Tools for Practice


#271 Be still my quivering heart: alcohol and atrial fibrillation


CLINICAL QUESTION
Does advising patients to abstain from alcohol prevent atrial fibrillation recurrence?

BOTTOM LINE
Observational studies consistently report a dose-response association between alcohol and new onset atrial fibrillation. Based on 1 randomized controlled trial (RCT) of “regular drinkers” with paroxysmal atrial fibrillation, recurrence of atrial fibrillation happened in ~50% who abstain compared to ~70% who continue drinking. Abstaining can prevent 1 atrial fibrillation-related hospital visit for every 9 people compared to those who continue to drink at 6 months. 


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EVIDENCE
Open-label RCT in Australia, 140 patients with atrial fibrillation for ~6 years (mainly paroxysmal) and “regular” alcohol use (mean 16 per week). Mean age 62, 85% male, randomized to oral and written advice to abstain from alcohol with monthly follow-up and positive reinforcement or control (no advice on drinking). At 6 months:1 
  • Mean alcohol intake per week: 2 (intervention) versus 13 (control). 
  • Complete abstinence: 61% (intervention). 
  • Atrial fibrillation recurrence: 53% versus 73% (control), number needed to treat (NNT)=5. 
  • Atrial fibrillation-related hospital admissions: 9% versus 20% (control), NNT=9. 
  • Other benefits: 3.7kg weight loss in intervention. 
  • Limitations: 70% of patients screened for study not interested in abstinence; participants had to be in normal sinus rhythm at randomization. 
Best systematic reviews of observational studies on relationship between chronic alcohol use and new onset atrial fibrillation:2,3 
  • Risk differs between studies due to different populations, definitions of alcohol use, adjustment for confounders and whether results separated by gender. Best estimates: 
    • Compared to non or infrequent users (<2 drinks per month), the relative risk of atrial fibrillation appears to increase ~10% per drink per day.2 
    • Absolute risk (per 1000 patient years) over ~4.5 years: 
      • 15 for low (<1 drink/week), 17 for moderate (≤2 drinks/day for women and 3 for men) and 21 for high [>2 per day (women) or 3/day (men)].4 
Context: 
  • Older data suggests up to 35% of new cases of atrial fibrillation are related to acute alcohol intoxication,5 and may recur with subsequent binge drinking.6 
  • Guidelines recommend lifestyle interventions for atrial fibrillation, including weight loss, increasing physical activity, quitting smoking and reducing alcohol intake.7 
August 10, 2020

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Author(s):

  • Adrienne J Lindblad BSP ACPR PharmD
  • Michael R Kolber MD CCFP MSc

1. Voskoboinik A, Kalman JM, De Silva A, et al. New Engl J Med. 2020; 382:20-8.

2. Larsson SC, Drca N, Wolk A. J Am Coll Cardiol. 2014 Jul 22; 64(3):281-9.

3. Gallagher C, Hendriks JML, Elliott AD, et al. Int J Cardiol. 2017; 246:46-52.

4. Liang Y, Mente A, Yusuf S, et al. CMAJ. 2012 Nov 6; 184(16):E857-66.

5. Lowenstein SR, Gabow PA, Cramer J, et al. Arch Intern Med. 1983 Oct; 143(10):1882-5.

6. Krishnamoorthy S, Lip GYH, Lane DA. Am J Med. 2009; 122:851-6.

7. Chung MK, Eckhardt LL, Chen LY, et al. Circulation. 2020 Mar 9; CIR0000000000000748 [epub ahead of print].

Authors do not have any conflicts of interest to declare.