Risk of Cryptogenic Ischemic Stroke in Young Adults Significantly Increased Through Heavy Alcohol Consumption

Nicholas Martinez-Majander, MD, PhD, MSc

Recently published findings from a multicenter study showed a strong association between heavy alcohol consumption, particularly binge drinking, and young-onset cryptogenic ischemic stroke (CIS), independent from coexisting stroke risk factors. These data further support reducing alcohol consumption as a lifestyle intervention in young adults to mitigate their risk of ischemic stroke, including CIS.¹

Led by Nicholas Martinez-Majander, MD, PhD, MSc, a neurologist at the Stroke Unit and Research Center at Helsinki University Hospital, the study included 540 patients with CIS (median age, 41 years) and 540 age- and sex-matched controls with detailed data on alcohol consumption available. Of all patients, 25.7% had a National Institutes of Health Stroke Scale (NIHSS) score of 0, 50.6% had mild strokes (NIHSS 1-4), 14.0% had moderate strokes (NIHSS 5-9), and 9.9% had severe strokes (NIHSS ≥10).

When comparing the groups, more patients with heavy alcohol consumption had more severe strokes than those without (mild strokes: 44.6% vs 51.4%; moderate strokes: 24.3% vs 12.3%; severe strokes: 12.2% vs 9.5%; P = .027). Using a univariate analysis, patients with CIS were more likely to be heavy alcohol users compared with controls (13.7% vs 6.7%; P <.001). Case-control analyses stratified by age groups showed that this difference was significant in men aged 18-34 years (32.3% vs 11.3%; P = .004) but not in other age groups.

Those with CIS were more likely to have a history of hypertension, and they were more often current smokers, overweight, less educated, physically inactive, and had more unhealthy diet. Investigators recorded a significant association between heavy alcohol consumption and young-onset CIS (OR, 2.56; 95% CI, 1.61-4.06; P <.001), which remained significant after adjustment for demographics (OR, 1.38-3.74; P = .001) and for further vascular risk factors (OR, 2.11; 95% CI, 1.22-3.63; P = .007).

"Mechanisms associated with heavy alcohol consumption and CIS include, for instance, adverse effects on hemostasis, fibrinolytics, blood clotting and subclinical cardiac arrhythmias, excluding documented AF," the study authors noted. "Heavy drinkers may also be more likely to suffer from head and neck trauma predisposing cervical or intracranial artery dissection and subsequent IS, although such mechanisms are not likely in CIS. Moreover, excessive alcohol consumption can predispose other risk factors including hypertension and visceral obesity, but also more acute conditions such as cerebral vasospasm."

READ MORE: Stroke: A Looming Threat for Younger Adults

There was no association found in women alone between heavy alcohol consumption and CIS when adjusting for demographics (OR, 1.58; 95% CI, 0.77-3.25; P = .215), nor in a fully adjusted model including demographics and vascular risk factors (OR, 1.56; 95% CI, 0.71-3.41; P = .267). For men, exploratory data revealed a significant association in the youngest men, with odds ratios of 12.11 (95% CI, 1.54-95.47; P = .018); however, there was no formal interaction between heavy alcohol consumption and age group in men (P for interaction = 0.665).

Heavy alcohol consumption was defined as more than 7 (women) and 14 (men) units per week or at least an average of 2 times per month in at least 5 (women) and 7 (men) units per instance (binge drinking). When focusing on binge drinkers, similar associations were found on univariate comparison for the entire study population (11.7% vs 4.8%; P <.001) and in men (15.1% vs 4.9%; P <.001) but not in women. Overall, the association with young-onset CIS was also significant in the entire population (fully adjusted OR, 2.43; 95% CI, 1.31-4.53; P = .005) and in men (fully adjusted OR, 3.36; 95% CI, 1.44-7.84; P = .005), but again, not in women (fully adjusted OR, 1.50; 95% CI, 0.58-3.92; P = .404).

The study had some limitations, including some selection bias with patients, as those more debilitating symptoms may have been left out. Because the data was collected mainly during hospitalization or shortly after discharge, there was a lack of information on the frequency, for instance, of newly-onset atrial fibrillation later diagnosed with an implantable loop recorder (IRL) or home telemetry. "However, the use of IRLs and external ECG recorders have become more prevalent only in recent years and were seldom used during the study’s recruitment," the study authors wrote.

REFERENCE
1. Martinez-Majander N, Kutal S, Ylikotila P, et al. Association between heavy alcohol consumption and cryptogenic ischemic stroke in young adults: a case-control study. Neurol, Neurosurg, and Psych. Published online June 21, 2024. doi:10.1136/jnnp-2024-333759