From the Guidelines
Alcohol consumption should be reduced to ≤3 standard drinks (≤30 grams of alcohol) per week in patients with atrial fibrillation (AF) to minimize the risk of adverse events, including thromboembolism, death, or AF-related hospitalization, as recommended by the 2024 ESC guidelines 1. Management options for AF in patients who consume alcohol should include both alcohol reduction strategies and standard AF treatments.
- Patients should be strongly advised to reduce or eliminate alcohol consumption, as even moderate drinking can trigger or worsen AF episodes.
- Complete abstinence is ideal, particularly for those with alcohol-triggered AF ("holiday heart syndrome").
- Standard AF management should still be implemented based on the patient's specific presentation, including:
- Rate control medications (beta-blockers like metoprolol 25-100mg twice daily, calcium channel blockers like diltiazem 120-360mg daily)
- Rhythm control medications (amiodarone 200mg daily, flecainide 50-200mg twice daily)
- Anticoagulation therapy (direct oral anticoagulants like apixaban 5mg twice daily or warfarin with target INR 2-3) based on stroke risk assessment using the CHA₂DS₂-VASc score
- Patients should be monitored for both AF recurrence and alcohol withdrawal symptoms if they were heavy drinkers. Alcohol reduction is particularly important because alcohol consumption increases AF risk in a dose-dependent manner by causing direct cardiac toxicity, autonomic nervous system changes, and electrolyte disturbances that create an arrhythmogenic substrate in the atria, as supported by the 2024 ESC guidelines 1.
From the Research
Management Options for Atrial Fibrillation in Patients who Consume Alcohol
- The management of atrial fibrillation (AF) in patients who consume alcohol involves several strategies, including reducing or abstaining from alcohol consumption, as it has been shown to trigger AF episodes and increase the risk of complications 2, 3, 4.
- Beta-blockers are often used to control the ventricular rate during AF and to maintain sinus rhythm, and are considered a first-line treatment for patients with AF, especially after myocardial infarction and in those with chronic heart failure and arterial hypertension 5, 6.
- The use of AV-nodal conduction-slowing drugs, such as calcium channel antagonists and beta-blockers, can also be effective in controlling the ventricular rate during AF 5.
- Reducing excessive alcohol consumption has been shown to reduce the risk of recurrent AF episodes and AF burden, and should be avoided for primary and secondary prevention of AF 3, 4.
Alcohol Consumption and Atrial Fibrillation Risk
- Acute alcohol consumption can trigger AF episodes, and habitual consumption is associated with adverse atrial remodeling, higher risk of incident AF, and AF recurrence 2, 3, 4.
- The association between low and moderate levels of alcohol consumption and the risk of AF is unclear, but heavy alcohol consumption appears to increase the risk of complications in patients with AF 2.
- Alcohol should be classified as a modifiable risk factor for atrial fibrillation, and also for heart disease in general 4.
Treatment Considerations
- Beta-blockers may be the first line of treatment to maintain sinus rhythm, especially after myocardial infarction and in patients with chronic heart failure and in those with arterial hypertension 5.
- However, recent evidence has questioned the use of beta-blockers as a preferred rate-control therapy in patients with atrial fibrillation, and further research is needed to determine the best treatment approach 6.