Cardiovascular benefits and risks of moderate

alcohol consumption
Authors:
Christine C Tangney, PhD
Robert S Rosenson, MD
Section Editor:
Bernard J Gersh, MB, ChB, DPhil, FRCP, MACC
Deputy Editor:
Jane Givens, MD
All topics are updated as new evidence becomes available and our peer review process is complete.
Literature review current through: Jun 2020. | This topic last updated: Apr 15, 2020.

INTRODUCTION Excessive alcohol use can lead to a variety of adverse

effects including liver disease, heart failure (HF), increased cancer risk, neurologic
complications, and unintentional injuries. Balanced against these deleterious effects is
the observation that, compared with abstinence or heavy drinking, moderate alcohol
intake may have sex-specific health benefits, particularly in regard to coronary heart
disease (CHD), overall cardiovascular disease (CVD), and diabetes.

However, some data have been published that have challenged the evidence that one
of the cardioprotective mechanisms underlying the benefit underpinning moderate
alcohol consumption is the increase in high-density lipoprotein (HDL) cholesterol
concentrations. The amount or frequency that constitutes moderate drinking, the
reference group (whether the comparison is abstainers, non-drinkers or prior drinkers,
etc), potential differences across low- and high-income countries, whether adjustment
for important confounders has been included, and/or differences in the cardiovascular
risk subtypes (stroke, myocardial infarction [MI], HF) may contribute to conflicting
findings.

The cardiovascular benefits and risks of alcohol consumption will be reviewed here. A
general review of the risk and benefits of alcohol consumption is presented separately.
(See "Overview of the risks and benefits of alcohol consumption".)

DEFINITIONS

Moderate drinking — The 2015 to 2020 Dietary Guidelines for Americans define

moderate drinking as having up to one drink per day for women and up to two drinks per
day for men. This definition refers to the amount of alcohol consumed on any single day
and is not intended as an average over several days [1]. Definition of the dose (grams
of alcohol) which provides protection from all-cause mortality or specific cardiovascular
outcomes has been challenged [2].
Standard drink — Definitions of a "standard drink" differ, both within and between
countries (figure 1) [3,4]. The Global Burden of Disease Study defined a standard drink
as 10 grams of pure ethyl alcohol consumed daily [2]. However, in the United States, a
standard drink contains 14 grams (0.6 fluid ounces) of pure alcohol, and around the
world the standard drink ranges from as few as 8 grams of alcohol to as many as 20
grams of alcohol [3,5,6].

Beverage type — Available data do not clearly support a definitive conclusion

regarding the differential benefits of various beverage types. However, it is generally
accepted that the type of alcohol is not as important a factor as the amount of alcohol
consumed and the pattern of intake [7-9].

However, the French paradox that coronary heart disease (CHD) mortality is lower in
France than would be expected from the high national prevalence of smoking and
saturated fat intake has been attributed to frequent red wine consumption [10]. Red
wine contains phenolic and flavonoid substances that have antithrombotic and
antioxidant properties [11,12]. Additionally, wine intake has been associated with
improvements in heart rate variability [13], which could contribute to improved prognosis
for CHD [11,14].

Data from clinical studies vary on whether the type of alcoholic beverage is a factor in
the cardioprotective effect of alcohol, with some suggesting that all alcoholic beverages
afford cardioprotective benefits [15], while others report that the cardioprotection is
strongest for wine [16,17].

●A dose-response relationship on risk of vascular events was seen for both

wine and beer, but the relationship was stronger for wine. A J-shaped
relationship was again observed between alcohol dose and total mortality
[16,17].
●One systematic review found that all beverage types are associated with
lower rates of CHD [18].
●A meta-analysis of 13 cohort studies, including 209,418 people, reported a
strong and statistically significant benefit for moderate consumption of both
beer and wine, although the effect was stronger for wine (32 versus 22
percent relative risk [RR] reduction) [17]. A dose-response relationship was
seen for both wine and beer with vascular risk, but the relationship was
stronger for wine. A J-shaped relationship was again observed for alcohol
dose and total mortality.

ADVICE TO PATIENTS REGARDING ALCOHOL USE Our approach

to advising patients about the benefits of alcohol as part of a strategy to reduce

cardiovascular disease (CVD) risk is as follows:
●Individuals who are not currently drinking, or those who have a personal
preference to avoid alcohol, should not be advised to consume alcohol solely
for the purpose of CVD risk reduction.
 ●Patients who have an underlying medical condition that precludes alcohol
use (eg, alcohol use disorder, liver disease, etc) should not be advised to
consume alcohol.
●Patients who choose to drink moderate amounts of alcohol, such as those
who drink alcohol less than one unit per day (or less than 15 g per day) [19] or
less than 100 g per week [20] may experience benefits for their health.

