Alcohol-induced Cardiomyopathy

Background

• Alcoholic cardiomyopathy refers to dilated cardiomyopathy caused by excessive alcohol consumption and involves dilation and impaired contraction of 1 or both myocardial ventricles with normal or reduced ventricular wall thickness in persons with history of alcohol misuse and no other causes of dilated cardiomyopathy
• Alcohol is common acquired cause of dilated cardiomyopathy and accounts for 21%-36% of causes, with risk proportional to amount and duration of alcohol intake.
• Alcoholic cardiomyopathy proposed to be due to combination of alcohol dose and individual predisposition.
• Clinical presentation
  • most common in men aged 30-55 years with history of heavy alcohol use > 10 years
  • patients may be asymptomatic until cardiac dysfunction advanced and irreversible and presentation of left ventricular or 4-chamber dilation and systolic dysfunction with signs and symptoms of heart failure, including
    • exertional dyspnea
    • fatigue
    • bilateral peripheral pitting edema
  • younger patients without heart disease may present with palpitations, chest pain, and dyspnea after acute consumption of large amounts of alcohol on weekends or holidays (may be referred to as holiday heart)
  • patients may also present with signs of other disease associated with alcohol use disorder, including liver disease, malnutrition, peripheral neuropathy, and other neurological disorders, such as Wernicke-Korsakoff syndrome

Evaluation

• No specific clinical or histologic features of alcoholic cardiomyopathy known.
• Diagnose alcoholic cardiomyopathy in patients with all of following:
  • dilated cardiomyopathy (diagnosed in patients with left ventricular [LV] or biventricular dilation and systolic dysfunction not explained by abnormal loading conditions or coronary artery disease; see also Dilated Cardiomyopathy)
  • no other causes of dilated cardiomyopathy
  • long history of alcohol misuse (most commonly defined as alcohol use > 80 g/day for > 5 years).

Management

• Alcohol abstinence considered most effective treatment of alcoholic cardiomyopathy and reported to promote recovery of LV dysfunction, but LV dysfunction may not be reversible in all patients.
• American Heart Association (AHA) recommendations for management of alcoholic cardiomyopathy
  • reduction of alcohol intake to < 60 g/day may be associated with significant improvement in ejection fraction in men with alcoholic cardiomyopathy
  • treat heart failure according to guideline-directed medical therapy, as no specific drug therapy for patients with alcoholic cardiomyopathy other than standard heart failure drugs
  • supplement thiamine and folate in patients with thiamine and folate deficiencies
• See also:
  • Heart Failure With Reduced Ejection Fraction (HFrEF)
  • Alcohol Use Disorder

Prognosis

• Prognosis depends on efficacy of treatment for alcohol use disorder, rate of deterioration of systolic function directly related to alcohol use, and duration of alcohol use.
• LV ejection fraction (LVEF) recovery in 42% of patients with alcoholic cardiomyopathy, and LVEF recovery associated with reduced risk of death and cardiac transplantation.