetes: a meta-analysis of prospective observational studies.
        Diabetes Care. 2005; 28: 719-725
        • Tanasescu M.
        • Hu F.B.
        • Willett W.C.
        • Stampfer M.J.
        • Rimm E.B.
        Alcohol consumption and risk of coronary heart disease among men with type 2 diabetes mellitus.
        J Am Coll Cardiol. 2001; 38: 1836-1842
        • Husemoen L.L.
        • Jørgensen T.
        • Borch-Johnsen K.
        • Hansen T.
        • Pedersen O.
        • Linneberg A.
        The association of alcohol and alcohol metabolizing gene variants with diabetes and coronary heart disease risk factors in a white population.
        PLoS One. 2010; 5: e11735
        • Djoussé L.
        • Arnett D.K.
        • Eckfeldt J.H.
        • Province M.A.
        • Singer M.R.
        • Ellison R.C.
        Alcohol consumption and metabolic syndrome: does the type of beverage matter?.
        Obes Res. 2004; 12: 1375-1385
        • Buja A.
        • Scafato E.
        • Sergi G.
        • et al.
        • ILSA Working Group
        Alcohol consumption and metabolic syndrome in the elderly: results from the Italian Longitudinal Study on Aging.
        Eur J Clin Nutr. 2010; 64: 297-307
        • Alkerwi A.
        • Boutsen M.
        • Vaillant M.
        • et al.
        Alcohol consumption and the prevalence of metabolic syndrome: a meta-analysis of observational studies.
        Atherosclerosis. 2009; 204: 624-635
      5. American Diabetes Association. Food & Fitness: Alcohol. http://www.diabetes.org/food-and-fitness/food/what-can-i-eat/alcohol.html. Updated November 11, 2013. Accessed October 18, 2013.

        • Mukamal K.J.
        • Jensen M.K.
        • Grønbaek M.
        • et al.
        Drinking frequency, mediating biomarkers, and risk of myocardial infarction in women and men.
        Circulation. 2005; 112: 1406-1413
        • Krenz M.
        • Korthuis R.J.
        Moderate ethanol ingestion and cardiovascular protection: from epidemiologic associations to cellular mechanisms.
        J Mol Cell Cardiol. 2012; 52: 93-104
        • Perissinotto E.
        • Buja A.
        • Maggi S.
        • et al.
        • ILSA Working Group
        Alcohol consumption and cardiovascular risk factors in older lifelong wine drinkers: the Italian Longitudinal Study on Aging.
        Nutr Metab Cardiovasc Dis. 2010; 20: 647-655
        • Wakabayashi I.
        Associations between alcohol drinking and multiple risk factors for atherosclerosis in smokers and nonsmokers.
        Angiology. 2010; 61: 495-503
        • De Oliveira e Silva E.R.
        • Foster D.
        • McGee Harper M.
        • et al.
        Alcohol consumption raises HDL cholesterol levels by increasing the transport rate of apolipoproteins A-I and A-II.
        Circulation. 2000; 102: 2347-2352
        • Mukamal K.J.
        • Mackey R.H.
        • Kuller L.H.
        • et al.
        Alcohol consumption and lipoprotein subclasses in older adults.
        J Clin Endocrinol Metab. 2007; 92: 2559-2566
        • McClelland R.L.
        • Bild D.E.
        • Burke G.L.
        • et al.
        • Multi-Ethnic Study of Atherosclerosis
        Alcohol and coronary artery calcium prevalence, incidence, and progression: results from the Multi-Ethnic Study of Atherosclerosis (MESA).
        Am J Clin Nutr. 2008; 88: 1593-1601
        • Xie X.
        • Ma Y.T.
        • Yang Y.N.
        • et al.
        Alcohol consumption and ankle-to-brachial index: results from the Cardiovascular Risk Survey.
        PLoS One. 2010; 5: e15181
        • Albert M.A.
        • Glynn R.J.
        • Ridker P.M.
        Alcohol consumption and plasma concentration of C-reactive protein.
        Circulation. 2003; 107: 443-447
        • Greenfield J.R.
        • Samaras K.
        • Hayward C.S.
        • Chisholm D.J.
        • Campbell L.V.
        Beneficial postprandial effect of a small amount of alcohol on diabetes and cardiovascular risk factors: modification by insulin resistance.
        J Clin Endocrinol Metab. 2005; 90: 661-672
        • Ebrahim S.
        • Lawlor D.A.
        • Shlomo Y.B.
        • et al.
        Alcohol dehydrogenase type 1C (ADH1C) variants, alcohol consumption traits, HDL-cholesterol and risk of coronary heart disease in women and men: British Women's Heart and Health Study and Caerphilly cohorts.
        Atherosclerosis. 2008; 196: 871-878
        • Sierksma A.
        • Patel H.
        • Ouchi N.
        • et al.
        Effect of moderate alcohol consumption on adiponectin, tumor necrosis factor-alpha, and insulin sensitivity.
        Diabetes Care. 2004; 27: 184-189
        • Greenfield J.R.
        • Samaras K.
        • Jenkins A.B.
        • Kelly P.J.
        • Spector T.D.
        • Campbell L.V.
        Moderate alcohol consumption, estrogen replacement therapy, and physical activity are associated with increased insulin sensitivity: is abdominal adiposity the mediator?.
        Diabetes Care. 2003; 26: 2734-2740
        • Davies M.J.
        • Baer D.J.
        • Judd J.T.
        • Brown E.D.
        • Campbell W.S.
        • Taylor P.R.
        Effects of moderate alcohol intake on fasting insulin and glucose concentrations and insulin sensitivity in postmenopausal women: a randomized controlled trial.
