AHA Offers a Primer on Alcohol’s CV Impact, Areas of Uncertainty

Much is still unknown about whether—if at all—alcohol consumption fits into a lifestyle that promotes cardiovascular health, according to a new scientific statement from the American Heart Association.

Mariann R. Piano, RN, PhD (Vanderbilt University School of Nursing, Nashville, TN), who chaired the document’s writing group, told TCTMD that alcohol’s health implications are a hot topic right now, with growing awareness about the risks of liver disease and cancer. Recently, too, studies “have really challenged this idea that alcohol [offers] any kind of cardioprotection or is heart-healthy,” she said.

Late last year, the National Academies of Sciences, Engineering, and Medicine released a report reviewing the evidence on alcohol and health, Piano pointed out, and the soon-to-be released 2025-2030 Dietary Guidelines for Americans are taking a fresh look at alcohol consumption. In January, the new US surgeon general, Vivek Murthy, MD, issued a summary of cancer risks and called for warning labels for alcoholic beverages.

“It’s just a constellation” of developments, said Piano.

The new statement offers up a comprehensive summary of the evidence to date, with attention paid to alcohol’s impact on coronary artery disease, stroke, arrhythmias, cardiomyopathy, and heart failure. It also focuses on the needs of special populations (women, older adults, and patients with comorbidities, for example) and the main knowledge gaps. The authors provide advice for clinicians on how to contextualize the data for patients when there’s still the popular notion, though one that’s waning, that alcohol can contribute to heart health.

Piano stressed that as a scientific statement, their paper does not give formal guideline recommendations. However, it does contain some practical advice for clinicians by delving into topics for patient education, ways to reduce the risks posed by alcohol, and clear explanations for how much constitutes a “standard” US drink.

“What we really wanted to do is, to the best of our ability, summarize the data and present it as it is,” said Piano, who added that their primary audience is clinicians, not only physicians but also other members of the care team. “Hopefully this is a wake-up call that we really need to be talking to our patients more about drinking.”

For Piano, a key concept to convey to patients is “levels of risk.” Specifically, she said, the message is: “If you want to drink, you’ve got to understand your risk.”

The document, published in Circulation, was created on behalf of the American Heart Association Council on Lifestyle and Cardiometabolic Health, Council on Cardiovascular and Stroke Nursing; Council on Clinical Cardiology, and Stroke Council.

No Good Comes from Drinking Too Much

While there’s a lot of debate over the consequences of low-to-moderate drinking, where evidence is mixed even for as little as one drink per day, what’s clear is that “drinking too much—which people don’t understand what that is—is not associated with any good outcomes across all kinds of cardiovascular diseases,” said Piano. “I think it’s incumbent on us as healthcare practitioners [to] talk to our patients in a respectful, nonbiased way about how much they’re drinking and to educate them [on what] ‘too much’ is.”

It’s incumbent on us as healthcare practitioners [to] talk to our patients in a respectful, nonbiased way about how much they’re drinking. Mariann R. Piano

Most of the literature on alcohol and cardiovascular disease stems from epidemiological studies, which can be prone to bias, depend on self-reported drinking, and lack granularity.

“Alcohol consumption, absorption, and metabolism vary across multiple domains, including beverage type, volume, frequency, duration, concomitant meals, and features inherent to the individual. These vagaries make the measurement of alcohol consumption and the characterization of dose-response relationships difficult, hindering universally applicable determinants of risks versus harms,” the authors note.

However, there’s now a shift towards novel approaches to research methods and statistical analysis that allow for more reliable comparisons. “More often, objective measures of alcohol consumption are being used, including transdermal ethanol sensors, home-based urine kits, and biomarkers of alcohol consumption such as phosphatidylethanol,” they write. “Smartphones are also used to track real-time use of alcohol and to enhance research participation.”

On the whole, the evidence shows that alcohol either raises risk or has no apparent effect on CVD. For MI specifically, though, some data suggest a benefit at lower levels of consumption, perhaps due to changes in lipid levels such as increased HDL. Yet as Piano noted to TCTMD, the shifts seem too small to explain the phenomenon.

Given the current “level of evidence, it remains unknown whether drinking is part of a healthy lifestyle,” the statement concludes. To offset harms, “clinicians should reinforce healthy lifestyle behaviors such as regularly engaging in physical activity, avoiding tobacco use, and maintaining healthy body weight.”

Piano proposed that one approach is to suggest patients take a break from drinking to see what changes that pause brings, Piano said. “To be abstinent I don’t think is going to be harmful. So, I encourage people: try it, see how you feel, see where your sleep is, monitor your weight, for sure monitor your blood pressure, because even if you’re normotensive, I bet you’re going to see a decrease in your blood pressure.”