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(Stroke. 1995;26:1691-1696.)
© 1995 American Heart Association, Inc.

Articles

Stroke and Alcohol Intake in a Hospital Population

A Case-Control Study

E. Beghi, MD; G. Bogliun, MD; P. Cosso, MD; G. Fiorelli, MD; C. Lorini, MD; M. Mandelli, MD A. Bellini, MD

From Clinica Neurologica e Istituto di Scienze Biomediche, Ospedale "San Gerardo," Monza (E.B., G.B.); Clinica Medica, Istituto di Scienze Biomediche, Ospedale "San Gerardo," Monza (P.C., G.F., C.L., M.M.); and Istituto di Ricerche Farmacologiche "Mario Negri," Milan (E.B., A.B.), Italy.

Correspondence to Dr Ettore Beghi, Istituto di Ricerche Farmacologiche "Mario Negri," Via Eritrea 62, 20157 Milan, Italy.

	Abstract

Top Abstract Introduction Subjects and Methods Results Discussion References

 
Background and Purpose The aim of the study was to assess whether excessive alcohol intake is an independent risk factor for stroke.

Methods A case-control study was undertaken in 200 consecutive ischemic and hemorrhagic stroke patients and 372 age- and sex-matched control subjects (170 hospital-based and 202 community-based individuals). Data were collected through direct interview regarding demographics, risk factors for stroke, current daily alcohol consumption, and diagnosis of alcoholism. Blood was also taken to test the common biological markers of alcohol intake (erythrocyte mean cell volume, uric acid, aspartate aminotransferase, and -glutamyl transferase).

Results After controlling for the most significant risk factors (antecedent strokes, hypertension, diabetes, smoking) and using hospital control subjects for reference, we determined the risk of stroke to be 2.2 (95% confidence interval [CI], 1.2 to 4.0) in moderate drinkers (men, 60 g/d; women, 40 g/d) and 2.9 (95% CI, 1.4 to 6.1) in heavy drinkers (men, >60 g/d; women, >40 g/d). The corresponding risk values obtained when we compared case subjects and external control subjects were 1.4 (95% CI, 0.8 to 2.7) and 3.0 (95% CI, 1.3 to 7.0). Even with some fluctuations across groups, the risk did not change significantly after subgroup analysis in men, patients with first-ever stroke, patients with ischemic stroke, and after exclusion of subjects with risk factors for stroke. Compared with hospital and external control subjects, stroke patients included a higher proportion of heavy drinkers (26.6% versus 20.6% versus 10.8%), alcoholics (14.6% versus 7.7% versus 2.5%), and cases with abnormal erythrocyte mean cell volume (63.0% versus 47.6% versus 34.2%) or -glutamyl transferase (35.5% versus 32.4% versus 12.9%). Mean alcohol consumption was 42.2 g/d in the case subjects, 30.8 g/d in the hospital control subjects, and 23.2 g/d in the external control subjects.

Conclusions The study indicates that alcohol can be considered an independent risk factor for stroke in Italy.

Key Words: alcohol drinking • Italy • risk factors • stroke

	Introduction

Top Abstract Introduction Subjects and Methods Results Discussion References

 
The effects of alcohol intake on the occurrence of stroke are still debated. In fact, despite the biological plausibility of a presumed adverse effect of alcohol on the cardiovascular system,^{1 2 3 4 5} coagulation,^{6 7 8 9 10} and cerebral blood flow,^{11 12 13} evidence is still conflicting regarding a link between alcohol intake and occurrence of stroke in clinical series.¹⁴ A J-shaped association has been postulated between moderate alcohol intake and ischemic stroke in white populations, whereas for intracerebral and subarachnoid hemorrhage a linear correlation with the extent of alcohol consumption has been detected. Although these different types of associations may explain in part the contradictory findings of the literature, several methodological inconsistencies may affect the results of the available reports and suggest further investigations. For these reasons and because of the general lack of information on this issue in the Italian population, a case-control study has been undertaken in Italy, with the following aims: (1) to assess whether excessive alcohol consumption is an independent risk factor for stroke and (2) to investigate the correlation between alcohol intake and stroke severity and types (ischemic versus hemorrhagic lesions).

