Plasma-free eicosapentaenoic acid/arachidonic acid ratio: a possible new coronary risk factor

Metabolic indices of polyunsaturated fatty acids: current evidence, research controversies, and clinical utility

The n-3 and n-6 polyunsaturated fatty acids (PUFA) are among the most studied nutrients in human metabolism. In the past few decades, prospective studies and controlled trials have supported the view that the effects of these essential fatty acids are clinically relevant. PUFA profiles in different blood compartments are reflections of both diet and metabolism, and their levels may be related to disease risk. Despite widespread interest, there is no consensus regarding which biomarkers best reflect PUFA status in the body. The measurement of PUFA levels is not straight-forward, and a wide variety of indices have been used in clinical studies, producing conflicting results. A major source of heterogeneity among studies is associated with research design, sampling, and laboratory analyses. To date, the n-3 index, n-6/n-3 ratio, and arachidonic acid (AA)/eicosapentaenoic acid (EPA) ratio are the most promising biomarkers associated with PUFA metabolism. Although hotly debated, these indices may be considered at least markers, if not risk factors, for several diseases, especially cardiovascular events and brain disorders. Here, we summarize the most updated evidence of n-3 and n-6 PUFA effects on human health, reviewing current controversies on the aforementioned indices and whether they can be considered valuable predictors of clinical outcomes.

The eicosapentaenoic acid:arachidonic acid ratio and its clinical utility in cardiovascular disease

Eicosapentaenoic acid (EPA) is a key anti-inflammatory/anti-aggregatory long-chain polyunsaturated omega-3 fatty acid. Conversely, the omega-6 fatty acid, arachidonic acid (AA) is a precursor to a number of pro-inflammatory/pro-aggregatory mediators. EPA acts competitively with AA for the key cyclooxygenase and lipoxygenase enzymes to form less inflammatory products. As a result, the EPA:AA ratio may be a marker of chronic inflammation, with a lower ratio corresponding to higher levels of inflammation. It is now well established that inflammation plays an important role in cardiovascular disease. This review examines the role of the EPA:AA ratio as a marker of cardiovascular disease and the relationship between changes in the ratio (mediated by EPA intake) and changes in cardiovascular risk. Epidemiological studies have shown that a lower EPA:AA ratio is associated with an increased risk of coronary artery disease, acute coronary syndrome, myocardial infarction, stroke, chronic heart failure, peripheral artery disease, and vascular disease. Increasing the EPA:AA ratio through treatment with purified EPA has been shown in clinical studies to be effective in primary and secondary prevention of coronary artery disease and reduces the risk of cardiovascular events following percutaneous coronary intervention. The EPA:AA ratio is a valuable predictor of cardiovascular risk. Results from ongoing clinical trials will help to define thresholds for EPA treatment associated with better clinical outcomes.

Icosapent Ethyl Effects on Fatty Acid Profiles in Statin-Treated Patients With High Triglycerides: The Randomized, Placebo-controlled ANCHOR Study

Introduction

Fatty acid content in plasma and red blood cells (RBCs) may provide insight into potential physiologic benefits of omega-3 fatty acids. Icosapent ethyl is a pure prescription form of eicosapentaenoic acid (EPA) ethyl ester approved by the US Food and Drug Administration at a dose of 4 g/day as an adjunct to diet to reduce triglyceride levels in adults with severe (≥ 500 mg/dl) hypertriglyceridemia.

Methods

This was a prespecified exploratory subset analysis of the ANCHOR study, which randomized 702 statin-treated patients at increased cardiovascular risk with triglycerides 200–499 mg/dl and controlled low-density lipoprotein cholesterol (40–99 mg/dl). This analysis examined effects of icosapent ethyl 4 g/day versus placebo on fatty acid levels in plasma and RBCs using a gas chromatograph assay method with flame ionization detector.

