Young and middle-aged women who average more than one alcoholic beverage a day are more likely to develop coronary heart disease than peers who drink less, according to a new study that will be presented in April at the American College of Cardiology’s Annual Scientific Session.

While that risk is especially high among binge drinkers, whether men or women, the researchers find the link between alcohol and heart disease particularly strong for women.

“When it comes to binge drinking, both men and women with excess alcohol consumption had a higher risk of heart disease,” said Dr. Jamal Rana, a cardiologist with The Permanente Medical Group, adjunct investigator in the Division of Research at Kaiser Permanente Northern California and the study’s lead author, in a written statement. “For women, we find consistently higher risk even without binge drinking. I wasn’t expecting these results among women in this lower age group because we usually see increased risk for heart disease among older women. It was definitely surprising.”

Coronary artery disease is the most common form of heart disease and the leading cause of death in the U.S. for women, according to the Centers for Disease Control and Prevention. Plaque in the walls of the arteries limits blood flow to the heart and other parts of the body. After menopause, hormone changes increase the risk of coronary artery disease, but many have considered risk low for younger women. This study casts doubt on that if women drink. Other common heart disease types in women are arrhythmia and heart failure.

Per the release, alcohol is known to raise blood pressure and cause metabolic changes that are associated with inflammation and obesity. Additionally, men and women process alcohol differently.

“When it comes to heart disease, the No. 1 thing that comes to mind is smoking and we do not think about alcohol as one of the vital signs,” Rana said. “I think a lot more awareness is needed, and alcohol should be part of routine health assessments moving forward.”

He told The Washington Post that alcohol use among young and middle-aged women has been increasing “as women may feel they’re protected against heart disease until they’re older, but this study shows that even in that age group, women who drink more than the recommended amount of one drink per day or tend to binge drink are at risk for coronary heart disease.”

Risk rises with consumption

According to a news release from the American College of Cardiology, “The study focused on 18- to 65-year-old adults and is among the largest and most diverse studies to date examining the links between alcohol and heart disease. Heart attacks and other forms of heart disease are on the rise in younger populations in the U.S., fueling concern about worsening health outcomes. At the same time, alcohol use and binge drinking have become more common among women than in previous decades.”

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Data from more than 430,000 people who were cared for by Kaiser Permanente Northern California providers was used, including 243,000 men and 189,000 women. Participants were an average of 44 years old and didn’t have heart disease when the study began. During primary care visits in 2014 and 2015, each was asked about alcohol intake and provided visual references to help calculate how much alcohol they drank.

The researchers considered one to two drinks a week for both men and women to be low intake, while moderate intake for men was three to 14 drinks in a week and three to seven for women. High intake was 15 or more drinks weekly for men and eight or more for women. They separately assessed binge drinking — more than four drinks for men and more than three for women in a single day during the past three months.

They excluded nondrinkers from the study and also adjusted for age, physical activity, smoking and other known cardiovascular risks.

In all, 3,108 study participants were diagnosed with cardiovascular disease in the four years they tracked after the initial assessment, the incidence rising as alcohol consumption increased. Women who reported high alcohol intake but not binge drinking had a 45% higher risk of heart disease than those with low intake, and 29% higher than those with moderate consumption. Those who binged were 68% more likely to develop heart disease compared to those with moderate intake.

Men who had high levels of alcohol consumption were 33% more likely to develop heart disease than those with moderate intake, per the study, funded by the National Institutes of Health and the National Institute on Alcohol Abuse and Alcoholism.