Caution is necessary when promoting the beneficial effects of alcohol for cardiovascular
risk reduction. The absolute benefits of alcohol consumption are unclear in the absence
of randomized controlled trials. There is little agreement regarding the upper limit of
alcohol consumption that correlates with benefit, nor are there good data about which
group of individuals might benefit from different levels of alcohol at no additional risk.
(See 'Effect of alcohol on cardiovascular risk' below.)

The potential cardiovascular benefit of moderate alcohol intake must be balanced

against the effect of alcohol on other disorders, such as cirrhosis and cancer, and the
total alcohol-attributable deaths [21,22]. The net risk-benefit balance associated with
moderate alcohol consumption will vary in different age groups and populations. As an
example, alcohol intake increases the risk for breast cancer in women [21]. For a young
woman with a low risk for coronary disease, the increased risk related to alcohol intake
and breast cancer might outweigh any potential cardiovascular benefits.

MECHANISMS OF BENEFIT Factors responsible for the apparent

cardiovascular benefits of light to moderate alcohol intake are uncertain. A meta-

analysis evaluated 42 clinical studies with information about biochemical markers
assessed before and after consumption of ethanol [23]. The following beneficial
changes, which were noted with an experimental dose of 30 grams of ethanol per day,
would be estimated to reduce the risk of coronary heart disease (CHD) by 25 percent:
●Serum apolipoprotein A-I increased by 8.8 mg/dL
●Plasma fibrinogen concentration decreased by 7.5 mg/dL
●Tissue-type plasminogen activator (tPA) concentration increased by 1.25
ng/mL
●Serum triglycerides increased by 5.7 mg/dL (potentially detrimental rather
than beneficial)

For many decades, light to moderate alcohol intake was proposed as a way to increase
serum high-density lipoprotein (HDL) cholesterol and thereby reduce cardiovascular
risk. While an increase of serum HDL cholesterol by 4 mg/dL or (0.1 mmol/L) may occur
following light to moderate alcohol intake, it should not be expected [23]. An updated
meta-analysis found similar results, finding a dose response for increased HDL
cholesterol levels and similar responses for the other markers listed above [24,25].
However, strategies directed at raising HDL cholesterol as a means of reducing
cardiovascular events have failed in multiple clinical trials [26]. (See "HDL cholesterol:
Clinical aspects of abnormal values".)
However, the effects of alcohol on various HDL functional measures requires further
exploration. In Mendelian randomization studies, self-reported alcohol intakes of
Japanese men and women were linearly related to increases in HDL particle numbers
and decreases in low-density lipoprotein (LDL) particle numbers [27]. Still, others
propose that the cardioprotective effects of alcohol may be related to the metabolite,
acetate, and its interaction with the adipocyte free fatty acid receptor 2 to elicit an
antilipolytic effect [28]. Changes in HDL cholesterol are markers of lower CHD risk but
not a target of nonpharmacologic or pharmacologic therapy [26]. (See "Pathogenesis of
type 2 diabetes mellitus".)

Antioxidant effects — Red wine and two of its antioxidants, but not other sources of
alcohol, also prevent the activation of mononuclear cell nuclear factor kappa B, a redox-
sensitive transcription factor that is involved in various processes that may contribute to
atherosclerosis [29]. In another study, use of antioxidants N-acetylcysteine and
resveratrol from wine inhibited macrophage reactive oxygen species production and
facilitated cell migration through restoration of focal adhesion kinase activity [30].

Further study of the dynamic modeling of arterial lesions by dietary or other lifestyle
behaviors is warranted. Endothelial progenitor cells are mobilized into circulation when
vascular repair and neovascularization are needed. Red wine and a major constituent of
red wine, resveratrol, slow endothelial progenitor cell senescence through a protein
kinase B (Akt) dependent mechanism [31]. When 14 healthy volunteers consumed 250
mL of red wine for 21 consecutive days, apoptosis of endothelial progenitor cells was
reduced and their migration and proliferation were significantly improved [29]. These
findings may contribute to the mechanism of cardiovascular protection observed with
regular, moderate consumption of red wine.

Enhanced insulin sensitivity — Consuming moderate amounts of alcohol has been

shown to enhance insulin sensitivity and glucose utilization for the subsequent 12 to 24
hours [32]. Fasting and postprandial insulin concentrations are reduced with two drinks
per day, and insulin sensitivity is also improved in randomized controlled trials [33]. The
mechanism by which insulin sensitivity is enhanced by alcohol is not entirely known but
may involve suppression of fatty acid release from adipose tissue and improved glucose
metabolism [28,34]. A more detailed discussion of this subject is presented separately.
(See "Overview of the risks and benefits of alcohol consumption", section on 'Diabetes
mellitus'.)

