Kenneth J. Mukamal, MD, MPH, MA; Alberto Ascherio, MD, DrPH; Murray A. Mittleman, MD, DrPH; Katherine M. Conigrave, MD; Carlos A. Camargo, MD, DrPH; Ichiro Kawachi, MD, PhD; Meir J. Stampfer, MD, DrPH; Walter C. Willett, MD, DrPH; Eric B. Rimm, ScD
Grant Support: By National Institutes of Health grants AA00299, AA11181, HL35464, and CA55075.
Potential Financial Conflicts of Interest:Honoraria: E.B. Rimm.
Requests for Single Reprints: Kenneth J. Mukamal, MD, MPH, MA, Division of General Medicine and Primary Care, Beth Israel Deaconess Medical Center, 330 Brookline Avenue, RO-114, Boston, MA 02215; e-mail, email@example.com.
Current Author Addresses: Dr. Mukamal: Division of General Medicine and Primary Care, Beth Israel Deaconess Medical Center, 330 Brookline Avenue, RO-114, Boston, MA 02215.
Drs. Ascherio, Willett, and Rimm: Department of Nutrition, Harvard School of Public Health, Building II, 655 Huntington Avenue, Boston, MA 02115.
Dr. Mittleman: Beth Israel Deaconess Medical Center, 185 Pilgrim Road, Dea-301, Boston, MA 02215.
Dr. Conigrave: Drug and Alcohol Department, Royal Prince Albert Hospital, Missenden Road, Camperdown, NSW 2050, Australia.
Dr. Camargo: Department of Emergency Medicine, Massachusetts General Hospital, Clinics Building 397, 55 Fruit Street, Boston, MA 02114.
Drs. Kawachi and Stampfer: Department of Epidemiology, Harvard School of Public Health, Kresge Building, 677 Huntington Avenue, Boston, MA 02115.
Author Contributions: Conception and design: E.B. Rimm.
Analysis and interpretation of the data: K.J. Mukamal, C.A. Camargo Jr., I. Kawachi, M.J. Stampfer.
Drafting of the article: K.J. Mukamal, I. Kawachi.
Critical revision of the article for important intellectual content: K.J. Mukamal, A. Ascherio, M.A. Mittleman, K.M. Conigrave, C.A. Camargo Jr., I. Kawachi, M.J. Stampfer, W.C. Willett, E.B. Rimm.
Final approval of the article: K.J. Mukamal, C.A. Camargo Jr., M.J. Stampfer, E.B. Rimm.
Provision of study materials or patients: E.B. Rimm.
Statistical expertise: M.J. Stampfer.
Obtaining of funding: K.J. Mukamal, E.B. Rimm.
Collection and assembly of data: I. Kawachi, E.B. Rimm.
Mukamal K., Ascherio A., Mittleman M., Conigrave K., Camargo C., Kawachi I., Stampfer M., Willett W., Rimm E.; Alcohol and Risk for Ischemic Stroke in Men: The Role of Drinking Patterns and Usual Beverage. Ann Intern Med. 2005;142:11-19. doi: 10.7326/0003-4819-142-1-200501040-00007
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Published: Ann Intern Med. 2005;142(1):11-19.
Past studies don't clearly show that alcohol consumption affects the risk for ischemic stroke.
This prospective cohort study involving 38 156 male health professionals followed for 14 years found that consuming more than 2 drinks daily was associated with an increased risk for ischemic stroke. Two drinks or fewer were not associated with increased risk. Consuming red wine, but not other beverage types, was associated with a lower risk.
The study had limited power to determine the precise drinking patterns that were associated with stroke risk.
These findings support public health recommendations to avoid consuming more than 2 drinks daily.
Columbia University Medical Center, New York, NY 10032
January 6, 2005
Alcohol and Risk of Ischemic Stroke: Is Depression a Confounder?
TO THE EDITOR: Mukamal et al. report an increased risk for ischemic stroke among men who consumed more than 2 alcoholic drinks per day (1). Risky or hazardous drinking in men, defined in the United States as more than 14 drinks per week (2), might be associated with depression (3). Depressive symptoms, in turn, were shown to be associated with increased risk for stroke among men (4) and elderly persons (5), and thus might partially explain the study's important finding. It would therefore be interesting to learn if the authors have any data on depression in their cohort.
