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MEDITERRANEAN ALCOHOL-DRINKING PATTERN, LOW TO MODERATE
ALCOHOL INTAKE AND RISK OF ATRIAL FIBRILLATION IN THE
PREDIMED STUDY
Bazal P.
a, b
; Gea A.
b, c
; Martínez-González M.A
b, c, d
, Salas-Salvadó J.
c, e
;
Asensio E.M
c, f
; Muñoz-Bravo C.
c, g
; Fiol M.
c, h
; Muñoz M.A.
c, i
; Lapetra J.
c, j
;
Serra-Majem LL.
c, k
; Pintó X.
c, l
; González J.I.
c, f
; Becerra-Tomás N.
c, e
; Fitó
M.
c, i
; Ros E.
c, m
; Alonso-Gómez A.
c, n
; Ruiz-Canela M.
b, c
a
Servicio Navarro de Salud-Osasunbidea, Pamplona, Spain;
b
Department of
Preventive Medicine and Public Health, School of Medicine, University of
Navarra, IdiSNA, Pamplona, Spain;
c
CIBER Fisiopatología de la Obesidad y
Nutrición (CIBEROBN), Instituto de Salud Carlos III (ISCIII), Madrid, Spain,
d
Department of Nutrition, Harvard TH Chan School of Public Health, Boston,
USA,
e
Human Nutrition Unit, University Hospital of Sant Joan de Reus, IISPV,
Rovira i Virgili University, Reus, Spain,
f
Department of Preventive Medicine,
University of Valencia, Valencia, Spain,
g
Department of Public Health, University
of Malaga, Malaga, Spain,
h
Institute of Health Sciences, University of Balearic
Islands and Son Espases Hospital, Palma de Mallorca, Spain.Hospital Clinic,
University of Barcelona, Barcelona, Spain, .
i
Cardiovascular Risk and Nutrition
(Regicor Study Group), Hospital del Mar Medical Research Institute (IMIM),
Barcelon, Spain,
j
Department of Family Medicine, Research Unit, Distrito
Sanitario Atención Primaria Sevilla, Sevilla, Spain;
k
Research Institute of
Biomedical and Health Sciences, University of Las Palmas de Gran Canaria, Las
Palmas, Spain;
l
Internal Medicine Department, Hospital Universitari de Bellvitge-
IDIBELL. Universidad de Barcelona, Barcelona, Spain;
m
IDIBAPS, Hospital
2
Clinic, University of Barcelona, Barcelona, Spain;
n
Department of Cardiology,
University Hospital Araba, Vitoria, Spain.
Correspondence to Miguel Ruiz-Canela,
Department of Preventive Medicine and Public Health, School of Medicine,
University of Navarra, Irunlarrea 1, 31008 Pamplona, Navarra, Spain.
E-mail: mcanela@unav.es
Telephone: +0034 647924047
Clinical Trials: URL: http://www.controlled-trials.com. Unique identifier:
ISRCTN35739639
Word counts: abstract (234 words), Text (2996 words), figures(1), Tables(4)
Key Words: Alcohol, atrial fibrillation, Mediterranean, red wine, antioxidant
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ABSTRACT
a) Background and Aims: There is ongoing controversy about the effect of a low
to moderate alcohol consumption on atrial fibrillation (AF). Our aim is to assess the
association between adherence to a Mediterranean alcohol drinking pattern and AF
incidence.
b) Methods and Results: A total 6527 out of the 7447 participants on the
PREDIMED trial met our inclusion criteria. A validated frequency food
questionnaire was used to measure alcohol consumption. Participants were
classified as non-drinkers, Mediterranean alcohol drinking pattern (MADP) (10-
30g/d in men and 5-15 g/day in women, preferably red wine consumption with low
spirits consumption), low-moderate drinking (<30 g/day men y <15 g/day women),
and heavy drinking. We performed multivariable Cox regression models to estimate
hazard ratios (HR) with 95% confidence intervals (95% CI) of incident AF
according to alcohol drinking patterns.
After a mean follow up of 4.4 years, 241 new incident AF cases were confirmed.
Alcohol consumption was not associated to AF incidence among low-moderate
drinkers (HR: 0.96; 95%CI: 0.67-1.37), adherents to MADP (HR: 1.15 95%CI: 0.75-
1.75), or heavy drinkers (HR: 0.92; 95%CI: 0.53-1.58), compared with non-
drinkers.
c) Conclusions: In a high cardiovascular risk adult population, a meditteranean
alcohol consumption pattern (low to moderate red wine consumption) was not
associated with an increased incidence of AF.
d) Registration number for clinical trials: PREDIMED trial, NCT02669602
(clinicalTrials.gov)
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a) INTRODUCTION
Alcohol consumption is considered a risk factor for atrial fibrillation (AF). It is well
known that excessive drinking, including binge drinking and a daily high amount
of alcohol consumption, increases the risk of AF [1–5] as well as the recurrences
of AF after an ablation[5]. Three meta-analyses have suggested a linear dose-
response relation between the amount of alcohol habitually consumed and AF
[6–8]. However, several studies and a recent meta-analysis have found that
moderate-to-low consumption of alcohol does not show any association with the
risk of AF [4,5,9–11]. Moreover, a curvilinear instead of a linear association has
been suggested in a recent cohort study [10].
The type of alcoholic beverages and drinking pattern could also be important
factors, but studies assessing these aspects in detail are scarce. A prospective
study found that consumption of liquor or wine but not beer was significantly
associated with AF risk[8]. More recently, a cohort study found relevant
differences in the association between AF and a moderate to high consumption
of specific beverage types [10]. However, the influence of these factors and
other aspects such us the alcohol drinking pattern and the regular consumption
of small amounts of alcohol, preferably of non-distilled alcoholic beverages have
less well studied.
It is well-recognized that low-to-moderate alcohol consumption has
cardiovascular benefits, specially based on an inverse association with
ischaemic heart disease. The American Heart Association recommends limit
alcoholic beverages to no more than 2 drinks per day for men and 1 drink per
5
day for women, ideally consumed within meals [12], in those with a regular
consumption. This pattern is associated with lower levels of blood pressure and
inverse associations with incident cardiovascular disease and it is sometimes
recommended in cardiovascular prevention (only for subjects who already
consume alcohol and are older than 40 years and have a high cardiovascular
risk) [13,14]. However, there is currently a debate regarding the limits for a
moderate alcohol drinking and if there is a difference between specific types of
alcoholic beverages. It can be also questionable whether a healthy alcohol
consumption pattern exists and if alcohol itself can provide cardioprotective
benefits [15].
As far as we know, no previous study has specifically assessed the association
between AF and the pattern of alcohol consumption which captures diverse
aspects of the characteristics of alcohol intake, including the amount and type of
alcohol consumed in the context of a Mediterranean population. The aim of our
study was to describe the association between AF and several alcohol
consumption patterns including the Mediterranean alcohol-drinking pattern
(MADP) [13,14]. Our hypothesis is that the cardioprotective effect of a healthy
alcohol-drinking pattern could be offset in the case of AF due to its potential
proarrhytmogenic effect.
b) METHODS
Population
The PREDIMED study was a Spanish multicentre trial conducted in 11 recruiting
centers[16]. Participants were 7447 men and women (55-80 years) at a high
