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(Stroke. 2001;32:591.)
© 2001 American Heart Association, Inc.
AHA Science Advisory |
Wine and Your Heart
A Science Advisory for Healthcare Professionals From the Nutrition Committee, Council on Epidemiology and Prevention, and Council on Cardiovascular Nursing of the American Heart Association
Key Words: AHA Science Advisory • alcohol • epidemiology • coronary disease • diet
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Introduction |
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 Top Introduction Epidemiological Association of...The Biological Basis for...Adverse Effects of Alcohol...What Conclusions Can We...References |
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Data regarding the incidence of coronary heart disease (CHD) in different populations have generated a series of hypotheses that protective substances in the diet may counteract the harmful effects of high-cholesterol, high-saturated-fat diets. One such potential food substance is wine, especially red wine. The purpose of this advisory is to summarize the current literature on wine intake and cardiovascular disease. As stated in a previous advisory on alcohol and CHD,1 recommendations for use of a nonessential dietary component with significant health hazards require definitive evidence of benefit. Although population surveys and in vitro experiments show that wine may have limited beneficial effects, more compelling data exist for other less-hazardous approaches to cardiovascular risk reduction.
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Epidemiological Association of Wine Intake and Cardiovascular Disease |
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TopIntroductionEpidemiological Association of...The Biological Basis for...Adverse Effects of Alcohol...What Conclusions Can We...References |
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Do Epidemiological Data Support a Role for Alcoholic Beverages (Wine in Particular) as a Cardioprotective Substance?
There are more than 60 prospective studies that suggest an inverse relation between moderate alcoholic beverage consumption and CHD.2 A consistent coronary protective effect has been observed for consumption of 1 to 2 drinks per day of an alcohol-containing beverage; however, higher intakes are associated with increased total mortality.3 4 Although ecological studies support an association between wine intake and lower CHD risk, these studies are confounded by lifestyle, diet, and other cultural factors.4 5 6 7 Most cohort studies do not support an association between type of alcoholic beverage and prevention of heart disease; however, a few have suggested that wine may be more beneficial than beer or spirits.8 9 It remains unclear whether red wine confers any advantage over white wine or other types of alcoholic beverages.
A synthesis of the observational studies is difficult because of wide variations in methodology, measurement error in alcohol consumption, and biological variability in response to alcohol consumption (which tends to underestimate effect). Moreover, consumption may vary over time, and this is often not taken into consideration in observational studies. Consumption of alcohol is associated with age, race, smoking, ethnic background, and education level. Wine drinkers tend to be less fat, to exercise more, and to drink with meals. Statistical modeling that includes potential confounders does not mitigate the beneficial effect of alcohol consumption on CHD. Furthermore, the residual protective effect of wine may be due to unmeasured factors or differences between drinkers and nondrinkers that cannot be adequately controlled for in statistical analyses. Because of these limitations, epidemiological data can be considered to be supportive of the alcohol-CHD hypothesis, but not definitive. More data are needed to clarify the effects of specific types of beverages in diverse populations.
The mortality rate from CHD in France is perhaps half the rate in the United States despite similar intakes of animal fats.10 This has been coined the "French paradox." When potential confounders and differences in reporting are taken into consideration, the gap is narrowed but probably not eliminated. Regional variation in CHD rates and risk factors in both the United States and France makes a simple explanation for the paradox unlikely. Nevertheless, one explanation for the lower risk of CHD among the French is an increased intake of wine, especially red wine.11 An inverse association between moderate consumption of alcoholic beverages (1 to 2 glasses per day) and CHD has been documented. However, data regarding the specific effects of red wine are less consistent, possibly for the reasons discussed above. Moreover, the protective effect appears to be influenced by whether the wine is consumed with meals.4 This hypothesis deserves further investigation, because the pattern of consumption of alcoholic beverages may be a marker for other lifestyle factors related to CHD risk.7 A number of dietary factors, such as consumption of fresh fruits, vegetables, and fish and reduced intake of milk products, differ between European populations and can be readily associated with reduced CHD risk.12 13
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The Biological Basis for a Protective Effect of Alcohol and Red Wine |
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TopIntroductionEpidemiological Association of...The Biological Basis for...Adverse Effects of Alcohol...What Conclusions Can We...References |
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Does Red Wine Decrease Atherosclerotic Cardiovascular Disease Because It Is an Antioxidant?
