Reduced Alcohol Intake Drives Significant Drop in AF Burden

Debra L. Beck

January 16, 2020

In case you need support to make a case for "Dryuary" to your atrial fibrillation (AF) patients, moderate to heavy drinkers who either quit drinking alcohol or reduced their intake substantially saw a significant reduction in arrhythmia burden, compared with those who continued their usual drinking habits, in a just published randomized trial.

"These randomized data allow clinicians to more strongly recommend substantial reduction, if not abstinence from alcohol, in patients with atrial fibrillation," senior author Peter Kistler, MB, BS, PhD, University of Melbourne, Australia, told theheart.org | Medscape Cardiology.

Several observational studies have shown a dose-dependent relation between alcohol intake and AF, but there is limited prospective evidence supporting a role for alcohol abstinence or reduced intake and AF outcomes.

The results from the Alcohol-AF trial, which were first presented at the American College of Cardiology 2019 meeting and covered at that time by theheart.org | Medscape Cardiology, have now been published in the New England Journal of Medicine. The first author was electrophysiologist Aleksandr Voskoboinik, MB, BS, PhD, also from the University of Melbourne.

The researchers enrolled 140 Australians, mostly men (85%), who had paroxysmal or persistent AF and were moderate to heavy drinkers, with an average alcohol consumption of almost 17 standard drinks per week.

Participants were assigned to either abstain from alcohol or continue their usual intake. A visual guide depicting standard drink sizes was provided to participants to help them accurately log their intake.

Patients assigned to abstinence reduced their intake by 87.5% (from 16.8 to 2.1 standard drinks per week), while those in the control group reduced their intake by 19.5% (from 16.4 to 13.2 drinks per week).

Complete abstinence was achieved in 61% of the abstinence group, and 76% managed to reduce their intake to two or fewer drinks per week.

Aiming for abstinence was associated with less AF recurrence at 6 months in the abstinence group than in the control group (53% vs 73%), a longer time to recurrence (hazard ratio, 0.55; = .005), and an overall reduction in AF burden (median percentage of time in AF, 0.5% vs 1.2%; P = .01). Electrocardiogram (ECG)-based end points were blindly adjudicated.

"The effect of alcohol abstinence was long-lasting, provided patients abstained," Kistler said in an email exchange. "Many patients remained motivated once they realized the relation between alcohol and AF episodes."

Patients logged their intake and were asked to transmit twice-daily 30-second ECG tracings, regardless of their symptoms. Those who did not complete the log were subject to random urine testing for alcohol metabolites. Seven-day Holter monitoring was reserved for participants who failed to transmit regular ECG recordings.

In four of 140 patients (2.9%), antiarrhythmic medications were changed or they underwent an AF-related procedure prior to their first documented AF recurrence.

Can Abstinence Be Sustained?

Abstaining from alcohol can be a tough sell, as evidence by the researchers' difficulty in enrolling participants. They screened 697 patients for participation, but most (70.4%) were not willing to consider abstinence.

"Getting patients with AF to abstain from alcohol is challenging, as you can see that we approached 697 patients to participate in the trial but only 176 agreed and 140 actually enrolled," said Kistler.

In an accompanying editorial, Anne M. Gillis, MD, University of Calgary, Alberta, Canada, pointed out that the study's steering committee shortened the follow-up from 12 months to 6 months because of the difficulty they found in getting AF patients to agree to a full year of abstinence.

The researchers targeted "social drinkers" who reported regular consumption of at least 10 standard drinks per week. One limitation of the trial, they noted, was the possibility that those who recognize alcohol as a trigger for AF might have been more likely to consent to participation.

"The clinical applicability of abstinence requires separate attention, since only a minority of patients who were screened agreed to abstain completely, and patients with previous alcohol-triggered arrhythmias may have been overrepresented," the researchers note.

Alcohol is the most common trigger of AF, reported in about 35% of patients, according to the authors.

In terms of how to best convince patients to cut back their drinking, Kistler said they found that the study requirement for abstinence, or close to it, was self-reinforcing.

"Often, once patients reduced alcohol intake and noticed the reduction in AF episodes, this positive feedback reinforced the behaviour," he said. "Other strategies included asking the partner to also reduce their alcohol intake, positive reinforcement, and emphasizing the additional benefits of weight loss, blood pressure reduction, and better sleep."

Although this study offers "a compelling argument for alcohol abstinence" for patients with AF, Gillis writes, "the sobering reality is that for many persons with atrial fibrillation, total abstinence from alcohol may be a difficult goal to achieve."

This trial was supported by the Government of Victoria Operational Infrastructure Support Program. Alive Technologies provided a 20% discount for AliveCor Kardia Mobile EKC Monitors. Voskoboinik, Kistler, and Gillis reported no conflicts relevant to the submitted work.

N Engl J Med. 2020;382:20-28. Abstract, Editorial

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