Acute inhibitory effect of alcohol on fibrinolysis

Elucidating the role of intrinsic adenosine A1 receptors in acute alcoholism using human-induced pluripotent stem cell-derived hepatocytes

Acute alcoholic hepatitis (AAH) from binge drinking is a serious disease. It is associated with a high mortality rate, especially among young adults. Apoptosis is known to be a primary cause of liver damage, and it can be induced by either intrinsic signaling pathways or by reactive oxygen species (ROS). Adenosine A1 receptors (ADORA1) are known to be involved in ethanol metabolism; however, underlying mechanism is not well understood. For investigating how the intrinsic ADORA1 function in ethanol metabolism in normal human hepatocytes without interference by extrinsic molecules, primary hepatocytes pose a challenge, due to unavoidable contamination by other kinds of cells in the liver. Also, they are difficult to culture stably. As a novel alternative, hepatocytes derived from human-induced pluripotent stem cells were employed because they display similar function to primary hepatocytes and they can be stably cultured. The dynamics and integrity of signal transduction mechanisms were investigated by following chronological changes in gene expression. This shed light on how and when the ADORA1 function and on causal relationships between the pathways and clinical symptoms. The findings of the present study shows that ADORA1 are most activated soon after exposure to ethanol, and transfection of small interfering RNA targeting ADORA1-messenger-RNA (ADORA1-siRNA) into the hepatocytes significantly suppresses production of actin protein and ROS. It suggests that ADORA1 in the liver contribute to apoptosis in acute alcoholism through both intrinsic pathway and ROS activity. Also, actin that is abundant in the cells could be an appropriate biomarker evaluating hepatic function status.

Alcohol Binge Drinking-Induced ST-Segment-Elevation Acute Coronary Syndrome

We present the case of a 26-year-old man, without any apparent cardiovascular risk factors, who experienced an ST-segment-elevation acute coronary syndrome after binge drinking high-proof alcohol, which was successfully managed with primary percutaneous coronary intervention and comprehensive, guideline-directed medical therapy.

Walking Under the Influence : Association of Time of the Day With the Incidence and Outcomes of Intoxicated Pedestrians Struck by Vehicles

AIM

Pedestrian fatalities commonly involve alcohol. We sought to characterize alcohol intoxication among pedestrians struck by vehicles and examine correlations between admission time and injury severity.

METHODS

The Los Angeles County Trauma and Emergency Medicine Information System database was reviewed for pedestrians struck by vehicles over a 16-year period starting January 2000. Subjects aged ≥18 years with available time and day of admission were selected. Patients with available blood alcohol content (BAC) were analyzed and those with positive (+) BAC (≥ 0.01%) were compared with those with negative (-) BAC. The primary outcome was mortality.

RESULT

35 840 patients met criteria, with 12 122 (33.8%) tested for BAC. 71.2% were (+) BAC. The proportion of (+) BAC pedestrians peaked at 02:00 (48.9% of admitted pedestrians, 88.5% of BAC tested pedestrians). Patients with a (+) BAC were more likely hypotensive (3.5% vs 2.7%, P = .019) and admitted with a Glasgow Coma Scale ≤ 8 (9.4% vs 7.1%, P < .001). Overall mortality was 4.6%. Those admitted from 06:00 to 11:00 had the highest odds of mortality in (+) BAC patients (4.7%, adjusted odds ratio 3.16, adjusted P < .001).

CONCLUSION

Pedestrians struck by vehicles during late hours are commonly intoxicated. These findings could help legislators to implement changes and strategies to decrease the risk and burden of injury in intoxicated pedestrians.

Alcohol and risk of non-traumatic bleeding events requiring hospital care in the general population: A prospective cohort study

Alcohol has a direct effect on blood coagulation and fibrinolysis. We studied how alcohol is related to common bleeding events (e.g., nose bleeding), as well as life-threatening bleeding events (e.g., hemorrhagic stroke) that required hospital care in the general population. We used data from The Copenhagen City Heart Study, 1991 to 1994 and 2001 to 2003. Baseline information on alcohol consumption and potential confounders was obtained by questionnaires, and participants were followed for incident bleeding events with nationwide registers until 2013. Among the 10,259 included participants, we observed 366 nose or other respiratory organ bleeding events, 149 hemorrhagic stroke events, 470 gastrointestinal bleeding events, 266 unspecified bleeding events, and 1088 any-bleeding events (composite endpoint) during follow-up. Compared to drinkers of 1-6 drinks per week, those drinking ≥35 drinks per week had a higher risk of hemorrhagic stroke [hazard ratio, 2.27 (1.14-4.55)] and non-variceal gastrointestinal bleeding [hazard ratio 2.04 (1.37-3.05)], whereas non-drinkers and drinkers of 7-13, 14-20, 21-27, and 28-34 drinks per week had not. Alcohol consumption was not associated with risk of nose or other respiratory organ bleeding or unspecified bleeding. For non-drinkers and drinkers of 7-13, 14-20, 21-27, 28-34, and 35 or more drinks per week, hazard ratios for the composite endpoint of any bleeding were 1.17 (95% CI: 0.99-1.37), 0.97 (95% CI: 0.81-1.15), 1.00 (95% CI: 0.80-1.26), 0.93 (95% CI: 0.69-1.25), 1.39 (95% CI: 1.00-1.94), and 1.83 (95% CI: 1.39-2.41) compared to drinkers of 1-6 drinks per week. In conclusion, drinking 35 or more drinks per week may be associated with a higher risk of hemorrhagic stroke and non-variceal gastrointestinal bleeding in the general population.

The French paradox three decades later: Role of inflammation and thrombosis

Although, three decades have pasted from the introduction of "French Paradox", is still an issue for debate. Epidemiology supports the J-shaped relationship between wine consumption and vascular events as well as cardiovascular mortality with a maximum protection at 21 g of alcohol consumption in the form of wine per day. Nevertheless, the aforementioned studies have used an observational design that raises concerns about potential confounding. Randomized clinical studies may provide data to end the controversy and in parallel with in vitro experiments to elucidate the mechanisms by which wine affects cardiovascular disease. In this concept, this review aims to address the presence of bioactive wine micro constituents, their potential mechanisms of action and also to summarize the cardio-protective effects of wine intake based on clinical trials. The role of wine micro-constituents in inflammation and haemostasis is discussed in detail.

