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Marcus MD, Link MS. Omega-3 Fatty Acids and Arrhythmias. Circulation 2024; 150:488-503. [PMID: 39102482 DOI: 10.1161/circulationaha.123.065769] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 08/07/2024]
Abstract
The pro- and antiarrhythmic effects of omega-3 polyunsaturated fatty acids (n-3 PUFAs) have been extensively studied in preclinical and human trials. Despite early evidence of an antiarrhythmic role of n-3 PUFA in the prevention of sudden cardiac death and postoperative and persistent atrial fibrillation (AF), subsequent well-designed randomized trials have largely not shown an antiarrhythmic benefit. Two trials that tested moderate and high-dose n-3 PUFA demonstrated a reduction in sudden cardiac death, but these findings have not been widely replicated, and the potential of eicosapentaenoic acid (EPA) and docosahexaenoic acid (DHA) to reduce arrhythmic death in combination, or as monotherapy, remains uncertain. The accumulated clinical evidence does not support supplementation of n-3 PUFA for postoperative AF or secondary prevention of AF. Several large, contemporary, randomized controlled trials of high-dose n-3 PUFA for primary or secondary cardiovascular prevention have demonstrated a small, significant, dose-dependent increased risk of incident AF compared with mineral oil or corn oil comparator. These findings were reproduced with both icosapent ethyl monotherapy and a mixed EPA+DHA formulation. The proarrhythmic mechanism of increased AF in contemporary cohorts exposed to high-dose n-3 PUFA is unknown. EPA and DHA and their metabolites have pleiotropic cardiometabolic and pro- and antiarrhythmic effects, including modification of the lipid raft microenvironment; alteration of cell membrane structure and fluidity; modulation of sodium, potassium, and calcium currents; and regulation of gene transcription, cell proliferation, and inflammation. Further characterization of the complex association between EPA, EPA+DHA, and DHA and AF is needed. Which formulations, dose ranges, and patient subgroups are at highest risk, remain unclear.
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Affiliation(s)
- Mason D Marcus
- Department of Medicine, Division of Cardiology, UT Southwestern Medical Center, Dallas, TX
| | - Mark S Link
- Department of Medicine, Division of Cardiology, UT Southwestern Medical Center, Dallas, TX
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Olshansky B, Bhatt DL, Miller M, Steg PG, Brinton EA, Jacobson TA, Ketchum SB, Doyle RT, Juliano RA, Jiao L, Kowey PR, Reiffel JA, Tardif J, Ballantyne CM, Chung MK. Cardiovascular Benefits of Icosapent Ethyl in Patients With and Without Atrial Fibrillation in REDUCE-IT. J Am Heart Assoc 2023; 12:e026756. [PMID: 36802845 PMCID: PMC10111466 DOI: 10.1161/jaha.121.026756] [Citation(s) in RCA: 9] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/03/2022] [Accepted: 10/31/2022] [Indexed: 02/23/2023]
Abstract
Background In REDUCE-IT (Reduction of Cardiovascular Events With Icosapent Ethyl-Intervention Trial), icosapent ethyl (IPE) versus placebo) reduced cardiovascular death, myocardial infarction, stroke, coronary revascularization, or unstable angina requiring hospitalization, but was associated with increased atrial fibrillation/atrial flutter (AF) hospitalization (3.1% IPE versus 2.1% placebo; P=0.004). Methods and Results We performed post hoc efficacy and safety analyses of patients with or without prior AF (before randomization) and with or without in-study time-varying AF hospitalization to assess relationships of IPE (versus placebo) and outcomes. In-study AF hospitalization event rates were higher in patients with prior AF (12.5% versus 6.3%, IPE versus placebo; P=0.007) versus without prior AF (2.2% versus 1.6%, IPE versus placebo; P=0.09). Serious bleeding rates trended higher in patients with (7.3% versus 6.0%, IPE versus placebo; P=0.59) versus without prior AF (2.3% versus 1.7%, IPE versus placebo; P=0.08). With IPE, serious bleeding trended higher regardless of prior AF (interaction P value [Pint]=0.61) or postrandomization AF hospitalization (Pint=0.66). Patients with prior AF (n=751, 9.2%) versus without prior AF (n=7428, 90.8%) had similar relative risk reductions of the primary composite and key secondary composite end points with IPE versus placebo (Pint=0.37 and Pint=0.55, respectively). Conclusions In REDUCE-IT, in-study AF hospitalization rates were higher in patients with prior AF especially in those randomized to IPE. Although serious bleeding trended higher in those randomized to IPE versus placebo over the course of the study, serious bleeding was not different regardless of prior AF or in-study AF hospitalization. Patients with prior AF or in-study AF hospitalization had consistent relative risk reductions across primary, key secondary, and stroke end points with IPE. Registration URL: https://clinicaltrials.gov/ct2/show/NCT01492361; Unique Identifier: NCT01492361.
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Affiliation(s)
| | - Deepak L. Bhatt
- Mount Sinai HeartIcahn School of Medicine at Mount Sinai Health SystemNew YorkNYUSA
| | - Michael Miller
- Department of MedicineCrescenz Veterans Affairs Medical Center and Hospital of the University of PennsylvaniaPhiladelphiaPAUSA
| | - Ph. Gabriel Steg
- French Alliance for Cardiovascular Trials, Hôpital BichatParisFrance
- Assistance Publique‐Hôpitaux de ParisUniversité Paris–Cité, INSERM UnitéParisFrance
| | | | - Terry A. Jacobson
- Lipid Clinic and Cardiovascular Risk Reduction Program, Department of MedicineEmory University School of MedicineAtlantaGAUSA
| | | | | | | | | | | | - James A. Reiffel
- Columbia University Vagelos College of Physicians & SurgeonsNew YorkNYUSA
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Nomani H, Saei S, Johnston TP, Sahebkar A, Mohammadpour AH. The Efficacy of Anti-inflammatory Agents in the Prevention of Atrial Fibrillation Recurrences. Curr Med Chem 2021; 28:137-151. [PMID: 32116184 DOI: 10.2174/1389450121666200302095103] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2019] [Revised: 01/30/2020] [Accepted: 02/17/2020] [Indexed: 11/22/2022]
Abstract
Several studies have indicated an association between inflammation and the recurrence of Atrial Fibrillation (AF), especially after ablation, which is a therapeutic option leading to local inflammation. On the other hand, each AF can lead to another AF, as a general rule. Thus, preventing recurrences of AF is extremely important for patient outcomes. In this paper, we attempted to review the effect of medicinal agents with anti-inflammatory properties on the prevention of AF recurrence. There are several randomized controlled trials (RCTs) and meta-analyses on the prevention of AF recurrence using agents with anti-inflammatory properties, which include steroids, colchicine, statins, and n-3 fatty acids (n-3 FA). Clinical trials evaluating the efficacy of anti-inflammatory drugs in preventing the recurrence of AF led to inconsistent results for corticosteroids, statins and n-3 FAs. These results may be related to the fact that inflammation is not the only factor responsible for triggering recurrences of AF. For example, the presence of structural, mechanical and electrical remodeling could potentially be the most important factors that trigger recurrences of AF but these factors have not been addressed in most of the reported studies. Therefore, future clinical trials are needed to compare the efficacy of anti-inflammatory drugs in AF patients with, or without other factors. For colchicine, a potent anti-inflammatory drug, there are limited studies. However, all the studies investigating colchicine in the context of AF were consistent and promising, especially when colchicine was used on a short-term basis following ablation in patients with paroxysmal AF. Therefore, colchicine could be a promising candidate for further clinical studies involving recurrent AF.