A widely held theory is that development of atherosclerotic plaque involves oxidation of lipoproteins within the artery wall. A large amount of in vitro data has shown that lipoprotein oxidation increases its uptake by cells and can cause cholesterol loading of macrophages, a process thought to be analogous to the evolution of lesional "foam cells." Some in vivo studies in rabbits and transgenic mice have suggested that antioxidants decrease atherosclerotic plaque formation. However, the studies are not conclusive; the intake of the antioxidant drug probucol by apolipoprotein (apo) E knockout mice14 and humans with peripheral vascular disease was not associated with reduced atherosclerosis.15 Moreover, several recent clinical intervention studies16 17 have failed to show a cardioprotective effect of vitamin E, a presumed antioxidant. Wine, especially red wine, contains a number of polyphenol compounds, such as resveratrol, and flavonoids that prevent lipoprotein oxidation in vitro.18 Flavonoids also occur in other alcoholic beverages, such as dark beer. Antioxidant compounds in wine are also found in non–alcohol-containing grape juice.19 Studies of the effects of resveratrol on atherosclerosis in animals are conflicting.20 21 Alcohol itself may be a pro-oxidant, and this effect of alcohol is thought to be associated with the increase in cancers of the oropharyngeal cavity in alcohol abusers. In contrast, alcohol addition to the diets of several strains of atherosclerosis-prone mice decreased atherosclerosis.22 23 In summary, wine consumption as a means of cardiovascular protection because of its antioxidant content is an unproven strategy. It is still unclear what the effects of other antioxidants on human disease may be. Fresh fruits and vegetables, including nonalcoholic grape beverages, should have a similar antioxidant action as red wine.
How Does Alcohol Ingestion Change
Lipoproteins?
Alcohol leads to 2 well-established changes in
lipoproteins; wine, as a source of alcohol, has no other known effects.
Like any other source of carbohydrates, alcohol can increase plasma
triglyceride levels and can serve as a source of excess calories. In
patients with underlying hypertriglyceridemia, the triglyceride
elevations can be
marked.24 25 The
association between alcohol-related hypertriglyceridemia and
exacerbation of pancreatitis is well known. The source of the increase
in triglyceride is an increase in triglyceride production and secretion
in very-low-density lipoprotein (VLDL). The best-known effect of
alcohol is to increase circulating levels of high-density lipoprotein
(HDL) cholesterol. One to 2 drinks per day increase HDL by 
12% on
average.26 This increase is
similar to that seen with several other interventions, including
exercise programs27 and
fibric acid medications. Niacin therapy is a more effective method to
raise HDL and leads to an 20% increase in HDL cholesterol.
Approximately half of the beneficial effects of alcohol on
cardiovascular disease have been ascribed to the increase in HDL
cholesterol.1 No clinical
trials have provided verification that alcohol can be used to increase
HDL cholesterol levels. In contrast, treatment of patients with low HDL
with statins as primary
prevention28 and with fibric
acids as secondary
prevention29 has been shown
to be beneficial.
Do Wine and Other Alcoholic Beverages Have
Significant Antithrombotic Actions?
For light to moderate intakes (up to 60 mL of alcohol
per day), the answer appears to be yes. Numerous studies have shown
statistically significant decreases in platelet aggregation (measured
in vitro) associated with the consumption of alcoholic
beverages.30 However,
controversy surrounds the issue of whether some forms of alcoholic
beverages, particularly red wine, are more effective than others. There
is some evidence that resveratrol and other polyphenolic compounds
found in red wine can have an independent and additive effect on the
reduction of platelet
aggregation.31 32 33
Other studies34 suggest that
most of the effects on platelets can be explained by the alcohol
component of the beverage. Primarily on the basis of in vitro studies,
inhibition of prostaglandin synthesis has been determined to be the
apparent mechanism by which alcoholic beverages decrease platelet
aggregation; aspirin works by a similar mechanism. Less well studied
than the effects on platelets are the effects of alcoholic beverages on
other aspects of coagulation. For example, there are occasional reports
of potentially beneficial effects of alcohol or resveratrol on plasma
fibrinogen levels
(decreased34 ) and cellular
tissue factor levels (also
decreased35 ), but more data
are needed to adequately evaluate these and related findings. Overall,
light to moderate consumption of any type of alcohol-containing
beverage appears to reduce platelet aggregation and thereby provides an
antithrombotic benefit similar to that of
aspirin.
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Adverse Effects of Alcohol Ingestion |
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TopIntroductionEpidemiological Association of...The Biological Basis for...Adverse Effects of Alcohol...What Conclusions Can We...References |
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Are There Downsides to Moderate Alcohol Consumption?
