We wish to highlight the potential for acute alcohol withdrawal to cause sudden cardiac death by precipitating acute coronary events and fatal cardiac arrhythmias and present some cases in our hospital that relate to this. There are a few case reports published in this regard [1-3]. In addition a prospective study of electrocardiographic (ECG) tracings of 19 patients in alcohol withdrawal showed that seven of them had horizontal or down sloping ‘suspicious’ ST segment depressions though none of them complained of clinical symptoms .
We did a prospective study of analyzing ECG changes of patients admitted with alcohol withdrawal to two tertiary care units in Sri Lanka (University Medical Unit of the National Hospital of Sri Lanka and National Institute of Mental Health, Sri Lanka). Institutional ethical clearance was obtained for the study. Over a 4 month period we recruited 20 patients. All fulfilled the clinical diagnostic criteria for alcohol withdrawal (International classification of diseases—10). We paid special attention to cardiac symptoms such as chest pain and palpitations and took daily 12-lead ECG recordings during their hospital stay. Echocardiographic findings and cardiac troponin enzyme assessments were also taken into account; if these were available (requesting these was at the discretion of the treating physician). The ECGs were independently interpreted by a cardiologist who was not part of the study team.
Of the total sample, five (25%) complained of chest pain and in two (10%) it was ischaemic in nature. Seven (35%) had palpitations. Two patients with ischaemic type chest pain had dynamic changes in their ECGs (patient 6—T inversions in leads V3 and V4, patient 13—T inversions in leads L1/aVL/V5 and V6). They could not afford a cardiac troponin assessment which could have helped to differentiate between unstable angina and non ST elevation myocardial infarction. They were both treated as for an acute coronary event. Of other significant findings, one patient had a previously undiagnosed right bundle branch block and sinus tachycardia was seen among seven (35%).
There are several theories as to how withdrawal states may precipitate acute coronary events such as; stimulation of coronary vessels by a withdrawal-induced adrenergic surge, imbalance of α and β adrenergic stimulation of coronaries , long term alcohol induced structural damage limiting coronary autoregulation at times of stress , magnesium deficiency and autonomic neuropathy .
While these theories should be further explored, what we have highlighted here is an important clinical statement. That is, the risk for sudden cardiac deaths during alcohol withdrawal is often overlooked and under-appreciated. The first step in saving these patients is to be aware of the problem. We propose that acute coronary events should be suspected in all patients in alcohol withdrawal. They should be kept under observation with frequent ECG recordings as many will not complain of symptoms due to delirium. This is an area requiring the urgent attention of clinicians and researchers to avoid preventable deaths.
Declarations of interest