Clinical communications Preclinical cardiomyopathy in chronic alcoholics: A sex difference Chia F. Wu, M.D. Maraboyina Sudhakar, M.D. Ghazanfar Jaferi, M.D. S. Sultan Ahmed, M.D. T i m o t h y J. Regan, M.D. Newark, N. J.
Clinical descriptions of cardiomyopathy in alcoholics have consistently indicated a predominant male distribution. 1 Although this m a y be related to a difference in the sex incidence of alcoholism, 2 a variation in the myocardial response to longterm ethanol use needs to be considered. While a preclinical abnormality of cardiac function has been described in male alcoholics, 3-s female subjects were rarely studied and the question of sex difference has not been examined. We have chosen this phase of the myocardial response to chronic ethanol use to examine this issue. Male and female alcoholics with a similar history in terms of duration and intensity were selected. In addition, a group with similar pathology of the liver, manifested as cirrhosis, was compared. Noninvasive studies of left ventricular function and conduction were performed. Methods
Studies were performed on 36 patients admitted to the hospital for a variety of alcohol-related diseases. Th ey were all chronic users of ethanol. Quantitation of history was approximate and was also obtained from relatives or friends in most instances. The average duration was 15 years and recent consumption of whiskey ranged from 8 to This investigation was supported in part by United States Public Health Service National Institute of Alcohol Abuse and Alcoholism Research Grant No. AA00242 and National Heart and Lung Institute Postgraduate Training Grant No. HL 05510. From the Department of Medicine, College of Medicine and Dentistry of New Jersey, New Jersey Medical School and Martland Hospital Unit, Newark, N. J. Received for publication Jan. 13, 1975. Reprint requests: Timothy J. Regan, M.D., New Jersey Medical School, 100 Bergen St., Newark, N. J. 07103.
March, 1976, Vol. 91, No. 3, pp. 281-286
32 oz. per day. Alcoholic subjects with signs and symptoms indicating presence of heart disease, hypertension, diabetes mellitus, pulmonary disease, and obesity were excluded from this study. The subjects were otherwise consecutive in t h a t none were excluded who gave consent. Conventional 12 lead electrocardiograms (ECG) and chest roentgenograms were normal in all the subjects. A total of 22 males and 14 females were investigated. Nineteen were found to have alcoholic cirrhosis confirmed by liver biopsy. Patients presented with delirium tremens or mild withdrawal symptoms, acute alcoholic gastritis, acute or chronic pancreatitis, etc. All subjects were studied after acute symptoms and signs had dissipated and were abstinent from alcoholic beverages for an average of 12 days (range, 4 to 60 days). Blood pressure was measured at the time of study and blood hematocrit, electrolytes and liver function tests were obtained at or near the time of study. T w ent y-t w o volunteers without heart disease who were known to be nonalcoholic served as a control group. All studies were done between 8:00 A.M. and 12:00 noon, in the postabsorptive phase and the supine position. The systolic time intervals were measured as described by Weissler and associates, 7, s from simultaneous ECG, phonocardiogram, and external carotid pulse tracings. T h e s e were recorded on an Electronics for Medicine oscillographic recorder at a paper speed of 100 ram. per second and time markers of 0.02 sec. T h e total electromechanical systole (QS2) was measured from the beginning of the QRS complex to the first rapid deflection of the second heart sound. T he left
American Heart Journal
281
W u e t al.
Table I. Systolic t i m e i n t e r v a l s i n c h r o n i c a l c o h o l i c s
Alcoholics
Number Age Blood pressure S D HR/min. PEP/LVET PEP (msec.) PEPI (msec.) LVETI (msec.) QS2I (msec.)
