Physiology Friday #275: Alcohol & Cardiovascular Health: Where the New American Heart Association Statement Falls Short
Moderate drinking is no longer considered to be beneficial for the heart, but should recommendations to limit drinking be more aggressive?
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Is alcohol out of vogue?
Thanks in part to science communicators like Andrew Huberman (whose episode on alcohol has over 7.5 million views on YouTube), there’s much more awareness about the negative mental and physical effects of alcohol. Many people are also becoming more in tune with how it makes them feel and perform. Occasional consumption or complete abstinence seems to be the norm among health-minded folks. Whether it’s a passing fad or a change in lifestyles that’s here to stay, I’m not sure. In any case, there has been a shift in the cultural zeitgeist about alcohol.
This shift, however, hasn’t been completely recognized by leading health organizations (at least in the United States). And the latest statement from the American Heart Association (AHA) is a good example.
The writing group brought together more than 400 citations to answer a simple (yet infinitely complex) question of whether drinking alcohol ever helps—or only harms—the heart and blood vessels.
After reading the review, I thought I’d share some of its main findings, conclusions, and then my personal takeaways about what they get right and where they fell short.1
It was once thought (and sometimes still is) that a moderate intake of alcohol was cardioprotective, imparting some beneficial effects on the heart at low doses that translate to a lower risk of cardiovascular diseases. Think of all the times you’ve heard that a glass of red wine or two with dinner is healthy (because, well, resveratrol!)
All of that evidence came from epidemiological studies, which showed that people consuming ~1–2 drinks per day were sometimes at a lower risk of heart disease and other conditions compared to non-drinkers. But epidemiology (especially nutritional epidemiology) is loaded with flaws, and one particularly pesky one when it comes to alcohol is known as the “sick quitter” effect.
Take someone who used to be a heavy drinker but, for one reason or another, no longer drinks (maybe they developed a health problem from excessive alcohol intake). If this person were surveyed about their current alcohol consumption, they’d be categorized as a non-drinker or abstainer, a classification that fails to capture their past drinking habits. Compare this non-drinker to someone who casually consumes a few drinks per week, and the moderate drinker appears to be healthier. This is what’s happened with the alcohol and cardiovascular disease literature on a large scale—most of it failed to account for the “sick quitter” effect. When it does (when “former drinkers” and “lifetime abstainers” are treated as separate groups), the beneficial effects of drinking somewhat disappear.
This small bit of background gives us some necessary context moving forward. Long story short is that moderate drinking isn’t thought to be that bad, and sometimes it’s even seen as being perfectly healthy.
Drinking patterns and cardiovascular health outcomes
This is an area where I think the newer literature paints a less rosy (but perhaps more accurate) picture of alcohol. My interpretation of the AHA’s conclusion is this: the effects of alcohol consumption at low doses remain uncertain, while the harms at higher doses are certain.
Light drinking (less than or equal to 1 drink/day) sometimes shows a lower risk of heart attack, but these effects shrink or vanish after controlling for genetics (using Mendelian randomization) and other modern bias-control methods. Importantly, there is no consistent benefit of low levels of alcohol intake for stroke, heart failure, or atrial fibrillation (areas where a small benefit was sometimes observed).
Moderate drinking (~1–2 drinks per day) offers little to no protection from any cardiovascular-disease-related complications. At this level of consumption, the risk of hypertension/high blood pressure and atrial fibrillation starts to rise.
Heavy drinking (more than 2 drinks per day or occasional episodes of binge drinking, defined as 5 or more drinks on a single occasion) uniformly increases the risk of hypertension, coronary heart disease, stroke, atrial fibrillation, cardiomyopathy, and heart failure. This risk rises in a dose-dependent manner.
How does alcohol promote cardiovascular disease?
More important than epidemiology (in my humble opinion) are the mechanistic studies that show us what happens when people consume alcohol—how it affects their heart, blood vessels, clotting factors in the blood, and so on. Several were highlighted in the AHA’s statement:
For one, acute and chronic alcohol consumption increases blood pressure—each additional drink per day raises one’s systolic blood pressure by about 1 mmHg. Crucially, cutting alcohol intake drops blood pressure within weeks.
Alcohol is cardiotoxic, promoting oxidative stress and mitochondrial injury in the heart. It also promotes conditions that make the heart more susceptible to an irregular rhythm (arrhythmia) by boosting sympathetic nervous system activity, changing the electrical conduction patterns, and promoting fibrosis. This is the reason for the condition known colloquially as “holiday heart,” in which a heart arrhythmia known as atrial fibrillation is triggered by heavy acute alcohol consumption (often reported on weekends or around holidays, hence the name).
Interestingly, in the short term, a few drinks tend to promote a reduction in platelet aggregation (it’s antithrombotic), but this doesn’t translate into lasting protection.
All of this is to say nothing of the indirect effects alcohol may have on cardiovascular health by reducing sleep quality, promoting weight gain, and adversely affecting blood lipids or other metabolic health components.
Who should avoid alcohol the most?
