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From the Department of Medicine1 and the Department of Cardiology, 2St Luke’s Roosevelt Hospital Center, Columbia University College of
Physicians and Surgeons, New York, NY
Heavy alcohol intake increases the risk of hypertension, CI, 0.99–1.33; P=.06), respectively, whereas a significantly
but the relationship between light to moderate alcohol increased risk of hypertension was found with heavy
consumption and incident hypertension remains controver- alcohol consumption of 31 to 40 g ⁄ d (RR, 1.77; 95% CI,
sial. The authors sought to analyze the dose-response 1.39–2.26; P<.001) and >50 g ⁄ d (RR, 1.61; 95% CI,
relationship between average daily alcohol consumption 1.38–1.87; P<.001). Among women, the meta-analysis
and the risk of hypertension via systematic review and indicated protective effects at <10 g ⁄ d (RR, 0.87; 95%
meta-analysis. Electronic databases were searched for CI, 0.82–0.92; P<.001) and a trend toward decreased risk
prospective control studies examining quantitative mea- of hypertension with alcohol consumption 11 to 20 g ⁄ d
surement of alcohol consumption and biological measure- (RR, 0.9; 95% CI, 0.87–1.04; P=.17), whereas a signifi-
ment of outcome. The primary endpoint was the risk of cantly increased risk of hypertension was indicated with
developing hypertension based on alcohol consumption. heavy alcohol consumption of 21 to 30 g ⁄ d (RR, 1.16;
The level of alcohol consumption from each study was 95% CI, 0.91–1.46; P=.23) and 31 to 40 g ⁄ d (RR, 1.19;
assigned to categorical groups based on the midpoint of 95% CI, 1.07–1.32; P=.002). In men, heavy alcohol con-
their alcohol consumption classes to make possible the sumption is associated with increased risk of hypertension,
comparison of heterogeneous classification of alcohol whereas there is a trend toward increased risk of hyperten-
intake. A total of 16 prospective studies (33,904 men and sion with low and moderate alcohol consumption. The rela-
193,752 women) were included in the analysis. Compared tionship between alcohol consumption and hypertension is
with nondrinkers, men with alcohol consumption with J-shaped in women. Limiting alcohol intake should be
<10 g ⁄ d and 11 to 20 g ⁄ d had a trend toward increased advised for both men and women. J Clin Hypertens (Green-
risk of hypertension (relative risk [RR], 1.03; 95% confi- wich). 2012;14:792–798. 2012 Wiley Periodicals, Inc.
dence interval [CI], 0.94–1.13; P=.51) and (RR, 1.15; 95%
Hypertension is a prevalent condition that affects dies have reported a linear association between alcohol
approximately 65 million individuals in the United intake and BP among men,7,8 while others have
States based on a preliminary report from the National reported a threshold only above which there is an
Health and Nutrition Examination Survey (NHANES) association in both men and women,9,10 and still oth-
2005–2006 and coincident US population estimates.1 ers a J- or U-shaped association among women,11,12
Due to its increasing clinical and public health impor- with the nadir among light to moderate alcohol drink-
tance, examining the risks or benefits of alcohol ers. These inconclusive results may have resulted in
consumption in patients with hypertension is needed part from ethnic or lifestyle differences in the study
to assist clinicians in developing appropriate strategies populations but also may have been strongly influ-
of prevention. In observational studies, moderate enced by different methods used to investigate the
alcohol consumption has been associated with lower association between alcohol intake and BP. The objec-
incidence of cardiovascular diseases such as coronary tive of the present study was to perform a systematic
artery disease, stroke, heart failure, and peripheral review and meta-analysis of the published prospective
vascular disease.2–4 studies to separately assess the risk of development of
Epidemiologic evidence suggests that heavy alcohol hypertension over a long-term period among men and
consumption is strongly associated with increased risk women based on their levels of alcohol consumption.