34.0
22 _+ 1.9
117.3 +_ 3.3 77.5 _ 1.8 66.6 _+ 1.6 0.313 _ 0.006 92.5 _+ 2.3 119.0 _+ 2.1 405.3 +_ 4.0 525.4 _+ 5.4
Cirrhosis
Total
Normals 38.0
36 _+_1.4
35.9
123.0 +_ 2.9 76.8 _+ 1.9 81.5 _+ 2.0t 0.381 _+ 0.016t 100.4 __ 3.3 132.9 _+ 3.1t 402.4 _+ 3.5 535.2 _+ 3.8
19 - 2.0
120.3 _+ 3.6 75.5 _+ 2.9 82.3 -+ 3.1t 0.359 + 0.0175 96.6 +-- 3.9 129.5 _+ 3.9* 407.5 _+ 3.3 537.0 +_ 4:8
]
Noncirrhosis 40.3
17 + 1.9'
126.1 _+ 4.8 78.3 + 2.6 80.6 -+ 2.65 0.406 -+ 0.027t 104.6 _+ 5.4* 136.8 + 4.95 396.8 _+ 6.3 533.2 + 6.3
*P
Clinical descriptions of cardiomyopathy in alcoholics have consistently indicated a predominant male distribution. 1 Although this m a y be related to a difference in the sex incidence of alcoholism, 2 a variation in the myocardial response to longterm ethanol use needs to be considered. While a preclinical abnormality of cardiac function has been described in male alcoholics, 3-s female subjects were rarely studied and the question of sex difference has not been examined. We have chosen this phase of the myocardial response to chronic ethanol use to examine this issue. Male and female alcoholics with a similar history in terms of duration and intensity were selected. In addition, a group with similar pathology of the liver, manifested as cirrhosis, was compared. Noninvasive studies of left ventricular function and conduction were performed. Methods
Studies were performed on 36 patients admitted to the hospital for a variety of alcohol-related diseases. Th ey were all chronic users of ethanol. Quantitation of history was approximate and was also obtained from relatives or friends in most instances. The average duration was 15 years and recent consumption of whiskey ranged from 8 to This investigation was supported in part by United States Public Health Service National Institute of Alcohol Abuse and Alcoholism Research Grant No. AA00242 and National Heart and Lung Institute Postgraduate Training Grant No. HL 05510. From the Department of Medicine, College of Medicine and Dentistry of New Jersey, New Jersey Medical School and Martland Hospital Unit, Newark, N. J. Received for publication Jan. 13, 1975. Reprint requests: Timothy J. Regan, M.D., New Jersey Medical School, 100 Bergen St., Newark, N. J. 07103.
March, 1976, Vol. 91, No. 3, pp. 281-286
32 oz. per day. Alcoholic subjects with signs and symptoms indicating presence of heart disease, hypertension, diabetes mellitus, pulmonary disease, and obesity were excluded from this study. The subjects were otherwise consecutive in t h a t none were excluded who gave consent. Conventional 12 lead electrocardiograms (ECG) and chest roentgenograms were normal in all the subjects. A total of 22 males and 14 females were investigated. Nineteen were found to have alcoholic cirrhosis confirmed by liver biopsy. Patients presented with delirium tremens or mild withdrawal symptoms, acute alcoholic gastritis, acute or chronic pancreatitis, etc. All subjects were studied after acute symptoms and signs had dissipated and were abstinent from alcoholic beverages for an average of 12 days (range, 4 to 60 days). Blood pressure was measured at the time of study and blood hematocrit, electrolytes and liver function tests were obtained at or near the time of study. T w ent y-t w o volunteers without heart disease who were known to be nonalcoholic served as a control group. All studies were done between 8:00 A.M. and 12:00 noon, in the postabsorptive phase and the supine position. The systolic time intervals were measured as described by Weissler and associates, 7, s from simultaneous ECG, phonocardiogram, and external carotid pulse tracings. T h e s e were recorded on an Electronics for Medicine oscillographic recorder at a paper speed of 100 ram. per second and time markers of 0.02 sec. T h e total electromechanical systole (QS2) was measured from the beginning of the QRS complex to the first rapid deflection of the second heart sound. T he left
American Heart Journal
281
W u e t al.
Table I. Systolic t i m e i n t e r v a l s i n c h r o n i c a l c o h o l i c s
Alcoholics
Number Age Blood pressure S D HR/min. PEP/LVET PEP (msec.) PEPI (msec.) LVETI (msec.) QS2I (msec.)
34.0
22 _+ 1.9
117.3 +_ 3.3 77.5 _ 1.8 66.6 _+ 1.6 0.313 _ 0.006 92.5 _+ 2.3 119.0 _+ 2.1 405.3 +_ 4.0 525.4 _+ 5.4
Cirrhosis
Total
Normals 38.0
36 _+_1.4
35.9
123.0 +_ 2.9 76.8 _+ 1.9 81.5 _+ 2.0t 0.381 _+ 0.016t 100.4 __ 3.3 132.9 _+ 3.1t 402.4 _+ 3.5 535.2 _+ 3.8
19 - 2.0
120.3 _+ 3.6 75.5 _+ 2.9 82.3 -+ 3.1t 0.359 + 0.0175 96.6 +-- 3.9 129.5 _+ 3.9* 407.5 _+ 3.3 537.0 +_ 4:8
]
Noncirrhosis 40.3
17 + 1.9'
126.1 _+ 4.8 78.3 + 2.6 80.6 -+ 2.65 0.406 -+ 0.027t 104.6 _+ 5.4* 136.8 + 4.95 396.8 _+ 6.3 533.2 + 6.3
*P