The proposed health benefits of alcohol consumption must be evaluated against the adverse effects of alcohol consumption, which include fetal alcohol syndrome, cardiomyopathy, hypertension, hemorrhagic stroke, cardiac arrhythmia, and sudden death. Most of these adverse effects are associated with long-term alcohol consumption with chronic intake of >3 servings of alcoholic beverages per day. Acute alcohol consumption may also have effects on the cardiovascular system that are primarily related to the negative inotropic and proarrhythmic effects of alcohol. Alcohol consumption should never be considered as a preventive measure for teenagers or young adults; automobile accidents, trauma, and suicide are leading causes of mortality in this age group, and use of alcohol can contribute to their incidence. Alcohol is an addictive substance, and adverse effects of drinking occur at more moderate levels in some individuals. An individual’s risk for developing alcoholism is difficult, if not impossible, to determine. There is particular concern about "moderate" alcohol consumption in women. A recent American Heart Association/American College of Cardiology consensus panel statement, "Guide to Preventive Cardiology for Women," 36 suggested that consumption of no more than 1 glass of alcohol per day is appropriate for women. In addition to concerns about prevention of CHD, there is some concern that alcohol intake >50 g/d may be associated with increased breast cancer risk.
Hypertension
There are more than 50 cross-sectional and 10
prospective epidemiological population-based studies that have
demonstrated a direct association of alcohol intake and hypertension in
men and women of different ages and races. Data from the Nurses Heath
Study37 demonstrate that
>20 g of alcohol per day (2 drinks) in women who are between 30 and 55
years of age is associated with a linear increase in the incidence of
hypertension. In men, alcohol consumption exceeding 20 g/d is also
linked to the development of hypertension; however, the increase in
blood pressure relative to the level of alcohol consumption is less
linear. In the Kaiser Permanente
study,38 men and women
drinking 6 to 8 drinks/d had a 9.1-mm Hg higher systolic blood
pressure and 5.6-mm Hg higher diastolic blood pressure than
nondrinkers. Daily intake of more than moderate amounts of alcoholic
beverages is a clear risk factor for the development of hypertension.
Patients who are hypertensive should avoid alcoholic
beverages.
Stroke
There appears to be consensus that long-term heavy
alcohol consumption (>60 g/d) increases an individual’s risk for all
stroke subtypes, especially intracerebral and subarachnoid hemorrhage.
The effects of moderate alcoholic beverage consumption (<2 drinks/d)
are less clear because of conflicting reports. Some
studies39 suggest that
moderate alcohol consumption may decrease the risk of ischemic stroke
in specific populations, whereas
others40 have not found a
protective association between alcohol intake and stroke. There may be
numerous variables, such as race/ethnicity, age, sex, drinking
patterns, and beverage type, that interact with the effects of alcohol
on stroke risk. Data remain inconclusive in this area, and therefore
specific recommendations are difficult to
formulate.
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What Conclusions Can We Make About a Protective Effect of Wine Against Heart Disease? |
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TopIntroductionEpidemiological Association of...The Biological Basis for...Adverse Effects of Alcohol...What Conclusions Can We...References |
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Moderate intake of alcoholic beverages (1 to 2 drinks per day) is associated with a reduced risk of CHD in populations. There is no clear evidence that wine is more beneficial than other forms of alcohol, although further research is needed regarding the potential protective non–lipoprotein-altering effects of substances unique to wine. If wine does have additional effects, it appears that many of the same additional biological effects might be achieved with grape juice.19 41 Despite the biological plausibility and observational data in this regard, it should be kept in mind that these are insufficient to prove causality. There are numerous examples in the cardiovascular literature of studies that have documented consistent population and mechanistic data that have not held up in clinical trials, eg, ß-carotene, vitamin E, and hormone replacement therapy. It is impossible to adequately adjust for factors related to human behavior that cannot be measured in observational designs. Although moderate use of wine and other alcohol-containing beverages does not appear to lead to significant morbidity, alcohol ingestion, unlike other dietary modifications, poses a number of health hazards. Without a large-scale, randomized, clinical end-point trial of wine intake, there is little current justification to recommend alcohol (or wine specifically) as a cardioprotective strategy. The American Heart Association maintains its recommendation that alcohol use should be an item of discussion between physician and patient.
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Footnotes |
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This statement was approved by the American Heart Association Science Advisory and Coordinating Committee in September 2000. A single reprint is available by calling 800-242-8721 (US only) or writing the American Heart Association, Public Information, 7272 Greenville Ave, Dallas, TX 75231-4596. Ask for reprint No. 71-0199.
This statement is being published in the January 23, 2001, issue of Circulation.
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