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Affiliation(s)
- Homa Nomani
- School of Pharmacy, Mashhad University of Medical Sciences, Mashhad, Iran
| | | | - Thomas P Johnston
- Division of Pharmacology and Pharmaceutical Sciences, School of Pharmacy, University of Missouri-Kansas City, Kansas City, Missouri, United States
| | | | - Amir Hooshang Mohammadpour
- Pharmaceutical Research Center, Pharmaceutical Technology Institute, Mashhad University of Medical Sciences, Mashhad, Iran
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Okada M, Hirata A, Kashiwase K, Nakanishi H, Amiya R, Ueda Y, Higuchi Y, Sakata Y. Impact of Preprocedural Serum Eicosapentaenoic Acid to Arachidonic Acid Ratio on Post-Ablation Recurrence of Atrial Fibrillation. Int Heart J 2019; 60:1334-1343. [PMID: 31735788 DOI: 10.1536/ihj.19-329] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
The aim of this study was to examine the impact of the serum eicosapentaenoic acid (EPA) to arachidonic acid (AA) ratio on recurrence after catheter ablation (CA) for atrial fibrillation (AF).A total of 192 patients who underwent first-time radiofrequency CA for AF were enrolled in this study. They were divided into two groups based on the median serum EPA/AA ratio before CA: a LOW group (< 0.30; n = 96) and a HIGH group (≥ 0.30; n = 96). Patients in the LOW group were younger and had smaller left atrial diameter (LAD) than those in the HIGH group. Although pulmonary vein triggers initiating AF were more frequently observed in the LOW group than the HIGH group (63% versus 46%, respectively; P = 0.021), no significant between-group difference was observed regarding the incidence of AF recurrence since the last procedure (17% versus 17%, P = 0.78; median follow-up, 37 months). Multivariate Cox regression analysis after adjustment for age and LAD revealed that EPA/AA of < 0.30 was not a significant predictor of AF recurrence (hazard ratio, 1.12; 95% confidence interval 0.53-2.37; P = 0.76). However, in the non-paroxysmal AF subgroup (n = 65), the incidence of AF recurrence was significantly higher in the LOW group than in the HIGH group (25.7% versus 6.7%, respectively; P = 0.031).In conclusion, a lower preprocedural EPA/AA ratio, which was associated with younger age and small left atrium, was not a predictor for the risk of AF recurrence after CA for AF. The potential impact of the ratio on recurrence in non-paroxysmal AF subgroups should be examined with larger samples.
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Affiliation(s)
| | - Akio Hirata
- Cardiovascular Division, Osaka Police Hospital
| | | | - Hiroyuki Nakanishi
- Department of Cardiovascular Medicine, Osaka University Graduate School of Medicine
| | | | - Yasunori Ueda
- Cardiovascular Division, National Hospital Organization Osaka National Hospital
| | | | - Yasushi Sakata
- Department of Cardiovascular Medicine, Osaka University Graduate School of Medicine
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Ghasemi Fard S, Wang F, Sinclair AJ, Elliott G, Turchini GM. How does high DHA fish oil affect health? A systematic review of evidence. Crit Rev Food Sci Nutr 2018; 59:1684-1727. [PMID: 29494205 DOI: 10.1080/10408398.2018.1425978] [Citation(s) in RCA: 125] [Impact Index Per Article: 20.8] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
The health benefits of fish oil, and its omega-3 long chain polyunsaturated fatty acid content, have attracted much scientific attention in the last four decades. Fish oils that contain higher amounts of eicosapentaenoic acid (EPA; 20:5n-3) than docosahexaenoic acid (DHA; 22:6n-3), in a distinctive ratio of 18/12, are typically the most abundantly available and are commonly studied. Although the two fatty acids have traditionally been considered together, as though they were one entity, different physiological effects of EPA and DHA have recently been reported. New oils containing a higher quantity of DHA compared with EPA, such as fractionated and concentrated fish oil, tuna oil, calamari oil and microalgae oil, are increasingly becoming available on the market, and other oils, including those extracted from genetically modified oilseed crops, soon to come. This systematic review focuses on the effects of high DHA fish oils on various human health conditions, such as the heart and cardiovascular system, the brain and visual function, inflammation and immune function and growth/Body Mass Index. Although inconclusive results were reported in several instances, and inconsistent outcomes observed in others, current data provides substantiated evidence in support of DHA being a beneficial bioactive compound for heart, cardiovascular and brain function, with different, and at times complementary, effects compared with EPA. DHA has also been reported to be effective in slowing the rate of cognitive decline, while its possible effects on depression disorders are still unclear. Interestingly, gender- and age- specific divergent roles for DHA have also been reported. This review provides a comprehensive collection of evidence and a critical summary of the documented physiological effects of high DHA fish oils for human health.
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Affiliation(s)
- Samaneh Ghasemi Fard
- a School of Medicine, Deakin University , Geelong , Australia.,b Nu-Mega Ingredients Pty Ltd , Altona North , Melbourne , Australia
| | - Fenglei Wang
- c Department of Food Science and Nutrition , Zhejiang University , Hangzhou , China
| | - Andrew J Sinclair
- a School of Medicine, Deakin University , Geelong , Australia.,e Department of Nutrition , Dietetics and Food, Monash University , Clayton , Australia
| | - Glenn Elliott
- b Nu-Mega Ingredients Pty Ltd , Altona North , Melbourne , Australia
| | - Giovanni M Turchini
- d School of Life and Environmental Sciences , Deakin University , Geelong , Australia
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Tong M, Wang J, Ji Y, Chen X, Wang J, Wang S, Ruan L, Cui H, Zhou Y, Zhang Q, Watanabe E. Effect of eicosapentaenoic acid and pitavastatin on electrophysiology and anticoagulant gene expression in mice with rapid atrial pacing. Exp Ther Med 2017; 14:2310-2316. [PMID: 28962160 DOI: 10.3892/etm.2017.4741] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2016] [Accepted: 04/21/2017] [Indexed: 12/19/2022] Open
Abstract
Atrial remodeling is considered to be any persistent change in atrial structure or function, and is responsible for the development and perpetuation of atrial fibrillation (AF). Oxidative stress and intracellular pH regulation may also be linked to AF; however it remains unclear whether eicosapentaenoic acid (EPA) or statins have beneficial therapeutic effects. The aim of the present study was to investigate the effects of EPA and pitavastatin on the electrophysiology of and gene expressions in mice with rapidly-paced atria. Mice were treated with EPA (10 mg/g/day) or pitavastatin (30 ng/g/day) for 6 weeks, following which AF was simulated by 8-h atrial pacing at 1,800 bpm. The atrial electrophysiological properties and the expression of cardiac genes, potassium voltage-gated channel subfamily A member 5 (Kcna5), Kcn subfamily D member 2 (Kcnd2), Kv channel-interacting protein 2 (KChIP2), solute carrier family 9 member A1, thrombomodulin (TM) and tissue factor pathway inhibitor (TFPI) were examined using reverse transcription-quantitative polymerase chain reaction. In control mice, significant atrial electrical remodeling was observed (P<0.05); however, treatment with either EPA or pitavastatin ameliorated these electrophysiological changes (P>0.05). mRNA levels of Kcnd2, KChIP2 and Kcna5 were significantly upregulated in control mice (P<0.05), whereas treatment with EPA or pitavastatin attenuated this upregulation (P>0.05). Administration of pitavastatin significantly reduced the downregulation of both TFPI and TM (P<0.05). EPA treatment attenuated the TFPI downregulation compared with control mice (P>0.05), however no significant effect on TM expression was observed. In addition, both EPA (P>0.05) and pitavastatin (P<0.05) suppressed the overexpression of endothelial nitric oxide synthase. This was also exhibited in Ras-related C3 botulinum toxin substrate 1 genes (P<0.01 for both treatments). In conclusion, the results of the present study suggested that EPA and pitavastatin are able to prevent atrial electrical remodeling, thrombotic states and oxidative stress in rapidly-paced murine atria.