The preliminary results of the present study, which focused on hospitalized stroke case subjects and hospital control subjects, have been reported elsewhere.¹⁵ In that report the role of alcohol as a risk factor for stroke proved to be small and was practically lost after adjustment for the most common risk factors for cerebrovascular disease. Here the results of an extended study are presented, with inclusion of a group of external control subjects.

	Subjects and Methods

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During the period April 1987 through June 1989, 200 consecutive stroke patients were enrolled into the study at the General Hospital of Monza, in the Milan area. With reference to the World Health Organization criteria,¹⁶ a diagnosis of stroke was made when there was an acute onset of a neurological deficit lasting 24 hours or longer, with no apparent cause other than vascular. A neurological consultation and a CT scan (within 15 days of the onset of symptoms) were required to confirm the diagnosis and exclude other clinical conditions. Age less than 20 years and drug addiction were reasons for exclusion. For each stroke index case two age- (±2 years) and sex-matched control subjects were selected from hospital inpatients and outpatients. Hospital control subjects were selected among subjects admitted within 24 hours in the same hospital for reasons other than stroke. The illnesses leading to hospital admission were as follows: cardiovascular, 37; respiratory, 35; genitourinary, 19; orthopedic, 18; gastrointestinal (not alcohol-related), 17; neurological (other than cerebrovascular), 12; cutaneous, 11; endocrine/metabolic, 10; hematologic, 3; and miscellaneous, 8. Twenty additional patients were later found to have been admitted for liver cirrhosis or chronic liver disease, 6 for other alcohol-related diseases (carcinoma of the larynx, oral cavity, and liver; delirium tremens; peptic ulcer), and 4 for transient ischemic attack (TIA) or chronic cerebrovascular disease. These patients were excluded from the main analysis and considered separately (see below). External control subjects were recruited in the hospital catchment area among the affiliates of four general practitioners requiring office medical consultation. One hundred eleven external control subjects had no major complaints; in the remainder the list of medical illnesses was as follows: cardiovascular, 16; respiratory, 14; genitourinary, 13; endocrine/metabolic, 10; neuropsychiatric, 10; gastrointestinal (not alcohol-related), 8; hematologic, 3; orthopedic, 3; and miscellaneous, 5. In 9 other individuals subsequent consultation with the general practitioner led to the diagnosis of peptic ulcer (4), hepatic cirrhosis or chronic liver disease (3), cancer of the larynx (1), or cerebrovascular disease (1). These subjects were retained in the analysis because these diseases were not reasons for the original medical consultation.

Case and control subjects were interviewed directly. When disability prevented an adequate response (17 case subjects and 7 hospital control subjects), the closest relative or accompanying person was interviewed. The following data were collected on ad hoc forms: main demographic variables, principal risk factors for stroke (see below), current daily alcohol consumption (expressed in grams per day according to a standard nomogram),¹⁷ and biological markers of alcohol intake: erythrocyte mean cell volume, aspartate aminotransferase, uric acid, and -glutamyl transferase.

A diagnosis of alcoholism was made with the use of the Michigan Alcoholism Screening Test (MAST),¹⁸ a 25-item questionnaire evaluating the social, legal, and health consequences of drinking. Each answer was assigned a weighted score. A total score of 5 points or more defined an alcoholic. According to the amount of ingested alcohol and with reference to the suggestions of the Italian Alcohol Society,¹⁹ case and control subjects were grouped in three classes: abstainers, moderate drinkers (men, 60 g/d; women, 40 g/d), and heavy drinkers (men, >60 g/d; women, >40 g/d). The most widely recognized risk factors for stroke²⁰ were defined in accordance with clinical and laboratory criteria. Previous TIA or strokes, use of oral contraceptives, smoking, cardiovascular disorders, diabetes, arterial hypertension, and dyslipidemia were assessed through direct interview supplemented by examination of hospital records and those of the general practitioner. Obesity was assessed by clinical examination, which included blood pressure measurement. Specific treatments were required to support the diagnosis of hypertension, diabetes, and cardiovascular disorders. Cardiovascular disorders included angina, myocardial infarction, atrial fibrillation and other cardiac arrhythmias, congestive heart failure, and valvular disease.