of hypertension.5,6 However, the effects of light to
moderate alcohol intake on blood pressure (BP) MATERIALS AND METHODS
remain unclear and controversial. Some previous stu-
Search Strategy
Address for correspondence: Franz H. Messerli, MD, Hypertension
We systematically searched the electronic databases
Program, Division of Cardiology, St Luke’s-Roosevelt Hospital, Columbia MEDLINE, PubMed, Embase, and the Cochrane
University College of Physicians and Surgeons, 1000 10th Avenue, Suite Library for Central Register of Clinical Trials using
3B-30, New York, NY 10019 the MESH terms ‘‘alcohol,’’ ‘‘hypertension,’’ ‘‘blood
E-mail: messerli.f@gmail.com
pressure,’’ and the names of individual alcoholic bev-
Manuscript received: May 17, 2012; Revised: July 15, 2012;
Accepted: August 1, 2012 erages. We limited our search to studies in human
DOI: 10.1111/jch.12008 subjects and English language in peer-reviewed
792 The Journal of Clinical Hypertension Vol 14 | No 11 | November 2012 Official Journal of the American Society of Hypertension, Inc.
Alcohol and Hypertension | Briasoulis et al.
Official Journal of the American Society of Hypertension, Inc. The Journal of Clinical Hypertension Vol 14 | No 11 | November 2012 793
Alcohol and Hypertension | Briasoulis et al.
different studies and at the same time allows inclusion articles, the study by Klatsky colleagues was excluded
of data from studies in which precise information on because it did not separately report the effects of
levels of alcohol consumption were not available. alcohol consumption on men and women14 (Figure 1).
When the upper bound of the highest category was This approach enabled us to minimize the bias related
not specified, we used the range of the previous to differences other than alcohol consumption between
reported category. The alcohol habits were assumed to individuals. Of these 16 articles, one included data on
be stable during the follow-up period. hypertension risk in both men and women. We identi-
One of the largest prospective cohort studied, con- fied 16 prospective cohort studies including 33,904
ducted by Klatsky colleagues,14 was not included in men and 193,752 women who recorded their drinking
our analysis. The authors studied cardiovascular habits and evaluated the risk of developing hyperten-
effects of alcohol separately in heavy drinkers sion (Table I and Table II). This difference in the
(>3 drinks per day), light drinkers (<2 drinks per overall number of men and women is due to the pre-
day), exdrinkers, and abstainers among 127,212 dominantly female population in the studies by Asche-
patients for 13.5 years. Although the authors did not rio colleagues,15 Sesso colleagues,16 Thadhani
report data separately on men and women, they con- colleagues,17 and Witteman colleagues.18 The average
cluded that any drinking level is far from benign and follow-up duration was 7.6 years for women and
is associated with increased risk of hypertension and 9.8 years for men.
adverse cardiovascular outcomes.
Effects of Different Alcohol Consumption
RESULTS Categories on Hypertension Risk
In men, the random-effects model showed a signifi-
Study Selection and Baseline Characteristics cantly increased risk of hypertension with alcohol
Based on our search strategy, we initially identified 50 consumption of 31 to 40 g ⁄ d (RR, 1.77; 95% confi-
potential relevant articles. Based on our inclusion cri- dence interval [CI], 1.39–2.26; P<.001) and >50 g ⁄ d
teria, 33 articles were rejected. Of the 17 remaining (RR, 1.61; 95% CI, 1.31–1.87; P<.001). There was a
TABLE I. Characteristics of Included Studies That Examined the Association Between Alcohol Consumption and
Hypertension in Men
Hypertensive
Author Year Type of Study Country Age, y Participants, No. Patients, No. Follow-up, y
TABLE II. Characteristics of Included Studies That Examined the Association Between Alcohol Consumption and
Hypertension in Females
Control Hypertensive
Author Year Type of Study Country Age, y Patients, No. Patients, No. Follow-up, y
15
Ascherio 1996 Prospective cohort United States 30–55 150,522 2526 4
Sesso16 2008 Prospective cohort United States 53.4 28,848 8680 9.8
Thadani17 2002 Prospective cohort United States 35.3 70,891 4188 8
Wiiteman18 1989 Prospective cohort United States 30–55 58,218 3320 4
Saremi24 2004 Prospective cohort United States 36.7 2240 395 14
Fuchs5 2001 Prospective cohort United States 52.6 4584 654 6
Klatsky20 2006 Prospective cohort United States 50 74,441 26,340 13.5
The study by Klatsky and colleagues included a predominantly female population.