Antithrombotic effects — Alcohol has antithrombotic activities that may contribute to

the observed reduction in CHD. These include modification of platelet function and of
other components of the clotting system and fibrinolysis [11,12].
●Platelet aggregation is inhibited by the same quantities of alcohol that reduce
CHD risk [35]; this effect may persist for six hours after a single alcohol drink,
even when the blood alcohol level has returned to baseline [36].
●Fibrinolysis also may be induced by moderate alcohol intake (three to seven
drinks per week) and may contribute to the cardiovascular benefit. Reduced
levels of plasminogen activator inhibitor (PAI) activity, fibrinogen, plasma
 viscosity, von Willebrand factor, factor VII, and increased concentrations of
tissue-type plasminogen activator (tPA) have been described [37,38].

By contrast, a higher intake of alcohol (7 to 21 drinks per week) is associated with

impaired fibrinolytic potential, manifested by higher levels of PAI antigen-1 and tPA
antigen [37]. 

Antiinflammatory effects — There appears to be an inverse relationship between

levels of antiinflammatory markers and mild to moderate alcohol intake.
●Patients with moderate alcohol consumption have lower concentrations of C-
reactive protein (CRP) than those who consume occasional or no alcohol [39].
In the PRINCE study, which correlated self-reported alcohol intake with CRP
levels in 2833 subjects (41 percent with a history of cardiovascular disease
[CVD]), there was a progressive decline in CRP levels with increasing alcohol
intake, from 2.6 mg/L for less than one drink per month to 1.6 mg/L for five to
seven drinks per week.
●A study of alcohol intake and inflammatory markers in a biracial cohort of
2574 older people (aged 70 to 79 years) identified a J-shaped relationship
between alcohol intake and both interleukin (IL) 6 and CRP levels [40].
Compared with people who drank one to seven drinks per week, people who
never drank or who drank eight or more drinks per week were more likely to
have high levels of IL-6 and CRP. However, in a subsequent study from the
same population, the benefit of light to moderate alcohol intake on cardiac
events and mortality persisted even after adjustment for levels of CRP and IL-
6, leading to questions of the role of antiinflammatory properties as a
mechanism of cardioprotection [41].

EFFECT OF ALCOHOL ON CARDIOVASCULAR RISK

Overview — No long-term randomized trials of alcohol consumption have been

performed. The available evidence is from observational studies (including meta-
analyses of numerous studies) that typically compare the characteristics of alcohol
users with nonusers. As such, the apparent effect of alcohol is subject to confounding.
As one example, moderate alcohol use is more common among those of higher
socioeconomic status, thereby introducing the likelihood of confounding by factors
associated with higher socioeconomic status [42,43].

Evidence from trend analyses by the National Health and Examination Survey
(NHANES) over a 15-year period (1999 to 2014) linked to the United States mortality
registry in 2015 suggest that alcohol use has increased and that use above the
recommended limits by the 2015 to 2020 Dietary Guidelines for Americans was
associated with enhanced all-cause and cause-specific mortality risk, ranging from 39 to
126 percent [44].
Several prospective cohort studies suggest that light to moderate alcohol consumption
decreases the risk of coronary heart disease (CHD) by 40 to 70 percent, compared with
drinking no alcohol or with heavy alcohol intake [7].

●A 2011 meta-analysis of 84 observational studies found that, relative to

nondrinkers, alcohol drinkers had a relative risk (RR) of 0.75 (95% CI 0.70-
0.80) for cardiovascular disease (CVD) mortality, 0.75 (95% CI 0.68-0.81) for
CHD mortality, and 0.71 (95% CI 0.66-0.77) for incident CHD [45]. This
protective effect has been found in multiple groups, including individuals
without CHD at baseline [20], those with risk factors for CHD [22,46], and
adults over age 65 [47].
●In a pooled analysis of nearly 600,000 patients from three major cohorts in
which the comparisons are made for current drinkers, the risk of myocardial
infarction (MI) was lowest in the patients whose consumption was greater
than 0 but less than 100 grams per week (figure 2) [20].
●A population-based cohort study from the United Kingdom followed close to
two million adults ≥30 years old who were free from CVD [48]. At a median
follow-up of six years, 5.9 percent of these individuals had received a
cardiovascular diagnosis. Non-drinking compared with moderate drinking was
associated with an increased risk of multiple CVD outcomes, including
unstable angina, MI, CHD death, heart failure (HF), ischemic stroke, and
peripheral arterial disease, whereas heavy drinking was generally associated
with worse cardiovascular outcomes.