Influence of alcohol consumption on blood coagulation in rotational thromboelastometry (ROTEM): an in-vivo study

Background

Twenty-five to 85% of trauma patients are under the influence of alcohol in addition to experiencing injury-related coagulation impairment. Viscoelastic point-of-care tests (thrombelastography [TEG], rotational thromboelastometry [ROTEM]) are popular tools for rapid hemostasis assessment and therapeutic decision-making in this and other settings. While alcohol affects these tests in-vitro, their specific effects in-vivo are unclear. Therefore, we evaluated the effects of alcohol ingestion on ROTEM parameters.

Methods

Twenty volunteers provided informed consent to drinking red wine, whisk(e)y, or vodka to a target blood alcohol concentration of 1‰ within one hour, calculated with the Widmark formula. Blood samples were collected before drinking, at a breath alcohol concentration of 0.5‰, and at 1.0‰, but no later than one hour. After each blood collection, ExTEM and FibTEM tests were performed directly "at the bedside."

Results

All participants had a blood alcohol concentration (BAC) of 0.00‰ at the beginning. The mean BACs at the second and third collection were 0.48 and 0.76‰, respectively. There were no significant differences in the ExTEM parameters. FibTEM measurements showed a significant difference at the A10 value (13.0 vs. 14.0 mm, P = 0.014) and a trend at the maximum amplitude (maximum clot firmness 13.7 vs. 16.2 mm, P = 0.075). We saw no significant differences in fibrinolysis parameters and no hyperfibrinolysis in our ROTEM measurements.

Conclusions

Ethanol ingestion can impair early fibrin polymerization. These results might be of special relevance in trauma and support routine application of ROTEM/TEG in such cases.

Do not drink and lyse: alcohol intoxication increases fibrinolysis shutdown in injured patients

Introduction

High alcohol consumption has been associated with decreased fibrinolysis and enhanced thrombosis risk in cardiovascular disease. In trauma, alcohol has been associated with poor clot formation; however, its effect on fibrinolysis has not been fully investigated. We assessed the association of blood alcohol levels and fibrinolysis in trauma activation patients.

Methods

We queried our prospective registry of trauma activations from 2014 to 2016. Associations between viscoelastic measurements [rapid thrombelastography (rTEG)] and blood alcohol level (BAL) were determined and adjusted for confounders by a multinomial logistic regression. Lysis phenotypes were defined by the % lysis in 30 min (LY30) as follows: hyperfibrinolysis ≥ 3%, physiologic 0.9–2.9%, and fibrinolysis shutdown < 0.9%.

Results

Overall, 191 (43.8%) had BAL measured. There were 65 (34%) patients that had no detectable BAL, 32 (16.8%) had BAL of 10–150 mg/dL, and 94 (49.2%) patients had BAL > 150 mg/dL. BAL had a moderate, but significant inverse correlation with LY30 (Rho = − 0.315, p < 0.001), while there were no significant correlations between BAL and other TEG values. The distribution of fibrinolysis phenotypes varied significantly by BAL levels (p < 0.009, with high BAL having more shutdown and less hyperfibrinolysis than the other two BAL level groups. Multinomial logistic regression showed that after adjustment for confounders, BAL levels > 150 mg/dL were independently associated with a threefold increase in the odds of shutdown compared to undetectable BAL (OR 3.37, 95% CI 1.04–8.05, p = 0.006). High BAL was also significantly associated with higher odds of shutdown compared to low BAL (OR 2.63, 95% CI 1.15–6.06). Compared to physiologic fibrinolysis, fibrinolysis shutdown was associated with increased mortality (OR 2.87, 95% CI 1.41–5.83) and VFD < 28 (OR 2.54, 95% CI 1.47–4.39).

Conclusion

In the injured patient, high blood alcohol levels are associated with increased incidence of fibrinolysis shutdown. This finding has implications for postinjury hemostatic resuscitation as these patients may be harmed by anti-fibrinolytics. Further research is needed to assess whether the association with fibrinolysis is modified by the chronicity and type of alcohol consumed and whether anti-fibrinolytic therapy in intoxicated patients produces adverse effects.

Exposing the bidirectional effects of alcohol on coagulation in trauma: Impaired clot formation and decreased fibrinolysis in rotational thromboelastometry

BACKGROUND

Alcohol has been associated with altered viscoelastic testing in trauma, indicative of impaired coagulation. Such alterations, however, show no correlation to coagulopathy-related outcomes. Other data suggest that alcohol may inhibit fibrinolysis. We sought to clarify these mechanisms after traumatic injury using thromboelastometry (ROTEM), hypothesizing that alcohol-related clot formation impairment may be counter-balanced by inhibited fibrinolysis.

METHODS

Laboratory, demographic, clinical, and outcome data were prospectively collected from 406 critically injured trauma patients at a Level I trauma center. ROTEM and standard coagulation measures were conducted in parallel. Univariate comparisons were performed by alcohol level (EtOH), with subsequent regression analysis.

RESULTS

Among 274 (58%) patients with detectable EtOH, median EtOH was 229 mg/dL. These patients were primarily bluntly injured and had lower GCS (p < 0.05) than EtOH-negative patients, but had similar admission pH and injury severity (p = NS). EtOH-positive patients had prolonged ROTEM clotting time and rate of clot formation time (CFT/α); they also had decreased fibrinolysis (max lysis %; all p < 0.05). In linear regression, for every 100 mg/dL increase in EtOH, clotting time increased by 13 seconds and fibrinolysis decreased by 1.5% (both p < 0.05). However, EtOH was not an independent predictor of transfusion requirements or mortality. In high-EtOH patients with coagulopathic ROTEM tracings, transfusion rates were significantly lower than expected, relative to EtOH-negative patients with similar ROTEM findings.

