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Kohansal E, Askarinejad A, MozafaryBazargany M, Sabahizadeh A, Pakmehr S, Haghjoo M. Assessing the impact of omega-3 fatty acids on ventricular tachyarrhythmia and survival in patients with ICDs: A systematic review and meta-analysis. IJC HEART & VASCULATURE 2024; 52:101397. [PMID: 38584673 PMCID: PMC10990970 DOI: 10.1016/j.ijcha.2024.101397] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2024] [Revised: 03/16/2024] [Accepted: 03/26/2024] [Indexed: 04/09/2024]
Abstract
Background Recent studies investigating the effects of fish oil on shocks administered by ICDs in patients with ventricular tachycardias produced inconclusive results. This systematic review aims to evaluate the effectiveness of omega-3 polyunsaturated fatty acids in lowering the risk of life-threatening VTs among individuals with implantable cardioverter-defibrillators. Methods We searched five databases, including Central, PubMed, EMBASE, Web of Science, and Scopus, for studies evaluating the efficacy of omega-3 polyunsaturated fatty acids (PUFAs) for the prevention of ICD events for VT or VF, published up to December 1, 2023. Results Four trials were finally included in the study. The pooled risk ratios for mortality and ICD events were 0.87 (95% CI:0.58-1.32) and 0.75 (95% CI:0.48-1.18), respectively. Conclusion No significant effect was discovered to support the antiarrhythmic properties or survival advantages of n-3 polyunsaturated fatty acids (PUFA) in individuals with implanted implantable cardioverter-defibrillators (ICD).
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Affiliation(s)
- Erfan Kohansal
- Rajaie Cardiovascular Medical and Research Institute, Iran University of Medical Sciences, Tehran, Iran
| | - Amir Askarinejad
- Rajaie Cardiovascular Medical and Research Institute, Iran University of Medical Sciences, Tehran, Iran
| | | | | | | | - Majid Haghjoo
- Department of Cardiac Electrophysiology, Rajaie Cardiovascular Medical and Research Institute, Iran University of Medical Sciences, Tehran, Iran
- Cardiac Electrophysiology Research Center, Rajaie Cardiovascular Medical and Research Institute, Iran University of Medical Sciences, Tehran, Iran
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Circulating linoleic acid at the time of myocardial infarction and risk of primary ventricular fibrillation. Sci Rep 2022; 12:4377. [PMID: 35288655 PMCID: PMC8921268 DOI: 10.1038/s41598-022-08453-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2021] [Accepted: 02/21/2022] [Indexed: 12/02/2022] Open
Abstract
Primary ventricular fibrillation (PVF) is a major driver of cardiac arrest in the acute phase of ST-segment elevation myocardial infarction (STEMI). Enrichment of cardiomyocyte plasma membranes with dietary polyunsaturated fatty acids (PUFA) reduces vulnerability to PVF experimentally, but clinical data are scarce. PUFA status in serum phospholipids is a valid surrogate biomarker of PUFA status in cardiomyocytes within a wide range of dietary PUFA. In this nested case–control study (n = 58 cases of STEMI-driven PVF, n = 116 control non-PVF STEMI patients matched for age, sex, smoking status, dyslipidemia, diabetes mellitus and hypertension) we determined fatty acids in serum phospholipids by gas-chromatography, and assessed differences between cases and controls, applying the Benjamini–Hochberg procedure on nominal P-values to control the false discovery rate (FDR). Significant differences between cases and controls were restricted to linoleic acid (LA), with PVF patients showing a lower level (nominal P = 0.002; FDR-corrected P = 0.027). In a conditional logistic regression model, each one standard deviation increase in the proportion of LA was related to a 42% lower prevalence of PVF (odds ratio = 0.58; 95% confidence interval, 0.37, 0.90; P = 0.02). The association lasted after the inclusion of confounders. Thus, regular consumption of LA-rich foods (nuts, oils from seeds) may protect against ischemia-driven malignant arrhythmias.
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Zelniker TA, Morrow DA, Scirica BM, Furtado JD, Guo J, Mozaffarian D, Sabatine MS, O'Donoghue ML. Plasma Omega-3 Fatty Acids and the Risk of Cardiovascular Events in Patients After an Acute Coronary Syndrome in MERLIN-TIMI 36. J Am Heart Assoc 2021; 10:e017401. [PMID: 33840228 PMCID: PMC8174157 DOI: 10.1161/jaha.120.017401] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background Plasma omega-3 polyunsaturated fatty acids (ω3-PUFAs) have been shown to be inversely correlated with the risk of cardiovascular death in primary prevention. The risk relationship in the setting of an acute coronary syndrome is less well established. Methods and Results Baseline plasma ω3-PUFA composition (α-linolenic acid, eicosapentaenoic acid, docosapentaenoic acid, and docosahexaenoic acid) was assessed through gas chromatography with flame ionization detection in a case-cohort study involving 203 patients with cardiovascular death, 325 with myocardial infarction, 271 with ventricular tachycardia, and 161 with atrial fibrillation, and a random sample of 1612 event-free subjects as controls from MERLIN-TIMI 36 (Metabolic Efficiency With Ranolazine for Less Ischemia in Non-ST-Elevation-Acute Coronary Syndrome-Thrombolysis in Myocardial Infarction 36), a trial of patients hospitalized with non-ST-segment-elevation -acute coronary syndrome. After inverse-probability-weighted multivariable adjustment including all traditional risk factors, a higher relative proportion of long-chain ω3-PUFAs (eicosapentaenoic acid, docosapentaenoic acid, docosahexaenoic acid) were associated with 18% lower odds of cardiovascular death (adjusted [adj] odds ratio [OR] per 1 SD, 0.82; 95% CI, 0.68-0.98) that was primarily driven by 27% lower odds of sudden cardiac death (adj OR per 1 SD, 0.73; 95% CI, 0.55-0.97). Long-chain ω3-PUFA levels in the top quartile were associated with 51% lower odds of cardiovascular death (adj OR 0.49; 95% CI, 0.27-0.86) and 63% lower odds of sudden cardiac death (adj OR, 0.37; 95% CI, 0.16-0.56). An attenuated relationship was seen for α-linolenic acid and subsequent odds of cardiovascular (adj OR, 0.92; 95% CI, 0.74-1.14) and sudden cardiac death (adj OR, 0.91; 95% CI, 0.67-1.25). No significant relationship was observed between any ω3-PUFAs and the odds of cardiovascular death unrelated to sudden cardiac death, myocardial infarction, atrial fibrillation, or early post-acute coronary syndrome ventricular tachycardia. Conclusions In patients after non-ST-segment-elevation-acute coronary syndrome, plasma long-chain ω3-PUFAs are inversely associated with lower odds of sudden cardiac death, independent of traditional risk factors and lipids. Registration URL: https://www.clinicaltrials.gov. Unique identifier: NCT00099788.
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Affiliation(s)
- Thomas A Zelniker
- Division of Cardiology Vienna General HospitalMedical University of Vienna Austria
| | - David A Morrow
- TIMI Study Group Division of Cardiovascular Medicine Brigham and Women's Hospital and Harvard Medical School Boston MA
| | - Benjamin M Scirica
- TIMI Study Group Division of Cardiovascular Medicine Brigham and Women's Hospital and Harvard Medical School Boston MA
| | - Jeremy D Furtado
- Department of Nutrition Harvard T. H. Chan School of Public Health Boston MA
| | - Jianping Guo
- TIMI Study Group Division of Cardiovascular Medicine Brigham and Women's Hospital and Harvard Medical School Boston MA
| | | | - Marc S Sabatine
- TIMI Study Group Division of Cardiovascular Medicine Brigham and Women's Hospital and Harvard Medical School Boston MA
| | - Michelle L O'Donoghue
- TIMI Study Group Division of Cardiovascular Medicine Brigham and Women's Hospital and Harvard Medical School Boston MA
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Watanabe Y, Tatsuno I. Omega-3 polyunsaturated fatty acids focusing on eicosapentaenoic acid and docosahexaenoic acid in the prevention of cardiovascular diseases: a review of the state-of-the-art. Expert Rev Clin Pharmacol 2020; 14:79-93. [PMID: 33306922 DOI: 10.1080/17512433.2021.1863784] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
INTRODUCTION : An epidemiological study of Greenlandic Inuit suggested the importance of omega-3 polyunsaturated fatty acids (PUFAs) in preventing ischemic heart disease. After this landmark study, large-scale epidemiological studies have examined the benefits of omega-3 PUFAs in the prevention of cardiovascular diseases. AREAS COVERED : This article reviews studies on omega-3 PUFAs, and identifies issues relevant to cardiovascular risk. EXPERT OPINION : Recent studies have focused on the anti-inflammatory effects of omega-3 PUFAs and specialized pro-resolving mediators. High-purity eicosapentaenoic acid (EPA) ethyl ester and EPA/docosahexaenoic acid (DHA) preparations have been developed primarily for the treatment of hypertriglyceridemia. Various trials on the cardiovascular protective effects of omega-3 PUFAs have been reported, but the results have not been consistent. Some issues of the trials have been suggested, such as using low-dose omega-3 PUFAs and not including hypertriglyceridemia in subject selection criteria. REDUCE-IT study that used a high dose of high-purity EPA preparation showed a relative reduction in cardiovascular events, but, the STRENGTH study that used a high dose of EPA/DHA preparation did not support this benefit. This article reviews the roles of omega-3 PUFAs in cardiovascular diseases, including progress in understanding the molecular mechanisms and recent large-scale clinical trials.
