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The once-vaunted epidemiologic J-curve for alcohol intake and cardiovascular outcomes has flattened a bit further with a new analysis based on a cohort from a vintage randomized trial. In it, patients with heart failure (HF) stage B — characterized by ventricular dysfunction but no symptoms — who reported either moderate or high alcohol intake showed a fourfold jump in risk for disease progression, clinically or on echocardiography.

And there was no sign of protection at any level of alcohol intake among those who started the trial with HF stage A, please us with your lyrical thesis characterized by risk factors such as hypertension, obesity, or diabetes, but without echo abnormalities.

But moderate to high alcohol intake, defined here as consumption of more than 70 g ethanol per week, in the stage A (“at risk for HF”) group wasn’t associated with greater risk for incident disease — that is, progression to HF stage B or C (“pre-HF” or “symptomatic HF,” respectively).

Nor did it seem to lower risk. And that, along with the study’s other findings, contradicts messaging that still lingers in some guidelines that suggests that some alcohol intake may be cardioprotective for some people, Bethany Wong, MBBS, St. Michael’s Hospital, Dublin, told theheart.org | Medscape Cardiology.

The analysis is based on 744 adults with HF stage A or B (mean age, 66 years, 53% female), who had been randomly assigned to either usual care or follow-up by echo and natriuretic peptide assays in the STOP-HF trial, which produced its primary publication in 2013. Wong presented the new secondary findings May 22 at the Heart Failure Association of the European Society of Cardiology (HFA-ESC) 2022 sessions, conducted both virtually and live in Madrid.

She pointed to the latest ESC guideline document for HF diagnosis and management, unveiled last year, which recommends against any alcohol use by people with alcohol-induced cardiomyopathy but proposes that no intake or only “light” intake “is beneficial” as a preventive strategy in the general population. The corresponding guideline from the North American societies mentions alcohol only few times and usually in terms of substance abuse.

“The ESC guidelines from 2021 report that for males, up to 140 grams per week is not only safe, but potentially protective from heart failure,” Wong said. “Whereas, that would be double the amount that we found to be associated with left ventricular dysfunction in this stage B population. And the heart failure guidelines from last year are at odds with the European preventive cardiology guidelines,” she added, as well as a recent push from the World Heart Federation.

If clinicians and the public are confused by the inconsistent messaging, they could look beyond the heart and even to other corners of cardiology for ways that drinking alcohol can be harmful rather than protective.

“It’s not just the heart that’s affected. We need to bear in mind that when we’re giving advice, we have to think about other organs as well,” Wong said.

The analysis excluded former drinkers and anyone with symptomatic HF. Its 484 participants at risk for HF, compared with the 260 participants with pre-HF, were younger, less likely to be male, had higher LV ejection fractions (LVEF), and had lower natriuretic peptides, left ventricular (LV) mass index, and LV volume index (P < .001 for all).

No alcohol intake was reported by 27% of the overall cohort, low use (≤70 g/week) was reported by 47.8%, and moderate to high use was reported by 25.1%. Participants reporting moderate to high alcohol use were younger, more likely to be male, and had a higher body mass index, Wong reported. For perspective, a standard bottle of wine, she explained, contains about 70 g ethanol.

Among patients with baseline pre-HF, the odds ratio (OR) for HF progression — defined as a fall in LVEF of 5 points or a rise in the E/e′ ratio of more than 2, an index of diastolic function — for those with moderate to high alcohol intake, compared with no intake, was 4.5 (95% CI, 1.7 – 15.9; P < .001) after adjustment for age, sex, obesity, blood pressure, diabetes, and other factors with known effects on ventricular function. The findings were similar in analyses separately comparing moderate and high intake levels to no alcohol intake.

The analysis has its limitations, Wong observed, including an older, “very homogenous European population” that limits generalizability and an assumption “that the alcohol use somebody describes and self-reports at a clinic visit is going to be stable over the follow-up, which we know isn’t the case.”

In contrast, that the cohort was in a clinical trial with baseline and follow-up echocardiography “may make it more robust,” she said. “We do need more research to confirm these findings prospectively, ideally.”

Wong reports that she has nothing to disclose.

Heart Failure Association of the European Society of Cardiology (HFA-ESC) 2022: Moderate alcohol consumption is associated with progression of left ventricular dysfunction in a European stage B heart failure population. Presented May 22, 2022.

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