The acute and chronic effects of alcohol on the myocardium have been well documented1, including the association between alcohol and atrial fibrillation.2 This case report demonstrates the utility of a beta-blocker immediately before alcohol consumption in order to prevent atrial fibrillation.
An active 75-year-old male with a structurally normal heart and a CHA2DS2-VASc score of 2 was referred for management of highly symptomatic atrial fibrillation.
His prior history was remarkable for an increased frequency of atrial fibrillation, which was often precipitated by moderate alcohol consumption (1 to 2 glasses of wine per day). Previously, he was managed acutely with oral diltiazem 120 mg daily.
The patient reported episodes of lightheadedness, shortness of breath, and fatigue. He acknowledged being aware of changes in his pulse. A Reveal LINQ Insertable Cardiac Monitoring System (ICM; Medtronic) was implanted, which confirmed the close association between the patient’s symptoms, recorded paroxysmal atrial fibrillation episodes, and alcohol intake. The patient was open to medication and lifestyle changes, but reluctant to undergo an ablation for atrial fibrillation. He was initially treated with a strategy of rate control and anticoagulation (rivaroxaban), but he continued to have paroxysmal episodes with increasing frequency, and often had difficulty with rate control. In addition to a calcium channel blocker (diltiazem), he tried a number of different beta-blockers. He had difficulty tolerating maintenance dose beta-blockers, both cardioselective and non-selective, due to fatigue and hypotension. He also tried a “pill in the pocket” approach with flecainide 300 mg orally, which worked initially; this later became less effective, and he was treated with flecainide 100 mg orally twice daily. The latter regimen resulted in atrial flutter with 2:1 atrioventricular conduction and a heart rate of 150 bpm. He spontaneously converted to sinus rhythm, and the flecainide was discontinued.
The patient was active in his healthcare, and working to decrease possible factors that could lead to atrial fibrillation. For example, he watched his weight (BMI = 22), exercised regularly, and decreased his caffeine intake. Since the patient reported that 98 percent of episodes were associated with alcohol, he decreased his wine intake to 1 to 2 times per week. Using an electrocardiogram app (Kardia app, AliveCor) on his smartphone, the patient noticed an association between his heart rate following alcohol consumption and the development of atrial fibrillation. Specifically, when his heart rate increased from a baseline of approximately 70 bpm to the mid 90s, he would go into atrial fibrillation. On his own, he decided to take 20 mg of propranolol orally about half an hour before drinking, with the hope of preventing the development of atrial fibrillation. He was able to tolerate propranolol administered in this manner, even though he was unable to previously tolerate it as a maintenance dose. For six months, this method allowed him to enjoy occasional alcohol (e.g., red or white wine) without experiencing any episodes of atrial fibrillation. To the best of the patient’s recollection, he took 36 prophylactic consecutive doses of beta-blockers prior to alcohol consumption over a six-month period, which was 100 percent effective at suppressing atrial fibrillation (36 of 36 beta-blocker pretreatments resulted in no episodes of atrial fibrillation).
Following this period, the patient had an episode of atrial fibrillation after forgetting to take his beta-blocker before consuming a moderate amount of alcohol. The atrial fibrillation persisted for nearly a week before spontaneously converting to sinus rhythm (Figure 1). He has since restarted taking his beta-blockers immediately prior to consuming alcohol, and has experienced no new atrial fibrillation events after two months (8 of 8 beta-blocker pretreatments with no new episodes of atrial fibrillation).
In this case, we highlight an approach of beta-blocker therapy prior to alcohol consumption in order to prevent atrial fibrillation. This patient took a total of 44 beta-blocker pretreatments, and every pretreatment prevented atrial fibrillation. The one instance in which he forgot to pretreat prior to consuming alcohol resulted in the development of atrial fibrillation. This case report demonstrates a consistent protective effect of beta-blockers in the prevention of atrial fibrillation. Although the utility of daily beta-blocker therapy pre- or post-cardiac surgery to avoid atrial fibrillation has previously been described, we were not able to find examples of a similar approach in the literature for as-needed beta-blocker use to prevent alcohol-induced atrial fibrillation (Figure 2).