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Affiliation(s)
- Yasuhiro Watanabe
- Center for Diabetes, Metabolism and Endocrinology, Toho University Sakura Medical Center , Chiba, Japan
| | - Ichiro Tatsuno
- Center for Diabetes, Metabolism and Endocrinology, Toho University Sakura Medical Center , Chiba, Japan
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Mareev VY, Mareev YV. Influence of Omega-3 PUFA on Non-invasive factors determining the risk of arrhYthmias eXcess and sudden cardiac death in patients with HFpEF with ischemic etiology (ONYX). ACTA ACUST UNITED AC 2020; 60:86-98. [DOI: 10.18087/cardio.2020.10.n1327] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2020] [Accepted: 10/30/2020] [Indexed: 11/18/2022]
Abstract
Aim Patients with heart failure with reduced left ventricular (LV) ejection fraction (HFrEF) who have had acute myocardial infarction have an unfavorable prognosis, largely due to ventricular arrhythmias (VA) and risk of sudden cardiac death (SCD). The optimal treatment (triple neurohormonal blockade plus implantable cardioverter defibrillator and cardiac resynchronization therapy) reduced the risk of SCD primarily due to reverse cardiac remodeling, but has not solved this problem completely. Efficacy of purified ω-3 polyunsaturated fatty acid esters (PUFA) in low doses (1 g/day) in reducing VA and risk of SCD in HFrEF patients was demonstrated in two large randomized clinical trials. The PUFA effects was suggested to be related also with increased heart rhythm variability (HRV) and chronotropic action, which might depend on the drug dose. The present open, prospective, randomized, comparative study in parallel groups evaluated the effect of Omacor in different doses on noninvasive markers of SCD risk in patients with ischemic HFrEF receiving the optimal drug therapy.Methods Patients (n=40) were randomized at a 1:1:2 ratio to the control group (n=10), the Omacor 1 g/day treatment group (n=10), and the Omacor 2 g/day treatment group (n=20) and were followed up for 12 months. Clinical evaluation included changes in the CHF functional class (FC) and Clinical Condition Scale (CCS) score; concentration of N-terminal pro-hormone brain natriuretic peptide (NT-proBNP); and peak oxygen consumption during exercise (peak VO2). The LV function was evaluated by LVEF. Holter ECG monitoring was used for evaluation of HRV (SDNN), average 24-h heart rate (HR), number of ventricular extrasystoles (VE) per hour and severity of VA, and presence of paired VE and VT runs.Results Improvement of CHF FC became significant only with the high-dose Omacor treatment (2 g/day). The CCS score showed a tendency towards decrease also with a lower dose (1 g/day) whereas the level of NT-proBNP significantly decreased with both Omacor doses. The increase in LV EF was significant only with the use of Omacor 2 g/day (+3 %, р=0.002). A negative chronotropic effect of ω-3 PUFA was observed. Average 24-h HR decreased by 8 bpm (р=0.05) and 11 bpm (р<0.001) with Omacor 1 g/day and 2 g/day, respectively. Either dose of ω-3 PUFA significantly improved VO2, which directly correlated with LV EF and inversely correlated with HR. The decrease in number of VE was associated not only with improved HRV (SDNN) but also with the decrease in 24-h HR, and thus Omacor 2 g/day significantly decreased the number of VE (by 16 per hour) and dangerous VA (paired VE and VT runs ceased to be detected in 40 % of patients).Conclusion Since HR, HRV, and VA are closely interrelated, the effect of ω-3 PUFA specifically on these noninvasive markers apparently determines its ability to decrease the risk of SCD in patients with ischemic HFrEF. The antiarrhythmic effect of Omacor was greater with higher doses of this drug.
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Affiliation(s)
- V. Yu. Mareev
- Medical Research and Educational Center of the M. V. Lomonosov Moscow State University, Moscow, Russia
Faculty of Fundamental Medicine, Lomonosov Moscow State University, Russia
| | - Yu. V. Mareev
- National Medical Research Centre for Therapy and Preventive Medicine, Moscow, Russia
Robertson Centre for Biostatistics, Glasgow, Great Britain
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Wang X, Verma S, Mason RP, Bhatt DL. The Road to Approval: a Perspective on the Role of Icosapent Ethyl in Cardiovascular Risk Reduction. Curr Diab Rep 2020; 20:65. [PMID: 33095318 PMCID: PMC7584545 DOI: 10.1007/s11892-020-01343-7] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/10/2020] [Indexed: 02/07/2023]
Abstract
PURPOSE OF REVIEW Epidemiological studies have long suggested the cardiovascular benefits of omega-3 fatty acids (OM3FAs). However, until recently, clinical trials using OM3FAs have been largely negative with respect to their cardioprotective effects. In this review, we aim to summarize key clinical trials, examine the clinical benefits of eicosapentaenoic acid (EPA) and potential mechanisms, and review the changes in guidelines and recommendations. RECENT FINDINGS The Reduction of Cardiovascular Events with Icosapent Ethyl-Intervention Trial (REDUCE-IT) has demonstrated significant cardiovascular mortality benefits of purified EPA ethyl ester, with a 25% relative risk reduction in major cardiovascular events. As first of its class to be approved, icosapent ethyl offers a new option to further reduce cardiovascular risks in patients already treated with maximally tolerated statins.
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Affiliation(s)
- Xiaowen Wang
- Brigham and Women's Hospital and Harvard Medical School, 75 Francis Street, Boston, MA, 02115, USA
| | | | - R Preston Mason
- Brigham and Women's Hospital and Harvard Medical School, 75 Francis Street, Boston, MA, 02115, USA
- Elucida Research LLC, Beverly, MA, USA
| | - Deepak L Bhatt
- Brigham and Women's Hospital and Harvard Medical School, 75 Francis Street, Boston, MA, 02115, USA.
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Abdelhamid AS, Brown TJ, Brainard JS, Biswas P, Thorpe GC, Moore HJ, Deane KHO, Summerbell CD, Worthington HV, Song F, Hooper L. Omega-3 fatty acids for the primary and secondary prevention of cardiovascular disease. Cochrane Database Syst Rev 2020; 3:CD003177. [PMID: 32114706 PMCID: PMC7049091 DOI: 10.1002/14651858.cd003177.pub5] [Citation(s) in RCA: 101] [Impact Index Per Article: 25.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
BACKGROUND Omega-3 polyunsaturated fatty acids from oily fish (long-chain omega-3 (LCn3)), including eicosapentaenoic acid (EPA) and docosahexaenoic acid (DHA)), as well as from plants (alpha-linolenic acid (ALA)) may benefit cardiovascular health. Guidelines recommend increasing omega-3-rich foods, and sometimes supplementation, but recent trials have not confirmed this. OBJECTIVES To assess the effects of increased intake of fish- and plant-based omega-3 fats for all-cause mortality, cardiovascular events, adiposity and lipids. SEARCH METHODS We searched CENTRAL, MEDLINE and Embase to February 2019, plus ClinicalTrials.gov and World Health Organization International Clinical Trials Registry to August 2019, with no language restrictions. We handsearched systematic review references and bibliographies and contacted trial authors. SELECTION CRITERIA We included randomised controlled trials (RCTs) that lasted at least 12 months and compared supplementation or advice to increase LCn3 or ALA intake, or both, versus usual or lower intake. DATA COLLECTION AND ANALYSIS Two review authors independently assessed trials for inclusion, extracted data and assessed validity. We performed separate random-effects meta-analysis for ALA and LCn3 interventions, and assessed dose-response relationships through meta-regression. MAIN RESULTS We included 86 RCTs (162,796 participants) in this review update and found that 28 were at low summary risk of bias. Trials were of 12 to 88 months' duration and included adults at varying cardiovascular risk, mainly in high-income countries. Most trials assessed LCn3 supplementation with capsules, but some used LCn3- or ALA-rich or enriched foods or dietary advice compared to placebo or usual diet. LCn3 doses ranged from 0.5 g a day to more than 5 g a day (19 RCTs gave at least 3 g LCn3 daily). Meta-analysis and sensitivity analyses suggested little or no effect of increasing LCn3 on all-cause mortality (risk ratio (RR) 0.97, 95% confidence interval (CI) 0.93 to 1.01; 143,693 participants; 11,297 deaths in 45 RCTs; high-certainty evidence), cardiovascular mortality (RR 0.92, 95% CI 0.86 to 0.99; 117,837 participants; 5658 deaths in 29 RCTs; moderate-certainty evidence), cardiovascular events (RR 0.96, 95% CI 0.92 to 1.01; 140,482 participants; 17,619 people experienced events in 43 RCTs; high-certainty evidence), stroke (RR 1.02, 95% CI 0.94 to 1.12; 138,888 participants; 2850 strokes in 31 RCTs; moderate-certainty evidence) or arrhythmia (RR 0.99, 95% CI 0.92 to 1.06; 77,990 participants; 4586 people experienced arrhythmia in 30 RCTs; low-certainty evidence). Increasing LCn3 may slightly reduce coronary heart disease mortality (number needed to treat for an additional beneficial outcome (NNTB) 334, RR 0.90, 95% CI 0.81 to 1.00; 127,378 participants; 3598 coronary heart disease deaths in 24 RCTs, low-certainty evidence) and coronary heart disease events (NNTB 167, RR 0.91, 95% CI 0.85 to 0.97; 134,116 participants; 8791 people experienced coronary heart disease events in 32 RCTs, low-certainty evidence). Overall, effects did not differ by trial duration or LCn3 dose in pre-planned subgrouping or meta-regression. There is little evidence of effects of eating fish. Increasing ALA intake probably makes little or no difference to all-cause mortality (RR 1.01, 95% CI 0.84 to 1.20; 19,327 participants; 459 deaths in 5 RCTs, moderate-certainty evidence),cardiovascular mortality (RR 0.96, 95% CI 0.74 to 1.25; 18,619 participants; 219 cardiovascular deaths in 4 RCTs; moderate-certainty evidence), coronary heart disease mortality (RR 0.95, 95% CI 0.72 to 1.26; 18,353 participants; 193 coronary heart disease deaths in 3 RCTs; moderate-certainty evidence) and coronary heart disease events (RR 1.00, 95% CI 0.82 to 1.22; 19,061 participants; 397 coronary heart disease events in 4 RCTs; low-certainty evidence). However, increased ALA may slightly reduce risk of cardiovascular disease events (NNTB 500, RR 0.95, 95% CI 0.83 to 1.07; but RR 0.91, 95% CI 0.79 to 1.04 in RCTs at low summary risk of bias; 19,327 participants; 884 cardiovascular disease events in 5 RCTs; low-certainty evidence), and probably slightly reduces risk of arrhythmia (NNTB 91, RR 0.73, 95% CI 0.55 to 0.97; 4912 participants; 173 events in 2 RCTs; moderate-certainty evidence). Effects on stroke are unclear. Increasing LCn3 and ALA had little or no effect on serious adverse events, adiposity, lipids and blood pressure, except increasing LCn3 reduced triglycerides by ˜15% in a dose-dependent way (high-certainty evidence). AUTHORS' CONCLUSIONS This is the most extensive systematic assessment of effects of omega-3 fats on cardiovascular health to date. Moderate- and low-certainty evidence suggests that increasing LCn3 slightly reduces risk of coronary heart disease mortality and events, and reduces serum triglycerides (evidence mainly from supplement trials). Increasing ALA slightly reduces risk of cardiovascular events and arrhythmia.