CONCLUSION

As assayed by ROTEM, alcohol appears to have a bidirectional effect on coagulation in trauma, both impairing initial clot formation and inhibiting fibrinolysis. This balancing of mechanisms may explain lack of correlation between altered ROTEM and coagulopathy-related outcomes. Viscoelastic testing should be used with caution in intoxicated trauma patients.

LEVEL OF EVIDENCE

Epidemiological study, level III.

Wine and its metabolic effects. A comprehensive review of clinical trials

The introduction of the term "French Paradox" motivated an extensive and in-depth research into health benefits of moderate wine consumption. The superiority of wine is thought to be attributed to its micro-constituents and consequent effort was made to isolate and identify these bioactive compounds as well as to elucidate the mechanisms of their action. Controlled trials offer more concrete answers to several raised questions than observational studies. Under this perspective, clinical trials have been implemented, mainly in healthy volunteers and rarely in patients, in order to investigate the acute or chronic effect of wine consumption on metabolism and physio-pathological systems, which are mainly associated with cardiovascular diseases. The aim of this review is to update the knowledge about the acute and long term effect of wine consumption on lipid and glucose/insulin metabolism as well as on the inflammatory and haemostatic systems, based on the reported data of controlled clinical trials. In conclusion, the most repeated result of wine consumption is on lipid metabolism, attributed mainly to ethanol, while wine micro-constituents seem to have an important role mainly in haemostatic and inflammatory/endothelial systems.

Electrocardiogram Changes with Acute Alcohol Intoxication: A Systematic Review

Background:

Acute alcohol intoxication has been associated with cardiac arrhythmias but the electrocardiogram (ECG) changes associated with acute alcohol intoxication are not well defined in the literature.

Objective:

Highlight the best evidence regarding the ECG changes associated with acute alcohol intoxication in otherwise healthy patients and the pathophysiology of the changes.

Methods:

A literature search was carried out; 4 studies relating to ECG changes with acute alcohol intoxication were included in this review.

Results:

Of the total 141 patients included in the review, 90 (63.8%) patients had P-wave prolongation, 80 (56%) patients had QTc prolongation, 19 (13.5%) patients developed T-wave abnormalities, 10 (7%) patients had QRS complex prolongation, 3 (2.12%) patients developed ST-segment depressions.

Conclusion:

The most common ECG changes associated with acute alcohol intoxication are (in decreasing order of frequency) P-wave and QTc prolongation, followed by T-wave abnormalities and QRS complex prolongation. Mostly, these changes are completely reversible.

Alcohol and Acute Myocardial Infarction

A number of studies from different countries and several large-scale meta-analyses have reported reduced coronary heart disease rates among those regularly consuming mild to moderate amounts of alcohol compared with those abstaining from alcohol. In contrast, various studies have also reported that heavy alcohol consumption promotes the progression of atherosclerosis and that binge drinking might trigger embolic stroke and acute myocardial infarction. We discuss the association between alcohol consumption and acute myocardial infarction on the basis of evidence from literature published recently. Alcohol consumption has both favourable and unfavourable effects on metabolism, lipid profile, blood coagulation and fibrinolysis, blood pressure and vascular tone depending on the amount of alcohol consumed and the way that it is drunk (i.e. drinking habits). We conclude that it is extremely important to warn people of the risks associated with binge drinking and to encourage them to remain within the recommended safe limits for alcohol consumption.

Predisposing factors to post-operative adhesion development

BACKGROUND

Adhesion development is the most common sequelae of intra-abdominal and pelvic surgery and represents a significant, yet poorly understood, cause of morbidity among post-operative patients. It remains unclear, for example, exactly why adhesions form more frequently in certain tissues and/or patients, or at specific locations within them, as opposed to others. This review contributes to the growing knowledge pool by elucidating factors that potentially predispose to the development of adhesions. Given the strong correlation between a hypofibrinolytic state and adhesion formation, this review article will examine not only those factors that have been shown to directly predispose to adhesion development, but also those that are likely do so indirectly by means of altering the coagulation/fibrinolytic profile.

METHODS

A literature search was performed using the PubMed database for all relevant English language articles up to February 2014. All of the identified articles were reviewed with particular attention to predisposing factors to post-operative adhesion development. In addition, the reference lists of each article were reviewed to identify additional relevant articles.

RESULTS

Various factors have been shown to directly increase the risk of post-operative adhesion development; namely, certain genetic polymorphisms in the interleukin-1 receptor antagonist, increased estrogen exposure, and endometriosis. In addition, numerous factors are known to increase the risk of fibrosis, therefore likely increasing the risk of adhesion development indirectly. These factors include genetic polymorphisms in plasminogen activator inhibitor-1 and thrombin-activatable fibrinolysis inhibitor, diabetes mellitus, metabolic syndrome, hyperglycemia, obesity, depression, binge alcohol consumption, anti-Parkinsonian medications, oral hormone therapy, pregnancy, and cancer.

CONCLUSIONS

The literature reviewed in this paper will help to direct future research aimed at understanding the mechanisms that underlie the association of certain factors with adhesion development. This information will be crucial in the creation of adequate preventative and treatment strategies.

The effects of alcohol on coagulation in trauma patients: interpreting thrombelastography with caution

BACKGROUND

The effects of alcohol on coagulation after trauma remain unclear. In vitro studies show that alcohol may decrease clot strength and inhibit fibrinolysis. Observational data indicate that alcohol leads to altered thrombelastography (TEG) parameters indicative of impaired clot formation. Clinical studies have been inconclusive to date.

METHODS

Longitudinal plasma samples were prospectively collected from 415 critically injured trauma patients at a single Level 1 trauma center and were matched with demographic and outcome data. Citrated kaolin TEG and standard coagulation measures were performed in parallel. Univariate and group comparisons were performed by alcohol status, with subsequent linear and logistic regression analysis.

