The association between alcohol consumption and heart failure with reduced and preserved ejection fraction: the Cardiovascular Health Study
Authors: Hoek A G , Mukamal K J , Van Oort S , Gottdiener J S , Kizer J R , Defilippi C R , Psaty B , Gardin J M , Shah S J , Elders P J , Beulens J W J 
Published: November 2023

Abstract

Background
Alcohol consumption has been associated with a lower risk of heart failure (HF) and myocardial infarction. Nevertheless, knowledge of the relationship between alcohol consumption and the two subtypes of HF; HF with reduced ejection fraction (HFrEF) and heart failure with preserved ejection fraction (HFpEF) is lacking.

Methods
The Cardiovascular Health study is a US-based prospective cohort study aiming to investigate cardiovascular risk factors and outcomes (5,888 subjects, ≥65 years, follow-up 18 years). Weekly alcohol consumption was assessed by questionnaires and categorized (long-term abstainers; quit-during-follow-up; former; &lt;1drinks/week, 1-&lt;7drinks/week; 7-&lt;14drinks/week; ≥14drinks/week. Incidence of new onset HF, HFpEF (left ventricular ejection fraction (LVEF) ≥50%) and HFrEF (LVEF &lt;50%) was determined by review of available data by an expert panel. Time-dependent multivariable Cox proportional hazard models were used to investigate the associations between time-varying alcohol consumption over up to 18 years follow up and HF, HFpEF and HFrEF. Multiple imputation (5-itterations) was used on variables with &gt;5% missing data (kindney-function/income). Long-term abstainers served as the reference category. Analyses were corrected for age, race, sex, body mass index, smoking status, education, marital status, physical activity, hypertension, glycemic status (normal/impaired/diabetes), kidney-function, lipid lowering medication, time-dependent myocardial infarction, stroke and atrial fibrillation. Effect modification by sex and glycemic status was investigated.

Results
At baseline 5,608 subjects who reported alcohol consumption were at risk for incident HF. 2,029 events occurred during follow-up (n(HFpEF) = 568, n(HFrEF) = 551, n(Unclassified) = 910). Compared with long-term abstainers, the fully-adjusted risk of HF was lower among subjects who reported consuming 1-&lt;7drinks/week (hazard ratio (HR]) 0.82, 95% confidence interval (CI); 0.70-0.97), 7-13 drinks/week (HR 0.83, 95%CI; 0.69-0.99) and ≥14drinks/week (HR 0.68, 95%CI; 0.49-0.93). For HFrEF, the fully adjusted risk was lower among subjects who reported consuming ≥14drinks/week (HR: 0.40, 95% CI; 0.20-0.82) compared with long-term abstainers. For both HF and HFrEF a cardioprotective trend was observed with increasing alcohol consumption (ptrend = 0.001 and ptrend = 0.004, respectively). No significant associations were found for alcohol consumption and HFpEF (HR 0.83, 95%CI; 0.46-1.51). Effect modification was not observed.

Conclusions
Among older adults, increasing alcohol consumption is associated with a lower risk of incident HF and consumption of ≥14drinks/week with HFrEF, but not with HFpEF. This is likely due to the different underlying pathophysiological mechanisms leading to different entities of HF. This study provides evidence that the observed protective effects in HF are likely to be driven by HFrEF.