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Affiliation(s)
- Asmaa S Abdelhamid
- University of East AngliaNorwich Medical SchoolNorwich Research ParkNorwichNorfolkUKNR4 7TJ
| | - Tracey J Brown
- University of East AngliaNorwich Medical SchoolNorwich Research ParkNorwichNorfolkUKNR4 7TJ
| | - Julii S Brainard
- University of East AngliaNorwich Medical SchoolNorwich Research ParkNorwichNorfolkUKNR4 7TJ
| | - Priti Biswas
- University of East AngliaMED/HSCNorwich Research ParkNorwichUKNR4 7TJ
| | - Gabrielle C Thorpe
- University of East AngliaSchool of Health SciencesEarlham RoadNorwichUKNR4 7TJ
| | - Helen J Moore
- Teesside UniversitySchool of Social Sciences, Humanities and LawMiddlesboroughUKTS1 3BA
| | - Katherine HO Deane
- University of East AngliaSchool of Health SciencesEarlham RoadNorwichUKNR4 7TJ
| | - Carolyn D Summerbell
- Durham UniversityDepartment of Sport and Exercise Sciences42 Old ElvetDurhamUKDH13HN
| | - Helen V Worthington
- Division of Dentistry, School of Medical Sciences, Faculty of Biology, Medicine and Health, The University of ManchesterCochrane Oral HealthCoupland Building 3Oxford RoadManchesterUKM13 9PL
| | - Fujian Song
- University of East AngliaNorwich Medical SchoolNorwich Research ParkNorwichNorfolkUKNR4 7TJ
| | - Lee Hooper
- University of East AngliaNorwich Medical SchoolNorwich Research ParkNorwichNorfolkUKNR4 7TJ
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Tierney JF, Fisher DJ, Burdett S, Stewart LA, Parmar MKB. Comparison of aggregate and individual participant data approaches to meta-analysis of randomised trials: An observational study. PLoS Med 2020; 17:e1003019. [PMID: 32004320 PMCID: PMC6993967 DOI: 10.1371/journal.pmed.1003019] [Citation(s) in RCA: 43] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/21/2019] [Accepted: 12/30/2019] [Indexed: 12/26/2022] Open
Abstract
BACKGROUND It remains unclear when standard systematic reviews and meta-analyses that rely on published aggregate data (AD) can provide robust clinical conclusions. We aimed to compare the results from a large cohort of systematic reviews and meta-analyses based on individual participant data (IPD) with meta-analyses of published AD, to establish when the latter are most likely to be reliable and when the IPD approach might be required. METHODS AND FINDINGS We used 18 cancer systematic reviews that included IPD meta-analyses: all of those completed and published by the Meta-analysis Group of the MRC Clinical Trials Unit from 1991 to 2010. We extracted or estimated hazard ratios (HRs) and standard errors (SEs) for survival from trial reports and compared these with IPD equivalents at both the trial and meta-analysis level. We also extracted or estimated the number of events. We used paired t tests to assess whether HRs and SEs from published AD differed on average from those from IPD. We assessed agreement, and whether this was associated with trial or meta-analysis characteristics, using the approach of Bland and Altman. The 18 systematic reviews comprised 238 unique trials or trial comparisons, including 37,082 participants. A HR and SE could be generated for 127 trials, representing 53% of the trials and approximately 79% of eligible participants. On average, trial HRs derived from published AD were slightly more in favour of the research interventions than those from IPD (HRAD to HRIPD ratio = 0.95, p = 0.007), but the limits of agreement show that for individual trials, the HRs could deviate substantially. These limits narrowed with an increasing number of participants (p < 0.001) or a greater number (p < 0.001) or proportion (p < 0.001) of events in the AD. On average, meta-analysis HRs from published AD slightly tended to favour the research interventions whether based on fixed-effect (HRAD to HRIPD ratio = 0.97, p = 0.088) or random-effects (HRAD to HRIPD ratio = 0.96, p = 0.044) models, but the limits of agreement show that for individual meta-analyses, agreement was much more variable. These limits tended to narrow with an increasing number (p = 0.077) or proportion of events (p = 0.11) in the AD. However, even when the information size of the AD was large, individual meta-analysis HRs could still differ from their IPD equivalents by a relative 10% in favour of the research intervention to 5% in favour of control. We utilised the results to construct a decision tree for assessing whether an AD meta-analysis includes sufficient information, and when estimates of effects are most likely to be reliable. A lack of power at the meta-analysis level may have prevented us identifying additional factors associated with the reliability of AD meta-analyses, and we cannot be sure that our results are generalisable to all outcomes and effect measures. CONCLUSIONS In this study we found that HRs from published AD were most likely to agree with those from IPD when the information size was large. Based on these findings, we provide guidance for determining systematically when standard AD meta-analysis will likely generate robust clinical conclusions, and when the IPD approach will add considerable value.
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Affiliation(s)
- Jayne F. Tierney
- MRC Clinical Trials Unit at UCL, Institute of Clinical Trials and Methodology, University College London, London, United Kingdom
| | - David J. Fisher
- MRC Clinical Trials Unit at UCL, Institute of Clinical Trials and Methodology, University College London, London, United Kingdom
| | - Sarah Burdett
- MRC Clinical Trials Unit at UCL, Institute of Clinical Trials and Methodology, University College London, London, United Kingdom
| | - Lesley A. Stewart
- Centre for Reviews and Dissemination, University of York, York, United Kingdom
| | - Mahesh K. B. Parmar
- MRC Clinical Trials Unit at UCL, Institute of Clinical Trials and Methodology, University College London, London, United Kingdom
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Watanabe Y, Tatsuno I. Prevention of Cardiovascular Events with Omega-3 Polyunsaturated Fatty Acids and the Mechanism Involved. J Atheroscler Thromb 2019; 27:183-198. [PMID: 31582621 PMCID: PMC7113138 DOI: 10.5551/jat.50658] [Citation(s) in RCA: 54] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
An epidemiological study of Greenlandic Inuit suggested that fish oil, or omega-3 polyunsaturated fatty acids (PUFA), was important in preventing atherosclerotic disease. After this landmark study, many large-scale epidemiological studies and meta-analyses have examined the health benefits of omega-3 PUFA as part of a fatty acid-rich diet to demonstrate its beneficial roles in the prevention of cardiovascular diseases. Recent research has also focused attention on the anti-inflammatory effects of omega-3 PUFA and on specialized pro-resolving mediators. Findings of these studies have led to the development of omega-3 PUFA preparations for the treatment of dyslipidemia, including a highly purified eicosapentaenoic acid (EPA)-ethyl ester product (Epadel®) in Japan and an EPA/docosahexaenoic acid (DHA) preparation (Lotriga®) in the United States and Europe. Although various large-scale clinical trials on the cardiovascular preventive effect of omega-3 PUFA were conducted and reported, the results were not always consistent. The issues of not targeting subjects with hypertriglyceridemia and using low dose of omega-3 PUFA have been suggested to contribute to the failure of demonstrating the preventive effect of omega-3 PUFA in these clinical trials. Taking into account the above issues, the REDUCE-IT trial evaluated a highly purified EPA preparation at a high dose of 4 g/day in patients with hypertriglyceridemia and high cardiovascular risk, and demonstrated an extraordinary outcome of 25% relative reduction in cardiovascular events. This article reviews studies on omega-3 fatty acids during the last 50 years, including the progress in elucidating molecular mechanisms and recent large-scale clinical studies.
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Affiliation(s)
- Yasuhiro Watanabe
- Center for Diabetes, Metabolism and Endocrinology, Toho University Sakura Medical Center
| | - Ichiro Tatsuno
- Center for Diabetes, Metabolism and Endocrinology, Toho University Sakura Medical Center
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About the controversies of the cardioprotective effect of n-3 polyunsaturated fatty acids (PUFAs) between animal studies and clinical meta-analyses: a review with several strategies to enhance the beneficial effects of n-3 PUFAs. J Physiol Biochem 2019; 75:241-251. [PMID: 30825060 DOI: 10.1007/s13105-019-00670-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2018] [Accepted: 02/21/2019] [Indexed: 10/27/2022]
Abstract
Several meta-analyses describing the effect of n-3 polyunsaturated fatty acids on the survival rate of the victims of an acute coronary event do not clearly support a beneficial impact of these fatty acids. Yet, animal studies consistently show n-3 PUFA-induced protection against ischemia-reperfusion-induced myocardial injuries. The impact on reperfusion arrhythmias of these PUFAs is more controversial. The literature shows the anti-arrhythmic properties of circulating n-3 PUFAs. However, when these fatty acids are incorporated in the cardiac membrane, they protect the myocardial tissue vis a vis cellular damage but they can be either pro- or anti-arrhythmic during reperfusion, depending on the severity of tissue injuries. The latter elements can explain the lack of beneficial effect observed in the meta-analyses, but a proper use of n-3 PUFAs may provide advantages in terms of survival rate. This review discusses the different results obtained in humans and animals and presents several strategies to enhance the beneficial effects of n-3 PUFAs.
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Abdelhamid AS, Brown TJ, Brainard JS, Biswas P, Thorpe GC, Moore HJ, Deane KHO, AlAbdulghafoor FK, Summerbell CD, Worthington HV, Song F, Hooper L. Omega-3 fatty acids for the primary and secondary prevention of cardiovascular disease. Cochrane Database Syst Rev 2018; 11:CD003177. [PMID: 30521670 PMCID: PMC6517311 DOI: 10.1002/14651858.cd003177.pub4] [Citation(s) in RCA: 95] [Impact Index Per Article: 15.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND Researchers have suggested that omega-3 polyunsaturated fatty acids from oily fish (long-chain omega-3 (LCn3), including eicosapentaenoic acid (EPA) and docosahexaenoic acid (DHA)), as well as from plants (alpha-linolenic acid (ALA)) benefit cardiovascular health. Guidelines recommend increasing omega-3-rich foods, and sometimes supplementation, but recent trials have not confirmed this. OBJECTIVES To assess effects of increased intake of fish- and plant-based omega-3 for all-cause mortality, cardiovascular (CVD) events, adiposity and lipids. SEARCH METHODS We searched CENTRAL, MEDLINE and Embase to April 2017, plus ClinicalTrials.gov and World Health Organization International Clinical Trials Registry to September 2016, with no language restrictions. We handsearched systematic review references and bibliographies and contacted authors. SELECTION CRITERIA We included randomised controlled trials (RCTs) that lasted at least 12 months and compared supplementation and/or advice to increase LCn3 or ALA intake versus usual or lower intake. DATA COLLECTION AND ANALYSIS Two review authors independently assessed studies for inclusion, extracted data and assessed validity. We performed separate random-effects meta-analysis for ALA and LCn3 interventions, and assessed dose-response relationships through meta-regression. MAIN RESULTS We included 79 RCTs (112,059 participants) in this review update and found that 25 were at low summary risk of bias. Trials were of 12 to 72 months' duration and included adults at varying cardiovascular risk, mainly in high-income countries. Most studies assessed LCn3 supplementation with capsules, but some used LCn3- or ALA-rich or enriched foods or dietary advice compared to placebo or usual diet. LCn3 doses ranged from 0.5g/d LCn3 to > 5 g/d (16 RCTs gave at least 3g/d LCn3).Meta-analysis and sensitivity analyses suggested little or no effect of increasing LCn3 on all-cause mortality (RR 0.98, 95% CI 0.90 to 1.03, 92,653 participants; 8189 deaths in 39 trials, high-quality evidence), cardiovascular mortality (RR 0.95, 95% CI 0.87 to 1.03, 67,772 participants; 4544 CVD deaths in 25 RCTs), cardiovascular events (RR 0.99, 95% CI 0.94 to 1.04, 90,378 participants; 14,737 people experienced events in 38 trials, high-quality evidence), coronary heart disease (CHD) mortality (RR 0.93, 95% CI 0.79 to 1.09, 73,491 participants; 1596 CHD deaths in 21 RCTs), stroke (RR 1.06, 95% CI 0.96 to 1.16, 89,358 participants; 1822 strokes in 28 trials) or arrhythmia (RR 0.97, 95% CI 0.90 to 1.05, 53,796 participants; 3788 people experienced arrhythmia in 28 RCTs). There was a suggestion that LCn3 reduced CHD events (RR 0.93, 95% CI 0.88 to 0.97, 84,301 participants; 5469 people experienced CHD events in 28 RCTs); however, this was not maintained in sensitivity analyses - LCn3 probably makes little or no difference to CHD event risk. All evidence was of moderate GRADE quality, except as noted.Increasing ALA intake probably makes little or no difference to all-cause mortality (RR 1.01, 95% CI 0.84 to 1.20, 19,327 participants; 459 deaths, 5 RCTs),cardiovascular mortality (RR 0.96, 95% CI 0.74 to 1.25, 18,619 participants; 219 cardiovascular deaths, 4 RCTs), and CHD mortality (1.1% to 1.0%, RR 0.95, 95% CI 0.72 to 1.26, 18,353 participants; 193 CHD deaths, 3 RCTs) and ALA may make little or no difference to CHD events (RR 1.00, 95% CI 0.80 to 1.22, 19,061 participants, 397 CHD events, 4 RCTs, low-quality evidence). However, increased ALA may slightly reduce risk of cardiovascular events (from 4.8% to 4.7%, RR 0.95, 95% CI 0.83 to 1.07, 19,327 participants; 884 CVD events, 5 RCTs, low-quality evidence with greater effects in trials at low summary risk of bias), and probably reduces risk of arrhythmia (3.3% to 2.6%, RR 0.79, 95% CI 0.57 to 1.10, 4,837 participants; 141 events, 1 RCT). Effects on stroke are unclear.Sensitivity analysis retaining only trials at low summary risk of bias moved effect sizes towards the null (RR 1.0) for all LCn3 primary outcomes except arrhythmias, but for most ALA outcomes, effect sizes moved to suggest protection. LCn3 funnel plots suggested that adding in missing studies/results would move effect sizes towards null for most primary outcomes. There were no dose or duration effects in subgrouping or meta-regression.There was no evidence that increasing LCn3 or ALA altered serious adverse events, adiposity or lipids, except LCn3 reduced triglycerides by ˜15% in a dose-dependant way (high-quality evidence). AUTHORS' CONCLUSIONS This is the most extensive systematic assessment of effects of omega-3 fats on cardiovascular health to date. Moderate- and high-quality evidence suggests that increasing EPA and DHA has little or no effect on mortality or cardiovascular health (evidence mainly from supplement trials). Previous suggestions of benefits from EPA and DHA supplements appear to spring from trials with higher risk of bias. Low-quality evidence suggests ALA may slightly reduce CVD event and arrhythmia risk.