However, in a cross-sectional study of over 2000 drinkers in Russia, levels of high-

sensitivity cardiac troponin T, N-terminal pro-B-type natriuretic peptide (NT-proBNP),
and high-sensitivity C-reactive protein (CRP) were greater among those receiving
treatment for alcohol problems than in the general population, and greater alcohol
intake was associated with higher NT-proBNP and CRP levels across all drinkers,
without a protective effect among light to moderate drinkers [49].

Cardiovascular mortality — Many studies have found that moderate alcohol

consumption is associated with a specific reduction in cardiovascular mortality
[45,50,51]. However, other results show no benefit on all-cause mortality [2,20,52].
Additionally, heavy alcohol consumption (six or more drinks per day) or binge drinking
increases the risk for many medical conditions, including sudden cardiac death [2,53].
(See "Overview of sudden cardiac arrest and sudden cardiac death".)

Patients without known CVD — Findings from representative studies of patients

without known CVD include the following:

●Data collected over nine iterations of the National Health Interview Study
(NHIS), a representative United States sample, including 10,000
cardiovascular deaths, reveal an inverse association with cardiovascular
mortality and light and moderate alcohol consumption [50]. Compared with
lifetime abstainers, the RR of CVD was 0.69 and 0.62 for light and moderate
drinkers, respectively. Similarly, after 13 waves of NHIS (including death index
 records in 2011), compared with lifetime abstainers, the RR of CVD was 0.74
(95% CI 0.69-0.80) and 0.71 (95% CI 0.64-0.78) for light and moderate
drinkers, respectively (figure 2) [46].
●In a combined analysis of three large-scale data sources (Emerging Risk
Factor Collaboration, European Prospective Investigation into Cancer and
Nutrition [EPIC] – Cardiovascular Disease, and United Kingdom Biobank) of
19 high-income countries and across 83 prospective studies, 599,912 current
drinkers were followed for a minimum of one year and a median of 7.5 years
[20]. The main analyses focused on current drinkers whose baseline alcohol
intakes were defined in grams consumed per week. There was a J-shaped
association for CVD outcomes. After adjustment for age, sex, smoking, and
history of diabetes, the amount of alcohol consumed had positive associations
with all disease subtypes except for MI, and associations were stronger for
fatal versus nonfatal events. For CVD subtypes other than MI, there was no
definitive threshold below which lower alcohol intakes ceased being
associated with lower risk of disease. For MI, the association was inverse and
stronger for non-fatal than fatal associations (figure 3).
●What if middle-aged adults initiate moderate alcohol consumption in an
attempt to lower CVD risk? Initiation of moderate drinking in adults aged 45 to
64 years was associated with a 40 percent decrease in risk of cardiovascular
events (odds ratio [OR] 0.62, 95% CI 0.41-0.94) over four years in a cohort of
prior nondrinkers participating in the Atherosclerosis Risk in Communities
(ARIC) survey [54].
●By contrast, the cardioprotection of light to moderate alcohol intake is not
universally seen. In a meta-analysis using 694 data sources of individual and
population-level alcohol consumption from 592 prospective and retrospective
studies, which included 28 million individuals aged 15 to 49 years, 12.2
percent of male deaths and 3.8 percent of female deaths were attributed to
alcohol use [2]. The protective effects of alcohol consumption on CVD were
complex in populations aged 50 years and older; these associations were
influenced by sex, age, and socio-demographic status. For men residing in
countries with high or low socio-demographic index (SDI), light to moderate
alcohol consumption had a protective effect on ischemic heart disease. For
females in high SDI regions, there were protective effects of alcohol on
diabetes beyond 60 years of age. In a sensitivity analysis that explored the
weighted influence for various health outcomes, the only protective effect of
alcohol was observed in populations where diabetes and ischemic heart
disease comprised more than 60 percent of total deaths. In at least two other
pooled analyses, the cardioprotective influence of light to moderate alcohol
consumption was not observed [52,55].

Patients with known CVD — Moderate alcohol intake also appears to be beneficial in

patients with known CVD. A 2010 meta-analysis of eight prospective studies, including
16,351 patients with a history of CVD, found a J-shaped curve between alcohol
consumption and cardiovascular mortality, with a maximal protection (22 percent
decreased risk) for consumption of 26 g per day of alcohol, equivalent to slightly less
than two glasses of alcohol daily [56]. In a subsequent study of 1818 men from the
Health Professionals Follow-up Study with prior MI, a U-shaped relationship between
alcohol consumption and mortality (both all-cause and cardiovascular) was seen, with
the greatest benefit for alcohol consumption between 10 and 30 grams per day,
compared with abstinence (for all-cause mortality, hazard ratio [HR] 0.66, 95% CI 0.51-
0.86; for cardiovascular mortality, HR 0.58, 95% CI 0.39-0.84). [57].

However, binge drinking in patients with a history of MI is associated with increased

mortality [58].

