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This has implications for counselling patients, public health communication, and clinical research, suggesting a more nuanced approach to the role of alcohol in prevention of cardiovascular disease is necessary.The relation between alcohol consumption and cardiovascular disease is both complex and controversial.12 There have been multiple systematic reviews and meta-analyses of the association between consumption and aggregated cardiovascular disease,1234567 as well as cardiovascular traits.189 Most have shown that, compared with non-drinking, moderate levels of alcohol intake are associated with a lower risk of morbidity and mortality from cardiovascular disease, as well as more favourable cardiovascular health profiles in general.Linked electronic health record data can be re-used to create cohorts of sufficient size and of satisfactory clinical resolution to be able to carry out such research.1820 Studies using linked electronic health record data in the context of cardiovascular disease have shown heterogeneous associations between disease phenotypes and various exposures, including sex, blood pressure, type 2 diabetes, and smoking.2122232425262728We used linked electronic health record data to create a contemporary cohort with a median of six years of follow-up (11 637 926 person years) to investigate for the first time at large scale and within the same study whether the association with alcohol consumption differs across a wide range of incident cardiovascular diseases that are recognised to have different biological mediators.In addition to increased endpoint resolution, we also separated non-drinkers from former and occasional drinkers to provide to additional clarity in this debate.Heavy drinking (exceeding guidelines) conferred an increased risk of presenting with unheralded coronary death (1.21, 1.08 to 1.35), heart failure (1.22, 1.08 to 1.37), cardiac arrest (1.50, 1.26 to 1.77), transient ischaemic attack (1.11, 1.02 to 1.37), ischaemic stroke (1.33, 1.09 to 1.63), intracerebral haemorrhage (1.37, 1.16 to 1.62), and peripheral arterial disease (1.35; 1.23 to 1.48), but a lower risk of myocardial infarction (0.88, 0.79 to 1.00) or stable angina (0.93, 0.86 to 1.00).Conclusions Heterogeneous associations exist between level of alcohol consumption and the initial presentation of cardiovascular diseases.Further details, including a diagram depicting our coding scheme (fig B) plus a full list of the exact Read codes used to define drinking categories (table B) as well as a series of proof of concept validation analyses of the association between these groups and cardiovascular traits (fig C), are available in the appendix.

In light of current debates on the U or J shaped relation observed between consumption and aggregated cardiovascular disease outcomes we defined five categories of drinking: non-drinkers (Read codes such as “teetotaller” and “non-drinker”), former drinkers (those with codes for “stopped drinking alcohol” and/or “ex-drinker”), occasional drinkers (those with codes for “drinks rarely” and/or “drinks occasionally”), current moderate drinkers (codes such as “alcohol intake within recommended sensible limits” and “light drinker”), and heavy drinkers (codes including “alcohol intake above recommended sensible drinking limits” and “hazardous alcohol use”).Results 114 859 individuals received an incident cardiovascular diagnosis during follow-up.Non-drinking was associated with an increased risk of unstable angina (hazard ratio 1.33, 95% confidence interval 1.21 to 1.45), myocardial infarction (1.32, 1.24 to1.41), unheralded coronary death (1.56, 1.38 to 1.76), heart failure (1.24, 1.11 to 1.38), ischaemic stroke (1.12, 1.01 to 1.24), peripheral arterial disease (1.22, 1.13 to 1.32), and abdominal aortic aneurysm (1.32, 1.17 to 1.49) compared with moderate drinking (consumption within contemporaneous UK weekly/daily guidelines of 21/3 and 14/2 units for men and women, respectively).There is, however, a growing scepticism around this observation, with recent commentary pieces pointing out several methodological shortcomings in the evidence on which the U shape is based.101112 These include failure to have disaggregated the current non-drinking group into lifelong abstainers, former drinkers, and those who drink on an occasional basis.It is known that former drinkers (who might have quit for health reasons) have an increased risk of mortality from cardiovascular disease13 compared with lifelong non-drinkers; therefore combination of these two groups is likely to lead to the overestimation of the protective effects of moderate drinking.

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