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Affiliation(s)
- Maoqing Tong
- Department of Cardiology, Key Laboratory of Molecular Medicine, The Affiliated Ningbo First Hospital, School of Medicine, Ningbo University, Ningbo, Zhejiang 315010, P.R. China
| | - Jiewen Wang
- Department of Gynecology and Obstetrics, The Second Affiliated Hospital of Bengbu Medical College, Bengbu, Anhui 233040, P.R. China
| | - Yunxin Ji
- Department of Psychosomatic Medicine, The Affiliated Ningbo First Hospital, School of Medicine, Ningbo University, Ningbo, Zhejiang 315010, P.R. China
| | - Xiaomin Chen
- Department of Cardiology, The Affiliated Ningbo First Hospital, School of Medicine, Ningbo University, Ningbo, Zhejiang 315010, P.R. China
| | - Jieru Wang
- Department of International Health, The Affiliated Ningbo First Hospital, School of Medicine, Ningbo University, Ningbo, Zhejiang 315010, P.R. China
| | - Shuangshuang Wang
- Department of Cardiology, The Affiliated Ningbo First Hospital, School of Medicine, Ningbo University, Ningbo, Zhejiang 315010, P.R. China
| | - Liemin Ruan
- Department of Psychosomatic Medicine, The Affiliated Ningbo First Hospital, School of Medicine, Ningbo University, Ningbo, Zhejiang 315010, P.R. China
| | - Hanbin Cui
- Department of Cardiology, The Affiliated Ningbo First Hospital, School of Medicine, Ningbo University, Ningbo, Zhejiang 315010, P.R. China
| | - Ying Zhou
- Department of Cardiology, Key Laboratory of Molecular Medicine, The Affiliated Ningbo First Hospital, School of Medicine, Ningbo University, Ningbo, Zhejiang 315010, P.R. China
| | - Qingyu Zhang
- Department of Psychosomatic Medicine, The Affiliated Ningbo First Hospital, School of Medicine, Ningbo University, Ningbo, Zhejiang 315010, P.R. China
| | - Eiichi Watanabe
- Department of Cardiology, Fujita Health University School of Medicine, Toyoake 470-1192, Japan
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Langlois PL, Hardy G, Manzanares W. ω-3 Polyunsaturated Fatty Acids in Cardiac Surgery Patients. JPEN J Parenter Enteral Nutr 2016; 41:152-154. [PMID: 27821661 DOI: 10.1177/0148607116677508] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Pascal L Langlois
- 1 Department of Anesthesiology and Reanimation, Faculty of Medicine and Health Sciences, Sherbrooke University Hospital, Sherbrooke, Québec, Canada
| | - Gil Hardy
- 2 Ipanema Research Trust, Auckland, New Zealand
| | - William Manzanares
- 3 Department of Critical Care, Intensive Care Unit, University Hospital, Faculty of Medicine, UDELAR, Montevideo, Uruguay
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Omega-3 polyunsaturated fatty acids in cardiac surgery patients: An updated systematic review and meta-analysis. Clin Nutr 2016; 36:737-746. [PMID: 27293143 DOI: 10.1016/j.clnu.2016.05.013] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2016] [Revised: 04/26/2016] [Accepted: 05/20/2016] [Indexed: 01/30/2023]
Abstract
BACKGROUND Omega-3 polyunsaturated fatty acids (ω-3 PUFA) supplementation is an attractive therapeutic option for patients undergoing open-heart surgery due to their anti-inflammatory and anti-arrhythmic properties. Several randomized controlled trials (RCT) have found contradictory results for perioperative ω-3 PUFA administration. Therefore, we conducted an updated systematic review and meta-analysis evaluating the effects of perioperative ω-3 PUFA on some clinically important outcomes for cardiac surgery. METHODS A systematic literature search was conducted to find RCT evaluating clinical outcomes after ω-3 PUFA therapy in adult patients undergoing cardiac surgery. Intensive care unit (ICU) length of stay (LOS) was the primary outcome; secondary outcomes were hospital LOS, postoperative atrial fibrillation (POAF), mortality and duration of mechanical ventilation (MV). Predefined subgroup analysis and sensibility analysis were performed. RESULTS A total of 19 RCT including 4335 patients met inclusion criteria. No effect of ω-3 PUFA on ICU LOS was found (weighted mean difference WMD -2.95, 95% confidence interval, CI -10.28 to 4.39, P = 0.43). However, ω-3 PUFA reduced hospital LOS (WMD -1.37, 95% CI -2.41 to -0.33; P = 0.010) and POAF incidence (Odds Ratio OR = 0.78, 95% CI 0.68 to 0.90; P = 0.004). No effects were found on mortality or MV duration. Heterogeneity remained in subgroup analysis and we found a significant POAF reduction when ω-3 PUFA doses were administered to patients exposed to extra-corporeal circulation. Oral/enteral administration seemed to further reduce POAF. CONCLUSIONS In patients undergoing cardiac surgery, ω-3 PUFA supplementation by oral/enteral and parenteral route reduces hospital LOS and POAF. Nonetheless considerable clinical and statistical heterogeneity weaken our findings.
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The Current Role of Omega-3 Fatty Acids in the Management of Atrial Fibrillation. Int J Mol Sci 2015; 16:22870-87. [PMID: 26402674 PMCID: PMC4613340 DOI: 10.3390/ijms160922870] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2015] [Revised: 08/22/2015] [Accepted: 09/10/2015] [Indexed: 12/17/2022] Open
Abstract
Background: The main dietary source of omega-3 polyunsaturated fatty acids (n-3 PUFA) is fish, which contains eicosapentaenoic acid (EPA) and docosahexaenoic acid (DHA). In the present manuscript, we aimed to review the current evidence regarding the clinical role of n-3 PUFA in the prevention of atrial fibrillation (AF) and the possible underlying mechanisms. Methods: A literature search based on PubMed listings was performed using “Omega-3 fatty acids” and “atrial fibrilation” as key search terms. Results: n-3 PUFA have been shown to attenuate structural atrial remodeling, prolong atrial effective refractory period through the prevention of reentry and suppress ectopic firing from pulmonary veins. Dietary fish intake has been found to have no effect on the incidence of AF in the majority of studies. Circulating DHA has been consistently reported to be inversely associated with AF risk, whereas EPA has no such effect. The majority of studies investigating the impact of n-3 PUFA supplementation on the incidence of AF following cardiac surgery reported no benefit, though most of them did not use n-3 PUFA pretreatment for adequate duration. Studies using adequate four-week pretreatment with n-3 PUFA before cardioversion of AF showed a reduction of the AF incidence. Conclusions: Although n-3 PUFA have antiarrhythmogenic properties, their clinical efficacy on the prevention of AF is not consistently supported. Further well-designed studies are needed to overcome the limitations of the existing studies and provide robust conclusions.
