解释房颤中酒精与cv之间的关联需要对饮酒行为和社会经济背景进行仔细研究

IF 1.1 4区 医学 Q4 CARDIAC & CARDIOVASCULAR SYSTEMS
Yuren Cao
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The potential cardioprotective effects of polyphenols in wine might dilute the overall observed risk, while a predominance of spirits could amplify harm—this heterogeneity introduces bias into the interpretation of dose–response relationships (Castaldo et al. <span>2019</span>). While this limitation has a lesser impact on the conclusion regarding HF protection (as chronic benefits may align more with regular, moderate consumption), it likely leads to a systematic underestimation of stroke and bleeding risks, diminishing the study's value for clinical decision-making. 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引用次数: 0

摘要

我们饶有兴趣地阅读了Oraii及其同事的文章(Oraii et al. 2025)。利用大型国际队列(RE-LY房颤登记),该研究为房颤(AF)患者不同水平饮酒与心血管结局(中风/全身栓塞、心力衰竭住院、大出血)之间的关系提供了新的见解。然而,在解释这些重要发现时,我们认为有值得注意的方法局限性,值得在未来的研究中注意和改进。该研究将酒精摄入量简化为每周平均摄入量,而没有区分饮酒模式或饮料类型,这可能会严重影响其结论的可靠性。特别值得关注的是,酗酒(每次≥5杯)的隐藏风险被每周平均分组所掩盖。强有力的证据表明,狂饮可使血压急剧升高,引发AF发作,并促进血小板聚集,单独使卒中风险增加约35%(合并RR = 1.35) (O'Donnell et al. 2010;Degerud et al. 2021)。在这项研究中,“重度饮酒者”组(≥14杯/周)可能包括了大量参与狂欢模式的高风险个体,但中风风险仅显示无显著降低(aOR = 0.79)。分离出酗酒亚组可能会发现卒中和出血风险显著升高,特别是在抗凝治疗的背景下,这可能会逆转酒精不会增加血栓形成风险的中性结论。同时,饮料类型的混淆效应不受控制。葡萄酒中多酚的潜在心脏保护作用可能会稀释观察到的总体风险,而烈酒的优势可能会放大危害——这种异质性在解释剂量-反应关系时引入了偏见(Castaldo et al. 2019)。虽然这一限制对HF保护的结论影响较小(因为慢性益处可能更多地与定期、适度的消费相一致),但它可能导致对中风和出血风险的系统性低估,从而降低了该研究对临床决策的价值。未来的研究迫切需要将饮酒方式和饮料类型的维度纳入酒精分类;如果做不到这一点,可能会给酗酒者等高危人群提供误导性的安全建议。仅根据国家收入对酒精与心力衰竭的关联进行分层,而不调整社会经济地位(SES)、医疗保健可及性或生活方式因素,从根本上削弱了结论(Allen et al. 2018)。高收入国家中明显的“保护效应”(aOR = 0.51)可能反映了高社会经济地位人群中更好的医疗保健(例如,早期干预)和更健康的行为,而不是酒精本身。相反,低收入饮酒者HF风险升高(aOR = 2.18)可能源于医疗资源稀缺(例如,无法获得利尿剂),而不是酒精引起的。未测量的社会经济地位混杂因素,如营养不良,进一步扭曲了结果。由于社会经济地位调整通常会使酒精对心血管的益处减半,控制教育/保险/饮食可能会使报告的心力衰竭风险降低无效——潜在地揭示了酒精在脆弱环境中的真正危害。这种宏观层面的过度简化将卫生不平等与生物效应混为一谈。尽管如此,Oraii等人的工作为全球房颤患者酒精模式提供了有价值的见解。心力衰竭风险的明显区域异质性突出了关键的研究方向。未来的研究应纳入颗粒性饮酒模式(例如,暴饮与正常饮酒)、饮料类型和个体社会经济/临床因素。这样的综合分析将澄清酒精在房颤结果中的真正作用,并使个性化建议成为可能。作者声明无利益冲突。
本文章由计算机程序翻译,如有差异,请以英文原文为准。
Interpreting Alcohol-CV Associations in AF Requires Scrutiny of Drinking Behaviors and Socioeconomic Context

We read with great interest the article by Oraii and colleagues (Oraii et al. 2025). Utilizing a large international cohort (the RE-LY AF registry), the study provides novel insights into the association between different levels of alcohol consumption and cardiovascular outcomes (stroke/systemic embolism, heart failure [HF] hospitalization, major bleeding) in patients with atrial fibrillation (AF). However, when interpreting these important findings, we believe there are noteworthy methodological limitations that warrant attention and improvement in future research.

