Alcohol use disorder (AUD) is a leading cause of disability and mortality globally. [1] AUD has been linked with at least 60 acute and chronic comorbidities across the lifespan, including higher risks of cardiovascular disease (CVD), [1] which is the leading cause of death worldwide. [2] Men or women with heavy alcohol use (generally >2 drinks/day) have been reported to have 1.5- to 3-fold risks of ischemic heart disease (IHD), stroke, heart failure, or atrial fibrillation. [3], [4], [5], [6], [7], [8] The underlying mechanisms include alcohol-related cardiotoxic and metabolic effects as well as co-occurring behavioral risk factors. [9], [10] CVD comorbidities frequently have a high burden of symptoms and lifestyle limitations, which may also contribute to psychosocial distress and poor mental health. [11], [12], [13], [14], [15], [16]

Prior studies have consistently reported higher risks of suicide death in people with AUD, including 3- to 4-fold risks after accounting for other mental disorders, [17], [18], [19] and even higher risks shortly after AUD registration. [20], [21] Family-based analyses have suggested underlying causal relationships [20] that may include direct effects of AUD on psychosocial distress, [22] social isolation, or depression. [23] However, despite high risks of both CVD and suicide, no studies to our knowledge have examined the influence of CVD on suicide risks in a large population-based cohort with AUD. Such knowledge would advance our understanding of the role of major comorbidities in suicide risk pathways and may help guide interventions to improve long-term health and survival in persons with AUD.

We sought to address these knowledge gaps using nationwide data for more than 500,000 people with AUD in Sweden. Our primary goals were to determine suicide risks associated with major CVD comorbidities in a large population-based cohort with AUD, and to examine whether such risks differ in men and women, because of known sex-specific differences in both CVD [24] and suicide. [25] We hypothesized that CVD comorbidities would be associated with higher risk of suicide death in both men and women with AUD.