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Omega-3 fatty acids for postoperative atrial fibrillation: alone or in combination with antioxidant vitamins? Heart Lung Circ 2014; 23:743-50. [PMID: 24685324 DOI: 10.1016/j.hlc.2014.02.018] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2014] [Accepted: 02/25/2014] [Indexed: 12/29/2022]
Abstract
BACKGROUND The effects of omega-3 polyunsaturated fatty acids (PUFA) on the prevention of postoperative atrial fibrillation (POAF) are inconclusive in current studies. Moreover, the most appropriate composition of PUFA to play the protective role is unclear. The aim of this meta-analysis was to ascertain the protective role of PUFA on POAF and the most appropriate composition. METHODS Studies were identified through PubMed, CENTRAL, EMBASE, reviews and reference lists of relevant papers. The odds ratio (OR) was calculated for POAF. Statistical analyses were performed with Review Manager 5.0. RESULTS Eleven randomised controlled trials with 3137 patients were included in the analysis. The use of PUFA alone did not reduce the incidence of POAF compared with the control (OR: 0.76; 95% confidence interval [CI]: 0.57-1.03; P=0.08; I(2)=52%). However, combination therapy with PUFA and vitamins C and E reduced the incidence of POAF by 68% (OR: 0.32; 95%CI: 0.17-0.60; P=0.0005; I(2)=38%). Subgroup analysis indicated that the ratio of EPA/DHA 1:2 was effective in preventing POAF (OR: 0.35; 95%CI: 0.24-0.50; P<0.00001; I(2)=0%), while the ratio not 1:2 failed. CONCLUSIONS Combination therapy with PUFA and vitamins C and E is effective in the prevention of POAF while PUFA alone is not. The ratio of EPA/DHA may influence the incidence of POAF, and 1:2 may be most appropriate. Studies about PUFA on the prevention of POAF are still worthwhile to be conducted in the future.
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Pathak R, Lau DH, Mahajan R, Sanders P. Structural and Functional Remodeling of the Left Atrium: Clinical and Therapeutic Implications for Atrial Fibrillation. J Atr Fibrillation 2013; 6:986. [PMID: 28496919 DOI: 10.4022/jafib.986] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2013] [Revised: 12/18/2013] [Accepted: 12/19/2013] [Indexed: 12/12/2022]
Abstract
Atrial fibrillation (AF) is the most commonly encountered arrhythmia in clinical practice. Despite advances in our understanding of the pathophysiology of this complex arrhythmia, current therapeutic options remain suboptimal. This review aimed to delineate the atrial structural and functional remodeling leading to the perpetuation of AF. We explored the complex changes seen in the atria in various substrates for AF and the therapeutic options available to prevent these changes or for reverse remodeling. Here we also highlighted the emerging role of aggressive risk factor management aimed at the arrhythmogenic atrial substrate to prevent or retard AF progression.
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Affiliation(s)
- Rajeev Pathak
- Centre for Heart Rhythm Disorders (CHRD), South Australian Health and Medical Research Institute (SAHMRI), University of Adelaide and Royal Adelaide Hospital, Adelaide, Australia
| | - Dennis H Lau
- Centre for Heart Rhythm Disorders (CHRD), South Australian Health and Medical Research Institute (SAHMRI), University of Adelaide and Royal Adelaide Hospital, Adelaide, Australia
| | - Rajiv Mahajan
- Centre for Heart Rhythm Disorders (CHRD), South Australian Health and Medical Research Institute (SAHMRI), University of Adelaide and Royal Adelaide Hospital, Adelaide, Australia
| | - Prashanthan Sanders
- Centre for Heart Rhythm Disorders (CHRD), South Australian Health and Medical Research Institute (SAHMRI), University of Adelaide and Royal Adelaide Hospital, Adelaide, Australia
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Xin W, Wei W, Lin Z, Zhang X, Yang H, Zhang T, Li B, Mi S. Fish oil and atrial fibrillation after cardiac surgery: a meta-analysis of randomized controlled trials. PLoS One 2013; 8:e72913. [PMID: 24039820 PMCID: PMC3769383 DOI: 10.1371/journal.pone.0072913] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2013] [Accepted: 07/13/2013] [Indexed: 01/01/2023] Open
Abstract
Background Influence of fish oil supplementation on postoperative atrial fibrillation (POAF) was inconsistent according to published clinical trials. The aim of the meta-analysis was to evaluate the effects of perioperative fish oil supplementation on the incidence of POAF after cardiac surgery. Methods Pubmed, Embase and the Cochrane Library databases were searched. Randomized controlled trials (RCTs) assessing perioperative fish oil supplementation for patients undergoing cardiac surgery were identified. Data concerning study design, patient characteristics, and outcomes were extracted. Risk ratio (RR) and weighted mean differences (WMD) were calculated using fixed or random effects models. Results Eight RCTs involving 2687 patients were included. Perioperative supplementation of fish oil did not significantly reduce the incidence of POAF (RR = 0.86, 95%CI 0.71 to 1.03, p = 0.11) or length of hospitalization after surgery (WMD = 0.10 days, 95% CI: 0.48 to 0.67 days, p = 0.75). Fish oil supplementation also did not affect the perioperative mortality, incidence of major bleeding or the length of stay in the intensive care unit. Meta-regression and subgroup analyses indicated mean DHA dose in the supplements may be a potential modifier for the effects of fish oil for POAF. For supplements with DHA >1 g/d, fish oil significantly reduced the incidence of POAF; while it did not for the supplements with a lower dose of DHA. Conclusions Current evidence did not support a preventative role of fish oil for POAF. However, relative amounts of DHA and EPA in fish oil may be important for the prevention of POAF.
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Affiliation(s)
- Wei Xin
- Department of Cardiology, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - Wei Wei
- Department of Pathophysiology, School of Medicine, Nankai University, Tianjin, China
| | - Zhiqin Lin
- Department of Cardiovascular Medicine, Affiliated Hospital of Guiyang Medical College, Guizhou, China
| | - Xiaoxia Zhang
- Department of Cardiology, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - Hongxia Yang
- Department of Cardiology, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - Tao Zhang
- Department of Cardiology, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - Bin Li
- Department of Cardiology, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - Shuhua Mi
- Department of Cardiology, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
- * E-mail:
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Rix TA, Joensen AM, Riahi S, Lundbye-Christensen S, Overvad K, Schmidt EB. Marine n-3 fatty acids in adipose tissue and development of atrial fibrillation: a Danish cohort study. Heart 2013; 99:1519-24. [DOI: 10.1136/heartjnl-2013-304385] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
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Effects of long-term ω-3 polyunsaturated fatty acid supplementation on paroxysmal atrial tachyarrhythmia burden in patients with implanted pacemakers: results from a prospective randomised study. Int J Cardiol 2013; 168:3812-7. [PMID: 23890856 DOI: 10.1016/j.ijcard.2013.06.030] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/19/2013] [Revised: 04/13/2013] [Accepted: 06/20/2013] [Indexed: 12/19/2022]
Abstract
BACKGROUND Sino-atrial node disease and aging increase AF risk. We investigated if long-term fish oil supplementation reduces paroxysmal atrial tachycardia/fibrillation (AT/AF) burden in patients aged ≥60 years with sinoatrial node disease and dual chamber pacemakers. METHODS Following a run-in period of 6 months (p1) where AT/AF burden was logged,78 patients were randomised to control or fish oil group (total omega-3 6 g/d) and AT/AF burden evaluated after 6 months (p2; 39 controls, 39 fish oil) and 12 months (p3; 39 controls; 18 fish oil). A subset of 21 fish oil patients crossed over to controls in the final 6 months (crossover group). RESULTS Median AT/AF burden increased significantly in controls (1.5%, 3.2%, 4.3%, P<.001) but not in fish oil patients at 6 months (1.4% to 2%, P=.46) or those continuing for 12 months (1.5%, 0.98%, 1%, P=.16). Time to first episode of AT/AF >1 min was not significantly different between the groups (P=.9). There was a rebound increase in AT/AF burden in p3 in cross over patients (2.2% to 5.8%, P=.01) reaching a level similar to controls (crossover vs. controls, 5.8% vs. 4.3%, P=.63) and higher than those who continued fish oil for 12 months (crossover vs. continued intake 5.8% vs. 1.2%, P=.02). Fish oil patients had shorter duration episodes of AT/AF with no difference in frequency compared to controls. CONCLUSION Long-term fish oil supplementation did not suppress AT/AF burden but may have attenuated its temporal progression related to aging and sinus node disease.
