Alcohol and Acute Ischemic Stroke Onset

8/6/2019 Alcohol and Acute Ischemic Stroke Onset

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E L I Z A B E T H M O S T O F S K Y, M P H ; M A R Y R . B U R G E R , M D ; G O T T F R I E DS C H L A U G , M D , P H D ;

K E N N E T H J . M U K A M A L , M D , M P H ; W A Y N E D . R O S A M O N D , P H D ;M U R R A Y A . M I T T L E M A N , M D , D R P H

Alcohol and Acute Ischemic

Stroke OnsetThe Stroke Onset Study


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Background

y Previous research: Regular heavy alcoholconsumption increases the risk for ischemicstroke, whereas frequent light to moderatealcohol intake may decrease the risk.

y The risk of ischemic stroke associated withtransient exposure to alcohol remains unclear.


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Purpose

y to determine if alcohol consumption affects theacute risk of ischemic stroke,

y

to determine the length of time betweenalcohol intake and the onset of symptoms(induction time), and

y to examine whether the risk varies by the typeof alcohol.


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M ethods

y 390 patients (209 men, 181 women) were interviewedbetween January 2001 and November 2006.

y Alcohol consumption in the hour before strokesymptoms was compared with its expected frequencybased on the usual frequency of alcohol consumptionover the prior year.


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Results

y Of 390 patients, 248 (64%) reported alcoholconsumption in the prior year, 104 within 24 hours and14 within 1 hour of stroke onset.

y The relative risk of stroke in the hour after consumingalcohol was 2.3 (95% CI, 1.4 to 4.0; P0.002).

y The relative risks were similar for different types of alcoholic beverages.


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Conclusions

y The risk of stroke onset is transiently elevated in the hourafter alcohol ingestion.

(Stroke. 2010;41:1845-1849.)


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Introduction

y Physiological effects within hours of alcohol consumption:impaired fibrinolysis, increased platelet activation,increased BP, and increased heart rate.

y M oderate alcohol consumption: enhanced fibrinolyticactivity, improvements in lipid profile, inflammatorymarkers, insulin activity, and adipokins, improvedvasodilatation & vascular adhesion molecules.


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Study Populations

y The Stroke Onset Study was conducted in 3 medicalcenters (in Boston, North Carolina & Canada).

y From January 2001 November 2006, 390 patients (209

men and 181 women) were interviewed after sustainingan acute ischemic stroke.


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Study Populations

y Eligible participants:D iagnosed with acute ischemic stroke either by clinical diagnosis orappropriate imaging studies by a neurologist,

English-speaking,

Free of dementia before the index event, and

Agreed to participate.


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Study Populations

y Exclusions:Not being able to identify the time of onset of the stroke symptoms,

Cognitively impaired,

With poor memory around the time of the stroke,Experienced aphasia, or

Too ill to complete the structured interview.


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Study Populations

y Across all sites, 43% of patients with confirmed ischemicstroke met all inclusion criteria.

y Of these, 83% agreed to participate, 5.5% refused, and

12.5% were discharged from the hospital before theinterview.

y The protocol was approved by the Review Boards at eachparticipating center,

y Informed consent was obtained from each patient.


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Study Populations

y When was their first symptoms of their stroke occured?y Had they consumed any alcoholic beverage in the year before

their stroke?y When was the last time they had consumed an alcoholic

beverage?y How many times was their usual frequency of alcohol

consumption over the prior year?y How many servings consumed each time they drank?

(A serving size of alcohol was defined as 12 ounces of beer, 4ounces of wine, or 1.5 ounces of liquor straight or in a mixeddrink)

y What were the types of alcohol consumed (beer, wine, orliquor)?


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Study D esigns

y The Stroke Onset Study used a case crossover studydesign.

y Alcohol use in the hazard period (the 1-hour period

immediately before the onset of ischemic strokesymptoms) was compared with its expected frequency.


