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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 CRITERIA

  • Decompensated congestive heart failure

  • Tachyarrhythmias

  • Syncope

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