Results

In plasma, treatment with icosapent ethyl 4 g/day resulted in significant increases versus placebo in the mean concentrations of EPA (+ 635%; P < 0.0001) and its metabolite, docosapentaenoic acid n-3 (+ 143%; P < 0.0001) with no significant change in docosahexaenoic acid. Treatment with icosapent ethyl 4 g/day versus placebo also resulted in significant decreases in the omega-6 fatty acids linoleic acid (− 25%) and arachidonic acid (AA; − 31%), as well as the AA/EPA ratio (− 91%). Icosapent ethyl 4 g/day also decreased the omega-9 fatty acid oleic acid (− 29%) and the saturated fatty acids palmitic acid (− 23%) and stearic acid (− 16%) (all P < 0.0001). Results were similar for RBCs.

Conclusions

Icosapent ethyl 4 g/day significantly increased EPA and produced other potentially beneficial shifts in fatty acids in plasma and RBCs versus placebo.

Trial Registration

ClinicalTrials.gov Identifier, NCT01047501

Funding

Amarin Pharma Inc.

Plain Language Summary

Plain language summary available for this article.

Coronary Artery Disease Severity and Cardiovascular Biomarkers in Patients with Peripheral Artery Disease

Cardiovascular mortality in peripheral artery disease (PAD) patients is higher in critical limb ischemia (CLI) than in intermittent claudication (IC). We sought to evaluate differential characteristics of coronary artery disease (CAD) severity and prognostic biomarkers for cardiovascular events between CLI and IC patients. Coronary angiography was performed on 242 PAD patients (age 73 ± 8 years) with either CLI or IC. High-sensitivity troponin T (hs-TnT), eicosapentaenoic acid-arachidonic acid ratio (EPA/AA), and lipoprotein(a), as biomarkers for prognostic factors, were measured from blood samples. The study patients were divided into a CLI-group (n = 42) and IC-group (n = 200). The Gensini score as an indicator of coronary angiographic severity was higher in the CLI-group than in the IC-group (39.1 ± 31.2 vs. 8.5 ± 8.3, p < 0.0001). Hs-TnT and lipoprotein(a) values were higher in the CLI-group than in the IC-group (0.152 ± 0.186 ng/mL vs. 0.046 ± 0.091, p < 0.0001, 45.9 ± 23.3 mg/dL vs. 26.2 ± 27.7, p = 0.0002, respectively) and EPA/AA was lower in the CLI-group than in the IC-group (0.22 ± 0.11 vs. 0.38 ± 0.29, p = 0.0049, respectively). Greater CAD severity, higher hs-TnT, and lipoprotein(a), and lower EPA/AA were observed in the CLI-group, which may explain higher cardiovascular events in patients with CLI.

Icosapent ethyl, a pure EPA omega-3 fatty acid: effects on plasma and red blood cell fatty acids in patients with very high triglyceride levels (results from the MARINE study)

INTRODUCTION

Icosapent ethyl (IPE) is a high-purity prescription form of eicosapentaenoic acid (EPA) ethyl ester. We evaluated IPE's effects on plasma and red blood cell (RBC) fatty acids (FA) and the relationship to triglyceride (TG) lowering.

MATERIALS AND METHODS

This was a predefined, exploratory analysis (N=229) of FA plasma concentration and RBC membrane content from the double-blind, placebo-controlled MARINE study.

RESULTS

Mean placebo-adjusted plasma EPA levels increased from baseline by 792% and 402% and the arachidonic acid/EPA plasma ratio decreased from baseline by 99% and 88% with IPE 4 g/day and 2 g/day, respectively (all P<.0001). Overall, the fractional pool of omega-3 FAs increased; there was a decrease or no change for omega-6 FAs. The increase in EPA levels with increased IPE dose corresponded with the TG-lowering effect. Similar FA shifts were observed in RBCs.

CONCLUSIONS

IPE significantly increased plasma and RBC FAs, which correlated to TG lowering.