Case and control subjects were interviewed by three of us (P.C., C.L., M.M.). Interrater agreement for all the interview items was previously tested on 9 subjects (3 abstainers, 4 moderate drinkers, and 2 heavy drinkers). The overall ²¹ documented a satisfactory interrater agreement, as it was 0.84 (95% confidence interval [CI], 0.54 to 1) for risk factors for stroke and 0.84 (95% CI, 0.64 to 1) for alcohol intake. Concordance among raters was complete for the diagnosis of alcoholism according to the MAST questionnaire.

Case subjects and hospital control subjects (or their relatives or friends when cooperation was impossible) were assessed at the bedside. External control subjects were examined in the general practitioner's office. Blood was taken from venipuncture for case subjects and hospital control subjects and for most of the external control subjects.

Data were analyzed with the use of univariate and multivariate techniques. Mantel-Haenszel odds ratios²² were used to measure relative risks. Data were also stratified in relation to selected variables thought to influence the drinking habits of our population (men versus women, presence or absence of risk factors for cardiovascular disease, first-ever stroke, and ischemic stroke). Multiple logistic regression analysis was used, with the principal risk factors for stroke as confounders. All the statistical analyses were performed after exclusion of hospital control subjects with alcohol-related disorders and cerebrovascular disease and were then repeated after these individuals were retained. The latter analysis was made to provide confirmatory evidence of our data after we adjusted for a possible underrepresentation of heavy drinkers in the control population.

	Results

Top Abstract Introduction Subjects and Methods Results Discussion References

 
The sample included 200 case and 602 control subjects (200 hospital-based and 202 community-based). The male-to-female ratio was 2.4:1. Age at admission ranged from 24 to 87 years in the case subjects and from 22 to 86 in the control subjects. After exclusion of individuals with exposure-related or disease-related conditions requiring hospital admission, there were 170 hospital control subjects. The general characteristics of this sample are depicted in Table 1. Mean age was 66.4 years for the case subjects, 67.2 years for the hospital control subjects, and 66.0 years for the external control subjects. Mean alcohol consumption was significantly higher in the case subjects: 42.2 g/d compared with 30.8 in hospital control subjects and 23.2 in external control subjects. Likewise, stroke patients had a higher proportion of heavy drinkers (26.6% versus 20.6% versus 10.8%), alcoholics (14.6% versus 7.7% versus 2.5%), and cases with abnormal erythrocyte mean cell volume or -glutamyl transferase. Hypertension was the most common disease in the three groups. Cardiovascular disorders prevailed among hospital control subjects and obesity among external control subjects. Compared with both control groups, stroke index case subjects included a significantly higher proportion with antecedent TIA/strokes, diabetes, and hypertension. Compared with abstainers, moderate drinkers were at slightly higher risk of stroke and heavy drinkers at a significantly higher risk (Table 2). The difference between the two control groups was modest, and the risk was greater (3.1) when the case subjects who were heavy drinkers were compared with the external control subjects. The diagnosis of alcoholism was most common among stroke index case subjects, although a significant difference in the risk values was detected across groups, with a peak (6.6) for external control subjects.

View this table: [in this window] [in a new window]   Table 1. General Characteristics of the Sample

View this table: [in this window] [in a new window]   Table 2. Risk Factors for Cerebrovascular Disorders in Stroke Patients (n=200), Hospital Controls (n=170), and External Controls (n=202)

Along with alcohol intake, other factors were associated with a higher risk of stroke. These included antecedent TIA/stroke, diabetes, and hypertension. Smoking seemed to affect the risk of stroke only when the case subjects were compared with the external control subjects. The role of obesity as a risk factor seemed limited to the hospital control subjects. When we adjusted for age, sex, history of TIA or stroke, diabetes, hypertension, and smoking and used the hospital control subjects for reference, the risk was 2.2 (95% CI, 1.2 to 4.0) in moderate drinkers and 2.9 (95% CI, 1.4 to 6.1) in heavy drinkers. The corresponding risk values obtained when we used the external control subjects for reference were 1.4 (95% CI, 0.8 to 2.7) and 3.0 (95% CI, 1.3 to 7.0).