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15
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Ofman P, Peralta A, Hoffmeister P, Gaziano JM, Djousse L. Do Omega-3 Fatty Acids Decrease the Incidence of Atrial Fibrillation? J Atr Fibrillation 2013; 6:836. [PMID: 28496856 DOI: 10.4022/jafib.836] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2013] [Revised: 05/29/2013] [Accepted: 05/30/2013] [Indexed: 12/22/2022]
Abstract
Although atrial fibrillation is a very common medical problem in general population and has a high incidence in the setting of open heart surgery, there are very few therapies to prevent occurrence or recurrence of atrial fibrillation. N-3 polyunsaturated fatty acids have been shown to change basic physiologic properties of the atrial tissue to make it less susceptible to atrial fibrillation. In this review, we first describe basic physiological mechanisms thought to be responsible for these changes and then discuss observational and interventional studies evaluating the use n-3 polyunsaturated fatty acids for primary and secondary prevention of atrial fibrillation in the general population, in subjects undergoing open heart surgery, and in special subgroups of patients.
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Affiliation(s)
- Peter Ofman
- Division of Cardiology, VA Boston Healthcare System and Harvard Medical School, Boston, MA.,Division of Aging, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA.,Massachusetts Veterans Epidemiology and Research Information Center (MAVERIC), Boston Veterans Affairs Healthcare System, Boston, MA
| | - Adelqui Peralta
- Division of Cardiology, VA Boston Healthcare System and Harvard Medical School, Boston, MA
| | - Peter Hoffmeister
- Division of Cardiology, VA Boston Healthcare System and Harvard Medical School, Boston, MA
| | - J Michael Gaziano
- Division of Cardiology, VA Boston Healthcare System and Harvard Medical School, Boston, MA.,Division of Aging, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA.,Massachusetts Veterans Epidemiology and Research Information Center (MAVERIC), Boston Veterans Affairs Healthcare System, Boston, MA.,Division of Preventive Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA.,Geriatric Research, Education, and Clinical Center (GRECC), Boston Veterans Affairs Healthcare System, Boston, MA
| | - Luc Djousse
- Division of Aging, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA.,Massachusetts Veterans Epidemiology and Research Information Center (MAVERIC), Boston Veterans Affairs Healthcare System, Boston, MA.,Geriatric Research, Education, and Clinical Center (GRECC), Boston Veterans Affairs Healthcare System, Boston, MA
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16
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Billman GE. The effects of omega-3 polyunsaturated fatty acids on cardiac rhythm: a critical reassessment. Pharmacol Ther 2013; 140:53-80. [PMID: 23735203 DOI: 10.1016/j.pharmthera.2013.05.011] [Citation(s) in RCA: 50] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2013] [Accepted: 05/17/2013] [Indexed: 11/28/2022]
Abstract
Although epidemiological studies provide strong evidence for an inverse relationship between omega-3 polyunsaturated fatty acids (n-3 PUFAs) and cardiac mortality, inconsistent and often conflicting results have been obtained from both animal studies and clinical prevention trials. Despite these heterogeneous results, some general conclusions can be drawn from these studies: 1) n-PUFAs have potent effects on ion channels and calcium regulatory proteins that vary depending on the route of administration. Circulating (acute administration) n-3 PUFAs affect ion channels directly while incorporation (long-term supplementation) of these lipids into cell membranes indirectly alter cardiac electrical activity via alteration of membrane properties. 2) n-3 PUFAs reduce baseline HR and increase HRV via alterations in intrinsic pacemaker rate rather than from changes in cardiac autonomic neural regulation. 3) n-3 PUFAs may be only effective if given before electrophysiological or structural remodeling has begun and have no efficacy against atrial fibrillation. 5) Despite initial encouraging results, more recent clinical prevention and animal studies have not only failed to reduce sudden cardiac death but actually increased mortality in angina patients and increased rather than decreased malignant arrhythmias in animal models of regional ischemia. 6) Given the inconsistent benefits reported in clinical and experimental studies and the potential adverse actions on cardiac rhythm noted during myocardial ischemia, n-3 PUFA must be prescribed with caution and generalized recommendations to increase fish intake or to take n-3 PUFA supplements need to be reconsidered.
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Affiliation(s)
- George E Billman
- Department of Physiology and Cell Biology, The Ohio State University, 304 Hamilton Hall, 1645 Neil Ave., Columbus, OH 43210-1218, United States.
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17
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Kumar S, Sutherland F, Lee JMS, Robinson T, Heck PM, Wong MCG, Kelland NF, Garg ML, Sparks PB. Effects of high dose intravenous fish oil on human atrial electrophysiology: implications for possible anti- and pro-arrhythmic mechanisms in atrial fibrillation. Int J Cardiol 2013; 168:2754-60. [PMID: 23602291 DOI: 10.1016/j.ijcard.2013.03.053] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/04/2013] [Accepted: 03/23/2013] [Indexed: 01/22/2023]
Abstract
BACKGROUND Intravenous omega-3 polyunsaturated fatty acids (ω-3 PUFAs) may prevent atrial fibrillation (AF) inducibility and perpetuation in animal models. We examined the effect of high dose IV ω-3 PUFAs on human atrial electrophysiology. METHODS AND RESULTS We randomised 88 patients with no structural heart disease to receive saline (control group) or high dose IV ω-3 PUFA infusion prior to detailed atrial electrophysiologic evaluation. Biologically active components, eicosapentaenoic acid (EPA) and docosahexaenoic acid (DHA) were measured in total lipids, free fatty acid and phospholipid (membrane incorporated) fraction pre and post infusion. Compared to pre-infusion values, EPA and DHA increased significantly in the total lipids and free fatty acid but were unchanged in the phospholipid fraction. IV ω-3 did not alter atrial refractory periods, however it slowed right, left and global atrial conduction (P<.05). Inducible AF was significantly less likely in ω-3 patients compared to controls (AF ≥ 5 min, 20% vs. 58%, P = .02) and was non-sustained (mean AF duration: 14s vs. 39 s, P<.001), however inducible and sustained atrial flutter was more common (≥ 5 min: 28% vs. 0%, P = .01). Organisation of AF into flutter was observed in a greater proportion of inductions in the ω-3 group (8.5% vs. 0.6%, P<.001). CONCLUSIONS IV ω-3 PUFAs (as free fatty acids) cause acute atrial conduction slowing, suppress AF inducibility, organise AF into atrial flutter and enhance atrial flutter inducibility. These findings provide a novel insight into potential anti and pro-arrhythmic mechanisms of fish oils in human AF.
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Affiliation(s)
- Saurabh Kumar
- Department of Cardiology, The Royal Melbourne Hospital, Parkville, Victoria, Australia; Department of Medicine, University of Melbourne, Parkville, Victoria, Australia
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18
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Abstract
PURPOSE OF REVIEW There are suggestions of effects of marine omega-3 polyunsaturated fatty acids (PUFAs) in relation to ventricular arrhythmia and sudden cardiac death and, more recently, also of possible effects related to atrial fibrillation. RECENT FINDINGS On the basis of the recently published human studies, this article not only focusses primarily on recent developments and current knowledge on the effect of marine omega-3 PUFAs on atrial fibrillation, but also provides a status for their effects on ventricular arrhythmias. SUMMARY Marine omega-3 PUFAs may protect against ventricular arrhythmias, and there is growing evidence for an effect of marine omega-3 PUFAs in the prevention and treatment of atrial fibrillation. Further studies are needed to establish which patients are more likely to benefit from omega-3 PUFAs, the timing of treatment, and the dosages.
