Critical Care Aspects of Alcohol Abuse

Ibrahim Al-Sanouri MD; Matthew Dikin MD; Ayman O. Soubani MD

Disclosures

South Med J. 2005;98(3):372-381. 

In This Article

Cardiovascular Complications

The direct effect of ethanol on the heart and long-term neurohumoral influence are the main causative factors in cardiac dysfunction caused by alcohol abuse.

The three main complications of cardiac dysfunction from ethanol requiring MICU care include cardiomyopathy, atrial and ventricular dysrhythmias, and variant angina.

Alcoholics may develop dilated cardiomyopathy with intake of more than 90 g/d of alcohol for at least 5 years.[100,101] A dilated left ventricle, normal or decreased left ventricular wall thickness and an increase in left ventricular mass characterize this type of cardiomyopathy.[102,103] The pathophysiology is not well understood, but mechanisms may include histologic and cellular changes, including myocyte loss,[104,105] intracellular organelle dysfunction,[106,107,108] decrease in contractile proteins, and changes in calcium regulation.[109,110]

The mechanism of dysrhythmias is also not known, but structural changes including myofibrillar necrosis, interstitial fibrosis, and dysfunction of myocyte sarcolemma and mitochondria alter the normal conduction system of the heart in chronic alcohol abuse. Ethanol or its metabolite acetylaldehyde may change the electrolyte balance at the cellular level and trigger cardiac dysrhythmias. Moreover, the combination of the increase in catecholamines along with electrolyte derangements may contribute to dysrhythmias. Finally, coronary vasospasm has been shown to occur in response to ethanol, which leads to angina.[111] The elevation in catecholamines and the poor cardiac contractility may also increase the coronary demand and cause variant angina.

The clinical signs and symptoms of cardiac dysfunction in alcoholic patients are similar to those in patients without a history of alcohol abuse. The diagnostic workup includes standard electrocardiogram, cardiac enzymes, thyroid function tests, chest radiogram, and cardiac echocardiogram. Endomyocardial biopsy is indicated in alcoholic cardiomyopathy if the diagnosis is not clear.[111] The biopsy will demonstrate myocyte hypertrophy, enlarged nuclei, and lymphocytic infiltrates.

Treatment of cardiac dysfunction from alcohol abuse in the MICU should focus on ruling out true coronary ischemia, controlling dysrhythmias, and improving cardiac function. Standard medical therapy for chest pain including aspirin, nitrates, and oxygen is similar in this population. Appropriate preload and afterload reduction is necessary if signs of congestive heart failure are present as a result of cardiomyopathy or dysrhythmias. Heart rate control with beta-blockade, calcium-channel blockers, and digitalis are indicated for a variety of dysrhythmias. Furthermore, beta-blockade for the increased neurohormonal activity in alcoholics has been shown to decrease further cardiac dysfunction.[111] Correction of nutritional and electrolyte deficits are also an important part of treatment for cardiac disease in this population. Acute atrial fibrillation induced by acute alcohol intoxication (holiday heart syndrome) is a benign condition with spontaneous recovery in the majority of cases.[112]

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