RESULTS

A total of 264 patients (63.6%) had detectable blood alcohol levels (EtOH, >10 mg/dL). These patients were primarily male (87% vs. 79%), were bluntly injured (77% vs. 59%), and had lower median Glasgow Coma Scale (GCS) score (9.5 vs. 14, all p < 0.05) than the EtOH-negative patients. There were no notable differences in pH (7.29 vs. 7.31, p = nonsignificant) or injury severity (median Injury Severity Score [ISS], 11 vs. 14; p = nonsignificant) between the groups. The alcohol-positive patients had a prolonged TEG citrated kaolin R-time (reaction time), or time to initial clot formation (5.91 minutes vs. 4.43 minutes, p = 0.013), prolonged K-time (kinetics time), or time to fixed level of clot strength (1.77 minutes vs. 1.43 minutes, p = 0.036), and decreased α angle (66.5 degrees vs. 70.2 degrees, p = 0.001). In multiple linear regression, for every 10-mg/dL increase in EtOH, R-time was prolonged by 3.84 seconds (p = 0.015), and α angle decreased by 0.11 degrees (p = 0.013). However, in multiple logistic regression analyses, EtOH was a negative predictor of coagulopathy by international normalized ratio (>1.3) and was not predictive of transfusion requirements or early or late mortality.

CONCLUSION

Patients with elevated EtOH present with impaired clot formation as assayed by TEG, but this does not correlate with standard measures of coagulopathy or with outcome. Reliance on TEG for determining coagulopathy in intoxicated trauma patients may lead to a misperceived hypocoagulable state and inappropriate transfusion. TEG appears to be affected by EtOH in a previously unreported way, warranting further investigation.

LEVEL OF EVIDENCE

Prognostic and epidemiologic study, level III.

Long-term alcohol consumption in relation to all-cause and cardiovascular mortality among survivors of myocardial infarction: the Health Professionals Follow-up Study

AIMS

The aim of this study was to examine the association between long-term alcohol consumption, alcohol consumption before and after myocardial infarction (MI), and all-cause and cardiovascular mortality among survivors of MI.

METHODS AND RESULTS

The Health Professionals Follow-up Study (HPFS) is a prospective cohort study of 51 529 US male health professionals. From 1986 to 2006, 1818 men were confirmed with incident non-fatal MI. Among MI survivors, 468 deaths were documented during up to 20 years of follow-up. Long-term average alcohol consumption was calculated beginning from the time period immediately before the first MI and updated every 4 years afterward. Cox proportional hazards were used to estimate the multivariable-adjusted hazard ratios (HR) and 95% confidence intervals (CI). Compared with non-drinkers, the multivariable-adjusted HRs for all-cause mortality were 0.78 (95% CI: 0.62-0.97) for 0.1-9.9 g/day, 0.66 (95% CI: 0.51-0.86) for 10.0-29.9 g/day, and 0.87 (95% CI: 0.61-1.25) for ≥30 g/day (P(quadratic)= 0.006). For cardiovascular mortality, the corresponding HRs were 0.74 (95% CI: 0.54-1.02), 0.58 (95% CI: 0.39-0.84), and 0.98 (95% CI: 0.60-1.60), P(quadratic)= 0.003. These findings were consistent when restricted to pre- and post-MI alcohol assessments. In subgroup analyses, moderate alcohol consumption was inversely associated with mortality among men with non-anterior infarcts, and among men with mildly diminished left ventricular function.

CONCLUSION

Long-term moderate alcohol consumption is inversely associated with all-cause and cardiovascular mortality among men who survived a first MI. This U-shaped association may be strongest among individuals with less impaired cardiac function after MI and should be examined further.

Ethanol intoxication is associated with a lower incidence of admission coagulopathy in severe traumatic brain injury patients

The aim of this study was to determine the impact of ethanol (ETOH) on the incidence of severe traumatic brain injury (sTBI)-associated coagulopathy and to examine the effect of ETOH on in-hospital outcomes in patients sustaining sTBI. Patients admitted to the surgical intensive care unit from June 2005 through December 2008 following sTBI, defined as a head Abbreviated Injury Scale (AIS) score ≥3, were retrospectively identified. Patients with a chest, abdomen, or extremity AIS score >3 were excluded to minimize the impact of extracranial injuries. Criteria for sTBI-associated coagulopathy included thrombocytopenia and/or elevated International Normalized Ratio (INR) and/or prolonged activated partial thromboplastin time (aPTT). The incidence of admission coagulopathy, in-hospital complications, and mortality were compared between patients who were ETOH positive [ETOH (+)] and ETOH negative [ETOH (-)]. During the study period, there were 439 patients with ETOH levels available for analysis. Overall, 46.5% (n=204) of these patients were ETOH (+), while 53.5% (n=235) were ETOH (-). Coagulopathy was significantly less frequent in the ETOH (+) patients compared to their ETOH (-) counterparts (5.4% versus 15.3%; adjusted p<0.001). In the forward logistic regression analysis, a positive ETOH level proved to be an independent protective factor for admission coagulopathy [OR (95% CI)=0.24 (0.10,0.54; p=0.001]. ETOH (+) patients had a significantly lower in-hospital mortality rate than ETOH (-) patients [9.8% versus 16.6%; adjusted p=0.011; adjusted OR (95% CI)=0.39 (0.19,0.81)]. For brain-injured patients arriving alive to the hospital, ETOH intoxication is associated with a significantly lower incidence of early coagulopathy and in-hospital mortality. Further research to establish the pathophysiologic mechanisms underlying any potential beneficial effect of ETOH on the coagulation system following sTBI is warranted.