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Statistical Analysis

y Relative risk (RR): The ratio of the observed exposurefrequency in the hazard period to the expectedfrequency.

y We multiplied the usual annual frequency of alcoholconsumption by the hypothesized window of itsphysiological effect (1 hour in the primary analysis) toestimate the amount of person-time exposed to alcohol.


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y The length of time from alcohol consumption to theonset of ischemic stroke was estimated by comparingexposure within different hypothesized windows of its

physiological effect with the estimated person-timeexposed to alcohol in the previous year.


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y Stratified analyses were conducted to assess the effect of drink type (beer, wine, liquor), sex, age (65 years of ageversus 65 years of age), smoking status (current smokers

versus nonsmokers and stroke etiology and compared theRRs by means of a test for homogeneity.


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Results

y Of the 390 patients with acute ischemic stroke, 248 (64%)reported that they had consumed alcohol in the prioryear (wine, n45; beer, n29; liquor, n32; >1 type, n142).

y Among the 248 subjects who drank alcohol in the prioryear:

47 (12%) drinking at least 1 serving per day,

38 (10%) drinking at least once per week,

163 (66%) drinking at least once per month.


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Results

y Within 1 hour after alcohol consumption, the risk of stroke onset was 2.3-fold higher (95% CI, 1.4 to 4.0;P0.002) compared with periods of nonuse.

y The RR was 1.6 (95% CI, 1.0 to 2.5; P0.05) in the second hour after drinking and returned to baseline thereafter(Figure 1).

y By 24 hours, there was a 30% lower risk (RR0.7, 95% CI,

0.5 to 0.9; P0.02).


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Results

y Of 14 participants who consumed alcohol in the hourbefore stroke onset: 7 drank liquor, 5 drank beer, and 2drank wine.

y In a sensitivity analysis using each patient s reportedfrequency of consumption in the past week as the controlinformation, the risk of ischemic stroke onset was 3.3-foldhigher (95% CI, 1.2 to 9.3; P0.03) within 1 hour of

consuming at least 1 serving of alcohol compared withperiods with no alcohol intake.


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D iscussion

y In this study, alcohol consumption was associated with atransient increased risk (2.3 times higher) of ischemicstroke in the subsequent hour than the risk during

periods with no alcohol consumption.y This risk returned to baseline by 3 hours and there was a

modestly lower risk by 24 hours.


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D iscussion

y Hillbom et al. moderate (151 to 300 g) and heavy (>300g) consumption of alcohol within the week before strokeonset is associated with a significantly higher risk of

stroke.y Hendriks and colleagues plasminogen activator inhibitor

was significantly higher after 40 g (1,5 oz) of alcohol thanwater (after 1, 3, and 5 hours, but was not significantly

different after 9 hours).


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D iscussion

y Some studies found that moderate alcohol consumptionmay have beneficial effects through changes in flow-mediated vasodilatation within minutes to hours and

improvements in lipid profile, inflammatory markers,soluble vascular adhesion molecules, and adipokineswithin weeks.

y Habitual heavy alcohol consumption is associated with an

increased risk of ischemic and hemorrhagic stroke.


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D iscussion

y M ukamal and colleagues compared with completeabstention from alcohol, light consumption (1 drink daily)is not associated with stroke risk, moderate alcohol

consumption (1 to 2 drinks daily) is protective, and intakeof 2 or more drinks per day is associated with anincreased risk of ischemic stroke.


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Summary

y The risk of ischemic stroke was transiently elevated for 2hours after drinking.

y The risk rapidly returned to baseline and was modestly

lower by 24 hours.y The clinical impact on ischemic stroke risk appears to

depend on the frequency and quantity of alcoholconsumption.

y D efinitive evidence would require a long-term clinicaltrial.


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Alcohol is alcohol. It s not what you drink,it s how much you drink that counts. If you

choose to drink, drink responsibly!

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Alcohol and Acute Ischemic Stroke Onset