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Affiliation(s)
- Asmaa S Abdelhamid
- University of East AngliaNorwich Medical SchoolNorwich Research ParkNorwichNorfolkUKNR4 7TJ
| | - Tracey J Brown
- University of East AngliaNorwich Medical SchoolNorwich Research ParkNorwichNorfolkUKNR4 7TJ
| | - Julii S Brainard
- University of East AngliaNorwich Medical SchoolNorwich Research ParkNorwichNorfolkUKNR4 7TJ
| | - Priti Biswas
- University of East AngliaMED/HSCNorwich Research ParkNorwichUKNR4 7TJ
| | - Gabrielle C Thorpe
- University of East AngliaSchool of Health SciencesEarlham RoadNorwichUKNR4 7TJ
| | - Helen J Moore
- Durham UniversityWolfson Research InstituteDurhamUKDH1 3LE
| | - Katherine HO Deane
- University of East AngliaSchool of Health SciencesEarlham RoadNorwichUKNR4 7TJ
| | - Fai K AlAbdulghafoor
- University of East AngliaNorwich Medical SchoolNorwich Research ParkNorwichNorfolkUKNR4 7TJ
| | - Carolyn D Summerbell
- Durham UniversityDepartment of Sport and Exercise Science42 Old ElvetDurhamUKDH13HN
| | - Helen V Worthington
- Division of Dentistry, School of Medical Sciences, Faculty of Biology, Medicine and Health, The University of ManchesterCochrane Oral HealthJR Moore BuildingOxford RoadManchesterUKM13 9PL
| | - Fujian Song
- University of East AngliaNorwich Medical SchoolNorwich Research ParkNorwichNorfolkUKNR4 7TJ
| | - Lee Hooper
- University of East AngliaNorwich Medical SchoolNorwich Research ParkNorwichNorfolkUKNR4 7TJ
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12
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Abdelhamid AS, Martin N, Bridges C, Brainard JS, Wang X, Brown TJ, Hanson S, Jimoh OF, Ajabnoor SM, Deane KHO, Song F, Hooper L. Polyunsaturated fatty acids for the primary and secondary prevention of cardiovascular disease. Cochrane Database Syst Rev 2018; 11:CD012345. [PMID: 30484282 PMCID: PMC6517012 DOI: 10.1002/14651858.cd012345.pub3] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
BACKGROUND Evidence on the health effects of total polyunsaturated fatty acids (PUFA) is equivocal. Fish oils are rich in omega-3 PUFA and plant oils in omega-6 PUFA. Evidence suggests that increasing PUFA-rich foods, supplements or supplemented foods can reduce serum cholesterol, but may increase body weight, so overall cardiovascular effects are unclear. OBJECTIVES To assess effects of increasing total PUFA intake on cardiovascular disease and all-cause mortality, lipids and adiposity in adults. SEARCH METHODS We searched CENTRAL, MEDLINE and Embase to April 2017 and clinicaltrials.gov and the World Health Organization International Clinical Trials Registry Platform to September 2016, without language restrictions. We checked trials included in relevant systematic reviews. SELECTION CRITERIA We included randomised controlled trials (RCTs) comparing higher with lower PUFA intakes in adults with or without cardiovascular disease that assessed effects over 12 months or longer. We included full texts, abstracts, trials registry entries and unpublished data. Outcomes were all-cause mortality, cardiovascular disease mortality and events, risk factors (blood lipids, adiposity, blood pressure), and adverse events. We excluded trials where we could not separate effects of PUFA intake from other dietary, lifestyle or medication interventions. DATA COLLECTION AND ANALYSIS Two review authors independently screened titles and abstracts, assessed trials for inclusion, extracted data, and assessed risk of bias. We wrote to authors of included trials for further data. Meta-analyses used random-effects analysis, sensitivity analyses included fixed-effects and limiting to low summary risk of bias. We assessed GRADE quality of evidence. MAIN RESULTS We included 49 RCTs randomising 24,272 participants, with duration of one to eight years. Eleven included trials were at low summary risk of bias, 33 recruited participants without cardiovascular disease. Baseline PUFA intake was unclear in most trials, but 3.9% to 8% of total energy intake where reported. Most trials gave supplemental capsules, but eight gave dietary advice, eight gave supplemental foods such as nuts or margarine, and three used a combination of methods to increase PUFA.Increasing PUFA intake probably has little or no effect on all-cause mortality (risk 7.8% vs 7.6%, risk ratio (RR) 0.98, 95% confidence interval (CI) 0.89 to 1.07, 19,290 participants in 24 trials), but probably slightly reduces risk of coronary heart disease events from 14.2% to 12.3% (RR 0.87, 95% CI 0.72 to 1.06, 15 trials, 10,076 participants) and cardiovascular disease events from 14.6% to 13.0% (RR 0.89, 95% CI 0.79 to 1.01, 17,799 participants in 21 trials), all moderate-quality evidence. Increasing PUFA may slightly reduce risk of coronary heart disease death (6.6% to 6.1%, RR 0.91, 95% CI 0.78 to 1.06, 9 trials, 8810 participants) andstroke (1.2% to 1.1%, RR 0.91, 95% CI 0.58 to 1.44, 11 trials, 14,742 participants, though confidence intervals include important harms), but has little or no effect on cardiovascular mortality (RR 1.02, 95% CI 0.82 to 1.26, 16 trials, 15,107 participants) all low-quality evidence. Effects of increasing PUFA on major adverse cardiac and cerebrovascular events and atrial fibrillation are unclear as evidence is of very low quality.Increasing PUFA intake probably slightly decreases triglycerides (by 15%, MD -0.12 mmol/L, 95% CI -0.20 to -0.04, 20 trials, 3905 participants), but has little or no effect on total cholesterol (mean difference (MD) -0.12 mmol/L, 95% CI -0.23 to -0.02, 26 trials, 8072 participants), high-density lipoprotein (HDL) (MD -0.01 mmol/L, 95% CI -0.02 to 0.01, 18 trials, 4674 participants) or low-density lipoprotein (LDL) (MD -0.01 mmol/L, 95% CI -0.09 to 0.06, 15 trials, 3362 participants). Increasing PUFA probably has little or no effect on adiposity (body weight MD 0.76 kg, 95% CI 0.34 to 1.19, 12 trials, 7100 participants).Effects of increasing PUFA on serious adverse events such as pulmonary embolism and bleeding are unclear as the evidence is of very low quality. AUTHORS' CONCLUSIONS This is the most extensive systematic review of RCTs conducted to date to assess effects of increasing PUFA on cardiovascular disease, mortality, lipids or adiposity. Increasing PUFA intake probably slightly reduces risk of coronary heart disease and cardiovascular disease events, may slightly reduce risk of coronary heart disease mortality and stroke (though not ruling out harms), but has little or no effect on all-cause or cardiovascular disease mortality. The mechanism may be via TG reduction.
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Affiliation(s)
- Asmaa S Abdelhamid
- University of East AngliaNorwich Medical SchoolNorwich Research ParkNorwichNorfolkUKNR4 7TJ
| | - Nicole Martin
- University College LondonInstitute of Health Informatics Research222 Euston RoadLondonUKNW1 2DA
| | - Charlene Bridges
- University College LondonInstitute of Health Informatics Research222 Euston RoadLondonUKNW1 2DA
| | - Julii S Brainard
- University of East AngliaNorwich Medical SchoolNorwich Research ParkNorwichNorfolkUKNR4 7TJ
| | - Xia Wang
- University of East AngliaNorwich Medical SchoolNorwich Research ParkNorwichNorfolkUKNR4 7TJ
| | - Tracey J Brown
- University of East AngliaNorwich Medical SchoolNorwich Research ParkNorwichNorfolkUKNR4 7TJ
| | - Sarah Hanson
- University of East AngliaSchool of Health SciencesEdith Cavell BuildingNorwichUKNR4 7TJ
| | - Oluseyi F Jimoh
- University of East AngliaNorwich Medical SchoolNorwich Research ParkNorwichNorfolkUKNR4 7TJ
| | - Sarah M Ajabnoor
- University of East AngliaNorwich Medical SchoolNorwich Research ParkNorwichNorfolkUKNR4 7TJ
| | - Katherine HO Deane
- University of East AngliaSchool of Health SciencesEdith Cavell BuildingNorwichUKNR4 7TJ
| | - Fujian Song
- University of East AngliaNorwich Medical SchoolNorwich Research ParkNorwichNorfolkUKNR4 7TJ
| | - Lee Hooper
- University of East AngliaNorwich Medical SchoolNorwich Research ParkNorwichNorfolkUKNR4 7TJ
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13
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Neumann U, Derwenskus F, Gille A, Louis S, Schmid-Staiger U, Briviba K, Bischoff SC. Bioavailability and Safety of Nutrients from the Microalgae Chlorella vulgaris, Nannochloropsis oceanica and Phaeodactylum tricornutum in C57BL/6 Mice. Nutrients 2018; 10:nu10080965. [PMID: 30049974 PMCID: PMC6116023 DOI: 10.3390/nu10080965] [Citation(s) in RCA: 31] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2018] [Revised: 07/18/2018] [Accepted: 07/23/2018] [Indexed: 12/20/2022] Open
Abstract
Microalgae are rich in macronutrients and therefore, they have been proposed as a potential future food source preserving natural resources. Here, we studied safety and bioavailability of algae nutrients in mice. Three microalgae species, Chlorella vulgaris, Nannochloropsis oceanica and Phaeodactylum tricornutum, were studied after ball mill disruption at different doses (5%, 15% and 25% dry weight) for 14 days. In response to all three algae diets, we observed a weight gain similar or superior to that in response to the control diet. No substantial differences in organ weights nor gut length occurred. Protein bioavailability from the algae diets did not differ from the control diet ranging from 58% to 77% apparent biological value. Fat absorption was lower for microalgae compared to soy oil in control diets, albeit still substantial. High liver eicosapentaenoic acid levels were measured following feeding with N. oceanica, the algae richest in omega-3 fatty acids. Neither histological nor serum analyses revealed any heart, kidney or liver toxicity induced by any of the algae diets. Algae-rich diets were thus well accepted, well tolerated and suitable for the maintenance of body weight and normal organ function. No toxicological effects were observed.