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Affiliation(s)
- Thomas A Rix
- Department of Cardiology, Aalborg AF Study Group, Aarhus University Hospital, Aalborg, Denmark.
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19
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Guerra F, Shkoza M, Scappini L, Roberti L, Capucci A. Omega-3 PUFAs and atrial fibrillation: have we made up our mind yet? Ann Noninvasive Electrocardiol 2012; 18:12-20. [PMID: 23347022 DOI: 10.1111/anec.12020] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
Atrial fibrillation (AF) is the most common type of arrhythmia in adults, accounting for about one third of total arrhythmia-related hospitalizations. AF impact on daily clinical practice is steadily rising, together with population aging and increased survival from underlying conditions closely associated with AF such as coronary heart disease and heart failure. Although antiarrhythmic therapy, oral anticoagulation, implanted device therapy, and ablation techniques are now all common and promptly available strategies in AF management, some of them are burdened by a low efficacy rate, while others are associated with increased proarrhythmic or hemorrhagic risk. Consequently, useful alternatives are being sought. Between those, polyunsaturated fatty acids (n-3 PUFAs) have risen from mere alternative to statins in dyslipidemia management to powerful and well-tolerated antiinflammatory, antithrombotic, and antiarrhythmogenic drugs. From the evidence collected through basic science studies, whether on in vivo myocytes, animal models, or surrogate end points in human, n-3 PUFAs seem to offer innumerable advantages. On the other hand, epidemiological and clinical trials failed to demonstrate a clear efficacy of n-3 PUFAs as antiarrhythmic drugs, although covered by an optimal safety profile. The aim of the present review is to summarize the most important evidences currently available on the role of n-3 PUFA in AF management and therapy.
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Affiliation(s)
- Federico Guerra
- Cardiology Clinic, Marche Polytechnic University, Ancona, Italy.
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20
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Mozaffarian D, Marchioli R, Macchia A, Silletta MG, Ferrazzi P, Gardner TJ, Latini R, Libby P, Lombardi F, O'Gara PT, Page RL, Tavazzi L, Tognoni G. Fish oil and postoperative atrial fibrillation: the Omega-3 Fatty Acids for Prevention of Post-operative Atrial Fibrillation (OPERA) randomized trial. JAMA 2012; 308:2001-11. [PMID: 23128104 PMCID: PMC3694745 DOI: 10.1001/jama.2012.28733] [Citation(s) in RCA: 162] [Impact Index Per Article: 13.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
CONTEXT Postoperative atrial fibrillation or flutter (AF) is one of the most common complications of cardiac surgery and significantly increases morbidity and health care utilization. A few small trials have evaluated whether long-chain n-3-polyunsaturated fatty acids (PUFAs) reduce postoperative AF, with mixed results. OBJECTIVE To determine whether perioperative n-3-PUFA supplementation reduces postoperative AF. DESIGN, SETTING, AND PATIENTS The Omega-3 Fatty Acids for Prevention of Post-operative Atrial Fibrillation (OPERA) double-blind, placebo-controlled, randomized clinical trial. A total of 1516 patients scheduled for cardiac surgery in 28 centers in the United States, Italy, and Argentina were enrolled between August 2010 and June 2012. Inclusion criteria were broad; the main exclusions were regular use of fish oil or absence of sinus rhythm at enrollment. INTERVENTION Patients were randomized to receive fish oil (1-g capsules containing ≥840 mg n-3-PUFAs as ethyl esters) or placebo, with preoperative loading of 10 g over 3 to 5 days (or 8 g over 2 days) followed postoperatively by 2 g/d until hospital discharge or postoperative day 10, whichever came first. MAIN OUTCOME MEASURE Occurrence of postoperative AF lasting longer than 30 seconds. Secondary end points were postoperative AF lasting longer than 1 hour, resulting in symptoms, or treated with cardioversion; postoperative AF excluding atrial flutter; time to first postoperative AF; number of AF episodes per patient; hospital utilization; and major adverse cardiovascular events, 30-day mortality, bleeding, and other adverse events. RESULTS At enrollment, mean age was 64 (SD, 13) years; 72.2% of patients were men, and 51.8% had planned valvular surgery. The primary end point occurred in 233 (30.7%) patients assigned to placebo and 227 (30.0%) assigned to n-3-PUFAs (odds ratio, 0.96 [95% CI, 0.77-1.20]; P = .74). None of the secondary end points were significantly different between the placebo and fish oil groups, including postoperative AF that was sustained, symptomatic, or treated (231 [30.5%] vs 224 [29.6%], P = .70) or number of postoperative AF episodes per patient (1 episode: 156 [20.6%] vs 157 [20.7%]; 2 episodes: 59 [7.8%] vs 49 [6.5%]; ≥3 episodes: 18 [2.4%] vs 21 [2.8%]) (P = .73). Supplementation with n-3-PUFAs was generally well tolerated, with no evidence for increased risk of bleeding or serious adverse events. CONCLUSION In this large multinational trial among patients undergoing cardiac surgery, perioperative supplementation with n-3-PUFAs, compared with placebo, did not reduce the risk of postoperative AF. TRIAL REGISTRATION clinicaltrials.gov Identifier: NCT00970489.
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Affiliation(s)
- Dariush Mozaffarian
- Division of Cardiovascular Medicine, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts, USA.
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21
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Ramadeen A, Connelly KA, Leong-Poi H, Hu X, Fujii H, Laurent G, Domenichiello AF, Bazinet RP, Dorian P. Docosahexaenoic Acid, but Not Eicosapentaenoic Acid, Supplementation Reduces Vulnerability to Atrial Fibrillation. Circ Arrhythm Electrophysiol 2012; 5:978-83. [DOI: 10.1161/circep.112.971515] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background—
The potential health benefits of ω-3 polyunsaturated fatty acids (PUFAs) usually are studied using a combination of docosahexaenoic acid (DHA) and eicosapentaenoic acid (EPA). This combination reduces vulnerability to experimentally induced atrial fibrillation (AF). It is unknown whether EPA and DHA have differential effects when taken alone. Using a model of pacing-induced atrial hemodynamic overload, we investigated the individual effects of EPA and DHA on vulnerability to AF and atrial remodeling.
Methods and Results—
Thirty-four dogs were randomized into 3 groups, all of which underwent simultaneous atrial and ventricular pacing at 220 beats per minute for 14 days. One group received purified DHA (≈1 g/d) orally for 21 days beginning 7 days before pacing began. Similarly, 1 group received ≈1 g/d purified EPA. In a third (control) group (No-PUFAs), 8 dogs received ≈1 g/d olive oil, and 12 were unsupplemented. Electrophysiological and echocardiographic measurements were taken at baseline and 21 days. Atrial tissue samples were collected at 21 days for histological and molecular analyses. Persistent AF inducibility was significantly reduced by DHA compared with No-PUFAs median [25–75 percentiles], 0% [0%–3%] for DHA versus 3.1% [2.2%–11%] for No-PUFAs;
P
=0.007) but not by EPA (3.4% [1.9%–8.9%]). DHA also reduced atrial fibrosis compared with No-PUFAs (11±6% versus 20±4%, respectively;
P
<0.05), whereas EPA did not (15±5%;
P
>0.05).
Conclusions—
DHA is more effective than EPA in attenuating AF vulnerability and atrial remodeling in structural remodeling–induced AF.