Association of serum levels of arachidonic acid and eicosapentaenoic acid with prevalence of major adverse cardiac events after acute myocardial infarction

We studied the association of serum levels of arachidonic acid (AA) and eicosapentaenoic acid (EPA) with the prevalence of major adverse cardiac events (MACE) after acute myocardial infarction (AMI). We measured serum AA and EPA on admission in 146 consecutive AMI patients. The primary clinical endpoint was occurrence of MACE, defined as cardiac death, occurrence of heart failure, reinfarction, recurrent angina pectoris, and requirement of coronary intervention. Common logarithmic transformed serum levels of AA (logAA) and EPA (logEPA) were used in the analyses. The optimum cutoff point of each fatty acid used to distribute patients into two groups for Kaplan-Meier analysis was determined by receiver operating characteristic curves analysis. MACE occurred in 40 patients (27.4%). Kaplan-Meier analysis disclosed that the group with a logAA above the cutoff point [145.3 μg/mL (logAA 2.162)] showed a higher prevalence of MACE than those with a logAA below the cutoff point (P < 0.01). Conversely, the prevalence of MACE was significantly higher in the group with a logEPA below the cutoff point [52.3 μg/mL (logEPA 1.719)] compared to the group with a logEPA above it (P < 0.01). Similar to logAA, logAA/logEPA showed significant differences in the MACE-free curve between the two groups (cutoff 1.301, P < 0.001). Cox proportional hazards regression analysis suggested that logAA, logEPA, and logAA/logEPA were independently associated with the prevalence of MACE. Although the present study included a limited number of patients with single-time point measurement, the results suggested an association of logAA, logEPA, and logAA/logEPA with the prevalence of MACE after AMI. The present study warrants further studies involving a large number of patients to confirm that the serum levels of these fatty acids and their ratios are predictors of MACE after AMI.

Serum fatty acid levels, dietary style and coronary heart disease in three neighbouring areas in Japan: the Kumihama study

CHD mortality is extremely low in Japan, particularly in rural districts, when compared with that in Western countries. This has been partly attributed to the difference in dietary lifestyle. We investigated the factors influencing CHD mortality in a rural coastal district of Japan, comprising mercantile, farming, and fishing areas with distinct dietary habits. We prospectively examined the incidence of CHD from 1994 to 1998, as well as coronary risk factors and serum fatty acid concentrations. The incidence of angina pectoris was significantly (P=0.01) lower in the fishing area than in the mercantile and farming areas. Blood pressure, physical activity, prevalence of diabetes, serum levels of uric acid and HDL-cholesterol were similar between the three areas. Total- and LDL-cholesterol levels were significantly lower but the smoking rate was markedly higher in the fishing area than in the other two areas. Serum levels of saturated fatty acids and n-6 polyunsaturated fatty acids (PUFA) were lowest in the fishing area, but n-3 PUFA did not differ significantly. The n-6:n-3 PUFA ratio was lowest and eicosapentaenoic:arachidonic acid was highest in the fishing area. Although many previous studies have emphasized the beneficial effect of n-3 PUFA in preventing CHD, the present study indicated that a lower intake of n-6 PUFA and saturated fatty acids has an additional preventive effect on CHD even when the serum level of n-3 PUFA is high because of high dietary fish consumption.

Effect of exercise on FA profiles in n-3 FA-supplemented and -nonsupplemented premenopausal women

The purpose of this double-blind study was to investigate the influence of exercise on the FA profile of the non-esterified FA (NEFA) and phospholipid fractions in plasma of sedentary women supplemented with n-3 FA vs. women supplemented with oil containing no n-3 FA. Twenty sedentary, premenopausal women were randomly assigned to receive 12 capsules daily of either fish oil (3.5 g EPA and 2.4 g DHA per day, each as the ethyl ester) or evening primrose oil capsules (no detectable EPA or DHA). Each subject consumed the capsules for one menstrual cycle. At the end of the supplementation period, the sedentary subjects underwent an acute exercise trial [55% maximal oxygen consumption (VO2 max), 45 min] on a cycle ergometer. Two subjects in the fish oil group were removed from all calculations owing to noncompliance for reasons not related to side effects. There were no changes in the phospholipid composition of either group of women after exercise. In both control and fish oil-supplemented women, NEFA levels in general rose after exercise. There were no changes in the percentage of any given individual NEFA in either supplementation group. However, absolute levels of certain individual NEFA (16:0, 18:0, 18:1, and 18:3n-3) increased with exercise. Women supplemented with fish oil had increased levels of n-3 NEFA IEPA, DHA, and docosapentaenoic acid (DPA)] prior to exercise. Exercise did not, however, increase the absolute levels of n-3 NEFA in the blood.