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Affiliation(s)
- Ulrike Neumann
- Institute of Clinical Nutrition, University of Hohenheim, Fruwirthstr. 12, 70593 Stuttgart, Germany.
| | - Felix Derwenskus
- Institute of Interfacial Process Engineering and Plasma Technology, University of Stuttgart, 70569 Stuttgart, Germany.
| | - Andrea Gille
- Department of Physiology and Biochemistry of Nutrition, Max Rubner-Institut, 76131 Karlsruhe, Germany.
| | - Sandrine Louis
- Institute of Clinical Nutrition, University of Hohenheim, Fruwirthstr. 12, 70593 Stuttgart, Germany.
- Department of Physiology and Biochemistry of Nutrition, Max Rubner-Institut, 76131 Karlsruhe, Germany.
| | - Ulrike Schmid-Staiger
- Fraunhofer Institute for Interfacial Engineering and Biotechnology, 70569 Stuttgart, Germany.
| | - Karlis Briviba
- Department of Physiology and Biochemistry of Nutrition, Max Rubner-Institut, 76131 Karlsruhe, Germany.
| | - Stephan C Bischoff
- Institute of Clinical Nutrition, University of Hohenheim, Fruwirthstr. 12, 70593 Stuttgart, Germany.
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14
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Abdelhamid AS, Martin N, Bridges C, Brainard JS, Wang X, Brown TJ, Hanson S, Jimoh OF, Ajabnoor SM, Deane KHO, Song F, Hooper L. Polyunsaturated fatty acids for the primary and secondary prevention of cardiovascular disease. Cochrane Database Syst Rev 2018; 7:CD012345. [PMID: 30019767 PMCID: PMC6513571 DOI: 10.1002/14651858.cd012345.pub2] [Citation(s) in RCA: 49] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
BACKGROUND Evidence on the health effects of total polyunsaturated fatty acids (PUFA) is equivocal. Fish oils are rich in omega-3 PUFA and plant oils in omega-6 PUFA. Evidence suggests that increasing PUFA-rich foods, supplements or supplemented foods can reduce serum cholesterol, but may increase body weight, so overall cardiovascular effects are unclear. OBJECTIVES To assess effects of increasing total PUFA intake on cardiovascular disease and all-cause mortality, lipids and adiposity in adults. SEARCH METHODS We searched CENTRAL, MEDLINE and Embase to April 2017 and clinicaltrials.gov and the World Health Organization International Clinical Trials Registry Platform to September 2016, without language restrictions. We checked trials included in relevant systematic reviews. SELECTION CRITERIA We included randomised controlled trials (RCTs) comparing higher with lower PUFA intakes in adults with or without cardiovascular disease that assessed effects over 12 months or longer. We included full texts, abstracts, trials registry entries and unpublished data. Outcomes were all-cause mortality, cardiovascular disease mortality and events, risk factors (blood lipids, adiposity, blood pressure), and adverse events. We excluded trials where we could not separate effects of PUFA intake from other dietary, lifestyle or medication interventions. DATA COLLECTION AND ANALYSIS Two review authors independently screened titles and abstracts, assessed trials for inclusion, extracted data, and assessed risk of bias. We wrote to authors of included trials for further data. Meta-analyses used random-effects analysis, sensitivity analyses included fixed-effects and limiting to low summary risk of bias. We assessed GRADE quality of evidence. MAIN RESULTS We included 49 RCTs randomising 24,272 participants, with duration of one to eight years. Eleven included trials were at low summary risk of bias, 33 recruited participants without cardiovascular disease. Baseline PUFA intake was unclear in most trials, but 3.9% to 8% of total energy intake where reported. Most trials gave supplemental capsules, but eight gave dietary advice, eight gave supplemental foods such as nuts or margarine, and three used a combination of methods to increase PUFA.Increasing PUFA intake probably has little or no effect on all-cause mortality (risk 7.8% vs 7.6%, risk ratio (RR) 0.98, 95% confidence interval (CI) 0.89 to 1.07, 19,290 participants in 24 trials), but probably slightly reduces risk of coronary heart disease events from 14.2% to 12.3% (RR 0.87, 95% CI 0.72 to 1.06, 15 trials, 10,076 participants) and cardiovascular disease events from 14.6% to 13.0% (RR 0.89, 95% CI 0.79 to 1.01, 17,799 participants in 21 trials), all moderate-quality evidence. Increasing PUFA may slightly reduce risk of coronary heart disease death (6.6% to 6.1%, RR 0.91, 95% CI 0.78 to 1.06, 9 trials, 8810 participants) andstroke (1.2% to 1.1%, RR 0.91, 95% CI 0.58 to 1.44, 11 trials, 14,742 participants, though confidence intervals include important harms), but has little or no effect on cardiovascular mortality (RR 1.02, 95% CI 0.82 to 1.26, 16 trials, 15,107 participants) all low-quality evidence. Effects of increasing PUFA on major adverse cardiac and cerebrovascular events and atrial fibrillation are unclear as evidence is of very low quality.Increasing PUFA intake slightly reduces total cholesterol (mean difference (MD) -0.12 mmol/L, 95% CI -0.23 to -0.02, 26 trials, 8072 participants) and probably slightly decreases triglycerides (MD -0.12 mmol/L, 95% CI -0.20 to -0.04, 20 trials, 3905 participants), but has little or no effect on high-density lipoprotein (HDL) (MD -0.01 mmol/L, 95% CI -0.02 to 0.01, 18 trials, 4674 participants) or low-density lipoprotein (LDL) (MD -0.01 mmol/L, 95% CI -0.09 to 0.06, 15 trials, 3362 participants). Increasing PUFA probably causes slight weight gain (MD 0.76 kg, 95% CI 0.34 to 1.19, 12 trials, 7100 participants).Effects of increasing PUFA on serious adverse events such as pulmonary embolism and bleeding are unclear as the evidence is of very low quality. AUTHORS' CONCLUSIONS This is the most extensive systematic review of RCTs conducted to date to assess effects of increasing PUFA on cardiovascular disease, mortality, lipids or adiposity. Increasing PUFA intake probably slightly reduces risk of coronary heart disease and cardiovascular disease events, may slightly reduce risk of coronary heart disease mortality and stroke (though not ruling out harms), but has little or no effect on all-cause or cardiovascular disease mortality. The mechanism may be via lipid reduction, but increasing PUFA probably slightly increases weight.
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Affiliation(s)
- Asmaa S Abdelhamid
- University of East AngliaNorwich Medical SchoolNorwich Research ParkNorwichUKNR4 7TJ
| | - Nicole Martin
- University College LondonFarr Institute of Health Informatics Research222 Euston RoadLondonUKNW1 2DA
| | - Charlene Bridges
- University College LondonFarr Institute of Health Informatics Research222 Euston RoadLondonUKNW1 2DA
| | - Julii S Brainard
- University of East AngliaNorwich Medical SchoolNorwich Research ParkNorwichUKNR4 7TJ
| | - Xia Wang
- University of East AngliaNorwich Medical SchoolNorwich Research ParkNorwichUKNR4 7TJ
| | - Tracey J Brown
- University of East AngliaNorwich Medical SchoolNorwich Research ParkNorwichUKNR4 7TJ
| | - Sarah Hanson
- University of East AngliaSchool of Health SciencesEdith Cavell BuildingNorwichUKNR4 7TJ
| | - Oluseyi F Jimoh
- University of East AngliaNorwich Medical SchoolNorwich Research ParkNorwichUKNR4 7TJ
| | - Sarah M Ajabnoor
- University of East AngliaNorwich Medical SchoolNorwich Research ParkNorwichUKNR4 7TJ
| | - Katherine HO Deane
- University of East AngliaSchool of Health SciencesEdith Cavell BuildingNorwichUKNR4 7TJ
| | - Fujian Song
- University of East AngliaNorwich Medical SchoolNorwich Research ParkNorwichUKNR4 7TJ
| | - Lee Hooper
- University of East AngliaNorwich Medical SchoolNorwich Research ParkNorwichUKNR4 7TJ
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15
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Abdelhamid AS, Brown TJ, Brainard JS, Biswas P, Thorpe GC, Moore HJ, Deane KHO, AlAbdulghafoor FK, Summerbell CD, Worthington HV, Song F, Hooper L. Omega-3 fatty acids for the primary and secondary prevention of cardiovascular disease. Cochrane Database Syst Rev 2018; 7:CD003177. [PMID: 30019766 PMCID: PMC6513557 DOI: 10.1002/14651858.cd003177.pub3] [Citation(s) in RCA: 114] [Impact Index Per Article: 19.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
BACKGROUND Researchers have suggested that omega-3 polyunsaturated fatty acids from oily fish (long-chain omega-3 (LCn3), including eicosapentaenoic acid (EPA) and docosahexaenoic acid (DHA)), as well as from plants (alpha-linolenic acid (ALA)) benefit cardiovascular health. Guidelines recommend increasing omega-3-rich foods, and sometimes supplementation, but recent trials have not confirmed this. OBJECTIVES To assess effects of increased intake of fish- and plant-based omega-3 for all-cause mortality, cardiovascular (CVD) events, adiposity and lipids. SEARCH METHODS We searched CENTRAL, MEDLINE and Embase to April 2017, plus ClinicalTrials.gov and World Health Organization International Clinical Trials Registry to September 2016, with no language restrictions. We handsearched systematic review references and bibliographies and contacted authors. SELECTION CRITERIA We included randomised controlled trials (RCTs) that lasted at least 12 months and compared supplementation and/or advice to increase LCn3 or ALA intake versus usual or lower intake. DATA COLLECTION AND ANALYSIS Two review authors independently assessed studies for inclusion, extracted data and assessed validity. We performed separate random-effects meta-analysis for ALA and LCn3 interventions, and assessed dose-response relationships through meta-regression. MAIN RESULTS We included 79 RCTs (112,059 participants) in this review update and found that 25 were at low summary risk of bias. Trials were of 12 to 72 months' duration and included adults at varying cardiovascular risk, mainly in high-income countries. Most studies assessed LCn3 supplementation with capsules, but some used LCn3- or ALA-rich or enriched foods or dietary advice compared to placebo or usual diet.Meta-analysis and sensitivity analyses suggested little or no effect of increasing LCn3 on all-cause mortality (RR 0.98, 95% CI 0.90 to 1.03, 92,653 participants; 8189 deaths in 39 trials, high-quality evidence), cardiovascular mortality (RR 0.95, 95% CI 0.87 to 1.03, 67,772 participants; 4544 CVD deaths in 25 RCTs), cardiovascular events (RR 0.99, 95% CI 0.94 to 1.04, 90,378 participants; 14,737 people experienced events in 38 trials, high-quality