During my more than 60 years of clinical and laboratory work, I was fascinated and focused on the complex relationship between alcoholism and hypertension. What is an alcoholic what is alcoholism.
In the United States, 16% of hypertensive disease is attributable to alcohol consumption.[ 1 ] In this letter, I wish to summarize my experience that the natural history of alcoholism in hypertension can be divided into 5 distinct phases. Each of these phases presents different therapeutic challenges.
In phase I, the consumption of alcohol is associated with an increase in blood pressure (BP). This effect is independent of age, sex, race, cigarette smoking, and coffee consumption[ 2 ] and is dependent on the amount ingested regardless of the source of alcohol.[ 3 ] Whereas several mechanisms have been proposed to explain the direct effect of alcohol on BP, most of the evidence supports the concept that in this phase, alcohol consumption increases sympathetic nervous system activity. In this phase, it is most important to initiate vigorous attempts at lifestyle modification. Various antihypertensive drugs can be used, and there is no evidence that BP-lowering drugs are particularly effective.
In phase II, an abstinence from alcohol reduces both the systolic and diastolic BP.[ 4 ] The BP effect occurs in days to months. Careful BP monitoring during abstinence is critical in order to know when to discontinue the antihypertensive drugs and avoid the risk of serious hypotension. In this phase, continuous abstinence will maintain BP at normal levels. Some drinkers may have true essential hypertension, and abstinence will not alter their BP.
What is an alcoholic what is alcoholism
In phase III, resumption of drinking invariably increases BP. Recidivism is a risk in all phases and in the course of 1 year, relapses of alcoholism range from 60% to 80%. BP returns again into the hypertensive range requiring the resumption of hypertensive medications. The toxic effects of alcohol emerge in phase III with the development of liver disease. In this phase, fatty infiltration of the liver develops in 90% of individuals who consume more than 60 g of alcohol a day.[ 5 ] Simple fatty infiltration of the liver is systematic and completely reversible with abstinence.
In phase IV, the alcohol-dependent patient with hypertension is at high risk of liver damage. Pathologically, the toxic effects of alcohol are seen in 90% of patients who develop fatty infiltration of the liver[ 6 ] to 30% who progress to cirrhosis.[ 7 ]
I reviewed 567 cases of alcoholism[ 5 ] and 504 had cirrhosis of the liver. In 9 cirrhotic patients, BP was reduced to normal levels. Five of the 7 cases with normotension were cirrhotic women and nearly one third of the alcohol-dependent patients in the United States are women.[ 8 ] Accompanying the BP reduction was a reversal of the albumin globulin ratio. Further studies on serum from alcoholic cirrhotic patients showed more angiotensin 1 than angiogenesis II in the serum, indicating a block in the angiogenesis-converting enzyme.[ 9 ] Monitoring BP frequently is mandatory in phase IV because most patients will have high BP, but, in a few cases, the BP may be quite low and continued use of the hypertensive medication can lead to hypotension and other adverse effects.
Phase V occurs with the onset of end-stage liver disease when the BP is usually high. However, in a retrospective observation, 3 alcohol-dependent hypertensive patients[ 7, 9 ] documented a reversal of hypertension with the onset of end-stage liver disease. Consequently, BP must be carefully monitored, because the development of end-stage liver disease in hypertensive alcoholics can be associated with substantial BP-lowering, which sometimes requires discontinuation of the BP medication.
The purpose of this letter is to describe the complex natural history of alcoholism in hypertension and to underscore the importance of early lifestyle modification as well as the need for close BP monitoring in all hypertensive alcoholic patients.
What is an alcoholic what is alcoholism