Alcohol consumption and metabolic syndrome

Drinking excessive amounts of alcohol regularly for years is toxic to almost every tissue of the body. On the other hand, epidemiological and clinical evidence shows that light-to-moderate drinking is associated with a reduced risk of coronary heart disease, total and ischemic stroke, and mortality. In the past two decades, metabolic syndrome, the combination of obesity, hypertension, dyslipidemia and hyperglycemia, are all also recognized as major cardiovascular risk factors, has given rise to much clinical and research attention, because of its high prevalence in the world. Therefore, it is of interest to evaluate the overall associations of alcohol consumption with the development of metabolic syndrome. Recently, the protective, detrimental or J-shaped associations have been reported between alcohol consumption and metabolic syndrome. This controversy may be due to the complex mechanistic relation between alcohol consumption and each component of metabolic syndrome, and almost all studies have various limitations and problem points. Prospective studies are therefore needed to confirm the association between alcohol consumption and prevalence of metabolic syndrome, and to assess the influence of alcohol drinking patterns and other possible factors, such as smoking, physical activity, socioeconomic status, education, occupation, diet and exercise. This article reviews the relation of alcohol consumption and components of metabolic syndrome, and discusses the epidemiological evidence for alcohol's putative vascular protective effects and plausible underlying biological mechanisms.

Relationship between alcohol consumption and myocardial infarction among ageing men using a marginal structural model

BACKGROUND

Studies on the association between alcohol consumption and myocardial infarction (MI) have typically used baseline data on alcohol consumption and potential confounders. This study aimed at investigating the association between alcohol consumption and MI considering time-varying alcohol consumption and time-varying confounders.

METHODS

Data were available for 1030 males participating in the Kuopio Ischaemic Heart Disease Risk Factor Study (Finland). Baseline data for the present study were collected in 1991-93. MIs were ascertained from national registries until December 2005. Alcohol consumption was categorized into four groups. Data were analysed using conventional discrete-time hazard and marginal structural models (MSMs). Time-invariant covariates were age, working status, diabetes and cigarette-years. Time-varying covariates in the MSM were prior alcohol consumption, smoking, history of cardiovascular diseases, body mass index, high-density lipoprotein cholesterol, systolic blood pressure, insulin and fibrinogen.

RESULTS

An insignificant increase of MI risk among the heaviest alcohol consumers (≥168 g week(-1)) compared with the reference group (12-83 g week(-1)) was observed when using a conventional model including baseline alcohol consumption and confounders measured prior to baseline [relative risk (RR) = 1.20, 95% confidence interval (95% CI) = 0.68-2.12]. When using a conventional model with time-varying alcohol consumption and adjusting for prior confounders, an increased risk of MI among the heaviest alcohol consumers was revealed (RR = 1.71, 95% CI = 1.03-2.85). There was also a trend towards increased risk among the heaviest consumers using the MSM (RR = 1.59, 95% CI = 0.93-2.72).

CONCLUSION

Our findings suggest that standard methods using only baseline data on alcohol consumption and confounders may lead to biased estimates on the association between alcohol consumption and MI.

Alcohol and acute ischemic stroke onset: the stroke onset study

BACKGROUND AND PURPOSE

Previous research suggests that regular heavy alcohol consumption increases the risk for ischemic stroke, whereas frequent light to moderate alcohol intake may decrease the risk. However, the risk of ischemic stroke associated with transient exposure to alcohol remains unclear. In this study, we used a case-crossover approach to test the hypothesis that alcohol consumption affects the acute risk of ischemic stroke, to determine the length of time between alcohol intake and the onset of symptoms (induction time), and to examine whether the risk varies by the type of alcohol.

METHODS

In this multicenter study, we interviewed 390 patients (209 men, 181 women) between January 2001 and November 2006 (median 3 days after stroke). Alcohol consumption in the hour before stroke symptoms was compared with its expected frequency based on the usual frequency of alcohol consumption over the prior year.

RESULTS

Of the 390 patients, 248 (64%) reported alcohol consumption in the prior year, 104 within 24 hours and 14 within 1 hour of stroke onset. The relative risk of stroke in the hour after consuming alcohol was 2.3 (95% CI, 1.4 to 4.0; P=0.002). The relative risks were similar for different types of alcoholic beverages and when the sample was restricted to those who were not simultaneously exposed to other potential triggers.

CONCLUSIONS

The risk of stroke onset is transiently elevated in the hour after alcohol ingestion.

Effects of ethanol intoxication and gender on blood coagulation

BACKGROUND

Ethanol intoxication is a common contributor to traumatic injury. It is unknown whether ethanol consumption contributes to the coagulation differences seen between men and women after trauma. Our aim was to examine the combined effect of ethanol intoxication and gender on coagulation.

METHODS

Fifty-eight healthy subjects participated and chose to enter into a control group (CG; n = 20; 10 men and 10 women) or drinking group (DG; n = 38; 20 men and 18 women). Venous blood samples for thrombelastography, plasminogen activator inhibitor, thrombin-antithrombin complex, and tissue plasminogen activator were drawn at the beginning of the study. Subjects then interacted in a social atmosphere for at least 2 hours, eating and consuming alcoholic (DG) or nonalcoholic (CG) beverages. After 2 hours, blood alcohol level was determined and blood was drawn for a second set of coagulation studies.

RESULTS

Demographics were similar between groups except for age (36.7 years CG vs. 29.9 years DG; p = 0.009). All baseline thrombelastography measurements were similar between the CG and DG. Blood alcohol levels in the DG were similar between genders at the end of study. At the end of study, a decreased rate of fibrin formation, decreased clot strength, and a decreased rate of fibrin cross-linking was seen in men but not in women. Fibrinolysis was inhibited in drinkers compared with controls.

CONCLUSIONS

Consumption of commonly ingested quantities of alcohol correlated with the development of a hypocoagulable state in men but had no effect on coagulation status in women. This phenomenon may contribute to differences in post-trauma coagulation status previously noted between genders.

High dose of red wine elicits enhanced inhibition of fibrinolysis

BACKGROUND AND DESIGN

The purpose of this randomized controlled cross-over study was to determine the acute effects of high doses of alcoholic beverages on circulating markers related to atherosclerosis and fibrinolysis.

METHODS

Twenty-two healthy men consumed a high dose (8.1+/-0.9 dl) of alcohol-containing red wine and dealcoholized red wine, and an equal ethanol dose of cognac (2.4+/-0.3 dl). Blood samples were taken before and shortly after interventions.