The analysis was then repeated after exclusion of hypertension in the model, under the assumption that hypertension could mediate the effect of alcohol on stroke. When we used hospital control subjects for reference, the risk of stroke was 2.3 (95% CI, 1.0 to 5.3) for moderate drinkers and 2.9 (95% CI, 1.1 to 7.6) for heavy drinkers. The corresponding values for external control subjects were 1.7 (95% CI, 0.7 to 4.2) and 6.0 (95% CI, 2.1 to 17.2).

The risk tended to decrease slightly and became of borderline significance after we added the 30 hospital control subjects with disease or exposure-related conditions. In that case, the risk of stroke for moderate drinkers was 1.5 (95% CI, 0.9 to 2.6) and 2.0 for heavy drinkers (95% CI, 1.1 to 3.7). No interaction was detected between smoking and alcohol intake.

Selected categories of patients were then considered to assess the risk of stroke according to the level of alcohol consumption (Table 3). Although some fluctuations were noted, an elevated risk of stroke among heavy drinkers was confirmed for men, patients with first-ever stroke, patients with ischemic stroke, and those with none of the most common risk factors for cerebrovascular disease.

View this table: [in this window] [in a new window]   Table 3. Alcohol Intake and Stroke by Stratified Analysis of Selected Risk Factors

Cerebral infarction was the most common stroke subtype (59%), followed by lacunarity (15%) and cerebral hemorrhage (9.5%). Among patients with cerebral infarction, heavy drinkers amounted to 29%. The corresponding percentages for patients with cerebral hemorrhage and lacunes were 26% and 30%. CT scan was normal in 18% of the patients. Cerebral atrophy was present in 33% of cases. CT scan was not available for 10 patients who died before they were examined. Eighteen patients died during the acute phase of the disease. Overall, stroke was mild in 44% of the patients, moderate in 37%, and severe in 19%. Heavy drinkers constituted 24% of those with mild stroke, 32% of those with moderate stroke, and 22% of those with severe stroke.

	Discussion

Top Abstract Introduction Subjects and Methods Results Discussion References

 
In the present study patients with heavy alcohol intake were at higher risk of stroke, and a dose-response effect could be documented. The abnormal values of some biochemical markers of alcohol consumption supported the self-reported associations.

A closer look at the two control groups showed moderate differences in the risk values, which in some respects depend on the different degree of exposure to alcohol and the different proportion of individuals with a diagnosis of alcoholism. As expected, the proportion of heavy drinkers and alcoholics was higher among the hospital control subjects than the external control subjects. The hospital control subjects also included a higher percentage of smokers and patients with cardiovascular disorders, hypertension, and diabetes. These differences may partly explain the differences in the risk values when comparisons were made between case subjects and the two control groups separately. However, the differences in the risk values across groups cannot be explained by a different distribution of alcohol-related disorders, since patients with alcohol-related conditions leading to hospital admission were excluded. This decision did not preclude inclusion of patients with alcohol-related disorders that did not require hospitalization (case subjects and hospital control subjects) or medical consultation (external control subjects) who were equally eligible for enrollment in the study.

Several pieces of evidence seem to support the concept of a causal relationship between alcohol consumption and stroke: the index case subjects included a larger proportion of heavy alcohol consumers and revealed a higher quantity of daily alcohol ingestion. The results were fairly similar when the case subjects were compared with the two control groups. The risk values did not change when data were adjusted for the principal confounders, including smoking, and (although with some fluctuations) when the analysis was repeated within selected subgroups of case and control subjects. Stroke patients also included a larger proportion of individuals with a diagnosis of alcoholism, although significant differences were detected when the index case subjects were compared with the two control groups separately.