Serum free fatty acid pattern and risk of myocardial infarction: a case-control study

OBJECTIVES

To investigate the association between composition of serum free fatty acid (FFA) fraction and risk of a first myocardial infarction (MI).

DESIGN

A case-control design.

SETTING

The patients were recruited from Ullevål Hospital in Oslo and Ostfold Central Hospital in Fredrikstad and Sarpsborg, Norway.

SUBJECTS

A total of 103 patients with first MI and 104 population controls, both men and postmenopausal women, age 45-75 years.

RESULTS

The mean molar percentage content of docosahexaenoic (DHA), eicosapentaenoic (EPA), stearic and myristic acid in the serum FFA fraction was significantly lower in cases than in controls, whereas that of oleic and linoleic acid was higher in cases. Increased percentage content of total very long-chain omega-3 fatty acids (VLC n-3) in serum FFA was associated with decreased risk of MI. Multivariate odds ratio (OR), adjusted for age, sex, waist-hip ratio, smoking, family history of coronary heart disease (CHD) and years of education was 0.20 (95% CI 0.06-0.63) for the highest vs. lowest quartile. Also increased content of stearic acid was associated with decreased risk. Multivariate OR adjusted as above was 0.38 (95% CI 0.14-1.04) for the highest versus lowest quartile. After adjustment for oleic acid, however, the inverse linear trend was no longer significant.

CONCLUSIONS

The percentage content of VLC n-3 as well as of stearic acid in serum FFA was inversely associated with risk of myocardial infarction. That of VLC n-3 may reflect diet, but additionally these free fatty acids might in some way be related to the pathogenetic process and not only reflect their content in adipose tissue.

Effect of supplementation with dietary seal oil on selected cardiovascular risk factors and hemostatic variables in healthy male subjects

The average daily consumption of seal oil by the Inuit people is approximately 8-9 g, yet there is very little information on the effect of seal oil consumption on cardiovascular disease risk factors. In this study, 19 healthy, normocholesterolemic subjects consumed 20 g of encapsulated seal oil containing eicosapentaenoic acid (EPA; 20:5n-3), docosahexaenoic acid (DHA; 22:6n-3), and docosapentaenoic acid (DPA; 22:5n-3) or 20 g of vegetable oil (control) per day for 42 days. Levels of selected cardiovascular and thrombotic risk factors as well as fatty acid profiles of serum phospholipid and nonesterified fatty acid (NEFA) were determined. EPA levels in serum phospholipid and NEFA increased by 4.3- and 2.7-fold, respectively, in the seal oil supplemented group. DHA levels rose 1.5- and 2.1-fold, respectively, and DPA levels rose 0.5- and 0.7-fold, respectively. Arachidonic acid (AA) levels dropped by 26% in both serum phospholipid and serum NEFA. There was a significant decrease in the ratio of n-6 to n-3 fatty acids in serum phospholipid from 7.2 to 2.1 and a significant increase in the ratio of EPA/AA in NEFA. Ingestion of seal oil raised the coagulant inhibitor, protein C, values by 7% and decreased plasma fibrinogen by 18%. No alterations in other hemostatic variables, including plasma activity of Factors VII, VIII, IX, and X and antithrombin, or in the concentrations of von Willebrand Factor, total cholesterol, high-density lipoprotein cholesterol, low-density lipoprotein cholesterol, triglyceride, glucose, Apo A-1, or lipoprotein(a) were observed in either group. Other risk factors for cardiovascular disease, including hematocrit, white blood cell count, plasma viscosity, systolic and diastolic blood pressures, heart rate, and platelet aggregation after stimulation with ADP or collagen did not change. Our results indicate that seal oil supplementation in healthy, normocholesterolemic subjects decreased the n-6/n-3 ratio and increased EPA, DHA, and DPA and the ratio of EPA/AA and DHA/AA in the serum phospholipid and NEFA, while exhibiting a modest beneficial effect on fibrinogen and protein C levels.