794 The Journal of Clinical Hypertension Vol 14 | No 11 | November 2012 Official Journal of the American Society of Hypertension, Inc.
Alcohol and Hypertension | Briasoulis et al.
trend towards increased risk of hypertension with 40 g ⁄ d (RR, 1.19; 95% CI, 1.07–1.32; P=.002) and a
alcohol consumption of <10 g ⁄ d (RR, 1.03; 95% CI, trend toward increased risk of hypertension with
0.94–1.13; P=.51), 11 to 20 g ⁄ d (RR, 1.15; 95% CI, alcohol consumption of 21 to 30 g ⁄ d (RR, 1.16; 95%
0.99–1.33; P=.06), 21 to 30 g ⁄ d (RR, 1.07; 95% CI, 0.91–1.46; P=.23).
CI, 0.86–1.34; P=.54), and 41 to 50 g ⁄ d (RR, 1.17; Despite the methodologic differences with previous
95% CI, 0.84–1.65; P=.34) (Figures 2–4). meta-analysis, the results of the present study are
In women, the random-effects model showed a similar to those reported by reported by Taylor and
significantly decreased risk of hypertension with alco- colleagues who also showed a modest protective
hol consumption of <10 g ⁄ d (RR, 0.87; 95% CI, effect of alcohol consumption in women at low
0.82–0.92; P<.001) and a trend toward decreased risk doses.27
of hypertension with alcohol consumption 11 to
20 g ⁄ d (RR, 0.9; 95% CI, 0.87–1.04; P=.17). The Publication Bias
meta-analysis revealed a significantly increased risk of The funnel plots did not show marked asymmetry and
hypertension with alcohol consumption of 31 to all Egger’s tests were not significant.
Male Distribution:
Female Distribution:
FIGURE 2. Risk of hypertension in men and women based on different alcohol consumption categories. CI indicates confidence interval.
Official Journal of the American Society of Hypertension, Inc. The Journal of Clinical Hypertension Vol 14 | No 11 | November 2012 795
Alcohol and Hypertension | Briasoulis et al.
796 The Journal of Clinical Hypertension Vol 14 | No 11 | November 2012 Official Journal of the American Society of Hypertension, Inc.
Alcohol and Hypertension | Briasoulis et al.
Official Journal of the American Society of Hypertension, Inc. The Journal of Clinical Hypertension Vol 14 | No 11 | November 2012 797
Alcohol and Hypertension | Briasoulis et al.
27. Taylor B, Irving HM, Baliunas D, et al. Alcohol and hypertension: 30. Fuchs FD. Vascular effects of alcoholic beverages: is it only alcohol
gender differences in dose-response relationships determined through that matters? Hypertension. 2005;45:851–852.
systematic review and meta-analysis. Addiction. 2009;104:1981– 31. Giovannucci E, Colditz G, Stampfer MJ, et al. The assessment of
1990. alcohol consumption by a simple self-administered questionnaire.
28. Russell M, Cooper ML, Frone MR, Welte JW. Alcohol drinking Am J Epidemiol. 1991;133:810–817.
patterns and blood pressure. Am J Public Health. 1991;81:452–457.
29. Puddey IB, Jenner DA, Beilin LJ, Vandongen R. An appraisal of the
effects of usual vs recent alcohol intake on blood pressure. Clin Exp
Pharmacol Physiol. 1988;15:261–264.
798 The Journal of Clinical Hypertension Vol 14 | No 11 | November 2012 Official Journal of the American Society of Hypertension, Inc.