Two other studies may be compared with our investigation because of the similarity of the study design. In a retrospective case-control study of 230 ischemic and hemorrhagic stroke patients and 230 matched control subjects with a mean age of 59 years, a significant correlation was found between heavy alcohol consumption and stroke in men, after adjustment for smoking, arterial hypertension, and medications.²³ In a larger stroke population, the same authors showed that the relative risks of stroke according to the extent of alcohol consumption followed a J-shaped association curve, suggesting that lower levels of alcohol intake may have a protective effect on the vascular system, whereas heavy alcohol intake may predispose to stroke of any type.²⁴ These data fit in part with our results and suggest that in a mixed stroke population, heavy alcohol intake may be an independent risk factor for cerebrovascular disease. In another study of predominantly black middle-aged and elderly patients an apparent association was found between acute alcohol intake and stroke; however, the association disappeared when the investigators adjusted for smoking and hypertension.²⁵ In a subsequent analysis of customary alcohol intake and smoking, the authors concluded that alcohol consumption may not be an independent risk factor for cerebral infarction in middle-aged and elderly patients when the confounding effects of smoking are accounted for.²⁶ We confirmed the presence of a higher risk of stroke among heavy alcohol consumers, even limiting the analysis to ischemic stroke patients and after adjusting for smoking. In the study by Gorelick and colleagues,²⁵ the inclusion of patients enrolled in a general medicine outpatient service may reflect the inclusion of a higher proportion of subjects with alcohol-related diseases than expected in the general population. An explanation of this assumption comes from our previous report, when we limited the analysis to hospitalized control subjects, including subjects with disease- and exposure-related conditions.¹⁵ Likewise, in the present investigation the risk of stroke in heavy drinkers became of borderline significance after inclusion of exposure- or disease-related conditions in hospital and external control subjects. As recently shown,²⁷ the risk associated with alcohol consumption varies depending on the selection of the control groups and may partly explain the fluctuations in our risk values and the contradictory results from previous case-control studies.

This study population included first-ever strokes and stroke recurrences. The inclusion of repeated strokes may introduce a selection bias because this group may include survivors of previous strokes who may have reduced alcohol intake as a consequence of the disease. The same holds true for the oldest patients and those with arterial hypertension, diabetes, and other chronic disorders, which may alter personal lifestyles. In this study arterial hypertension was considered a confounding factor because it is commonly accepted as an independent risk factor for stroke. However, in studies on alcohol consumption and alcoholism, adjustment on the basis of hypertension may not be justified since hypertension could mediate the effect of alcohol on stroke.^{4 28} This assumption seems confirmed by the increased risk values when our case subjects were compared with the external control subjects after exclusion of hypertension from the logistic regression model. We may similarly explain the slightly higher risk of first-ever stroke among heavy alcohol consumers and the higher estimated relative risk in the individuals without risk factors for cerebrovascular disease.

Contrary to the findings of Gill et al,²³ stroke subtypes have been detected in the present study by neuroradiological assessment in almost all cases. No significant differences were present when ischemic or hemorrhagic stroke and alcohol consumption were compared, nor was an association found between alcohol intake and the severity of stroke. However, the small numbers in some diagnostic and prognostic categories, the different distribution of stroke subtypes in the present series, and the low proportion of cases with hemorrhagic strokes may prevent definite conclusions.

Our findings confirm the results of certain English authors,²³ according to whom the higher risk of stroke was limited to men. However, consistent with their results, the numbers in the female group were small, thus preventing any meaningful conclusion.

The different sources of case subjects and the presumedly different control populations may explain the difference between our results and those of the West Birmingham Stroke Project,²⁹ which showed a lack of association between alcohol consumption and cardiovascular risk factors and stroke.

The results of the present study provide epidemiological and biochemical confirmation of the effects of alcohol on the vascular system, which have been repeatedly emphasized by experimental and clinical reports. In that sense, the significant increase of some biochemical markers of excessive alcohol intake among our stroke index cases is worth noting. We do not know to what extent our findings can be generalized to other countries and populations, which may have different social and alimentary habits. However, even with the limitations of the different methodological approaches, our findings are consistent with the results of other clinical series showing that ischemic stroke^{30 31 32 33} and stroke of undetermined origin^{34 35 36 37} may be related to heavy alcohol intake.

	Acknowledgments

 
Statistical analysis was performed with the contribution of Regione Lombardia (Delibera Giunta Regionale 17084).

Received November 10, 1994; revision received April 11, 1995; accepted June 12, 1995.

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