evidence), coronary heart disease (CHD) mortality (RR 0.93, 95% CI 0.79 to 1.09, 73,491 participants; 1596 CHD deaths in 21 RCTs), stroke (RR 1.06, 95% CI 0.96 to 1.16, 89,358 participants; 1822 strokes in 28 trials) or arrhythmia (RR 0.97, 95% CI 0.90 to 1.05, 53,796 participants; 3788 people experienced arrhythmia in 28 RCTs). There was a suggestion that LCn3 reduced CHD events (RR 0.93, 95% CI 0.88 to 0.97, 84,301 participants; 5469 people experienced CHD events in 28 RCTs); however, this was not maintained in sensitivity analyses - LCn3 probably makes little or no difference to CHD event risk. All evidence was of moderate GRADE quality, except as noted.Increasing ALA intake probably makes little or no difference to all-cause mortality (RR 1.01, 95% CI 0.84 to 1.20, 19,327 participants; 459 deaths, 5 RCTs),cardiovascular mortality (RR 0.96, 95% CI 0.74 to 1.25, 18,619 participants; 219 cardiovascular deaths, 4 RCTs), and it may make little or no difference to CHD events (RR 1.00, 95% CI 0.80 to 1.22, 19,061 participants, 397 CHD events, 4 RCTs, low-quality evidence). However, increased ALA may slightly reduce risk of cardiovascular events (from 4.8% to 4.7%, RR 0.95, 95% CI 0.83 to 1.07, 19,327 participants; 884 CVD events, 5 RCTs, low-quality evidence), and probably reduces risk of CHD mortality (1.1% to 1.0%, RR 0.95, 95% CI 0.72 to 1.26, 18,353 participants; 193 CHD deaths, 3 RCTs), and arrhythmia (3.3% to 2.6%, RR 0.79, 95% CI 0.57 to 1.10, 4,837 participants; 141 events, 1 RCT). Effects on stroke are unclear.Sensitivity analysis retaining only trials at low summary risk of bias moved effect sizes towards the null (RR 1.0) for all LCn3 primary outcomes except arrhythmias, but for most ALA outcomes, effect sizes moved to suggest protection. LCn3 funnel plots suggested that adding in missing studies/results would move effect sizes towards null for most primary outcomes. There were no dose or duration effects in subgrouping or meta-regression.There was no evidence that increasing LCn3 or ALA altered serious adverse events, adiposity or lipids, although LCn3 slightly reduced triglycerides and increased HDL. ALA probably reduces HDL (high- or moderate-quality evidence). AUTHORS' CONCLUSIONS This is the most extensive systematic assessment of effects of omega-3 fats on cardiovascular health to date. Moderate- and high-quality evidence suggests that increasing EPA and DHA has little or no effect on mortality or cardiovascular health (evidence mainly from supplement trials). Previous suggestions of benefits from EPA and DHA supplements appear to spring from trials with higher risk of bias. Low-quality evidence suggests ALA may slightly reduce CVD event risk, CHD mortality and arrhythmia.
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Affiliation(s)
- Asmaa S Abdelhamid
- University of East AngliaNorwich Medical SchoolNorwich Research ParkNorwichUKNR4 7TJ
| | - Tracey J Brown
- University of East AngliaNorwich Medical SchoolNorwich Research ParkNorwichUKNR4 7TJ
| | - Julii S Brainard
- University of East AngliaNorwich Medical SchoolNorwich Research ParkNorwichUKNR4 7TJ
| | - Priti Biswas
- University of East AngliaMED/HSCNorwich Research ParkNorwichUKNR4 7TJ
| | - Gabrielle C Thorpe
- University of East AngliaSchool of Health SciencesEarlham RoadNorwichUKNR4 7TJ
| | - Helen J Moore
- Durham UniversityWolfson Research InstituteDurhamUKDH1 3LE
| | - Katherine HO Deane
- University of East AngliaSchool of Health SciencesEarlham RoadNorwichUKNR4 7TJ
| | - Fai K AlAbdulghafoor
- University of East AngliaNorwich Medical SchoolNorwich Research ParkNorwichUKNR4 7TJ
| | - Carolyn D Summerbell
- Durham UniversityDepartment of Sport and Exercise Science42 Old ElvetDurhamUKDH13HN
| | - Helen V Worthington
- Division of Dentistry, School of Medical Sciences, Faculty of Biology, Medicine and Health, The University of ManchesterCochrane Oral HealthJR Moore BuildingOxford RoadManchesterUKM13 9PL
| | - Fujian Song
- University of East AngliaNorwich Medical SchoolNorwich Research ParkNorwichUKNR4 7TJ
| | - Lee Hooper
- University of East AngliaNorwich Medical SchoolNorwich Research ParkNorwichUKNR4 7TJ
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Benes LB, Bassi NS, Kalot MA, Davidson MH. Evolution of Omega-3 Fatty Acid Therapy and Current and Future Role in the Management of Dyslipidemia. Cardiol Clin 2018; 36:277-285. [DOI: 10.1016/j.ccl.2017.12.009] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
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Weisman D, Beinart R, Erez A, Koren-Morag N, Goldenberg I, Eldar M, Glikson M, Luria D. Effect of supplemented intake of omega-3 fatty acids on arrhythmias in patients with ICD: fish oil therapy may reduce ventricular arrhythmia. J Interv Card Electrophysiol 2017; 49:255-261. [DOI: 10.1007/s10840-017-0267-1] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/01/2017] [Accepted: 06/20/2017] [Indexed: 10/19/2022]
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18
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Watanabe Y, Tatsuno I. Omega-3 polyunsaturated fatty acids for cardiovascular diseases: present, past and future. Expert Rev Clin Pharmacol 2017; 10:865-873. [PMID: 28531360 DOI: 10.1080/17512433.2017.1333902] [Citation(s) in RCA: 54] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
INTRODUCTION Large-scale epidemiological studies on Greenlandic, Canadian and Alaskan Eskimos have examined the health benefits of omega-3 fatty acids consumed as part of the diet, and found statistically significant relative reduction in cardiovascular risk in people consuming omega-3 fatty acids. Areas covered: This article reviews studies on omega-3 fatty acids during the last 50 years, and identifies issues relevant to future studies on cardiovascular (CV) risk. Expert commentary: Although a meta-analysis of large-scale prospective cohort studies and randomized studies reported that fish and fish oil consumption reduced coronary heart disease-related mortality and sudden cardiac death, omega-3 fatty acids have not yet been shown to be effective in secondary prevention trials on patients with multiple cardiovascular disease (CVD) risk factors. The ongoing long-term CV interventional outcome studies investigate high-dose, prescription-strength omega-3 fatty acids. The results are expected to clarify the potential role of omega-3 fatty acids in reducing CV risk. The anti-inflammatory properties of omega-3 fatty acids are also important. Future clinical trials should also focus on the role of these anti-inflammatory mediators in human arteriosclerotic diseases as well as inflammatory diseases.
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Affiliation(s)
- Yasuhiro Watanabe
- a Center for Diabetes, Metabolism and Endocrinology , Toho University Sakura Medical Center , Sakura, Chiba , Japan
| | - Ichiro Tatsuno
- a Center for Diabetes, Metabolism and Endocrinology , Toho University Sakura Medical Center , Sakura, Chiba , Japan
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19
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Wilson RA, Deasy W, Hayes A, Cooke MB. High fat diet and associated changes in the expression of micro-RNAs in tissue: Lessons learned from animal studies. Mol Nutr Food Res 2017; 61. [PMID: 28233461 DOI: 10.1002/mnfr.201600943] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2016] [Revised: 01/15/2017] [Accepted: 02/13/2017] [Indexed: 12/13/2022]
Abstract
Environment and genetic factors play an important role in the development of obesity, and diet is one of the main contributing factors to this disease. High fat intake is associated with body weight gain, leading to obesity and other metabolic diseases. MicroRNAs (miRNAs) are a group of small, noncoding RNAs that are important regulators of gene expression at posttranscriptional level. Studies have shown that high fat intake, independent of body weight status, can significantly impact both negatively and positively the expression of miRNAs and thus the biological function of tissues such as adipose, skeletal, and cardiac muscle, liver, neuronal, and endothelial. This review will summarize the effects of high calorie diet in the form of high fat intake on miRNA expression in various tissues of animal models and of high fat fed offspring. We will also briefly review the impact of different dietary lipids on miRNA expression. Given changes in miRNA expression have been associated with the development of many diseases including obesity, understanding their biological role could have important clinical implications and offer tangible therapeutic targets for the prevention, management, and/or treatment of obesity and other lifestyle-related disorders.
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Affiliation(s)
- Robin A Wilson
- College of Health and Biomedicine, Victoria University, Melbourne, VIC, Australia.,Australian Institute for Musculoskeletal Science (AIMSS), Western Health, Melbourne, VIC, Australia
| | - William Deasy
- College of Health and Biomedicine, Victoria University, Melbourne, VIC, Australia.,Australian Institute for Musculoskeletal Science (AIMSS), Western Health, Melbourne, VIC, Australia
| | - Alan Hayes
- College of Health and Biomedicine, Victoria University, Melbourne, VIC, Australia.,Australian Institute for Musculoskeletal Science (AIMSS), Western Health, Melbourne, VIC, Australia
| | - Matthew B Cooke
- College of Health and Biomedicine, Victoria University, Melbourne, VIC, Australia.,Australian Institute for Musculoskeletal Science (AIMSS), Western Health, Melbourne, VIC, Australia
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20
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Abstract
In this review, the pro- and anti-arrhythmic effects of a diet rich in fish oil fatty acids and of hypercholesterolemia will be discussed in relation to two major mechanisms of arrhythmogenesis (triggered activity and re-entry). Whereas a diet rich in fish oil is pro-arrhythmic in relation to re-entry based arrhythmias (as occur in acute myocardial ischemia) and anti-arrhythmic in relation to triggered activity based arrhythmias (as occur in heart failure), the reverse is true for hypercholesterolemia. Changing the lipid composition of cardiomyocytes likely has powerful pro- or anti-arrhythmic consequences, depending on the mechanism of arrhythmias, and has corresponding therapeutic potential.
