European Heart Journal (2021) 00, 1–3 VIEWPOINT

doi:10.1093/eurheartj/ehab654 Epidemiology and Prevention

Wine, chocolate, and coffee: forbidden joys?

1,2,3,4

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Thomas F. Lüscher *
1
National Heart and Lung Institute, Imperial College London, London, UK; 2Royal Brompton and Harefield Hospitals, Sidney Street, London SW3 6NP, UK; 3King’s College
London, London, UK; and 4Center for Molecular Cardiology, University of Zürich, Zürich, Switzerland

Received 27 April 2021; revised 18 May 2021; editorial decision 10 August 2021; accepted 9 September 2021

Diabetes Stroke
BP Monitor +

888
136
81
148
Coronary
DCM 109
T
88
Tornette Protection

Atrial Fibrillation Weight Gain/Obesity

Hypertension
140 160 180
120 200
200
ER 220
22
100 ANOMET
PHYG
SPHYGM 240
80 60
260
60 CE 0123 280 80
40
20 0 300

Graphical Abstract Cardiovascular effects of wine, coffee, and chocolate: protective effects are shown in green and harmful effects in red col-
our. DCM, dilated cardiomyopathy.

..
Life is more than work, also for dedicated cardiologists; thus, we .. Alcohol
enjoy wine, drinks, sweets, and coffee—are these forbidden joys or ..
..
are they possibly even protective? That is here the question! The an- .. Intentionally fermented beverages existed as early as the
swer is more complex than a simple yes or no—so, let us consider .. Neolithic age; in a prehistoric burial site in a cave near Haifa, resi-
..
the evidence seriously. . dues of 13 000-year-old beer, apparently used for ritual feasts,

* Corresponding author. Email: cardio@tomluescher.ch

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Published on behalf of the European Society of Cardiology. All rights reserved. V
2 T.F. Lüscher

..
was found. At that time, fermentation was the only way to pre- ..
..
Chocolate and cacao
serve beverages.
..
Today, we still enjoy alcoholic beverages in different forms, al- .. The late Norman Hollenberg heard that the Kuna Indians living on an
though we have lots of means for preservation. We consume the .. island outside of Panama consumed lots of salt and paradoxically had
..
same amount of alcohol with any drink as the glass for beer is the .. low blood pressure and decided to spend a sabbatical there.9 Indeed,
largest, the one for wine is smaller and the smallest is used for spirits. .. the Kuna Indians ate cacao nuts with salt, yet their blood pressure
..
However, the ingredients other than alcohol differ: Wine contains .. remained around 110/70 mmHg throughout life. Biochemical analy-
cardioprotective antioxidant flavonoids and resveratrol stimulating .. ses of their urine showed that they excrete lots of derivatives of nitric