Coronary heart disease — Similar to the benefit on total CVD mortality, moderate

alcohol consumption is associated with a reduced risk of CHD in both men and women
[15,59-61].

Binge drinking, however, increases the risk for CHD [62,63]. As one example, in a
pooled meta-analysis of case-control studies, the RR for fatal and nonfatal MI was 1.45
(95% CI 1.24-1.70) comparing those who reported irregular heavy drinking (≥5 drinks
per occasion or intoxication at least monthly) with those who did not [62].

Hypertension — Multiple studies have shown an association between excess alcohol

intake and the development of hypertension [64-66]. However, light to moderate alcohol
consumption may be beneficial in reducing the risk of hypertension.

In a meta-analysis of 36 trials, a decrease in alcohol intake reduced blood pressure in

people who drank more than two drinks per day; however, a reduction was not seen in
those consuming two or fewer drinks per day [67]. In patients who consumed six or
more drinks per day, a 50 percent decrease in alcohol intake resulted in a 5.5 mmHg
(95% CI 4.3-6.7) reduction in systolic blood pressure and a 4 mmHg (95% CI 3.2-4.7)
reduction in diastolic blood pressure. (See "Definition, risk factors, and evaluation of
resistant hypertension".)

On the other hand, moderate alcohol intake appears to have a cardioprotective effect,
even in patients with preexisting hypertension [68,69]. A 2014 meta-analysis of nine
cohort studies including over 390,000 patients with hypertension found that, compared
with abstainers or occasional drinkers, those who consumed 8 to 10 grams of alcohol
per day had a decreased risk for all-cause mortality (RR 0.82, 95% CI 0.76-0.88) [69].

Heart failure — Chronic consumption of large amounts of alcohol may lead to alcohol-

induced cardiomyopathy. This condition is discussed separately. (See "Alcoholic
cardiomyopathy".)

By comparison, light to moderate alcohol intake may protect against the development of
HF [70,71]. Among 7686 subjects initially free of HF or coronary disease prospectively
followed in the Framingham Heart Study, the risk of HF in men was significantly lower at
all levels of alcohol consumption, whereas among women, the consumption of one to
seven drinks per week was also associated with a lower risk of HF [72].

A related issue is the effect of light to moderate alcohol intake in patients with left
ventricular (LV) dysfunction. The SOLVD study evaluated this issue in an analysis of
6797 patients with an ejection fraction of 35 percent or less [73]. When compared with
nondrinkers, light to moderate drinkers (1 to 14 drinks per week) with ischemic LV
dysfunction had a lower all-cause mortality (7.2 versus 9.4 deaths/100 person-years),
particularly death from MI. Alcohol had no significant effect on mortality in patients with
a nonischemic cardiomyopathy.

In patients with diabetes mellitus — Light to moderate alcohol consumption appears

to protect against development of CHD and the risk of coronary death in diabetic men
and women [74-76].
●In the Health Professionals Follow-up Study of 2419 men with type 2
diabetes over the age of 30, moderate alcohol intake was associated with a
lower risk for CHD [76]. Alcohol also protects against the risk of CHD death in
patients with diabetes. Among 2790 men with diabetes in the Physicians'
Health Study who were free of MI, cancer, or liver disease at baseline, those
men with diabetes who consumed alcohol on a weekly or daily basis had a
significantly lower risk of death from CHD compared with those who rarely or
never consumed alcohol (adjusted RR 0.67 and 0.42) [74].
●Among 5103 women in the Nurses' Health Study with a diagnosis of diabetes
at ≥30 years of age who were free of CHD, stroke, or cancer at baseline, the
adjusted RR for nonfatal or fatal CHD for diabetic women reporting a daily
intake of 0.1 to 4.9 grams of alcohol (<0.5 drinks) or ≥5.0 grams (≥0.5 drinks)
was 0.72 and 0.45, respectively, compared with abstainers [75].
(See "Prevalence of and risk factors for coronary heart disease in patients
with diabetes mellitus".)

In addition, moderate alcohol consumption may lower the risk of developing type 2
diabetes, as reported in a meta-analyses of 15 prospective cohort studies [77].
(See "Overview of the risks and benefits of alcohol consumption", section on 'Diabetes
mellitus'.)