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Affiliation(s)
- R Coronel
- Dept. Exp. Cardiology, Academic Medical Center, Amsterdam, The Netherlands; IHU Liryc, Electrophysiology and Heart Modeling Institute, Fondation Bordeaux Université, F-33600 Pessac Bordeaux, France.
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21
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Kones R, Howell S, Rumana U. n-3 Polyunsaturated Fatty Acids and Cardiovascular Disease: Principles, Practices, Pitfalls, and Promises - A Contemporary Review. Med Princ Pract 2017; 26:497-508. [PMID: 29186721 PMCID: PMC5848472 DOI: 10.1159/000485837] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/26/2017] [Accepted: 11/29/2017] [Indexed: 12/15/2022] Open
Abstract
Amidst voluminous literature, inconsistencies and opposing results have confused rather than clarified cardiologists' ability to assess the potential benefits of n-3 polyunsaturated fatty acids (n-3 PUFA). In perspective, there are common themes that emerge from n-3 PUFA studies, even as imperfect as they may be. The approach taken was to identify and unite these themes into a manageable, cohesive, evidence-based, yet useful synthesis. In all reviews and meta-analyses, the selection of component studies and assumptions influences outcomes. This overarching principle must be combined with the totality of the data, particularly when evidence is incompletely understood and gaps in knowledge must be bridged. Both the older literature and the most recent rigorous meta-analyses indicate that n-3 PUFA are highly pleiotropic agents with many documented positive physiological effects. Concordance among preclinical, observational, randomized clinical trials and meta-analyses is impressive. These agents have modest, statistically significant benefits which accrue over time. Given their favorable safety profile, a risk reduction of about 10% justifies their potential use in cardiovascular disease.
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Affiliation(s)
- Richard Kones
- The Cardiometabolic Research Institute, Texas, USA
- *Richard Kones MD, FAHA, FESC, FRSM, FCCP, FAGS, FRSH, FRSB, Cardiometabolic Research Institute, 8181 Fannin Street, Building 3, Unit 314, Houston, TX 77054-2913 (USA), E-Mail
| | - Scott Howell
- Department of Medicine, BMU School of Medicine, Winston-Salem, North Carolina, USA
| | - Umme Rumana
- The Cardiometabolic Research Institute, Texas, USA
- University of Texas Health Science Center Houston, Houston, Texas, USA
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22
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Tudur Smith C, Marcucci M, Nolan SJ, Iorio A, Sudell M, Riley R, Rovers MM, Williamson PR. Individual participant data meta-analyses compared with meta-analyses based on aggregate data. Cochrane Database Syst Rev 2016; 9:MR000007. [PMID: 27595791 PMCID: PMC7125394 DOI: 10.1002/14651858.mr000007.pub3] [Citation(s) in RCA: 48] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
BACKGROUND Meta-analyses based on individual participant data (IPD-MAs) allow more powerful and uniformly consistent analyses as well as better characterisation of subgroups and outcomes, compared to those which are based on aggregate data (AD-MAs) extracted from published trial reports. However, IPD-MAs are a larger undertaking requiring greater resources than AD-MAs. Researchers have compared results from IPD-MA against results obtained from AD-MA and reported conflicting findings. We present a methodology review to summarise this empirical evidence . OBJECTIVES To review systematically empirical comparisons of meta-analyses of randomised trials based on IPD with those based on AD extracted from published reports, to evaluate the level of agreement between IPD-MA and AD-MA and whether agreement is affected by differences in type of effect measure, trials and participants included within the IPD-MA and AD-MA, and whether analyses were undertaken to explore the main effect of treatment or a treatment effect modifier. SEARCH METHODS An electronic search of the Cochrane Library (includes Cochrane Database of Systematic Reviews, Database of Abstracts of Reviews of Effectiveness, CENTRAL, Cochrane Methodology Register, HTA database, NHS Economic Evaluations Database), MEDLINE, and Embase was undertaken up to 7 January 2016. Potentially relevant articles that were known to any of the review authors and reference lists of retrieved articles were also checked. SELECTION CRITERIA Studies reporting an empirical comparison of the results of meta-analyses of randomised trials using IPD with those using AD. Studies were included if sufficient numerical data, comparing IPD-MA and AD-MA, were available in their reports. DATA COLLECTION AND ANALYSIS Two review authors screened the title and abstract of identified studies with full-text publications retrieved for those identified as eligible or potentially eligible. A 'quality' assessment was done and data were extracted independently by two review authors with disagreements resolved by involving a third author. Data were summarised descriptively for comparisons where an estimate of effect measure and corresponding precision have been provided both for IPD-MA and for AD-MA in the study report. Comparisons have been classified according to whether identical effect measures, identical trials and patients had been used in the IPD-MA and the AD-MA, and whether the analyses were undertaken to explore the main effect of treatment, or to explore a potential treatment effect modifier.Effect measures were transformed to a standardised scale (z scores) and scatter plots generated to allow visual comparisons. For each comparison, we compared the statistical significance (at the 5% two-sided level) of an IPD-MA compared to the corresponding AD-MA and calculated the number of discrepancies. We examined discrepancies by type of analysis (main effect or modifier) and according to whether identical trials, patients and effect measures had been used by the IPD-MA and AD-MA. We calculated the average of differences between IPD-MA and AD-MA (z scores, ratio effect estimates and standard errors (of ratio effects)) and 95% limits of agreement. MAIN RESULTS From the 9330 reports found by our searches, 39 studies were eligible for this review with effect estimate and measure of precision extracted for 190 comparisons of IPD-MA and AD-MA. We classified the quality of studies as 'no important flaws' (29 (74%) studies) or 'possibly important flaws' (10 (26%) studies).A median of 4 (interquartile range (IQR): 2 to 6) comparisons were made per study, with 6 (IQR 4 to 11) trials and 1225 (542 to 2641) participants in IPD-MAs and 7 (4 to 11) and 1225 (705 to 2541) for the AD-MAs. One hundred and forty-four (76%) comparisons were made on the main treatment effect meta-analysis and 46 (24%) made using results from analyses to explore treatment effect modifiers.There is agreement in statistical significance between the IPD-MA and AD-MA for 152 (80%) comparisons, 23 of which disagreed in direction of effect. There is disagreement in statistical significance for 38 (20%) comparisons with an excess proportion of IPD-MA detecting a statistically significant result that was not confirmed with AD-MA (28 (15%)), compared with 10 (5%) comparisons with a statistically significant AD-MA that was not confirmed by IPD-MA. This pattern of disagreement is consistent for the 144 main effect analyses but not for the 46 comparisons of treatment effect modifier analyses. Conclusions from some IPD-MA and AD-MA differed even when based on identical trials, participants (but not necessarily identical follow-up) and treatment effect measures. The average difference between IPD-MA and AD-MA in z scores, ratio effect estimates and standard errors is small but limits of agreement are wide and include important differences in both directions. Discrepancies between IPD-MA and AD-MA do not appear to increase as the differences between trials and participants increase. AUTHORS' CONCLUSIONS IPD offers the potential to explore additional, more thorough, and potentially more appropriate analyses compared to those possible with AD. But in many cases, similar results and conclusions can be drawn from IPD-MA and AD-MA. Therefore, before embarking on a resource-intensive IPD-MA, an AD-MA should initially be explored and researchers should carefully consider the potential added benefits of IPD.
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Affiliation(s)
- Catrin Tudur Smith
- The University of LiverpoolDepartment of BiostatisticsShelley's CottageBrownlow StreetLiverpoolUKL69 3GS
| | - Maura Marcucci
- McMaster UniversityDepartment of Clinical Epidemiology and Biostatistics1280 Main Street WestHamiltonONCanadaL8S 4K1
- University of Milan & Geriatric UnitDepartment of Clinical Sciences and Community HealthFondazione IRCCS Ca' Granda Ospedale Maggiore PoliclinicoVia Francesco Sforza, 35MilanItaly20122
| | - Sarah J Nolan
- The University of LiverpoolDepartment of BiostatisticsShelley's CottageBrownlow StreetLiverpoolUKL69 3GS
| | - Alfonso Iorio
- McMaster UniversityDepartment of Clinical Epidemiology and Biostatistics1280 Main Street WestHamiltonONCanadaL8S 4K1
| | - Maria Sudell
- The University of LiverpoolDepartment of BiostatisticsShelley's CottageBrownlow StreetLiverpoolUKL69 3GS
| | - Richard Riley
- Keele UniversityResearch Institute for Primary Care and Health SciencesDavid Weatherall Building, Keele University CampusStaffordshireEnglandUKST5 5BG
| | - Maroeska M Rovers
- Radboud University Nijmegen Medical CentreDepartment of Operating RoomsHp 630, route 631PO Box 9101NijmegenNetherlands6500 HB
| | - Paula R Williamson
- University of LiverpoolCentre for Medical Statistics and Health EvaluationShelley's CottageBrownlow StreetLiverpoolMerseysideUKL69 3GS
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Chiesa G, Busnelli M, Manzini S, Parolini C. Nutraceuticals and Bioactive Components from Fish for Dyslipidemia and Cardiovascular Risk Reduction. Mar Drugs 2016; 14:md14060113. [PMID: 27338419 PMCID: PMC4926072 DOI: 10.3390/md14060113] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2016] [Revised: 05/11/2016] [Accepted: 05/26/2016] [Indexed: 12/12/2022] Open
Abstract
Cardiovascular disease remains the most common health problem in developed countries, and residual risk after implementing all current therapies is still high. Permanent changes in lifestyle may be hard to achieve and people may not always be motivated enough to make the recommended modifications. Emerging research has explored the application of natural food-based strategies in disease management. In recent years, much focus has been placed on the beneficial effects of fish consumption. Many of the positive effects of fish consumption on dyslipidemia and heart diseases have been attributed to n-3 polyunsaturated fatty acids (n-3 PUFAs, i.e., EPA and DHA); however, fish is also an excellent source of protein and, recently, fish protein hydrolysates containing bioactive peptides have shown promising activities for the prevention/management of cardiovascular disease and associated health complications. The present review will focus on n-3 PUFAs and bioactive peptides effects on cardiovascular disease risk factors. Moreover, since considerable controversy exists regarding the association between n-3 PUFAs and major cardiovascular endpoints, we have also reviewed the main clinical trials supporting or not this association.
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Affiliation(s)
- Giulia Chiesa
- Department of Pharmacological and Biomolecular Sciences, Università degli Studi di Milano, via Balzaretti 9, Milano 20133, Italy.
| | - Marco Busnelli
- Department of Pharmacological and Biomolecular Sciences, Università degli Studi di Milano, via Balzaretti 9, Milano 20133, Italy.
| | - Stefano Manzini
- Department of Pharmacological and Biomolecular Sciences, Università degli Studi di Milano, via Balzaretti 9, Milano 20133, Italy.
| | - Cinzia Parolini
- Department of Pharmacological and Biomolecular Sciences, Università degli Studi di Milano, via Balzaretti 9, Milano 20133, Italy.
