Reduction in the recurrence of stroke by eicosapentaenoic acid for hypercholesterolemic patients: subanalysis of the JELIS trial

What should medical practitioners know about the role of alternative medicines in cardiovascular disease management?

Alternative medications as a term call up many different meanings, significance, and perceptions to various medical practitioners. Some are good; others are bad. A wide range of alternative medications with relevance or connection to cardiovascular (CV) disease have been considered. While many are worthless, others have definite benefit, and at least one, chelation therapy, is associated with definite harm, significant risk, no benefit, and enrichment of the practitioners who prescribe it. The issues concerning alternative therapies will likely never be studied with randomized clinical trials due to the lack of a profit motive on the part of pharmaceutical companies--only rarely do other institutions, such as the National Institutes of Health, support medicinal studies. Basic knowledge of alternative therapies is essential for the CV specialist and other practicing physicians and other practitioners, since at least a few of their patients will take these medications regardless of medical advice. The result is that a number of these alternative medications will then interact with conventional CV medications, many times unfavorably.

Management of Cholesterol to Reduce the Burden of Stroke in Asia: Consensus Statement

Stroke is a major cause of morbidity and mortality in Asia, and its pattern is changing. The incidence of haemorrhagic stroke is declining while the incidence of ischaemic stroke caused by large artery atherothromboembolism is increasing secondary to an increase in the prevalence of hypercholesterolemia. The Working Group on Stroke and Lipids Management in Asia Consensus Panel assembled leading experts from the region to reach a consensus on how to address this challenge. The group discussed the observational epidemiology of the relationship between cholesterol and risk of stroke, the clinical trial evidence base for cholesterol-lowering for stroke prevention, and issues specific to stroke and lipid management for Asian doctors and patients. Stroke guidelines from many of the Asian countries have recently recommended consideration of statins for recurrent stroke prevention in patients with previous ischaemic stroke or transient ischaemic attack. However, because these recommendations have yet to be

Preventive effects of eicosapentaenoic acid on coronary artery disease in patients with peripheral artery disease

BACKGROUND

The JELIS trial examined the preventive effects of eicosapentaenoic acid (EPA) on coronary artery disease (CAD) in hypercholesterolemia. Previous investigators have reported that patients with peripheral artery disease (PAD) have a poor prognosis due to the potential risk for CAD. We conducted a subanalysis to examine whether the incidence of CAD was high in patients with PAD and whether EPA prevented the occurrence of CAD.

METHODS AND RESULTS

Of 18,645 the Japan EPA lipid intervention study (JELIS) patients, 223 had PAD (control group; complicated (n=77), newly diagnosed (n=29), EPA group; complicated (n=96), newly diagnosed (n=21)). We analyzed the incidence of major coronary events (MCE) in the 2 groups. Cox proportional hazard ratio adjusted for baseline risk factor levels was used to test differences between the 2 groups. The incidence of MCE in the control group was significantly higher in patients complicated with PAD and in those newly diagnosed with PAD than in patients without PAD (complicated: hazard ratio 1.97, P=0.039; newly diagnosed: hazard ratio 2.88, P=0.030). As for patients with PAD, the EPA group had a significantly lower MCE hazard ratio than the control group (hazard ratio 0.44, 95% confidence interval 0.19-0.97, P=0.041).

CONCLUSIONS

Subanalysis of the JELIS trial demonstrated that in patients with PAD the incidence of CAD was higher than in controls, and that EPA markedly reduced the occurrence of CAD in those patients.

Low level of n-3 polyunsaturated fatty acids in erythrocytes is a risk factor for both acute ischemic and hemorrhagic stroke in Koreans

Evidence suggesting an association between n-3 polyunsaturated fatty acids (PUFA) and stroke risk has been inconsistent, possibly because previous studies have not differentiated between different stroke types. The present study investigated the hypothesis that tissue levels of n-3 PUFA are positively associated with hemorrhagic stroke and negatively associated with ischemic stroke. We recruited 120 subjects for this case-control study, with 40 cases each of hemorrhagic stroke, ischemic stroke, and unaffected controls. Patients with a family history of hemorrhagic stroke had a significantly increased risk for hemorrhagic stroke. Omega-3 Index (20:5n3 + 22:6n3 in erythrocytes) and 22:6n3 were negatively (P < .01) associated with the risk of both hemorrhagic and ischemic stroke in multivariate analyses. Saturated fatty acids 16:0 and 18:0 were positively associated, whereas 18:2n6 and 18:3n6 were negatively (P < .05) associated with risk of ischemic stroke. Monounsaturated fatty acid, 18:1n9, increased (P = .03) the odds of hemorrhagic stroke. Omega-3 Index and docosahexaenoic acid were significantly lower in patients with both subtypes of hemorrhagic stroke, subarachnoid and intracerebral hemorrhage, but only in one subtype of ischemic stroke, small-artery occlusion. Saturated fatty acids 16:0 and 18:0 were significantly higher, but 20:4n6 was significantly lower, in patients with small-artery occlusion. Linoleic acid was significantly lower in patients with small-artery occlusion and large-artery atherosclerosis, whereas 18:1n9 was higher in both subgroups of hemorrhagic stroke. In conclusion, the results of our case-control study suggest that erythrocyte n-3 PUFA may protect against hemorrhagic stroke and ischemic stroke, particularly in the case of small-artery occlusion.