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Affiliation(s)
- Andrew Ramadeen
- From the Keenan Research Centre in the Li Ka Shing Knowledge Institute (A.R., K.A.C., H.L.-P., X.H., H.F., P.D.), Division of Cardiology (K.A.C., H.L.-P., P.D.), St. Michael’s Hospital, Toronto, Ontario, Canada; Department of Pharmacology and Toxicology (A.R., P.D.), Cardiovascular Sciences Collaborative Program (A.R., P.D.), Department of Medicine (K.A.C., H.L.-P., P.D.), and Department of Nutritional Sciences (A.F.D., R.P.B.), University of Toronto, Toronto, Ontario, Canada; and Department of
| | - Kim A. Connelly
- From the Keenan Research Centre in the Li Ka Shing Knowledge Institute (A.R., K.A.C., H.L.-P., X.H., H.F., P.D.), Division of Cardiology (K.A.C., H.L.-P., P.D.), St. Michael’s Hospital, Toronto, Ontario, Canada; Department of Pharmacology and Toxicology (A.R., P.D.), Cardiovascular Sciences Collaborative Program (A.R., P.D.), Department of Medicine (K.A.C., H.L.-P., P.D.), and Department of Nutritional Sciences (A.F.D., R.P.B.), University of Toronto, Toronto, Ontario, Canada; and Department of
| | - Howard Leong-Poi
- From the Keenan Research Centre in the Li Ka Shing Knowledge Institute (A.R., K.A.C., H.L.-P., X.H., H.F., P.D.), Division of Cardiology (K.A.C., H.L.-P., P.D.), St. Michael’s Hospital, Toronto, Ontario, Canada; Department of Pharmacology and Toxicology (A.R., P.D.), Cardiovascular Sciences Collaborative Program (A.R., P.D.), Department of Medicine (K.A.C., H.L.-P., P.D.), and Department of Nutritional Sciences (A.F.D., R.P.B.), University of Toronto, Toronto, Ontario, Canada; and Department of
| | - Xudong Hu
- From the Keenan Research Centre in the Li Ka Shing Knowledge Institute (A.R., K.A.C., H.L.-P., X.H., H.F., P.D.), Division of Cardiology (K.A.C., H.L.-P., P.D.), St. Michael’s Hospital, Toronto, Ontario, Canada; Department of Pharmacology and Toxicology (A.R., P.D.), Cardiovascular Sciences Collaborative Program (A.R., P.D.), Department of Medicine (K.A.C., H.L.-P., P.D.), and Department of Nutritional Sciences (A.F.D., R.P.B.), University of Toronto, Toronto, Ontario, Canada; and Department of
| | - Hiroko Fujii
- From the Keenan Research Centre in the Li Ka Shing Knowledge Institute (A.R., K.A.C., H.L.-P., X.H., H.F., P.D.), Division of Cardiology (K.A.C., H.L.-P., P.D.), St. Michael’s Hospital, Toronto, Ontario, Canada; Department of Pharmacology and Toxicology (A.R., P.D.), Cardiovascular Sciences Collaborative Program (A.R., P.D.), Department of Medicine (K.A.C., H.L.-P., P.D.), and Department of Nutritional Sciences (A.F.D., R.P.B.), University of Toronto, Toronto, Ontario, Canada; and Department of
| | - Gabriel Laurent
- From the Keenan Research Centre in the Li Ka Shing Knowledge Institute (A.R., K.A.C., H.L.-P., X.H., H.F., P.D.), Division of Cardiology (K.A.C., H.L.-P., P.D.), St. Michael’s Hospital, Toronto, Ontario, Canada; Department of Pharmacology and Toxicology (A.R., P.D.), Cardiovascular Sciences Collaborative Program (A.R., P.D.), Department of Medicine (K.A.C., H.L.-P., P.D.), and Department of Nutritional Sciences (A.F.D., R.P.B.), University of Toronto, Toronto, Ontario, Canada; and Department of
| | - Anthony F. Domenichiello
- From the Keenan Research Centre in the Li Ka Shing Knowledge Institute (A.R., K.A.C., H.L.-P., X.H., H.F., P.D.), Division of Cardiology (K.A.C., H.L.-P., P.D.), St. Michael’s Hospital, Toronto, Ontario, Canada; Department of Pharmacology and Toxicology (A.R., P.D.), Cardiovascular Sciences Collaborative Program (A.R., P.D.), Department of Medicine (K.A.C., H.L.-P., P.D.), and Department of Nutritional Sciences (A.F.D., R.P.B.), University of Toronto, Toronto, Ontario, Canada; and Department of
| | - Richard P. Bazinet
- From the Keenan Research Centre in the Li Ka Shing Knowledge Institute (A.R., K.A.C., H.L.-P., X.H., H.F., P.D.), Division of Cardiology (K.A.C., H.L.-P., P.D.), St. Michael’s Hospital, Toronto, Ontario, Canada; Department of Pharmacology and Toxicology (A.R., P.D.), Cardiovascular Sciences Collaborative Program (A.R., P.D.), Department of Medicine (K.A.C., H.L.-P., P.D.), and Department of Nutritional Sciences (A.F.D., R.P.B.), University of Toronto, Toronto, Ontario, Canada; and Department of
| | - Paul Dorian
- From the Keenan Research Centre in the Li Ka Shing Knowledge Institute (A.R., K.A.C., H.L.-P., X.H., H.F., P.D.), Division of Cardiology (K.A.C., H.L.-P., P.D.), St. Michael’s Hospital, Toronto, Ontario, Canada; Department of Pharmacology and Toxicology (A.R., P.D.), Cardiovascular Sciences Collaborative Program (A.R., P.D.), Department of Medicine (K.A.C., H.L.-P., P.D.), and Department of Nutritional Sciences (A.F.D., R.P.B.), University of Toronto, Toronto, Ontario, Canada; and Department of
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Kumar S, Qu S, Kassotis JT. Effect of Omega-3 Polyunsaturated Fatty Acid Supplementation in Patients with Atrial Fibrillation. J Atr Fibrillation 2012; 5:502. [PMID: 28496756 DOI: 10.4022/jafib.502] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2011] [Revised: 05/11/2012] [Accepted: 06/21/2012] [Indexed: 12/19/2022]
Abstract
Atrial fibrillation (AF) is the most common sustained atrial arrhythmia conferring a higher morbidity and mortality. Despite the increasing incidence of AF; available therapies are far from perfect. Dietary fish oils, containing omega 3 fatty acids, also called polyunsaturated fatty acid [PUFA] have demonstrated beneficial electrophysiological, autonomic and anti-inflammatory effects on both atrial and ventricular tissue. Multiple clinical trials, focusing on various subsets of patients with AF, have studied the role of PUFA and their potential role in reducing the incidence of this common arrhythmia. While PUFA appears to have a beneficial effect in the primary prevention of AF in the elderly with structural heart disease, this benefit has not been universally observed. In the secondary prevention of AF, PUFA seems to have a greater impact in the reducing AF in patients with paroxysmal or persistent AF, stages of AF associated with less atrial fibrosis and negative structural remodeling. However, AF suppression has not been consistently demonstrated in clinical trials. In patients undergoing heart surgery, increasing PUFA intake has yielded mixed results in terms of AF prevention post-operatively; however, increased PUFA has been associated with a reduction in hospital stay. Therefore recommending the use of PUFA for the purpose of AF reduction remains controversial. This is in part attributable to the complexity of AF. Other conflicting variables include: heterogeneous patient populations studied; variable dosing; duration of follow-up; comorbidities; and, concomitant pharmacotherapy. This review article reviews in detail available basic and clinical research studies of fish oil in the treatment of AF, and its role in the treatment of this common disorder. ABBREVIATIONS AF=Atrial fibrillation, CHS=Cardiovascular Health Study,CABG=Coronary artery bypass surgery, d=Day, DHA=Docosahexaenoic acid, EPA=Eicosapentaenoic acid, ERP= Effective refractory period, g=Gram, PAF= Paroxysmal atrial fibrillation, PeAF= Persistent atrial fibrillation PUFA= Polyunsaturated fatty acid.