1. Mukamal KJ, Ascherio A, Mittleman MA, Conigrave KM, Camargo CA, Kawachi I, et al. Alcohol and risk for ischemic stroke in men: the role of drinking patterns and usual beverage. Ann Intern Med. 2005;142:11-9.
2. U.S. Preventive Services Task Force. Screening and behavioral counseling interventions in primary care to reduce alcohol misuse: recommendation statement. Ann Intern Med. 2004;140:554-6.
3. Kessler RC, Crum RM, Warner LA, Nelson CB, Schulenberg J, Anthony JC. Lifetime co-occurrence of DSM-III-R alcohol abuse and dependence with other psychiatric disorders in the National Comorbidity Survey. Arch Gen Psychiatry. 1997; 54:313-21.
4. Gump BB, Matthews KA, Eberly LE, Chang YF. Depressive symptoms and mortality in men: results from the Multiple Risk Factor Intervention Trial. Stroke. 2005;36:98-102.
5. Wassertheil-Smoller S, Applegate WB, Berge K, Chang CJ, Davis BR, Grimm R Jr, et al. Change in depression as a precursor of cardiovascular events. SHEP Cooperative Research Group (Systoloc Hypertension in the elderly). Arch Intern Med. 1996;156:553-61.
Comando Brigata alpina "Julia"
January 12, 2005
Anti-inflammatory effect of alcohol and risk of ischemic stroke
TO THE EDITOR: Mukamal and colleagues, analyzing data from the Health Professionals Follow-up Study (HPFS), found that alcohol consumption was associated with a higher risk for ischemic stroke among heavy drinkers but with a trend toward lower risk with light drinking (1). In this association, however, they did not consider the role of systemic inflammation. Findings from the same HPFS have shown that elevated levels of inflammatory markers, particularly C-recative protein (CRP), are associated with an increased risk of coronary artery disease (2). There is a growing body of evidence that light alcohol consumption decreases the levels of CRP (3) and that the baseline concentration of such a marker of systemic inflammation predicts the risk of future ischemic stroke (4,5). Moreover, a recent study reported a possible inverse association between light to moderate alcohol intake and risk of cardiovascular mortality in men with a history of stroke (6). Therefore, light alcohol consumption should not be discouraged in patients at risk for ischemic stroke. Luca Mascitelli, MD Comando Brigata alpina "Julia" Udine, Italy 33100
Francesca Pezzetta, MD Presidio Ospedaliero di San Vito al Tagliamento San Vito al Tagliamento, Italy 33078
References 1. Mukamal KJ, Ascherio A, Mittleman MA, Conigrave KM, Camargo Jr. CA, Kawaki I, et al. Alcohol and risk for ischjemic stroke in men: the role of drinking patterns and usual beverage. Ann Intern Med. 2005;142:11-19. 2. Pai JK, Pischon T, Ma J, Manson JE, Hankinson SE, Joshipura K, et al. Inflammatory markers and the risk of coronary heart disease in men and women. N Engl J Med. 2004;351:2599-610. 3. Imhof A, Woodward M, Doering A, Helbecque N, Loewel H, Amouyel P, et al. Overall alcohol intake, beer, wine, and systemic markers of inflammation in western Europe: results from three MONICA samples (Augsburg, Glasgow, Lille). Eur Heart J. 2004;25:2092-100. 4. Rost NS, Wolf PA, Kase CS, Kelly-Hayes M, Silbershatz H, Massaro JM, et al. Plasma concentration of C-reactive protein and risk of ischemic stroke and transient ischemic attack: the Framingham study. Stroke. 2001;32:2575- 9. 5. Cao JJ, Thach C, Manolio TA, Psaty BM, Kuller LH, Chaves PH, et al. C- reactive protein, carotid intima-media thickness, and incidence of ischemic stroke in the elderly: the Cardiovascular healt study. Circulation. 2003;108:166-70. 6. Jackson VA, Sesso HD, Buring JE, Gaziano JM. Alcohol consumption and mortality in men with preexisting cerebrovascular disease. Arch Intern Med. 2003;163:1189-93.
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