RESULTS

Red wine, unlike dealcoholized red wine and cognac, increased tissue plasminogen activator inhibitor-1 levels significantly, indicating an acute inhibition of fibrinolysis after a high dose.

CONCLUSION

Findings may explain the increased risk of cardiovascular mortality among binge drinkers.

Hemostatic gene polymorphisms in severe acute pancreatitis

OBJECTIVE

Systemic inflammatory reaction in acute pancreatitis (AP) is associated with activation of the coagulation system. The prothrombotic component of the coagulation system, which may promote microvascular thrombosis and vital organ injury, is strengthened by genetic factors such as polymorphism of plasminogen activator inhibitor type 1 (PAI-1) and factor V Leiden (FVL) mutation. This prompted us to study the occurrence of FVL and PAI-1 4G/5G polymorphisms in patients with AP.

METHODS

This case control association study included 397 patients with AP and 310 controls. Severe AP was determined according to the Atlanta Classification. Genotyping was performed by matrix-assisted laser desorption/ionization-time-of-flight mass spectrometry-assisted genotyping method.

RESULTS

Factor V Leiden was identified in 5 (3.3%) of 152 cases of severe AP and in 8 (3.3%) of 245 cases of mild AP. The prothrombotic PAI-1 4G allele frequency was 0.49 for patients with severe AP and 0.57 for patients with mild AP (P < 0.05). Patients with septic infectious complications (n = 47) and patients with organ failure (n = 55) had genotype distribution not different from those with mild, uncomplicated disease (n = 245).

CONCLUSIONS

The results do not support the hypothesis that prothrombotic polymorphisms such as FVL mutation and PAI-1 4G/5G are associated with AP severity.

Chronobiology of hemostasis and inferences for the chronotherapy of coagulation disorders and thrombosis prevention

The hemostatic system in its multiple components displays an intricate organization in time which is characterized by circadian (approximately 24-hour), circaseptan (approximately 7-day), menstrual (approximately monthly), and circannual (approximately yearly) bioperiodicities. The interaction of the rhythms of the variables participating in hemostasis determine transient risk states of thromboembolic events, including myocardial infarction and stroke, and of hemorrhage and hemorrhagic events, each with a unique timing. The circadian staging of the rhythms in vascular, cellular, and coagulation factors that favors blood coagulation and thrombosis coincides with the daily minimum in fibrinolytic activity; as a result there is elevated risk in the morning of acute myocardial infarction and stroke. Similar hemostatic rhythms may determine the epidemiology of thromboembolic and hemorrhagic events during the week, month and year. This article focuses on the large-amplitude circadian rhythms operative in the hemostatic system. Their implication for preventive and curative pharmacotherapy of hemostatic disorders is presented, with discussion of related problems.

Clotted blood as sign of alcohol intoxication: a retrospective study

A total of 138 autopsies performed at the Institute of Legal Medicine of the University of Münster between 1994 and 2006 were subdivided into two groups: (1) 69 asphyxial deaths with a blood alcohol level (BAL) > 1 per thousand and (2) 69 asphyxial deaths with a BAL of 0.00 per thousand. The coagulation state in the central vessels was registered in all cases as fluid, compactly clotted or loosely clotted, and the post-mortem interval was recorded. Histology investigations were performed on the liver to analyze the incidence of hepatic fibrosis/cirrhosis. Fisher's exact test was performed to check for statistical significance. The blood was found to be clotted in 49.3% of the cases of group (1) and in 5.8% of group (2) (p < 0.01). The post-mortem interval did not have any influence on the coagulation state as observed in both groups. Liver fibrosis/cirrhosis was a rare finding detected in three cases in group 1 and in two cases in the control group 2 and, therefore, not relative to our observations. A distinctly positive BAL is often associated with heavy stages of blood coagulation as observed during autopsy. Distinctly positive alcohol concentrations have an influence on the fibrinolytic process and, hence, on the coagulation status.

Ethanol impairs coagulation and fibrinolysis in whole blood: a study performed with rotational thromboelastometry

The objective was to study the effects of ethanol on coagulation and fibrinolysis in whole blood. Blood samples from healthy volunteers were analyzed before and after in-vitro addition of ethanol in order to achieve ethanol concentrations of 0, 1, 2 and 4 per thousand, respectively (0, 22, 44 and 88 mmol/l). Coagulation and fibrinolysis were then assessed using rotational thromboelastometry. We found that increasing ethanol levels increasingly impaired coagulation as evaluated with rotational thromboelastometry, with a maximum prolongation of the clot formation time of 118% at an ethanol level of 4 per thousand (P < 0.000001). We also found a very strong impairment of fibrinolysis already at an ethanol level of 1 per thousand. This is the first study assessing the effects of ethanol on coagulation and fibrinolysis in a whole blood model. The impairment of coagulation is similar in nature to the impairment found in patients suffering from hypothermia. The impairment is at a level that may be of clinical importance (e.g. in patients suffering from trauma). The inhibition of fibrinolysis is obvious already at an ethanol level of 1 per thousand and it may be a contributing factor to the increased amount of coronary and cerebrovascular ischemic events after binge drinking.

Dietary Flavanols and Platelet Reactivity

Epidemiology studies suggest that the consumption of diets rich in flavonoids is associated with reduced risk of cardiovascular disease. Plant-derived foods and beverages, such as red wine, tea, grape and grape juice, cocoa and chocolate, can be rich in 1 particular class of flavonoid, the flavan-3-ols. There is now an increasing body of research that suggests that consuming flavanol-rich foods can positively affect hemostasis, through mechanisms that either directly affect platelet function or increase certain endothelium-derived factors that maintain platelet acquiescence or increase fibrinolysis. In this paper, we will review a series of in vivo studies on the effects of flavanol-rich cocoa and chocolate on platelet activation and platelet-dependent hemostasis. In addition, we will briefly review the body of literature with regard to other flavanol-rich foods and beverages, and possible mechanisms of action.

Faut-il conseiller à nos patients de boire du vin?