        JAMA. 2002; 287: 2559-2562
        • Dorn J.M.
        • Hovey K.
        • Muti P.
        • et al.
        Alcohol drinking patterns differentially affect central adiposity as measured by abdominal height in women and men.
        J Nutr. 2003; 133: 2655-2662
        • Li H.
        • Förstermann U.
        Red wine and cardiovascular health [editorial].
        Circ Res. 2012; 111: 959-961
        • Chiva-Blanch G.
        • Urpi-Sarda M.
        • Ros E.
        • et al.
        Dealcoholized red wine decreases systolic and diastolic blood pressure and increases plasma nitric oxide: short communication.
        Circ Res. 2012; 111: 1065-1068
        • Krnic M.
        • Modun D.
        • Budimir D.
        • et al.
        Comparison of acute effects of red wine, beer and vodka against hyperoxia-induced oxidative stress and increase in arterial stiffness in healthy humans.
        Atherosclerosis. 2011; 218: 530-535
        • Halanych J.H.
        • Safford M.M.
        • Kertesz S.G.
        • et al.
        Alcohol consumption in young adults and incident hypertension: 20-year follow-up from the Coronary Artery Risk Development in Young Adults Study.
        Am J Epidemiol. 2010; 171: 532-539
        • Roy A.
        • Prabhakaran D.
        • Jeemon P.
        • et al.
        Impact of alcohol on coronary heart disease in Indian men.
        Atherosclerosis. 2010; 210: 531-535
        • Yusuf S.
        • Hawken S.
        • Ounpuu S.
        • et al.
        • INTERHEART Study Investigators
        Effect of potentially modifiable risk factors associated with myocardial infarction in 52 countries (the INTERHEART study): case-control study.
        Lancet. 2004; 364: 937-952
        • Ronksley P.E.
        • Brien S.E.
        • Turner B.J.
        • Mukamal K.J.
        • Ghali W.A.
        Association of alcohol consumption with selected cardiovascular disease outcomes: a systematic review and meta-analysis.
        BMJ. 2011; 342: d671
        • Schooling C.M.
        • Sun W.
        • Ho S.Y.
        • et al.
        Moderate alcohol use and mortality from ischaemic heart disease: a prospective study in older Chinese people.
        PLoS One. 2008; 3 ([published correction appears in PLoS ONE. 2008;3(6). http://dx.doi.org/10.1371/annotation/d27238c8-7f54-4bbb-afa4-b99443f1b9f0]): e2370
        • Chiva-Blanch G.
        • Urpi-Sarda M.
        • Ros E.
        • et al.
        Effects of red wine polyphenols and alcohol on glucose metabolism and the lipid profile: a randomized clinical trial.
        Clin Nutr. 2013; 32: 200-206
        • Di Castelnuovo A.
        • Costanzo S.
        • Donati M.B.
        • Iacoviello L.
        • de Gaetano G.
        Prevention of cardiovascular risk by moderate alcohol consumption: epidemiologic evidence and plausible mechanisms.
        Intern Emerg Med. 2010; 5: 291-297
        • Mukamal K.J.
        • Maclure M.
        • Muller J.E.
        • Mittleman M.A.
        Binge drinking and mortality after acute myocardial infarction.
        Circulation. 2005; 112: 3839-3845
        • Ruidavets J.B.
        • Ducimetière P.
        • Evans A.
        • et al.
        Patterns of alcohol consumption and ischaemic heart disease in culturally divergent countries: the Prospective Epidemiological Study of Myocardial Infarction (PRIME).
        BMJ. 2010; 341: c6077
        • Bagnardi V.
        • Zatonski W.
        • Scotti L.
        • La Vecchia C.
        • Corrao G.
        Does drinking pattern modify the effect of alcohol on the risk of coronary heart disease? evidence from a meta-analysis.
        J Epidemiol Community Health. 2008; 62: 615-619
        • O'Keefe J.H.
        • Gheewala N.M.
        • O'Keefe J.O.
        Dietary strategies for improving post-prandial glucose, lipids, inflammation, and cardiovascular health.
        J Am Coll Cardiol. 2008; 51: 249-255
        • O'Keefe J.H.
        • Patil H.R.
        • Lavie C.J.
        • Magalski A.
        • Vogel R.A.
        • McCullough P.A.
        Potential adverse cardiovascular effects from excessive endurance exercise [published correction appears in Mayo Clin Proc. 2012;87(7):704].
        Mayo Clin Proc. 2012; 87: 587-595
        • Eigenbrodt M.L.
        • Mosley Jr., T.H.
        • Hutchinson R.G.
        • Watson R.L.
        • Chambless L.E.
        • Szklo M.
        Alcohol consumption with age: a cross-sectional and longitudinal study of the Atherosclerosis Risk in Communities (ARIC) study, 1987-1995.
        Am J Epidemiol. 2001; 153: 1102-1111
      6. American Heart Association. Alcohol and heart disease. American Heart Association website. http://www.heart.org/HEARTORG/Conditions/More/MyHeartandStrokeNews/Alcohol-and-Heart-Disease_UCM_305173_Article.jsp. Updated September 20, 2012. Accessed October 18, 2013.

        • Poli A.
        • Marangoni F.
        • Avogaro A.
        • et al.
        Moderate alcohol use and health: a consensus document.
        Nutr Metab Cardiovasc Dis. 2013; 23: 487-504
      7. Park SY, Kolonel LN, Lim U, White KK, Henderson BE, Wilkens LR. Alcohol consumption and breast cancer risk among women from five ethnic groups with light to moderate intakes: the Multiethnic Cohort Study [published online ahead of print September 12, 2013]. Int J Cancer. http://dx.doi.org/10.1002/ijc.28476.