Stroke risk — Different studies have reported disparate outcomes regarding the impact
of light to moderate alcohol intake on stroke risk.
●Moderate alcohol intake (up to two glasses per day) has been associated
with a decreased risk of ischemic stroke in most studies [45,78-81].
●In a combined analysis of three large-scale data sources (Emerging Risk
Factor Collaboration, European Prospective Investigation into Cancer and
Nutrition [EPIC] – Cardiovascular Disease, and United Kingdom Biobank) of
19 high-income countries and across 83 prospective studies, 599,912 current
drinkers were followed for a minimum of one year and a median of 7.5 years
(figure 4) [20]. The amount of alcohol had a positive, nearly linear relationship
with stroke (HR 1.14, 95% CI 1.10-1.17), both ischemic and hemorrhagic.
●In a cohort study of 38,156 male health professionals published subsequent
to this meta-analysis, light alcohol consumption (<10 g/day) had no effect on
the risk of ischemic stroke (RR 0.99, 95% CI 0.72-1.37) [79]. Consumption of
more than two drinks daily (>29.9 g per day) appeared to be associated with
an increased risk of ischemic stroke (RR 1.42, 95% CI 0.97-2.09). Data
collected over 26 years (>1,695,000 person-years) from the Nurses' Health
 Study found that, compared with abstainers, the risk of stroke was decreased
in women who drank less than 15 g/day of alcohol (RR 0.83, 95% CI 0.75-
0.92 for <5 g per day and RR 0.79, 95% CI 0.70-0.90 for 5.0 to 14.9 g per
day) [81]. There was no difference between the incidence of ischemic or
hemorrhagic stroke.
●Binge drinking (≥6 drinks in one session for men, or ≥4 drinks for women)
was associated with increased risk for all strokes (HR 1.85) and for ischemic
strokes (HR 1.99) [82].
●The effect of alcohol may be modified by ethnicity. Two studies found a
protective effect of moderate alcohol use among whites, blacks, and Latinos
[80], but studies from Asia consistently show no such benefit [83]. As a result,
in the United States where ischemic strokes outnumber hemorrhagic strokes
by roughly four to one, moderate alcohol use lowers total stroke risk. By
contrast, in Japan, where hemorrhagic stroke is more common, moderate
alcohol use may slightly raise the risk of dying from a stroke [84].

Peripheral artery disease — Alcohol appears to reduce the risk of peripheral artery

disease (PAD) among apparently healthy people. Moderate alcohol intake (one to two
drinks per day in men and 0.5 to 1.0 drinks per day in women) also reduces the risk of
intermittent claudication [85]. It is difficult to account for the influences of dietary pattern
and alcohol consumption on disease outcomes, although the PREDMED study
examined the risk of developing PAD in their trial participants; nearly 50 percent had
type 2 diabetes. Moderate alcohol consumption, non-smoking, physical activity, and
following a Mediterranean diet pattern were inversely associated with incident PAD [86].

The effects of alcohol on risk for abdominal aortic aneurysm are discussed in detail
elsewhere. (See "Epidemiology, risk factors, pathogenesis, and natural history of
abdominal aortic aneurysm", section on 'Food and alcohol consumption'.)

Atrial fibrillation — Both heavy binge drinking and heavy chronic alcohol use have
been reported to increase the incidence of atrial fibrillation (AF), while chronic moderate
alcohol use does not appear to increase the incidence of AF. Evidence suggests there
is no benefit from light to moderate alcohol intakes with respect to incident AF [87].
Even ablation treatment for AF is less successful amongst moderate and heavy drinkers
[88]. (See "Epidemiology of and risk factors for atrial fibrillation", section on 'Alcohol'.)

Advice from professional societies — There is uncertainty as to whether the

available data support encouraging middle-aged men or women, with or without CHD,
who do not drink or who drink only occasionally to take up regular drinking [3,7,89-92].
●In 2001, an American Heart Association (AHA) Science Advisory reached the
following conclusion [93]: "Moderate intake of alcoholic beverages (one to two
drinks per day) is associated with a reduced risk of CHD in populations…
Despite the biologic plausibility and observational data in this regard, it should
be kept in mind that these are insufficient to prove causality… 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 National Institute on Alcohol Abuse and Alcoholism (NIAAA) indicates
that "individuals who are not currently drinking should not be encouraged to
drink solely for health reasons, because the basis for health improvements
has not yet been established as deriving from alcohol itself" [94].
●A 2016 report from the Department of Health in the United Kingdom states
that "people who do not drink any alcohol at all should not be recommended
to start drinking in the interests of their health" [95].

SOCIETY GUIDELINE LINKS Links to society and government-sponsored

guidelines from selected countries and regions around the world are provided
separately. (See "Society guideline links: Alcohol consumption".)

INFORMATION FOR PATIENTS UpToDate offers two types of patient

education materials, "The Basics" and "Beyond the Basics." The Basics patient
education pieces are written in plain language, at the 5 th to 6th grade reading level, and
they answer the four or five key questions a patient might have about a given condition.
These articles are best for patients who want a general overview and who prefer short,
easy-to-read materials. Beyond the Basics patient education pieces are longer, more
sophisticated, and more detailed. These articles are written at the 10 th to 12th grade
reading level and are best for patients who want in-depth information and are
comfortable with some medical jargon.

