Giving Up Alcohol for Secondary Prevention of A-fib: New Insights

Avoiding alcohol may lessen symptom duration and reduce the likelihood of recurrence in patients with established A-fib, new research shows. Regular drinkers in the study randomized to abstain from alcohol for 6 months also had less than half the incidence of hospitalization for their A-fib compared with those who continued their usual pattern of drinking.

“The impact of a significant reduction or abstinence should be explored in patients with symptomatic AF,” senior study author Peter M. Kistler, MB, BS, PhD (Baker Heart and Diabetes Institute, Melbourne, Australia), told TCTMD in an email. “We would recommend working collaboratively with patients who drink excessively to encourage them to cut down their alcohol intake.”

Alcohol as an trigger for atrial fibrillation has been an active area of research in recent years, with other studies showing associations between regular alcohol consumption and physical damage to the heart including increased left atrial size, impairments in atrial mechanical and reservoir function, and adverse electrical remodeling. Less clear, say researchers led by Aleksandr Voskoboinik, MB, BS, PhD (Baker Heart and Diabetes Institute), is whether abstaining from alcohol can reduce arrhythmias in people with an established history of A-fib.

The paper was published January 2, 2020, in the New England Journal of Medicine.

Compliance and Short Follow-up

In the Alcohol-AF study of 140 randomized patients, the abstinence group reduced their total alcohol intake by 87.5%, from approximately 17 drinks a week to two drinks. The control group also saw a reduction of nearly 20%, from 16 drinks a week to 13. Recurrence of A-fib, a co-primary endpoint, was lower in the abstinence group than in the control group (53% vs 73%), while the time to recurrence was longer. Abstaining from alcohol also was associated with lower A-fib burden compared with the control group (P = 0.01).

In addition to the reduction in hospitalization for A-fib, other benefits seen in patients who were randomized to 6 months of alcohol abstinence included weighing less and having better scores on the modified European Heart Rhythm Association classification of A-fib symptoms. There also was a suggestion that the abstinence group had lower systolic and diastolic blood pressure values at 6-month follow-up compared with controls.

In an accompanying editorial, Anne M. Gillis, MD (University of Calgary, Canada), notes that while alcohol can be an important modifiable risk factor in managing A-fib patients, many questions remain regarding whether a no-alcohol strategy would be effective in everyone with A-fib—including those at highest risk of recurrence—and whether total abstinence or merely a reduction in drinks per week is required to see benefits. Most important of all, Gillis says, while the study does make a compelling argument for avoiding alcohol, “the sobering reality is that for many persons with atrial fibrillation, total abstinence from alcohol may be a difficult goal to achieve.”

Drinking alcohol is not the reason people have A-fib. Not drinking may control and reduce the amount of [A-fib] for a time, but it’s not a solution and will not eliminate it. Luigi Di Biase

Commenting on the study for TCTMD, Luigi Di Biase, MD, PhD (Montefiore Medical Center, Bronx, NY), pointed out that although controlling and treating risk factors including alcohol excess is important, it’s also important for patients to understand that there is no evidence that avoiding the occasional drink will prevent them from ever having an A-fib recurrence.

“I perform ablation procedures in my A-fib patients to improve their quality of life,” he said. “If I have a 65-year-old patient who likes to enjoy a glass of wine with his meal and suddenly someone tells him he cannot do this, he's probably going to be depressed, and 5 years later he's going to end up with A-fib anyway. Drinking alcohol is not the reason people have A-fib. Not drinking may control and reduce the amount of [A-fib] for a time, but it’s not a solution and will not eliminate it.”

An important limitation of the study, one pointed out by both the study authors and Gillis, is that the 12-month follow-up that was initially planned had to be scaled back to 6 months due to difficulty recruiting patients willing to participate for that long if they were randomized to the abstinence group. Additionally, 70% of patients who were approached about participating in the study declined because they would not consider giving up alcohol.

To TCTMD, Kistler said while the Alcohol-AF participants were not formally followed beyond the end of the study period or advised to continue avoiding alcohol, anecdotally those who had noted benefits of abstinence continued this behavior.

“In my mind, you are not treating the problem, you are just trying to put it into sleep mode for a time,” Di Biase said of asking patients to never drink again. “Yes, you have to control your risk factors, but we want our patients to live better and, to me, complete abstinence is asking too much.”

The study, which was published at the tail end of the festive season, struck a chord on #CardioTwitter, with some praising it and others suggesting the gains in terms of reduce A-fib might be a tough sell for patients.

We must be responsible as leaders in our field and advocate the whole person approach inc alcohol reduction and wt loss. real world safety & success of ablation should be considered The median AF burden was low but benefits of abstinence unequivocal @NEJM @PrashSanders @drjohnm

— peterkistler (@peterkistler3) January 3, 2020

Radical study by @Vosko1984 & @peterkistler3 - provides great proof of concept. As in our work - not mutually exclusive with ablation #AblationIsSalvation but, optimising success is essential

— Prash Sanders (@PrashSanders) January 2, 2020

In fact, the study follow up was shortened because patients were not compliant to abstinence

— Andrea Natale, MD (@andreanatalemd) January 3, 2020

Lifestyle modifications (weight loss/ alcohol moderation) are complementary to ablation, and not substitutes/ threats to Ablation. In PRAISE study, only pts with high BMI or alcohol excess had AF recurrence after documented durable PVI https://t.co/43LWo5uG14

— Dr Dhiraj Gupta (@DhirajGuptaBHRS) January 4, 2020