Effects of a prudent diet containing either lean beef and mutton or fish and skinless chicken on the plasma lipoproteins and fatty acid composition of triacylglycerol and cholesteryl ester of hypercholesterolemic subjects11This study was sponsored by the Meat Board of South Africa

In this two-phase crossover study, 39 hypercholesterolemic subjects followed a prudent diet with either lean red meat or fish and skinless chicken (treatment groups), and 13 subjects (reference group) followed their habitual diet. Fasting blood samples were analyzed for plasma total cholesterol, triacylglycerol (TAG), high density lipoprotein cholesterol (HDL-C), low density lipoprotein one- and two-cholesterol, apolipoprotein-B, very low density lipoprotein cholesterol, and very low density lipoprotein TAG, and fatty acid composition of plasma TAG and cholesteryl ester (CE). Body mass and blood pressure were determined. Seven-day dietary records were kept once at baseline and twice during the treatment periods. Significant differences were observed in dietary intake between the baseline and treatment diets and between the two treatment diets. HDL-C (P < 0.05) and diastolic blood pressure (P < 0.01) were higher in patients on the red meat diet than in those on the chicken-fish diet. No other significant differences in lipoproteins were observed between the effects of the two treatment diets. The linoleic acid (%), eicosapentaenoic acid (%), and the eicosapentaenoic acid/arachidonic acid ratios in TAG and CE were higher (P < 0.01) in subjects on the chicken-fish diet than in those on the red meat diet. In conclusion, this study showed that the effect of two lipid-lowering diets containing either lean red meat or skinless chicken and fish on the atherogenic lipoproteins did not differ significantly. A prudent diet with skinless chicken and fish, however, had a more favorable effect on the fatty acid composition of the plasma TAG and the CE than did the lean red meat diet.

Ratios of substrates and inhibitors of prostaglandin synthesis in blood plasma of patients with heart ischemia

To check the proposed hypothesis that the relative content of individual polyunsaturated fatty acids (PUFAs)--substrates and inhibitors of prostanoid synthesis--in plasma can be regarded as a quantitative risk factor of blood clotting, a test was conducted on free fatty acids content in blood plasma of healthy people (group 0) and patients with heart ischemia before (group 1) and after (group 2) they were treated for a month with a food additive called "Eiconol," enriched with PUFA omega 3. Different proportions of PUFAs have been calculated in all cases, accounting for the contribution of each acid to the process of primary clotting. Comparison of PUFA rations among the three groups showed significant differences of means between groups 0 and 1 and also group 1 and 2 for 6 out of 7 proposed coefficients, which disappeared after "Eiconol" treatment (comparison of groups 0 and 2). The results led to the conclusion that out of the proposed PUFA proportions, the coefficients describing the relative content of arachidonic acid in blood plasma may be the most informative for diagnosis and treatment efficiently in evaluation of heart and vascular diseases.

Plasma lipids and fatty acids in urbanized Bushmen, Hereros and Kavangos of southern Africa (Namibia)

Thirty-nine urbanized ethnic Namibian people comprising 21 Bushmen (semi-urbanized), 7 Hereros and 11 Kavangos were assessed for plasma lipids and fatty acid (FA) composition. Total cholesterol and triacylglycerol concentrations were measured by enzymatic methods, and neutral lipid FA composition by gas-liquid chromatography. The results demonstrated that while total cholesterol concentrations were not significantly different, significant differences in triacylglycerol concentrations (P < 0.05) were seen between Bushmen and Kavangos. By comparing Bushmen with Hereros and Kavangos, significant differences between Bushmen and Kavangos were also observed in plasma triacylglycerol FA compositions, particularly 16:0 (32.73% vs. 25.05%), 16:1n-7 (7.00% vs. 5.06%), 18:2n-6 (9.30% vs. 22.25%) and 20:3n-6 (0.12% vs. 0.48%), while Kavangos had higher 20:4n-6 levels than Hereros (1.44% vs. 2.00%). In plasma cholesteryl esters, Bushmen were significantly different from Kavangos in 16:1n-7 (8.85% vs. 4.93%), 18:1n-9 (32.06% vs. 23.07%) and 20:4n-6 (6.91% vs. 10.00%). Significant differences were also observed between Bushmen and Hereros in 18:0 (1.08% vs. 1.29%) and 18:2n-6 (35.68% vs. 45.50%). The FA of Namibian groups were also compared with South African reference groups comprising urbanized whites and Xhosas and rural Vendas. The differences in blood lipid values can be explained primarily by excessive alcohol consumption. These results suggest that semi-urbanized Bushmen have changed their diets under urbanized conditions which may increase their risk of coronary heart disease.