The approach to managing atrial fibrillation typically consists of either a rate control and anticoagulation strategy, or a rhythm control and anticoagulation strategy. Recently, the CABANA study failed to demonstrate that cardiac ablation resulted in a significant reduction in all-cause mortality, cardiac arrest, stroke, or serious bleeding, as compared to drug therapy.3 There was no significant difference between a rate and rhythm control strategy, by intention to treat, since both strategies helped maintain left ventricular function and improved symptoms.4-5
Wearable technology such as smartwatches can monitor heart rate and detect atrial fibrillation events, as demonstrated in the preliminary results of the Apple Heart Study.6-7 Direct comparisons between wearable technologies and insertable cardiac monitors have also shown them to be highly sensitive in detecting atrial fibrillation when compared with an ICM.8
Lifestyle modifications using either wearable and/or implantable technology can be helpful in monitoring and managing atrial fibrillation. Current evidence suggests that moderate physical activity, healthy weight, tobacco and recreational drug abstinence, reduced alcohol intake, blood pressure control, and glycemic control if diabetic can help prevent atrial fibrillation.9-10
Maintenance dose beta-blockers without a typical Vaughan-Williams Class I or III antiarrhythmic effect have not been clearly demonstrated to prevent atrial fibrillation. However, they can reduce the likelihood of developing atrial fibrillation in patients with congestive heart failure.11 In addition, this category of medication has been shown to improve mortality in this cohort.
Based on the clinical findings in this case report, we have designed an animal study in order to test the hypothesis that prophylactic beta-blocker therapy prior to alcohol consumption can reliably minimize and/or prevent atrial fibrillation in a rat model. The study has been approved by the New York Institute of Technology College of Osteopathic Medicine’s Institutional Animal Care and Use Committee, and is well underway. The study utilizes a previously defined method of inducing atrial fibrillation in rats exposed to alcohol,12 and tests whether beta-blocker therapy or another class of drugs (dantrolene, a ryanodine receptor blocker) can have an impact on alcohol-induced atrial fibrillation. The study consists of four groups: a normal control group, an alcohol-exposed group, a beta-blocker subjected group immediately prior to alcohol exposure, and a ryanodine receptor blocker subjected group immediately prior to alcohol exposure. The results of this trial may shed light on the mechanisms of beta-blocker effectiveness in attenuating and/or preventing alcohol-induced atrial fibrillation. We look forward to presenting the results of this study in the near future.
Disclosures: The authors have no conflicts of interest to report regarding the content herein.
- Piano MR. Alcohol's Effects on the Cardiovascular System. Alcohol Res. 2017;38(2):219-241.
- Gémes K, Malmo V, Laugsand LE, et al. Does Moderate Drinking Increase the Risk of Atrial Fibrillation? The Norwegian HUNT (Nord‐Trøndelag Health) Study. J Am Heart Assoc. 2017;6(10).
- Packer DL, Mark DB, Robb RA, et al. Effect of Catheter Ablation vs Antiarrhythmic Drug Therapy on Mortality, Stroke, Bleeding, and Cardiac Arrest Among Patients With Atrial Fibrillation: The CABANA Randomized Clinical Trial. JAMA. 2019;321(13):1261-1274.
- Wyse DG, Waldo AL, DiMarco JP, et al. A Comparison of Rate Control and Rhythm Control in Patients with Atrial Fibrillation. N Engl J Med. 2002;347(23):1825-1833.
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- Turakhia MP, Desai M, Hedlin H, et al. Rationale and design of a large-scale, app-based study to identify cardiac arrhythmias using a smartwatch: The Apple Heart Study. Am Heart J. 2019;207:66-75.
- Turakhia MP, Desai M, Hedlin H, et al. Apple Heart Study demonstrates ability of wearable technology to detect atrial fibrillation. Published March 16, 2019. https://med.stanford.edu/news/all-news/2019/03/apple-heart-study-demonstrates-ability-of-wearable-technology.html. Accessed May 29, 2019.
- Wasserlauf J, You C, Patel R, Valys A, Albert D, Passman R. Smartwatch Performance for the Detection and Quantification of Atrial Fibrillation. Circ Arrhythm Electrophysiol. 2019;12(6):e006834.
- January CT, Wann LS, Alpert JS, et al. 2014 AHA/ACC/HRS Guideline for the Management of Patients With Atrial Fibrillation. J Am Coll Cardiol. 2014;64(21).
- Gorenek Chair B, Pelliccia Co-Chair A, Benjamin EJ, et al. European Heart Rhythm Association (EHRA)/European Association of Cardiovascular Prevention and Rehabilitation (EACPR) position paper on how to prevent atrial fibrillation endorsed by the Heart Rhythm Society (HRS) and Asia Pacific Heart Rhythm Society (APHRS). Eur J Prev Cardiol. 2016;24(1):4-40.
- Nasr IA, Bouzamondo A, Hulot JS, Dubourg O, Heuzey JY, Lechat P. Prevention of atrial fibrillation onset by beta-blocker treatment in heart failure: a meta-analysis. Eur Heart J. 2007;28(4):457-462.
- Yan J, Thomson JK, Zhao W, et al. Role of Stress Kinase JNK in Binge Alcohol-Evoked Atrial Arrhythmia. J Am Coll Cardiol. 2018;71(13):1459-1470.