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..
the longevity gene SIRT1.1 Beer contains grain, mostly malted barley, .. oxide due to the stimulation of nitric oxide synthase by the flavonol
but also hops and yeast. Barley grass also contains flavonoids, super-
.. epicathechin, an ingredient of cacao beans. Of note, when Kuna
..
oxide dismutase, and vitamins and grains polyphenols and phytoster- .. Indians move from their island to Panama City this protection is lost.
ols that also provide antioxidant effects. Whisky contains barley,
.. Chocolate is made out of cacao beans with different amounts of
..
yeast, and water, besides lots of alcohol. .. milk and sugar. Cacao may loose the protective epicathecin, depend-
Is alcohol good or bad? Infusion of alcohol in healthy volunteers
.. ing on how they are dried and roasted. As it turned out dark, bitter
..
increases muscle sympathetic nerve activity and blood pressure .. chocolate that is adstringent in the cheeks is CV protective. Indeed,
(Graphical Abstract).2 Alcohol stimulates the release of corticotropin-
.. dark, but not milk chocolate improves endothelial function in other-
..
releasing hormone in the brain, which has sympatho-excitatory .. wise healthy smokers. This endothelial protection has been con-
.. firmed in coronary arteries using the cold pressor test to assess
effects. As such dexamethasone suppresses the pressor response of
... vasomotion.10 Furthermore, dark chocolate has positive effects on
alcohol. These sympathoexcitatory effects are the reason why, after ..
too heavy a party, we wake up at 3 am with palpitations unable to get .. blood pressure, insulin resistance and platelet function (Graphical
.. Abstract). Finally, large registries suggest an inverse relation of choc-
back to sleep. ..
It has been implied that this sympatho-excitatory effect may ex- .. olate consumption with major CV events, although the evidence is
.. somewhat limited. 11 Chocolate may even improve brain function.
plain why habitual alcohol consumption is does-dependently associ- ..
ated with an increase in blood pressure. However, in prospectively .. The downside is that in particular milk chocolate contains fat and
..
followed 28 848 women from the Women’s Health Study and 13 455 .. sugar and thus calories that may increase the body weight.
men from the Physicians’ Health Study free of baseline hypertension, ..
..
CV disease, and cancer, light-to-moderate alcohol consumption ..
..
decreased hypertension risk in women, but increased it in men. The .. Coffee
threshold for hypertension risk emerged at 4 drinks per day or more ..
in women but already at 1 drink per day or more in men.3 .. The goat herder Kaldi, so the legend goes, discovered coffee beans in
..
Besides its sympathoexcitatory effects, the calory intake associated .. ancient Ethiopia when after eating berries from a certain tree, his
with habitual alcohol consumption leads to increases in body weight,
.. goats became so energetic that they did not want to sleep at night.
..
which may also contribute to the increases in blood pressure. .. Even today, a coffee in the morning is a must for most of us to get
Furthermore, the sympatho-excitatory action may explain the strong
.. going; and indeed, it stimulates the sympathetic nervous system and
..
association of daily alcohol consumption with atrial fibrillation;4 in- .. causes palpitations and increases blood pressure in those not used to
deed, the risk of the arrhythmia increases already with one drink a
.. it.12 Unlike virgin drinkers, habitual drinkers are protected from the
..
day and continues to increase with any additional drink per day. .. stimulatory cardiovascular effects of coffee due to down-regulation
Does alcohol protect from myocardial infarction and stroke? The
.. of the sympathetic response. Surprisingly, this effect of coffee is inde-
..
INTERHEART study with a case–control design (not randomized as .. pendent of caffeine und due to another ingredient(s) that remain to
..
nobody wanted to end up in the placebo group. . .) showed some .. be discovered.
protection with moderate alcohol consumption (i.e. up to 4 drinks/ .. Furthermore, coffee enhances the cardiovascular response to
..
week),5 an observation confirmed by a systematic review and meta- .. mental stress in nonhabitual coffee drinkers, with an additional in-
analysis 6 However, others have challenged that conclusion. A genetic .. crease in systolic BP, whereas in habitual drinkers, the response is
..
epidemiology study involving >500 000 subjects found that the ap- .. blunted (Graphical Abstract). Caffeine alone does not exert any poten-
parent protective effect of moderate alcohol intake against stroke is .. tiating effect, confirming that again ingredient(s) other than caffeine
..
largely non-causal. Alcohol consumption uniformly increased blood .. are at least partially responsible. In line with this observation, moder-
pressure and stroke risk in that analysis and appeared to have little ef- .. ate coffee consumption is inversely associated with the risk of heart
..
fect on myocardial infarction.7 Also, concerning is the fact that alco- .. failure, with the largest effect with 4 servings per day, recently con-
hol consumption, even at moderate levels, is associated with adverse .. firmed in a machine learning analysis of several registries.13 Most like-
..
brain outcomes in a dose-dependent fashion including hippocampal .. ly, moderate coffee drinking attenuates the massive sympathetic
atrophy, differences in corpus callosum microstructure, and faster .. activation in heart failure and as such provides some protection. In a
..
decline in lexical fluency.8 Finally, high-level alcohol consumption has .. large registry involving 42 659 participants of the European Prospective
been linked to dementia due to reduction in brain volume and MRI .. Investigation into Cancer and Nutrition (EPIC)–Germany study, coffee
..
signs of brain damage (Graphical Abstract). Thus, overall alcohol pro- .. consumption during 9 years of follow-up, did not affect the overall
vides little if any health protection.
.. risk of chronic disease. However, both caffeinated and decaffeinated
Viewpoint 3

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Conflict of interest: Work of the author on chocolate and epica- .. 2376–2382.
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