Here are the patient education articles that are relevant to this topic. We encourage you
to print or e-mail these topics to your patients. (You can also locate patient education
articles on a variety of subjects by searching on “patient info” and the keyword(s) of
interest.)

●Beyond the Basics topics (see "Patient education: Risks and benefits of

alcohol (Beyond the Basics)")

The National Institute on Alcohol Abuse and Alcoholism (NIAAA), under the National
Institutes of Health (NIH) maintains an active website for the general public
(www.niaaa.nih.gov/alcohol-health). Patient information specific to the interaction of
alcohol intake and the effect on the body is available within this site
(www.niaaa.nih.gov/alcohol-health/alcohols-effects-body).

SUMMARY AND RECOMMENDATIONS

●The 2015 to 2020 Dietary Guidelines for Americans define moderate drinking
as having up to one drink per day for women and up to two drinks per day for
men. Definitions of a "standard drink" differ, both within and between
 countries, with a standard drink containing from as few as 8 grams of alcohol
to as many as 20 grams of alcohol. (See 'Definitions' above.)
●Moderate alcohol consumption most likely reduces the risk of myocardial
infarction (MI) through its effects on insulin sensitivity, thrombotic activity, and
inflammation. (See 'Mechanisms of benefit' above.)
●It is uncertain whether wine is more cardioprotective than other types of
alcohol; however, it is likely that the type of alcohol is not as important as the
amount of alcohol consumed and the pattern of intake. (See 'Beverage
type' above.)
●No long-term randomized trials of alcohol consumption have been
performed. Most studies have found that light to moderate alcohol
consumption is associated with a specific reduction in cardiovascular
mortality, with several prospective cohort studies suggesting that light to
moderate alcohol consumption decreases the risk of coronary heart disease
(CHD) compared with drinking no alcohol or with heavy alcohol intake.
However, other data have challenged this potential benefit on CHD risk and
CHD mortality, and no level of drinking has shown to be beneficial for other
cardiovascular disease (CVD) risks (eg, stroke, hypertension, heart failure
[HF], etc). (See 'Effect of alcohol on cardiovascular risk' above.)
●Our approach to advising patients about the benefits of alcohol as part of a
strategy to reduce CVD risk is as follows (see 'Advice to patients regarding
alcohol use' above):
•Individuals who are not currently drinking, or those who have a personal
preference to avoid alcohol, should not be advised to consume alcohol
solely for the purpose of CVD risk reduction.
•Patients who have an underlying medical condition that precludes
alcohol use (eg, alcohol use disorder, liver disease, etc) should not be
advised to consume alcohol and seek counseling, if needed, to abstain
from alcohol.
•Patients who choose to drink moderate amounts of alcohol, such as
those who drink alcohol less than one unit per day (or less than 15 g per
day) or less than 100 g per week, may experience benefits for their
health.
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Topic 2784 Version 44.0

GRAPHICS
What is a standard drink?
US: United States; oz.: ounces.

* It can be difficult to estimate the number of standard drinks in a single mixed drink made with hard liquor.

Depending on factors such as the type of spirits and the recipe, a mixed drink can contain from 1 to 3 or

more standard drinks.

Reproduced with content from: National Institutes on Alcohol Abuse and Alcoholism. Rethinking Drinking:

Alcohol and your health. Available at: http://rethinkingdrinking.niaaa.nih.gov.

Graphic 56818 Version 5.0
Alcohol consumption and all-cause mortality

This study examined the association between alcohol consumption and mortality risk in United States

adults, using data from the National Health Interview Surveys of 333,247 participants ≥18 years of

age and categorizing participants according to self-reported alcohol consumption patterns. Median
follow-up was 8.2 years. Compared with lifetime abstainers, individuals who were light or moderate

consumers were at a reduced risk of all-cause mortality, but that risk increased significantly with

heavy alcohol consumption, as seen in this J-shaped curve. Dashed lines: 95% CI.

HR: hazard ratio.

Reproduced from: Xi B, Veeranki SP, Zhao M, et al. Relationship of Alcohol Consumption to All-Cause,

Cardiovascular, and Cancer-Related Mortality in U.S. Adults. J Am Coll Cardiol 2017; 70:913. Illustration

used with the permission of Elsevier Inc. All rights reserved.

Graphic 119228 Version 1.0
Associations of usual alcohol consumption with fatal and non-fatal
myocardial infarction (MI) and stroke
Adjusted for age, smoking, and history of diabetes, and stratified by sex and EPIC center. Alcohol

consumption categories amongst current drinkers were >0 to ≤50 grams/week, >50 to ≤100

grams/week, >100 to ≤150 grams/week, >150 to ≤250 grams/week, >250 to ≤350 grams/week and

>350 grams/week. The reference category is the lowest baseline alcohol consumption category (>0

and ≤50 grams/week). HRs are plotted against the mean usual alcohol consumption in each category.

