INCIDENCE AND THERAPY OF ARRHYTHMIAS IN PATIENTS WITH DILATED ALCOHOLIC CARDIOMYOPATHY
Received for publication: 10th of December, 2012
Revised: 5th of February, 2013
SUMMARY: (Hide the summary)
Chronic, excessive alcohol consumption is a major cause of secondary cardiomyopathy, associated with congestive heart failure, arrhythmias and sudden death. The risk of developing this type of cardiomyopathy is partially genetically determined. The consumption of alcohol may result in myocardial damage caused by a presumed direct toxic effect of alcohol and its metabolites (especially acetaldehyde), nutritional effects most commonly in association with thiamine deficiency and rarely, toxic effects due to additives. We studied 53 patients with dilated cardiomyopathy were admitted in the Clinic of Cardiology of the County Hospital Timisoara for arrhythmias and/or worsening of congestive heart failure between 2009 and 2012. Alcohol consumption was implicated in the etiology. Most of the patients had associated risk factors, especially smoking and other concomitant diseases (chronic obstructive pulmonary diseases, diabetes mellitus, alcoholic liver disease, etc.). All patients had clinical examination with asassessment of the NYHA class and laboratory investigations like chest roentgenogram, repeated ECG, echocardiography and Holter monitoring. Arrhythmias were detected in 47 (88.67%) patients; most of them (53 - 81.13%) had supraventricular ones (atrial fibrillation, atrial fluter), but 53 - 50.96% had ventricular arrhythmias, some of them severe (Lown class IV or V) and 7 patients (13.20%) had episodes of ventricular tachycardia (sustained or unsustained). The episodes of congestive heart failure were treated with betablockers, diuretics, digitalis, enzyme converting inhibitors, trimetasidine; arrhythmias were treated with various antiarrhythmic agents. Amiodarone was preferred for the treatment of high risk ventricular arrhythmias and a few patients were reffered for the insertion of ICD. For concomitant diseases specific therapy was added.
dilated cardiomyopathy, arrhythmias, antiarrhythmic therapy
Chronic, excessive consumption of alcohol is the major cause of a specific cardiomyopathy, associated with congestive heart failure, arrhythmias and sudden death (1). The risk of developing cardiomyopathy is partially genetically determined, but it is estimated that over two-thirds of the adult population use alcohol to some extent, and more than 10% are heavy drinkers. The consumption of alcohol may result in myocardial damage by three basic mechanisms: a presumed direct toxic effect of alcohol and its metabolites (especially acetaldehyde), nutritional effects most commonly in association with thiamine deficiency and rarely toxic effects due to additives in the alcoholic beverage (cobalt). In addition, alcohol has an important pro-arrhythmogenic effect responsible for high incidence of arrhythmias and risk for sudden death.
AIM OF THE STUDY
The aim of our study is to evaluate the incidence and drug therapy of arrhythmias in addition to a standard heart failure care in order to improve the clinical evolution and outcome in a group of patients with dilated cardiomyopathy.
MATERIAL AND METHOD
We studied 53 patients with dilated cardiomyopathy which were admitted in the Clinic of Cardiology of the County Hospital Timisoara for arrhythmias and/or acute congestive heart failure due to dilated alcoholic cardiomyopathy between 2009 and 2012. Alcohol consumption was implicated in the aetiology of this disease. From this group only 11 (20.75%) had alcoholic cardiomyopathies alone, the other 42 (79.24%) had also an important ischemic component. The majority of the patients, 52 (98.11%) were men and only 1 (1.88%) women, with ages between 33 and 69 years (mean age = 49.6±12.7 years). Most of the patients had associated risk factors, especially smoking (49 subjects - 92.45%) and other concomitant illnesses (pulmonary diseases, diabetes mellitus, alcoholic liver disease, etc.).
All patients had clinical examination with assessment of the NYHA class, chest roentgenogram, ECG and Holter ECG monitoring and echocardiography.
The patients were first admitted in the hospital for worsening of congestive heart failure and/or arrhythmias.
In most cases they had associated diseases. After clinical examinations, chest roentgenogram, ECG and echocardiography were performed and classification in NYHA classes was established. The results of laboratory examinations are presented in table 1 and the initial evaluation in NYHA classes in table 2.
Therapy: all patients were strongly advised to give up alcohol consumption and a low salt diet was recommended. Episodes of decompensated heart failure were treated with betablockers, angiotensin enzyme converting inhibitors or angiotensin receptor blockers; diuretics, digitalis, supraventricular arrhythmias were treated with beta-blockers, atrial fibrillation with beta-blocker, eventually digitalis and amiodarone or propaphenone in the paroxysmal forms; Premature ventricular beats were treated with beta-blockers or other antiarrhythmic agents, but for ventricular tachycardia electric conversion, amiodarone intravenous and then orally was recommended. 2 patients were addressed for ICD implantation.
Table 1. Results of laboratory examinations.
Table 2. Classification in NYHA cases after the first admission in the hospital.
Table 3. Associated diseases in patients with alcoholic cardiomyopathy.
Table 4. Evolution of the study group after 3 years of follow up.
RESULTS AND DISCUSSIONS
The study group consisted almost only of middle aged men, with important alcohol consumption in the past 10 years and additional cardiovascular risk factors like smoking, diabetes mellitus or dyslipidemia. Most of them (51 P = 96.22%) had concomitant diseases, as presented in table 3.
The evolution of the patients was followed for a period of 1, 2 and maximum 3 years. The results are shortly resumed in table 4.
Patients with isolated alcoholic cardiomyopathy had a better prognosis (2), with lower mortality and less complications, but with a higher incidence of arrhythmias comparing to the patients with combined ischemic and alcoholic cardiomyopathy. In the abstinent subject group, especially in those with mild heart failure at the first admission, mortality was lower, with less complications and stagnation or even reversal of the illness.
Patients with alcoholic and ischemic cardiomyopathy had also a better prognostic after cessation of alcohol consumption. Comparing the patients from the abstinent group with those which continued alcohol intake, the first ones had lower mortality, less admissions in the hospital, but still a high incidence of arrhythmias, correlated with the severity of ischemia (3, 4). In this group were included 5 patients with history of myocardial infarction and we have noticed on the Holter monitoring, episodes of severe ventricular arrhythmias resulting in cardiac arrest.
- Alcohol consumption is a major health problem; patients with alcoholic cardiomyopathy have often associated risk factors and other diseases;
- In patients with alcoholic dilated cardiomyopathy, an ischemic component is frequently involved in the aetiology;
- The presence of associated ischemia is a supplementary negative prognostic factor;
- The pro-arrhythmogenic effect of ethanol is responsible for some of the arrhythmias and sudden death in subjects with this cardiomyopathy;
- Continuation of alcohol consumption is a negative prognostic factor; severity associated with worsening of heart failure; rate of complications and mortality are closely related to alcohol abuse;
- Abstinence may halt the progression of the disease or even reverse heart failure;
- Arrhythmias are frequently associated with this disease and implicate specific therapy.
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