ISFAR members thought that this was a very well done, comprehensive summary of a large number of studies on alcohol and cardiovascular disease. ISFAR welcomed the discussion in the paper as to causality and regarding future directions in research, with more emphasis into how physicians and individual patients might respond to encouragement to consume alcohol for its potentially beneficial effects on cardiovascular disease. Most believe that there is no substitute for balanced judgment by a knowledgeable, objective health professional when discussing alcohol intake, and this requires a synthesis of common sense and the best available scientific facts as they apply to the individual.

Members also emphasised that: It is unlikely that there will ever be adequate clinical trials to judge the effects of alcohol consumption on major cardiovascular outcomes such as myocardial infarction or cardiac death in humans. Hence, for these lifestyle habits, we must use our best judgment based on carefully done observational studies, research into potential mechanisms of effect, and studies of intermediate outcomes that are in the pathways and processes in the development of disease.

The results of this 2011 meta-analysis are in line with what we know from the previous meta-analyses and the many individual studies: risk reductions for alcohol drinkers relative to non-drinkers of 25% for cardiovascular disease mortality, 29% for incident coronary heart disease, 25% for CHD mortality and 13 % for all cause mortality. The lowest risk of CHD mortality occurred with 1-2 drinks (15-30 grams of alcohol) per day is also in line with previous knowledge.

Messages to the public: Forum member Erik Skovenborg stated: “The public health messages should (and in many countries do) acknowledge the reduced risk of incidence and mortality of coronary heart disease associated with moderate drinking. However, we should not expect official recommendations of light drinking on a par with exercise, vegetables, and not smoking. The caveats would be too many, and official recommendations should be based on prospective, randomized studies. The role of alcohol drinking is best discussed in a scenario of a patient taking medical advice from his personal physician.”

Professor Arthur Klatsky also had pertinent comments on this topic: “In the final section of the paper the authors are struggling with the matter of advice. They are trying to come up with a new angle. We should keep in mind that many practitioners have been interacting with their patients about the benefits of light-moderate drinking for years. An overwhelming majority of persons (at least in our Northern California area) have heard of the benefits of light drinking, with many believing that this is specific for red wine. Some do not believe it as, no doubt, do some practitioners. The emotional baggage many have about alcohol will not go away. For these reasons, my enthusiasm is limited for the authors’ suggested approach of ‘evaluating the receptivity of both physicians and patients’ to recommendations to drink moderately."&having practiced cardiology for 50 years, it is clear to me that all advice — even upon matters with good evidence — needs individualization. With respect to light-moderate drinking, I’ll quote the final sentences of my JACC Editorial from 2010: ‘The risks of moderate drinking differ by sex, age, personal history, and family history. As is often the case in medical practice, advice about lifestyle must be based on something less than certainty. There is no substitute for balanced judgment by a knowledgeable, objective health professional. What is required is a synthesis of common sense and the best available scientific facts.’

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References: 1. Brien SE, Ronksley PE,Turner BJ, Mukamal KJ, Ghali WA. Effect of alcohol consumption on biological markers associated with risk of coronary heart disease: systematic review and meta-analysis of interventional studies. BMJ 2011;342:d636; doi:10.1136/bmj.d636. 2. Ronksley PE, Brien SE, Turner BJ, Mukamal KJ, Ghali WA. Association of alcohol consumption with selected cardiovascular disease outcomes: a systematic review and meta-analysis. BMJ 2011;342:d671; doi:10.1136/bmj.d671 )

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Contact: R Curtis Ellison
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Boston University Medical Center