No study has shown that moderate wine consumption has any adverse effect on cardiovascular risk. Binge drinking induces a risk of thrombosis. The continuation of moderate wine consumption is reasonable and probably beneficial as secondary prevention. Polyphenols are antioxidants, antiaggregants, and NO donors; they increase HDL cholesterol levels. Moderate wine consumption appears to protect cognitive function in the elderly.

Acute myocardial infarction associated with heavy alcohol intake in an adolescent with normal coronary arteries

Acute ingestion of large quantities of alcohol is known to be able to trigger acute myocardial infarction. A 19-year-old boy presented at the emergency department of our hospital with complaints of severe retrosternal chest pain. One night before this event, he had drunk large amounts of alcohol. The level of alcohol in his blood was measured at 0.59 grams per litre. A 12-lead electrocardiogram showed elevations of the ST segment, averaging from 2 to 10 millimetres, in leads V1-6, DI and aVL. Since consumption of alcohol is very common in the community, the triggering effect of binge-drinking and consumption of large amounts of alcohol on acute myocardial infarction should be considered as a crucial subject for public health so as to raise the consciousness of the population, especially young persons.

Binge drinking and mortality after acute myocardial infarction

BACKGROUND

Moderate drinkers have a lower risk of mortality after myocardial infarction (MI). Although binge drinking has been associated with a higher risk of MI in some studies, its relation to prognosis after MI is uncertain.

METHODS AND RESULTS

In a prospective, inception cohort study conducted at 45 US hospitals, 1935 patients hospitalized with a confirmed MI between 1989 and 1994 underwent detailed personal interviews. Patients reported their usual frequency of binge drinking of beer, wine, and liquor, defined as intake of 3 or more drinks within 1 to 2 hours, and were followed up for mortality for a median of 3.8 years. Of 1919 eligible patients, 250 (94% men) reported binge drinking during the prior year, and a total of 318 patients died during follow-up. Binge drinkers had a 2-fold higher risk of mortality than drinkers who did not binge (hazard ratio, 2.0; 95% confidence interval, 1.3 to 3.0). A comparison of 192 binge drinkers and 192 other patients matched on propensity scores yielded a similar result. The association between binge drinking and total mortality tended to be similar among patients whose usual alcohol intake was light or heavier and for binge drinkers who consumed beer, wine, or liquor. Usual alcohol intake was inversely associated with mortality, but binge drinking completely attenuated this relation.

CONCLUSIONS

Our results suggest that alcohol consumption may be linked to potential hazards among patients who survive acute MI. Although moderate intake has been associated with lower mortality, binge drinking, even among light drinkers, appears to be associated with 2-fold higher mortality.

Effects of alcohol on hemostasis

Several epidemiologic studies have shown that moderate intake of alcohol is associated with a lower risk of cardiovascular disease (CVD), but the mechanism is not fully elucidated. One of the proposed mechanisms of the protective effect of moderate alcohol intake is its beneficial effect on hemostasis. The aim of this review is to summarize the effect of ethanol intake on platelet aggregation and activation, coagulation factors including von Willebrand factor (vWF), and the fibrinolytic system. With regard to the effect of alcohol on platelet function, evidence in the literature suggests both platelet activation and platelet inhibition by ethanol. A unifying hypothesis is that platelets are partially activated by ethanol, with partial degranulation allowing for continued circulation of platelets with impaired function. Evidence also exists showing that ethanol intake decreases fibrinogen, factor VII, and vWF levels. In addition, alcohol intake has been found to increase fibrinolysis by increasing tissue plasminogen activator activity. The effect of ethanol on platelets, coagulation factors, and the fibrinolytic system is likely to contribute to protection against CVD.

Behavioral and emotional triggers of acute coronary syndromes: a systematic review and critique

OBJECTIVE

The objective of this study was to review the evidence that behavioral and emotional factors are triggers of acute coronary syndromes.

METHOD

Systematic review of the published literature from 1970 to 2004 of trigger events, defined as stimuli or activities occurring within 24 hours of the onset of acute coronary syndromes.

RESULTS

There is consistent evidence that physical exertion (particularly by people who are not normally active), emotional stress, anger, and extreme excitement can trigger acute myocardial infarction and sudden cardiac death in susceptible individuals. Many triggers operate within 1 to 2 hours of symptom onset. There are methodologic limitations to the current literature, including sampling, retrospective reporting, and presentation biases, the role of memory decay and salience, and reverse causation because of silent prodromal events.

CONCLUSIONS

Behavioral and emotional factors are probable triggers of acute coronary syndromes in vulnerable individuals, and the pathophysiological processes elicited by these stimuli are being increasingly understood. The benefits to patients of knowledge to these processes have yet to accrue.

Plasma PAI-1 levels are more strongly related to liver steatosis than to adipose tissue accumulation

OBJECTIVE

Because obesity and insulin resistance (IR) are strongly associated with liver steatosis (LS), we investigated the relation between the degree of LS and plasminogen activator inhibitor-1 (PAI-1) in ob/ob mice, in C57/BL6 mice with alcoholic LS, and in severely obese humans.

METHODS AND RESULTS

In both mouse models, plasma PAI-1 levels were associated with PAI-1 expression in the liver and with the degree of LS. Liver PAI-1 antigen was associated with the tumor necrosis factor receptor-II (TNFRII) antigen, whereas association with TNF antigen content was found in ob/ob mice only. No significant correlation between plasma PAI-1 and PAI-1 expression in adipose tissue of ob/ob mice was observed. Furthermore, the relation between plasma PAI-1 levels and body weight was positive in ob/ob mice but negative in C57/BL6 mice (both P<0.001). In humans, PAI-1 levels were correlated with the degree of LS, and 26% of plasma PAI-1 activity was independently explained by LS and serum insulin levels.

CONCLUSIONS

Plasma PAI-1 levels are more closely related to fat accumulation and PAI-1 expression in the liver than in adipose tissue. In steatotic liver, PAI-1 antigen content is associated with those of TNF and TNFRII. Therefore, we suggest that TNF pathway dysregulation in LS could be involved in increased plasma PAI-1 in obesity with IR.

