How Alcohol Affects Heart Failure

Medically Reviewed by Brunilda Nazario, MD on January 25, 2021
5 min read

Asking heart failure patients about their alcohol habits is something cardiologist David Brown, MD, does every day. So he was surprised when one of them, an older man who always told Brown that he didn’t drink, was contradicted by his wife when she came along for his checkup.

“She looked incredulously at me and said, ‘I would have been divorced long ago if I didn’t allow him his one martini each night,’ ” recalls Brown, a professor of medicine in the Cardiovascular Division at Washington University School of Medicine in St. Louis. “I think he assumed that I was asking him about his alcohol use because if he answered yes, I would tell him to stop.”

Many people with heart failure hesitate to talk to their doctors about alcohol, even if they’re not heavy drinkers, heart experts say. There’s no standard recommendation about whether it’s OK for people with heart failure. But it’s an important issue, because people with heart failure usually need to make lifestyle changes to manage their symptoms well.

“The issue was important enough to him that he kept the truth from his doctor,” Brown explains. “We owe it to our patients with heart failure to tell them that there’s really no evidence of harm and possibly some benefit of alcohol and to acknowledge that quality of life is as important as quantity.”

A lot of research has focused on the link between alcohol and heart health, with conflicting results. Some studies have shown that moderate drinking -- one drink a day for women and two for men -- leads to lower risks of dying from heart disease. One drink generally means a 12-ounce beer, a 6-ounce glass of wine, or a 1½-ounce shot of liquor.

Other studies have suggested that moderate drinking can slightly raise levels of “good” HDL cholesterol. And alcohol appears to cut the chances of blood clots that can lead to heart attacks and strokes, Brown says.

“In general, alcohol is considered protective for heart disease,” Brown says. “And based on all the studies, there’s really no signal that a small amount of alcohol consumed on a regular basis is harmful to the heart.”

But is it true that a little bit of drinking can help with heart failure? Not enough research has addressed this issue, he notes.

Brown co-authored one of the few studies that looked into it. It showed that people 65 and older who had heart failure and drank moderately lived an average of about a year longer than those who never drank.

As with studies suggesting that alcohol benefits overall heart health, Brown says, his research couldn’t prove that it caused heart failure patients to live longer. Other factors might also have influenced the results, he says.

“If you don’t drink, I wouldn’t recommend you start,” Brown says. “But if you enjoy a cocktail or a glass of wine, having one a night for women and one to two per night for men is probably not going to harm you.”

It’s important to note that one form of heart failure is directly caused by alcohol, experts say. Alcoholic cardiomyopathy (ACM) can be blamed on excess or binge drinking.

“Alcoholic cardiomyopathy is heart weakness due to alcohol. It’s rare, and you have to drink a lot of alcohol on a regular basis, and it probably also has some kind of genetic predisposition to it,” Brown explains. “Certainly, no one should drink eight or 10 drinks or a case of beer a day.”

For those who already have heart failure, there’s little scientific evidence that light or moderate drinking can make your condition worse, says Kenneth Mukamal, MD, an associate professor of medicine at Beth Israel Deaconess Medical Center in Boston, who has researched heart failure and drinking.

“It’s interesting that many people have taken a rather simplistic view that if alcohol can cause cardiomyopathy, it must therefore worsen heart failure at even lower doses,” Mukamal says. “But there’s not really any proof of that.”

But heavy drinking might indirectly make your heart failure or its symptoms worse, experts say. It might:

  • Raise your blood pressure. “One notable effect of excess alcohol is, it can raise blood pressure,” Brown explains. “We like to keep heart failure patients with the lowest blood pressure possible, because it means their heart has to do less work.”
  • Raise your heart rate, which also makes the heart work harder.
  • Contribute to obesity. “Mixed drinks and cocktails in particular tend to have high sugar amounts, so they’re caloric,” Brown says. “A glass of wine is 60 to 90 calories, but a margarita can be 300 to 400. If you have two, that adds up to a lot of extra calories that can be unhealthy over time.”

In addition to adding to the heart’s workload, Brown says, extra pounds can make you sluggish and hinder physical activity. This could lead to more swelling in your legs, a common heart failure symptom.

When you drink alcohol, your liver breaks it down. But heavy drinking can affect how well the liver can make proteins that help control blood clotting. That’s the main way drinking can interfere with medications commonly taken by people with heart failure -- specifically certain blood thinners, Brown and Mukamal say.

“My biggest concern with drinking is with blood thinners, because we know that alcohol acts as a little bit of a blood thinner by itself,” Mukamal explains. “If you’re taking blood thinners, your risk of bleeding goes up, and you should definitely talk to your doctor about whether it’s safe to drink.”

Like Brown, many doctors already ask heart failure patients about their drinking habits. But you can also bring up the subject on your own, especially if you’re having trouble controlling your blood pressure, Mukamal says. Some medications for many kinds of conditions can cause blood pressure to drop when you stand up, especially if your heart isn’t pumping well, and drinking can add to this dizziness.

If your heart failure is controlled with medication and you’re not retaining fluids, Mukamal and Brown are OK with alcohol, but no more than one drink a day for women and two for men.

“There are studies that clearly suggest that small levels of drinking within those recommended limits” tend to be linked with the best outcomes for people with heart failure, Mukamal says. “It’s not a recommendation for drinking, but potentially evidence that they don’t need to stop.”