Cardiomyopathy, Alcoholic

KEY FEATURES

ESSENTIALS OF DIAGNOSIS

• There are no unique identifying features that distinguish alcoholic cardiomyopathy apart from other etiologies of dilated cardiomyopathy, but a history of heavy alcohol use and a lack of other inciting factors are key to diagnosis

• Heavy, chronic alcohol consumption: an excess of 80 g/day for 5 years or more

• Symptoms and signs of biventricular congestive heart failure

• Proximal myopathy common

• Regression of cardiomegaly with alcohol cessation

GENERAL CONSIDERATIONS

• Mechanism of alcohol-induced myocyte damage remains unclear but is likely a direct toxic result of ethanol and/or its metabolites (eg, acetaldehyde and fatty acid ethyl esters)

• Environmental (cobalt, arsenic) and genetic factors (HLA-B8, alcohol dehydrogenase alleles) may increase susceptibility to systolic dysfunction in alcohol drinkers

• Higher prevalence among males than females (due to a higher rate of alcohol abuse in men), but females appear more sensitive to alcohol’s cardiotoxic affects

• May be the cause of up to one-third of cases of dilated cardiomyopathy

• Light to moderate alcohol consumption (ie, 1–2 drinks per day or 3–9 drinks per week) decreases the risk of myocardial infarction

CLINICAL PRESENTATION

SYMPTOMS AND SIGNS

• Dyspnea, orthopnea, and paroxysmal nocturnal dyspnea

• Fatigue

• Palpitations

• Chest discomfort

• Dizziness, syncope

• Anorexia

PHYSICAL EXAM FINDINGS

• Generalized cachexia

• Reduced pulse pressure

• Pulmonary rales

• Tachycardia

• Laterally displaced, diffuse point of maximal impulse

• Holosystolic murmurs of mitral and tricuspid regurgitation

• S₃ and S₄

• Elevated jugular venous pressure

• Hepatomegaly

• Peripheral edema

• Cool extremities

• Muscle atrophy and weakness

DIFFERENTIAL DIAGNOSIS

• Certain heavy metals (cobalt, lead, iron) found in illegally produced alcoholic beverages

• Metabolic disturbances in alcoholics: hypermagnesemia, hypokalemia, selenium deficiency, thiamine deficiency

• Hypertensive heart disease common in alcoholics

• Other causes of dilated cardiomyopathy

DIAGNOSTIC EVALUATION

ELECTROCARDIOGRAPHY

• Premature atrial or ventricular contractions

• Supraventricular tachycardia

• First- or second-degree atrioventricular block

• Left or right bundle branch block

• Voltage criteria for left ventricular hypertrophy

• Prolonged QT interval

• Nonspecific ST- and T-wave changes

• Abnormal Q waves also possible

IMAGING STUDIES

• Chest x-ray:

  • – Enlarged cardiac silhouette

  • – Pulmonary vascular congestion

  • – Pleural effusions

• Echocardiogram:

  • – Four-chamber cardiac enlargement with reduced left and right ventricular systolic function in a global pattern

  • – Doppler evidence of left ventricular diastolic dysfunction, left ventricular hypertrophy, and intracardiac thrombi in the atria or ventricles

• Stress nuclear imaging of echo imaging can screen for coronary artery disease

DIAGNOSTIC PROCEDURES

• Cardiac catheterization: not always necessary, but may be useful to exclude other causes of heart failure

TREATMENT

CARDIOLOGY REFERRAL

• Suspected alcoholic cardiomyopathy

• Congestive heart failure

HOSPITALIZATION ...