The study's simplification of alcohol intake to weekly averages, without distinguishing drinking patterns or beverage types, may substantially impact the reliability of its conclusions. Of particular concern is that the concealed risk of binge drinking (≥ 5 drinks per occasion) is obscured by the weekly average grouping. Robust evidence indicates that binge drinking can acutely elevate blood pressure, trigger AF episodes, and promote platelet aggregation, independently increasing stroke risk by approximately 35% (Pooled RR = 1.35) (O'Donnell et al. 2010; Degerud et al. 2021). The “heavy drinker” group (≥ 14 drinks/week) in this study likely included a significant proportion of such high-risk individuals engaging in binge patterns, yet showed only a non-significant reduction in stroke risk (aOR = 0.79). Isolating a binge drinking subgroup might reveal significantly elevated stroke and bleeding risks, especially in the context of anticoagulant therapy, potentially reversing the neutral conclusion that alcohol does not increase thrombotic risk. Concurrently, the confounding effect of beverage type was uncontrolled. The potential cardioprotective effects of polyphenols in wine might dilute the overall observed risk, while a predominance of spirits could amplify harm—this heterogeneity introduces bias into the interpretation of dose–response relationships (Castaldo et al. 2019). While this limitation has a lesser impact on the conclusion regarding HF protection (as chronic benefits may align more with regular, moderate consumption), it likely leads to a systematic underestimation of stroke and bleeding risks, diminishing the study's value for clinical decision-making. Future research urgently needs to integrate dimensions of drinking pattern and beverage type into alcohol categorization; failure to do so risks misleading safety advice for high-risk populations like binge drinkers.

Stratifying the alcohol-heart failure association solely by country income, without adjusting for socioeconomic status (SES), healthcare access, or lifestyle factors, fundamentally weakens the conclusion (Allen et al. 2018). The apparent “protective effect” in high-income countries (aOR = 0.51) likely reflects superior healthcare (e.g., early intervention) and healthier behaviors in high-SES populations, not alcohol itself. Conversely, elevated HF risk in low-income drinkers (aOR = 2.18) probably stems from medical resource scarcity (e.g., unavailable diuretics), not alcohol causation. Unmeasured SES confounders like malnutrition further distort results. Since SES adjustment typically halves alcohol's purported cardiovascular benefits, controlling for education/insurance/diet would likely nullify the reported HF risk reduction—potentially unmasking alcohol's true hazards in vulnerable settings. This macro-level oversimplification conflates health inequities with biological effects.

Nevertheless, Oraii et al.'s work provides valuable insights into global AF patient alcohol patterns. The stark regional heterogeneity in heart failure risk highlights critical research directions. Future studies should incorporate granular drinking patterns (e.g., binge vs. regular), beverage types, and individual socioeconomic/clinical factors. Such integrated analysis will clarify alcohol's true role in AF outcomes and enable personalized recommendations.

Th author declares no conflicts of interest.

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来源期刊
CiteScore
3.40
自引率
0.00%
发文量
88
审稿时长
6-12 weeks
期刊介绍: The ANNALS OF NONINVASIVE ELECTROCARDIOLOGY (A.N.E) is an online only journal that incorporates ongoing advances in the clinical application and technology of traditional and new ECG-based techniques in the diagnosis and treatment of cardiac patients. ANE is the first journal in an evolving subspecialty that incorporates ongoing advances in the clinical application and technology of traditional and new ECG-based techniques in the diagnosis and treatment of cardiac patients. The publication includes topics related to 12-lead, exercise and high-resolution electrocardiography, arrhythmias, ischemia, repolarization phenomena, heart rate variability, circadian rhythms, bioengineering technology, signal-averaged ECGs, T-wave alternans and automatic external defibrillation. ANE publishes peer-reviewed articles of interest to clinicians and researchers in the field of noninvasive electrocardiology. Original research, clinical studies, state-of-the-art reviews, case reports, technical notes, and letters to the editors will be published to meet future demands in this field.
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