Alcoholism—use and abuse
Methods
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Beer: 12 fluid ounces of 5 % beer = 355 ml fluid = 17.5 ml 100 % alcohol.
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Wine: 5 fluid ounces of 12 % wine = 148 ml fluid = 17.76 ml of 100 % alcohol.
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Distilled spirits: 1.5 fluid ounces of ~40 % liquor = 44 ml = 17.6 ml of 100 % alcohol.
A historical perspective
Nutritional causes of “alcoholic” cardiomyopathy
Beriberi heart disease
Manchester arsenic-in-beer epidemic
Quebec‘s beer drinker disease
Cardiac cirrhosis or cirrhotic cardiomyopathy
Hypertension
Alcoholic cardiomyopathy: Cytotoxicity of alcohol on heart muscle
Alcohol and myocarditis
Coronary artery disease and atherosclerosis
Signal transduction and beta-receptors
Arrhythmias and stroke
Clinical work-up for alcoholic cardiomyopathy
Work-up of | Criteria/findings |
---|---|
Cardiac symptoms | Fatigue, dyspnea, edema, nocturia, tachycardia |
Noncardiac physical examination | Mental state (delirium tremens, depression, anxiety, psychosis) Neurology (cognitive decline, cerebellar degeneration, peripheral neuropathy, proximal myopathy) Respiratory function (aspiration pneumonitis, pneumonia, tuberculosis, smoking) Gastrointestinal tract (malnutrition, liver disease, pancreatic disease) Endocrine function: pseudo-Cushing’s syndrome, hypogonadism |
ECG | Atrial fibrillation, complete or incomplete left or right bundle branch blocks, ST-segment and T‑wave alterations |
Echocardiography | LV dilatation or hypertrophy, atrial dilatation, reduced shortening and ejection fraction, small pericardial effusion, mitral and tricuspid regurgitation, atrial thrombi in atrial fibrillation |
Endomyocardial biopsy | Similar to dilated cardiomyopathy with myocyte hypertrophy or loss, reparative fibrosis, low grade leukocyte infiltration, variable, sometimes increase in Major Histocompatibility Complex(MHC) class I and II expression, immunoglobulin binding to sarcolemma and myosin; helpful in differential diagnosis of other forms of cardiomyopathies, theoretically suited for follow-up or improvement but not in common use for this purpose |
Cardiac MRI | Helpful in ruling out other cardiomyopathies, e. g. hypertrophic cardiomyopathy, myocarditis, constrictive pericarditis |
Cardiac CT | Only as noninvasive method to exclude coronary disease |
Laboratory findings
Laboratory marker | Indicative for | Time to normalize | Monitor abstinence |
---|---|---|---|
Alcohol concentration | In acute alcohol intoxication | Hours | Yes |
Mean corpuscular volume of red blood cells (MCV) | Increased | 3 months | No |
GGT, GOT, GPT, GOT/GPT ratio | Liver disease in patients with alcohol abuse | 4 weeks | No |
CDT (carbohydrate-deficient transferrin) | Chronic alcohol abuse | 4 weeks | No |
Ethyl glucuronide and ethyl sulphate | High-risk drinkers | 2 days | Yes |
Phosphatidyl ethanol | High-risk drinkers | 4 weeks | No |
NT-proBNP | Heart failure, helpful in follow-ups | Several weeks | No |
Troponins, CKMB | Acute myocyte destruction | 1–3 days | No |
Is there an immediate risk of alcohol intake?
Prognosis and treatment
Medication | Treatment goal | Dosage | Adverse reaction | Evidence |
---|---|---|---|---|
Pharmacological for maintaining abstinence
| ||||
Naltrexone | Abstinence | 50–100 mg/day (oral) 380 mg i. m. per month | Nausea, headache, dizziness, joint and muscle pain | High |
Acamprosate | Abstinence | 666 mg three times daily | Diarhea, pruritus, rash, altered libido | High |
Disulfiram | Abstinence | 200 mg/day (oral) | Dizziness, rash, headache, polyneuritis, impotence, hepatotoxicity | Mixed, needs supervision |
Nalmefene | Reduced drinking or abstinence | 18 mg/day (oral) | Dizziness, rash, headache, nausea, vomiting | Moderate |
Diazepam | Avoid delirium | As needed | Dizziness, sleepiness | Only symptomatic |
Pharmacological for heart failure (HF)
| ||||
ACE inhibitors | HF+ prognosis | As tolerated |
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| High in HF |
Betablockers | HF+ prognosis | As tolerated |
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| High in HF |
Diuretics | HF+ prognosis | As needed |
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| High in HF |
Digitalis | Rate control | According to digoxin or digitoxin level | Avoid overdosage | Moderate in atrial fibrillation (AF) |
Anticoagulants | Avoid stroke | INR 1.8–2.2 in AF | Bleeding | High in AF |