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HES provides information on all hospital admissions and ONS on cause specific mortality records for all deaths in England and Wales.

Information is coded with the hierarchical clinical coding schemes (Read codes,35 ICD-10 (international statistical classification of diseases, 10th revision), and Office of the Population Censuses and Surveys classification of interventions and procedures36).

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.

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).

We included 1 937 360 anonymised patients from the CALIBER (CArdiovascular research using LInked Bespoke studies and Electronic health Records) programme.29 Details of the enrolment, follow-up, and data sources are presented in the appendix.

Main outcome measures 12 common symptomatic manifestations of cardiovascular disease, including chronic stable angina, unstable angina, acute myocardial infarction, unheralded coronary heart disease death, heart failure, sudden coronary death/cardiac arrest, transient ischaemic attack, ischaemic stroke, intracerebral and subarachnoid haemorrhage, peripheral arterial disease, and abdominal aortic aneurysm.

CPRD patients are representative of the UK population in terms of age, sex, ethnicity,3031 and overall mortality32 and have been validated for epidemiological research.33 Patient CPRD data were further linked with three other data sources: the Myocardial Ischaemia National Audit Project registry (MINAP)34; hospital episodes statistics (HES); and the Office for National Statistics (ONS).

MINAP is a national registry of patients admitted to hospital with acute coronary syndromes in England and Wales.

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.

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