Studies with fewer than 5 events of any outcome were excluded from the analysis of that outcome.

The sizes of the boxes are proportional to the inverse of the variance of the log-transformed HRs.

Vertical lines represent 95% CIs.

MI: myocardial infarction; EPIC: European Prospective Investigation into Cancer and Nutrition prospective

cohort study; HRs: hazard ratios; CIs: confidence intervals.

From: Wood AM, Kaptoge S, Butterworth AS, et al. Risk thresholds for alcohol consumption: combined

analysis of individual-participant data for 599,912 current drinkers in 83 prospective studies. Lancet 2018;

391:1513. Copyright © 2018 Elsevier

Inc. https://www.sciencedirect.com/science/article/pii/S014067361830134X?via%3Dihub. Reproduced

under the terms of the  Creative Commons Attribution License 4.0.

Graphic 119243 Version 2.0
Associations of usual alcohol consumption and risk of stroke
Adjusted for age, smoking, and history of diabetes, and stratified by sex and EPIC center. Baseline

alcohol consumption categories amongst current drinkers were >0 to ≤50 grams/week, >50 to ≤100

grams/week, >100 to ≤150 grams/week, >150 to ≤250 grams/week, >250 to ≤350 grams/week and

>350 grams/week. The reference category is the lowest baseline alcohol consumption category (>0

and ≤50 grams/week). HRs are plotted against the mean usual alcohol consumption in each category.

Studies with fewer than 5 events of any outcome were excluded from the analysis of that outcome.

The sizes of the boxes are proportional to the inverse of the variance of the log-transformed HRs.

Vertical lines represent 95% CIs.

EPIC: European Prospective Investigation into Cancer and Nutrition prospective cohort study; HRs: hazard

ratios; CIs: confidence intervals.

From: Wood AM, Kaptoge S, Butterworth AS, et al. Risk thresholds for alcohol consumption: combined

analysis of individual-participant data for 599,912 current drinkers in 83 prospective studies. Lancet 2018;

391:1513. Copyright © 2018 Elsevier

Inc. https://www.sciencedirect.com/science/article/pii/S014067361830134X?via%3Dihub. Reproduced

under the terms of the  Creative Commons Attribution License 4.0.

Graphic 119239 Version 2.0

Contributor Disclosures
Christine C Tangney, PhDNothing to discloseRobert S Rosenson, MDGrant/Research/Clinical Trial
Support: Akcea [Lipids]; Amgen [Lipids (Evolocumab)]; AstraZeneca [Antiplatelets (Ticagrelor)]; The
Medicines Company [Lipids (Inclisiran)]; Novartis [Lipids]; Regeneron [Lipids (Evinacumab)].
Consultant/Advisory Boards: Akcea [Lipids]; Amgen [Lipids]; Cordvidia [Antiinflammatory]; CVS
Caremark; The Medicines Company [Lipids (Inclisiran)]. Equity Ownership/Stock Options:
MediMergent [Pharmacy claims database]. Other Financial Interests: Kowa [Lipids (Pitavastatin)];
Amgen [Lipids (Evolocumab)]; Pfizer [Lipids (Atorvastatin)]; Regeneron [Lipids (Alirocumab)].Bernard
J Gersh, MB, ChB, DPhil, FRCP, MACCConsultant/Advisory Boards: Bain Institute [CRO for trials
involving Edwards percutaneous valve devices]; Boston Scientific Corporation [Data Safety Monitoring
Board (REPRISE study)]; Cardiovascular Research Foundation [Data Safety Monitoring Board
(RELIEVE-HF Trial)]; Duke Clinical Research Institute [Data Safety Monitoring Board (PIONEER
HCM)]; Icahn School of Medicine at Mount Sinai [Data Safety Monitoring Board (ENVISAGE-TAVI
study)]; Janssen Scientific Affairs [Executive committee (ORBIT Registries); Chairman (DSMB);
Steering Committee & Writing Committee (REVEAL Trial)]; Kowa Research Institute [Data Safety
Monitoring Board (PROMINENT study)]; Medtronic [REVEAL AF study]; Mount Sinai St Luke's
[Chairman (TWILIGHT study)]; MyoKardia [General consulting]; Sirtex Med Limited [General
consulting]; Thrombosis Research Institute [Data Safety Monitoring Board (GARFIELD study)]; Baim
Institute [CRO for trials involving Edwards Percutaneous Valve Devices].Jane Givens,
MDConsultant/Advisory Boards (Partner): CVS Health/CVS Omnicare [Pharmaceutical management of
formulary decision-making].

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