Everyone isn’t at the same risk when it comes to alcohol and cardiovascular health, and the AHA statement highlights a few special groups who might be particularly susceptible.
Women (due to their presumably lower body size and lower levels of alcohol-metabolizing enzymes) experience faster and more pronounced rises in their blood alcohol content. As such, they experience higher risks of hypertension and atrial fibrillation at the same or even lower intakes than men. Pregnant women should avoid alcohol completely (a point that should go without saying).
Older adults with comorbidities (diseases other than CVD) who might be taking medications that interact with alcohol should also be wary of their consumption. For adults with cardiovascular diseases, even light drinking can worsen blood pressure control, trigger arrhythmias, and impair heart function.
Last are young adults (20-somethings), a population who, sadly, is chronically exposed to alcohol (have you been to college?) Binge drinking patterns (the norm for this age group) have been shown to promote vascular damage. Given that the brain is still developing at this time point, there’s no safe level of alcohol consumption.
The writing group stops shy of calling alcohol toxic at any dose, but concludes there is no proven cardiovascular benefit to drinking, and plenty of evidence for harm once intake exceeds about 1 drink daily. For clinicians and the public alike, the safest guidance remains: “If you don’t drink, don’t start; if you do, keep it well under two drinks a day and avoid binges.”
This is a major upgrade and, to me, reflects the best available scientific evidence. I’m not convinced that having a few drinks per week (for those who choose to imbibe) can’t be part of an otherwise healthy lifestyle. It probably carries few, if any, health repercussions. I’m not a teetotaler—a cold beer or a glass of wine a few times per month brings me joy and, on the surface, doesn’t appear to affect my mental or physical well-being.
But here’s where I think the AHA falls short. As a major health organization, they aren’t staunch enough about recommending against reducing or eliminating alcohol for the sake of heart health.
The World Health Organization’s stance is that “there is no safe level of alcohol consumption that does not affect health.” Canada’s guidelines on low-risk drinking behaviors state that “no matter where you are on the continuum, for your health, less alcohol is better.” Both of these center on the general consensus that alcohol is toxic at any dose and most people are better off not drinking.
Even as someone who drinks, I think that this stance is the more correct one. You’re going to be healthier if you don’t drink than if you do. That might seem like a bold statement (and I know, there are various biopsychosocial reasons why people consume alcohol, some of which may even be health-promoting), but it aligns with everything we know about how alcohol affects the body, even one standard drink.
While the AHA is a heart health organization whose main focus is to compile the evidence on heart health-related matters, their recommendations fail to at least mention the other areas of health where alcohol at any dose appears to be detrimental. Specifically, white matter degeneration and the risk of most cancers rise in a dose-dependent manner at any level of alcohol consumption above zero!
I realize that, practically, groups like the AHA are operating on the idea that most people do and will want to continue drinking alcohol. Telling patients to avoid alcohol completely and forever is a big (and perhaps unreasonable) task. However, that doesn’t mean it’s the wrong recommendation to make. A health organization leading the charge should probably take a strong, if not stubborn, stance on alcohol. Not to demonize it, but to accurately reflect the science.
Thanks for reading. See you next Friday.
~Brady~
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Piano MR, Marcus GM, Aycock DM, Buckman J, Hwang CL, Larsson SC, Mukamal KJ, Roerecke M; on behalf the American Heart Association Council on Lifestyle and Cardiometabolic Health; Council on Cardiovascular and Stroke Nursing; Council on Clinical Cardiology; and Stroke Council. Alcohol Use and Cardiovascular Disease: A Scientific Statement From the American Heart Association. Circulation. 2025 Jun 9. doi: 10.1161/CIR.0000000000001341. Epub ahead of print. PMID: 40485439.
Effect size is important and should be quantified in any discussion on this.
If one glass of wine per day statistically reduces life expectancy by 20 minutes, it is not particularly important if one abstains, and it is a preference issue. If it reduced life expectancy by 20 years, it’d be imperative to abstain.
If you are wondering if the recommendations to limit drinking should be more aggressive, you should look at the effect size. If our best data right now is uncertain - that is to say, if we are not even certain about the direction of the effect let alone the magnitude - then the answer to the question is “no, the current evidence does not justify more aggressive recommendations.”
When I was young I lived in Spain, in the province of Alicante. Your suppositions seem simplistic to me as back then every home where I lived made their own wine for home consumption and had a Barrel of it in the house. Normal consumption for a male was a couple of glasses with each meal. Often a Spanish Brandy was taken with early morning coffee. In most households in our village there were three generations living together and the 75 yr olds went out to the countryside with their ravaged arteries with their mule and cart to work the fields every day returning in the evening. I am not a scientist of which there are precious few these days but my experiences then are more valuable to me than tests and papers usually qualified by maybe's and perhapses. Remember how much the scientists knew about Covid? Is Hanson's residual fatigue or the train/ recover system the answer. Both succeed and both have their scientific approvals. Be careful about preaching stuff that to ones own eyes appears contradictory to what happens in real life.