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Affiliation(s)
- Sanjay Kumar
- Department of Cardiovascular Diseases, SUNY Downstate Medical Center, 450 Clarkson Avenue, Box 1199 Brooklyn, NY 11203
| | - Sarah Qu
- Department of Cardiovascular Diseases, SUNY Downstate Medical Center, 450 Clarkson Avenue, Box 1199 Brooklyn, NY 11203
| | - John T Kassotis
- Department of Cardiovascular Diseases, SUNY Downstate Medical Center, 450 Clarkson Avenue, Box 1199 Brooklyn, NY 11203
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Rix TA, Mortensen LM, Schmidt EB. Fish, Marine n-3 Fatty Acids, and Atrial Fibrillation - Experimental Data and Clinical Effects. Front Physiol 2012; 3:152. [PMID: 22654766 PMCID: PMC3360493 DOI: 10.3389/fphys.2012.00152] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/29/2012] [Accepted: 05/02/2012] [Indexed: 01/22/2023] Open
Abstract
Marine n−3 polyunsaturated fatty acids (PUFA) may have beneficial effects in relation to atrial fibrillation (AF) with promising data from experimental animal studies, however, results from studies in humans have been inconsistent. This review evaluates the mechanisms of action of marine n−3 PUFA in relation to AF based on experimental data and provides a status on the evidence obtained from observational studies and interventional trials. In conclusion, there is growing evidence for an effect of marine n−3 PUFA in prevention and treatment of AF. However, further studies are needed to establish which patients are more likely to benefit from n−3 PUFA, the timing of treatment, and dosages.
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Affiliation(s)
- Thomas Andersen Rix
- Department of Cardiology, Aalborg AF Study Group, Center for Cardiovascular Research, Aalborg Hospital, Aarhus University Hospital Aalborg, Denmark
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24
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von Schacky C. Omega-3 Fatty acids: anti-arrhythmic, pro-arrhythmic, or both? Front Physiol 2012; 3:88. [PMID: 22529815 PMCID: PMC3327892 DOI: 10.3389/fphys.2012.00088] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2011] [Accepted: 03/23/2012] [Indexed: 11/13/2022] Open
Abstract
This review focuses on developments after 2008, when the topic was last reviewed by the author. Pertinent publications were found by medline searches and in the author’s personal data base. Prevention of atrial fibrillation (AF) was investigated in a number of trials, sparked by one positive report on the effects of eicosapentaenoic acid (EPA) and docosahexaenoic acid (DHA), considerations of upstream therapy, data from electrophysiologic laboratories and animal experiments. If EPA + DHA prevent postoperative AF, the effect is probably smaller than initially expected. The same is probably true for maintenance of sinus rhythm after cardioversion and for new-onset AF. Larger trials are currently ongoing. Prevention of ventricular arrhythmias was studied in carriers of an implanted cardioverter-defibrillator, with no clear results. This might have been due to a broad definition of the primary endpoint, including any ventricular arrhythmia and any action of the device. Epidemiologic studies support the contention that high levels of EPA + DHA prevent sudden cardiac death (SCD). However, since SCD is a rare occurrence, it is difficult to conduct an adequately powered trial. In patients with congestive heart failure, EPA + DHA reduced total mortality and rehospitalizations, but not SCD or presumed arrhythmic death. Of three trials in patients after a myocardial infarction, two were inadequately powered, and in one, the dose might have been too low. Taken together, while epidemiologic studies support an inverse relation between EPA + DHA and occurrence of SCD or arrhythmic death, demonstrating this effect in intervention trials remained elusive so far. A pro-arrhythmic effect of EPA + DHA has not been seen in intervention studies, and results of epidemiologic and animal studies also rather argue against such an effect. A different, and probably more productive, perspective is provided by a standardized analytical assessment of a person’s status in EPA + DHA by use of the omega-3 index, EPA + DHA in red cell fatty acids. In populations with a high omega-3 index, SCD is rare. Intervention trials can become more effective by including a low omega-3 index into the inclusion criteria, thus creating a study population more likely to demonstrate an effect of EPA + DHA. This is especially relevant in case of rare endpoints, like new-onset AF or SCD.
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Affiliation(s)
- C von Schacky
- Preventive Cardiology, Medizinische Klinik and Poliklinik I, Ludwig Maximilians-University Munich Munich, Germany
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Rauch B, Senges J. The effects of supplementation with omega-3 polyunsaturated Fatty acids on cardiac rhythm: anti-arrhythmic, pro-arrhythmic, both or neither? It depends…. Front Physiol 2012; 3:57. [PMID: 22485090 PMCID: PMC3317266 DOI: 10.3389/fphys.2012.00057] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2011] [Accepted: 02/28/2012] [Indexed: 12/11/2022] Open
Abstract
Supplementation of omega-3 fatty acids (Ω-3) has been associated with a decreased cardiovascular risk, thereby concentrating attention on a potentially preventive effect regarding tachyarrhythmias and sudden cardiac death. However, recent randomized controlled trials challenge the efficacy of the additional application of Ω-3 and its anti-arrhythmic effect under certain clinical conditions. The present paper reflects the results of earlier and recent clinical studies with respect to the individual background conditions that may determine the clinical outcome of Ω-3 supplementation and thereby explain apparently conflicting clinical results. It is concluded that the efficacy of Ω-3 supplementation to prevent cardiac arrhythmias strongly depends on the underlying clinical and pharmacological conditions, a hypothesis that also is supported by data from experimental animal studies and by molecular interactions of Ω-3 at the cellular level.
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Affiliation(s)
- Bernhard Rauch
- Zentrum für Ambulante Rehabilitation am Klinikum der Stadt Ludwigshafen Ludwigshafen am Rhein, Germany
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Long-term omega-3 polyunsaturated fatty acid supplementation reduces the recurrence of persistent atrial fibrillation after electrical cardioversion. Heart Rhythm 2011; 9:483-91. [PMID: 22120130 DOI: 10.1016/j.hrthm.2011.11.034] [Citation(s) in RCA: 59] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/21/2011] [Indexed: 01/24/2023]
Abstract
BACKGROUND Persistent atrial fibrillation (AF) is associated with a high risk of recurrence after electrical cardioversion. OBJECTIVE We examined if long-term supplementation with omega-3 polyunsaturated fatty acids in fish oils commenced >1 month prior to electrical cardioversion and continued thereafter reduces recurrence of persistent AF. METHODS This was an open-label, randomized study of 178 patients with persistent AF >1-month duration. Participants were assigned to control group (n = 87) or omega-3 group (6 g/d fish oil; n = 91) and underwent cardioversion 1 month later. Concurrent antiarrhythmic use of sotalol or amiodarone was permitted. Fish oil was continued till return of persistent AF or a maximum of 1 year. Intention-to-treat analysis was performed for the primary end point defined as the recurrence of persistent AF. RESULTS Mean duration of fish oil intake was 56 days precardioversion and a total of 242 days in follow-up. Eicosapentaenoic acid and docosahexaenoic acid, the active components of fish oils, were 1.8-fold and 2.1-fold higher, respectively, in the omega-3 group compared with controls at the time of cardioversion (P <.001). At 90 days, 38.5% of the patients receiving omega-3 fatty acid supplement had AF recurrence compared with 77.5% of the controls (hazard ratio [omega-3 vs control] 0.38; 95% confidence interval 0.27-0.56; P <.001). Omega-3 intake was associated with a significant reduction in AF recurrence with or without concurrent antiarrhythmic drugs. CONCLUSIONS Omega-3 polyunsaturated fatty acid supplementation commenced >1 month prior to electrical cardioversion and continued thereafter reduces the recurrence of persistent AF. Randomized controlled trials on long-term fish oil supplementation are needed to confirm these findings.
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