Omega-6 and omega-3 fatty acids: partners in prevention

PURPOSE OF REVIEW

This review addresses the cardiovascular benefits of the two families of essential polyunsaturated fatty acids (FAs): omega-6 and omega-3. The former (and the shorter chain species of the latter) are found in vegetable oils and nuts, whereas the longer chain omega-3 FAs are found in fish oils. Although most clinicians understand that the omega-3 FAs are beneficial, there have been calls in the popular press to reduce the intake of the omega-6 FAs because of presumed proinflammatory and prothrombotic effects.

RECENT FINDINGS

The American Heart Association's Nutrition Committee has published two 'Science Advisories', one in 2002 on omega-3 FAs and a new one on omega-6 FAs. Both considered a wide variety of data regarding their effects on cardiac risk.

SUMMARY

The AHA concludes that Americans need to increase their intake of long-chain omega-3 FAs and that they should maintain (and possibly even increase) their intakes of omega-6 FAs. For the omega-3 FAs, a healthy target intake is about 500 mg per day (whether from oily fish or fish oil capsules) and for linoleic acid, approximately 15 g per day (12 g for women and 17 g for men). Achieving healthy intakes of both omega-6 and omega-3 FAs is an important component of the nutritional prevention and treatment of coronary heart disease.

Diminished omega-3 fatty acids are associated with carotid plaques from neurologically symptomatic patients: Implications for carotid interventions

The omega-3 fatty acids, eicosapentaenoic acid (EPA) and docosahexaenoic acid (DHA), are prevalent in fish oil and their cardioprotective effects are thought to be mediated by anti-inflammatory mechanisms. The aim of this study is to determine whether omega-3 fatty acids are associated with carotid plaques from neurologically symptomatic patients. Plaques were obtained from 41 patients (mean age 62 [44-84]; 24-asymptomatic, 17-symptomatic). Intra-plaque lipids were assessed with mass spectrometry. Compared to asymptomatic patients, significantly diminished omega-3 fatty acids DHA (545.8+/-98 ng/g vs. 270.7+/-19.6 ng/g, p=0.0096) and EPA (385.9+/-68 ng/g vs. 216.4+/-17.6 ng/g, p=0.0189) were found in carotid plaques from neurologically symptomatic patients. However, no differences were found in the levels of the omega-6 fatty acid arachidonic acid (p=0.2003). Immunohistochemistry and ELISA analysis (CD68(+) cells, 0.461+/-0.04 vs. 0.312+/-0.03, p=0.003) demonstrated an increased inflammatory infiltrate in plaques from neurologically symptomatic, compared to asymptomatic, patients. Carotid plaques from neurologically symptomatic patients are inflammatory and have decreased intra-plaque levels of omega-3 fatty acids. Future trials will determine whether interventions that increase omega-3 fatty acid incorporation into carotid plaques prevent stroke and improve the safety of carotid interventions.

Towards establishing dietary reference intakes for eicosapentaenoic and docosahexaenoic acids

There is considerable interest in the impact of (n-3) long-chain PUFA in mitigating the morbidity and mortality caused by chronic diseases. In 2002, the Institute of Medicine concluded that insufficient data were available to define Dietary Reference Intakes (DRI) for eicosapentaenoic acid (EPA) or docosahexaenoic acid (DHA), noting only that EPA and DHA could contribute up to 10% toward meeting the Adequate Intake for alpha-linolenic acid. Since then, substantial new evidence has emerged supporting the need to reassess this recommendation. Therefore, the Technical Committee on Dietary Lipids of the International Life Sciences Institute North America sponsored a workshop on 4-5 June 2008 to consider whether the body of evidence specific to the major chronic diseases in the United States--coronary heart disease (CHD), cancer, and cognitive decline--had evolved sufficiently to justify reconsideration of DRI for EPA+DHA. The workshop participants arrived at these conclusions: 1) consistent evidence from multiple research paradigms demonstrates a clear, inverse relation between EPA+DHA intake and risk of fatal (and possibly nonfatal) CHD, providing evidence that supports a nutritionally achievable DRI for EPA+DHA between 250 and 500 mg/d; 2) because of the demonstrated low conversion from dietary ALA, protective tissue levels of EPA+DHA can be achieved only through direct consumption of these fatty acids; 3) evidence of beneficial effects of EPA+DHA on cognitive decline are emerging but are not yet sufficient to support an intake level different from that needed to achieve CHD risk reduction; 4) EPA+DHA do not appear to reduce risk for cancer; and 5) there is no evidence that intakes of EPA+DHA in these recommended ranges are harmful.