No acute effect of red wine on the coagulation pathway in healthy men

Binge drinking is associated with an increased risk of cardiovascular events. Those events often happen within hours after alcohol is consumed. Apart from arrhythmias and changes in blood pressure, these events may be caused by an acute (i.e., occurring within a 24-h period) shift of the hemostatic balance in a thrombogenic direction. Alcohol can influence platelet aggregation and inhibit fibrinolysis, but little is known about its direct effect on coagulation. In the current study, parameters of coagulation, reflecting either stimulation or inhibition, were measured 5 and 15 h after the consumption of four (62.5 g of alcohol) and eight (125 g of alcohol) glasses of red wine. Both doses had no direct effect on activated cephalin time, thrombin-antithrombin complexes, factors VII and VIII, and von Willebrand factor. In contrast with the observed effects on thrombocytes and fibrinolysis, the consumption of large amounts of wine does not influence the coagulation pathway.

Spirits and gastrectomy increase risk for chronic pancreatitis in Japanese male alcoholics

INTRODUCTION

Most cases of chronic pancreatitis are alcohol-related, but not all alcoholics develop pancreatitis.

AIM

To elucidate historical and biologic risk factors for this disease.

METHODOLOGY

Alcoholic Japanese men (n = 132) consecutively admitted to the National Alcoholism Center over 24 months, including 54 with chronic pancreatitis (diagnosed by endoscopic retrograde cholangiopancreatography) and 78 without, were surveyed about drinking history, smoking, education, and marital status, and tested for amylase, glycosylated hemoglobin, body mass, alcohol and aldehyde dehydrogenase genotypes, and K-ras gene mutations in pancreatic juice.

RESULTS

Higher risk for chronic pancreatitis was associated with drinking spirits rather than lower-alcohol beverages (odds ratio [OR], 2.58; p= 0.01). Daily ethanol consumption by those who drank spirits was greater than that among those who drank lower-alcohol beverages; however, no differences in either daily ethanol consumption or duration of drinking were observed between alcoholics with and without chronic pancreatitis. Postgastrectomy patients were at higher risk for chronic pancreatitis than unoperated comparison subjects (OR, 4.35, P< 0.05). Elevated glycosylated hemoglobin (OR, 4.62, p< 0.01), decreased amylase (OR 4.20, P<0.02), and low body mass (OR 1.89, P<0.1) were more frequent in alcoholics with chronic pancreatitis. K- gene mutations existed in 18.8% of alcoholics with chronic pancreatitis but in only 11.4% of those without the disorder. The frequencies of alcohol and aldehyde dehydrogenase genotypes in alcoholics with and without pancreatitis did not differ significantly.

CONCLUSION

Our study strongly suggested that spirits and partial gastrectomy increase the risk for chronic pancreatitis in male alcoholics.

Alcohol-triggered acute myocardial infarction

Heavy alcohol drinking may trigger the onset of acute myocardial infarction. Although the underlying mechanisms are poorly understood, alcohol-induced changes in blood homeostasis, endothelial dysfunction, decreased fibrinolysis, and coronary spasm are the possible explanations. There are rare reports of acute myocardial infarction in young individuals triggered by acute heavy alcohol intake. We present a case of acute ST segment elevation myocardial infarction triggered by heavy alcoholic binge drinking in a man and discuss the available explanations of this rare association.

Blessings of the grape

Numerous epidemiological studies have shown an inverse correlation between moderate consumption of alcoholic drinks and the risk of coronary heart disease. Wine, especially red wine, may be more favorable in this respect than beer or spirits because of its high content of flavonoids. These polyphenols originate from the skins, seeds, and vine stems of the grapes while some are formed during the process of vinification. In nature they exhibit a wide range of biological effects as antioxidants, antimicrobials, and modulators of various enzyme systems. Potential beneficial effects for humans have been demonstrated in experimental studies and include influences on the oxidation of LDL-cholesterol, on platelet aggregation, and on prostaglandin and nitric oxide metabolism. However, most of these studies concern semi in vivo experiments and research in animal models; data from human intervention trials are scarce. Furthermore, little is known about the absorption, bioavailability, and bioactivity of most of these compounds because of difficulties in reliable quantification in biological fluids. Until these issues are well addressed, and despite the enthusiasm and faith of many believers, evidence-based medicine justifies a critical attitude towards the application of these compounds outside the context of scientific research. Yet, there is no need to deny their potential, nor should we close our eyes to the blessings of the grape.

Effects of alcohol on the heart

Some evidence suggests that light to moderate alcohol consumption protects against cardiovascular diseases. However, this cardioprotective effect of alcohol consumption in adults is absent at the population level. Approximately 20 to 30% of patients admitted to a hospital are alcohol abusers. In medical practice, it is essential that patients' levels of consumption are known because of the many adverse effects that might result in the course of routine care. Ethanol damage to the heart is evident if alcohol consumption exceeds 90 to 100 g/d. Heavy ethanol consumption leads to increased risk for sudden cardiac death and cardiac arrhythmias. In patients with coronary heart disease, alcohol use was associated with increased mortality. An early response to drinking was an increased ventricular wall thickness to diameter ratio, possibly proceeding with continuous drinking to alcoholic cardiomyopathy, which had a worse outcome compared with idiopathic dilative cardiomyopathy if drinking was not stopped or at least reduced (< 60 g/d). In the ICU, patients with chronic alcoholism have more cardiac complications postoperatively. These complications probably are caused by biventricular dysfunction, particularly with the occurrence of severe infections or septic shock, events that are three to four times more frequent among chronic alcoholics than occasional drinkers or nondrinkers. To prevent further complications from drinking and for long-term management of drinking, patients with alcohol abuse and heart failure should be treated in brief intervention and follow-up programs. Prognosis is good even in patients with New York Heart Association class IV heart failure caused by cardiomyopathy if complete abstinence is accomplished. Noncompliance to smoking and alcohol restrictions, which are amenable to change, dramatically increases the risk for hospital readmissions among patients with heart failure.