Effect of albumin-bound DHA on phosphoinositide phosphorylation in collagen stimulated human platelets

The effect of exogenous albumin-bound docosahexaenoic acid (22:6n-3) (DHA), arachidonic acid (20:4n-6) (AA), and eicosapendaenoic acid (20:5n-3) (EPA) on phosphoinositide metabolism following collagen stimulation was studied using [3H]inositol prelabelled platelets. Collagen stimulation (3 min, 1.8 micrograms/ml) increased the labelling of both phosphatidylinositol 4-monophosphate (PIP), and phosphatidylinositol 4,5-biphosphate (PIP2). Of the fatty acids tested, only pre-incubation (2 min) with DHA (20 microM) significantly attenuated the collagen-induced increased PIP and PIP2 labelling; EPA was without effect, while AA enhanced PIP labelling. Forty microM DHA was less effective at attenuating the increased PIP and PIP2 labelling even though this concentration of DHA resulted in greater inhibition of platelet aggregation. Neither concentration of DHA attenuated the increased polyphosphoinositide labelling resulting from stimulation by the endoperoxide analogue U46619, or the phorbol ester, PMA. These data suggest that the effect of DHA on attenuating the increased PIP and PIP2 labelling following collagen stimulation likely occurs before thromboxane receptor occupancy, may not occur at the level of protein kinase C activation, and could be mediated in part via a lessened synthesis of thromboxane A2.

Albumin-bound docosahexaenoic acid and collagen-induced human platelet reactivity

An in vitro system designed to mimic the effect of various plasma nonesterified (polyunsaturated) fatty acids on platelet function and metabolism was employed. Human platelet aggregation induced by submaximal (1.8 micrograms/ml) collagen stimulation was significantly inhibited by 2 min preincubation with 20 microM albumin-bound docosahexaenoic acid (22:6n-3) (DHA), but not by the other fatty acids tested. [3H]Phosphatidic acid (PA) formation, an indicator of phospholipase C activation following platelet stimulation, was moderately inhibited by eicosapentaenoic acid (20:5n-3), 11,14,17-eicosatrienoic acid (20:3n-3), dihomo-gamma-linolenic acid (20:3n-6), as well as DHA, but not by arachidonic acid (20:4n-6); this inhibition of phospholipase C activation could not explain the differential effect of DHA on platelet aggregation. The decreased production of thromboxane A2 (TxA2), as assessed by [3H]12-hydroxy-5,8,10-heptadecatrienoic acid (HHT) formation, may account for the inhibition of collagen-induced aggregation by 20 microM DHA. Surprisingly, preincubation with 40 microM albumin-bound DHA, even though resulting in greater inhibition of collagen-induced aggregation, had less impact on HHT formation. A small but significant increase in [3H]prostaglandin D2 (PGD2) levels following 3-min collagen stimulation may have contributed to the greater antiaggregatory effect of 40 muM DHA. It is concluded that increased plasma nonesterified DHA may contribute to the dampened platelet activation and altered metabolism following fish oil supplementation of the diet.

Serum lipids in Finnish and Japanese postmenopausal women

Serum lipids were measured in 30 Finnish and Japanese postmenopausal women. Total cholesterol, HDL cholesterol, LDL cholesterol, apo B and the HDL cholesterol/apo A1 ratio were higher in Finnish than in Japanese women. The LDL cholesterol/apo B and apo A1/apo B ratios were lower in Finns than in Japanese. In serum phospholipids the percentage of arachidonic acid was higher and the percentage of the n - 3 fatty acids, eicosapentaenoic acid and docosahexaenoic acid, and the eicosapentaenoic acid/arachidonic acid ratio were lower in Finnish than in Japanese women. No significant correlations were found between serum oestrone levels and lipid parameters.