Alcoholic Heart Disemse

Abstract

Fifty patients with evidence of myocardial disease and, a long-standing high consumption of alcohol were seen over a ten-year period. The usual causes of myocardial disease were excluded as far as possible. All but one were male, and their ages ranged from the fourth to eighth decades. Three clinical syndromes which depend on the dominant derangement of circulatory function at any one time were recognized. Cardiac beriberi (aneurin-responsive disease) was the least frequent and least serious disorder. It occurred in five heavy beer-drinkers (not averse to spirits as well) and two of these had had a previous gastrectomy, which was thought to provide an additional adverse nutritional factor. Therapeutic response to aneurin and withdrawal of alcohol was good in these patients, but relapse has occurred following resumption of previous habits in at least one, and another has cardiographic evidence of persistent myocardial abnormality. A second, larger, group of patients presented with arrhythmia —especially atrial fibrillation—with or without varying degrees of heart failure. The ventricular rate tended to be fast and multifocal ventricular ectopics were common. Spontaneous return to sinus rhythm occurred in some, but usually relapse followed after a variable period. Fast heart rates, frequent extrasystoles, cardiomegaly, and abnormal QRST complexes on the cardiogram distinguished the condition from so-called idiopathic atrial fibrillation. Treatment with digitalis, diuretics, and conversion of rhythm met with variable success in this group. Reasonable health has been maintained in some when total abstinence has been observed and when the disease process was not far advanced on first presentation. The development of an arrhythmia with accompanying palpitation may draw attention to alcoholic heart disease before irreversible damage has been done. A third group of patients presented with hypokinetic heart failure, cardiomegaly and electrocardiographic evidence of severe myocardial disease. Response to treatment was moderate at first but an episodic downhill course was usual. The electrocardiogram showed a wide range of abnormality as in other forms of cardiomyopathy. There was a fairly close correlation between the degree of cardiographic abnormality and the severity of the myocardial disease as judged by heart size and response to treatment. Mild polycythaemia was observed in many patients, and was thought to be a response to low-grade chronic cardiac insufficiency. Serum cholesterol levels tended to be lower than average and were believed to be the result of dietary replacement by ethanol. Diagnostic problems abound in these patients, especially when the story of alcoholism is missed or its significance overlooked. In our experience most of these men consumed far more than was admitted in the initial interrogation. “Fallen hypertension ” and silent coronary occlusion were common diagnostic errors (there was no occlusive coronary disease in nine cases examined at necropsy). Atrial fibrillation, a fast ventricular rate, sweating, and tremor with a low serum cholesterol combined to produce a superficial resemblance to thyrotoxicosis. As in other forms of cardiomyopathy, constrictive pericarditis has been erroneously diagnosed in patients with severe heart failure, but attention to clinical detail and the electrocardiogram should indicate the correct diagnosis and prevent unwarranted surgery. The pathological findings on nine necropsy cases are described and possible mechanisms of Pathogenesis discussed. It is concluded that the association of high alcohol consumption for a long time and myocardial disease, manifest by arrhythmias and heart failure, is not fortuitous but causal. However, we have no evidence on the pathogenesis of the process nor on the nature of individual susceptibility. © 1964, British Medical Journal Publishing Group. All rights reserved.