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24
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Glück T, Alter P. Marine omega-3 highly unsaturated fatty acids: From mechanisms to clinical implications in heart failure and arrhythmias. Vascul Pharmacol 2016; 82:11-9. [PMID: 27080538 DOI: 10.1016/j.vph.2016.03.007] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2015] [Revised: 03/12/2016] [Accepted: 03/29/2016] [Indexed: 12/17/2022]
Abstract
Therapeutic implications of marine omega-3 highly unsaturated fatty acids (HUFA) in cardiovascular disease are still discussed controversially. Several clinical trials report divergent findings and thus leave ambiguity on the meaning of oral omega-3 therapy. Potential prognostic indications of HUFA treatment have been predominantly studied in coronary artery disease, sudden cardiac death, ventricular arrhythmias, atrial fibrillation and heart failure of various origin. It is suspected that increased ventricular wall stress is crucially involved in the prognosis of heart failure. Increased wall stress and an unfavorable myocardial remodeling is associated with an increased risk of arrhythmias by stretch-activated membrane ion channels. Integration of HUFA into the microenvironment of cardiomyocyte ion channels lead to allosteric changes and increase the electrical stability. Increased ventricular wall stress appears to be involved in the local myocardial as well as in the hepatic fatty acid metabolism, i.e. a cardio-hepatic syndrome. Influences of an altered endogenous HUFA metabolism and an inverse shift of the fatty acid profile was underrated in the past. A better understanding of these interacting endogenous mechanisms appears to be required for interpreting the findings of recent experimental and clinical studies. The present article critically reviews major studies on basic pathophysiological mechanisms and treatment effects in clinical trials.
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Affiliation(s)
- Tobias Glück
- Department of Medicine, Pulmonary and Critical Care Medicine, Philipps University, Marburg, Germany; Department of Medicine, Cardiology and Angiology, AGAPLESION Evangelisches Krankenhaus Mittelhessen, Gießen, Germany.
| | - Peter Alter
- Department of Medicine, Pulmonary and Critical Care Medicine, Philipps University, Marburg, Germany.
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25
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Bernard M, Maixent JM, Gerbi A, Lan C, Cozzone PJ, Pieroni G, Armand M, Coste TC. Dietary docosahexaenoic acid-enriched glycerophospholipids exert cardioprotective effects in ouabain-treated rats via physiological and metabolic changes. Food Funct 2015; 7:798-804. [PMID: 26662260 DOI: 10.1039/c5fo01300c] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
Docosahexaenoic acid (DHA) might prevent heart failure or optimise drug treatments by improving cardiac contraction. We investigated whether DHA-enriched avian glycerophospholipids (GPL-DHA) exert cardioprotection in ouabain-treated rats after 4 weeks of dietary supplementation with 10, 35 or 60 mg DHA per kg body weight versus none (DHA10, DHA35, DHA60 and control groups, respectively). The contractile responsiveness to different doses of ouabain (10(-7) to 10(-4) M), ouabain intoxication (at 3 × 10(-4) M), and relative variations in cardiac energy metabolism were determined using (31)P NMR in isolated perfused rat hearts. The fatty acid composition of cardiac membranes was analysed by gas chromatography. DHA accretion in the heart was dose-dependent (+8%, +30% and +45% for DHA10, DHA35 and DHA60, respectively). The cardiac phosphocreatine content significantly increased at the baseline in DHA35 (+45%) and DHA60 groups (+85%), and at the different doses of ouabain in the DHA60 group (+73% to 98%). The maximum positive inotropy achieved at 10(-4) M ouabain was significantly increased in all DHA groups versus control (+150%, +122.5% and +135% for DHA10, DHA35 and DHA60, respectively), and ouabain intoxication was delayed. The increase in myocardial phosphocreatine content and the improved efficacy of ouabain on myocardial contraction without toxicity suggest the potential of GPL-DHA as a dietary supplement or ingredient for functional food, and possibly as a co-treatment with digitalis drugs in humans.
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Affiliation(s)
- Monique Bernard
- Aix-Marseille Université, CNRS, CRMBM UMR 7339, F-13385 Marseille, France.
| | | | - Alain Gerbi
- RDVC Produits Santé, F-76600 Le Havre, France
| | - Carole Lan
- Aix-Marseille Université, CNRS, CRMBM UMR 7339, F-13385 Marseille, France.
| | | | - Gérard Pieroni
- Application Santé des Lipides, ASL, Bioparc de Vichy, F-03270 Hauterive, France
| | - Martine Armand
- Aix-Marseille Université, CNRS, CRMBM UMR 7339, F-13385 Marseille, France.
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Daimiel-Ruiz L, Klett-Mingo M, Konstantinidou V, Micó V, Aranda JF, García B, Martínez-Botas J, Dávalos A, Fernández-Hernando C, Ordovás JM. Dietary lipids modulate the expression of miR-107, a miRNA that regulates the circadian system. Mol Nutr Food Res 2015; 59:1865-78. [DOI: 10.1002/mnfr.201570094] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Affiliation(s)
- Lidia Daimiel-Ruiz
- Nutritional Genomics of Cardiovascular Disease and Obesity; IMDEA-Food Institute, CEI UAM+CSIC; Madrid Spain
| | - Mercedes Klett-Mingo
- Nutritional Genomics of Cardiovascular Disease and Obesity; IMDEA-Food Institute, CEI UAM+CSIC; Madrid Spain
| | - Valentini Konstantinidou
- Nutritional Genomics of Cardiovascular Disease and Obesity; IMDEA-Food Institute, CEI UAM+CSIC; Madrid Spain
| | - Victor Micó
- Nutritional Genomics of Cardiovascular Disease and Obesity; IMDEA-Food Institute, CEI UAM+CSIC; Madrid Spain
| | - Juan Francisco Aranda
- Vascular Biology and Therapeutics Program; Yale University School of Medicine; New Haven CT USA
- Integrative Cell Signaling and Neurobiology of Metabolism Program; Section of Comparative Medicine, Yale University School of Medicine; New Haven CT USA
| | - Belén García
- Nutritional Genomics of Cardiovascular Disease and Obesity; IMDEA-Food Institute, CEI UAM+CSIC; Madrid Spain
| | - Javier Martínez-Botas
- Servicio de Bioquímica-Investigación; Hospital Universitario Ramón y Cajal, Instituto Ramón y Cajal de Investigación Sanitaria (IRyCIS); Madrid Spain
| | - Alberto Dávalos
- Nutritional Genomics of Cardiovascular Disease and Obesity; IMDEA-Food Institute, CEI UAM+CSIC; Madrid Spain
| | - Carlos Fernández-Hernando
- Vascular Biology and Therapeutics Program; Yale University School of Medicine; New Haven CT USA
- Integrative Cell Signaling and Neurobiology of Metabolism Program; Section of Comparative Medicine, Yale University School of Medicine; New Haven CT USA
| | - José Maria Ordovás
- Nutritional Genomics of Cardiovascular Disease and Obesity; IMDEA-Food Institute, CEI UAM+CSIC; Madrid Spain
- Nutrition and Genomics Laboratory; JM-USDA Human Nutrition Research Center on Aging at Tufts University; Boston MA USA
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27
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Arakawa K, Himeno H, Kirigaya J, Otomo F, Matsushita K, Nakahashi H, Shimizu S, Nitta M, Yano H, Endo M, Kimura K, Umemura S. Impact of n-3 polyunsaturated fatty acids in predicting ischemia/reperfusion injury and progression of myocardial damage after reperfusion in patients with ST-segment elevation acute myocardial infarction. J Cardiol 2015; 66:101-7. [DOI: 10.1016/j.jjcc.2015.03.009] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/27/2014] [Revised: 02/02/2015] [Accepted: 03/04/2015] [Indexed: 10/23/2022]
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28
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Daimiel-Ruiz L, Klett-Mingo M, Konstantinidou V, Micó V, Aranda JF, García B, Martínez-Botas J, Dávalos A, Fernández-Hernando C, Ordovás JM. Dietary lipids modulate the expression of miR-107, an miRNA that regulates the circadian system. Mol Nutr Food Res 2015; 59:552-65. [PMID: 25522185 DOI: 10.1002/mnfr.201400616] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2014] [Revised: 12/01/2014] [Accepted: 12/07/2014] [Indexed: 02/06/2023]
Abstract
SCOPE The increased prevalence of cardiovascular diseases (CVDs) has been hypothesized to be the result of an increased exposure to a host of atherogenic environmental factors, paramount among them being unhealthy dietary habits. Long-chain n-3 polyunsaturated fatty acids have been shown to have cardio protective effects, partially due to their ability to regulate gene expression. In this regard, increasing attention has been devoted to the role of miRNAs as regulators of multiple metabolic pathways whose deregulation has been associated with CVD risk. METHODS AND RESULTS In this work, we investigated whether miRNA expression was regulated by docosahexanoic acid, conjugated linoleic acid, and cholesterol in Caco-2 cells. The modulated miRNAs, miR-107 was differentially expressed by all treatments and this modulation was independent of its hosting gene, PANK1, possibly through its own promoter, which contains binding sites for metabolically relevant transcription factors. Among the putative target genes of miR-107, we found some genes with key roles in circadian rhythm. Specifically, we demonstrated that binding of miR-107 to the CLOCK gene results in the deregulation of the circadian rhythm of the cells. CONCLUSION Since chronodisruption has been linked to metabolic disorders such as type 2 diabetes, atherosclerosis, obesity, and CVD, our findings suggests that miR-107 could represent a new approach for pharmacological treatment of these diseases.
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Affiliation(s)
- Lidia Daimiel-Ruiz
- Nutritional Genomics of Cardiovascular Disease and Obesity, IMDEA-Food Institute, CEI UAM+CSIC, Madrid, Spain
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von Schacky C. Omega-3 fatty acids in cardiovascular disease--an uphill battle. Prostaglandins Leukot Essent Fatty Acids 2015; 92:41-7. [PMID: 24935800 DOI: 10.1016/j.plefa.2014.05.004] [Citation(s) in RCA: 67] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/07/2013] [Revised: 02/13/2014] [Accepted: 05/06/2014] [Indexed: 12/12/2022]
Abstract
In cardiology, results of recent large intervention trials with eicosapentaenoic acid (EPA) plus docosahexaenoic acid (DHA) supplements were neutral. In contrast, in epidemiologic studies, an inverse relation between clinical events and intake of EPA+DHA was found which was steeper for higher levels of EPA+DHA. A standardized way of determining levels is the Omega-3 Index, which is the percentage of EPA+DHA of a total of 26 fatty acids measured in erythrocytes. According to current criteria, a low Omega-3 Index is a cardiovascular risk factor. What can explain this contradiction? Trial participants were recruited irrespective of their baseline status in EPA+DHA - an important predictor of events. Levels of EPA+DHA have a statistically normal distribution; together with the large inter-individual variability of levels' responding to increased intake, this created a large overlap of EPA+DHA levels between intervention and control groups. Moreover, trial participants were advised to take EPA+DHA supplements with breakfast, frequently a low fat meal, resulting in poor bioavailability. As a result, there is an urgent need for new intervention trials in cardiology, for which participants with a low baseline omega-3 index are recruited, and then treated with individually tailored doses of EPA+DHA to a prespecified target range.
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Affiliation(s)
- Clemens von Schacky
- Medizinische Klinik I, Department Preventive Cardiology, Ludwig-Maximilians-University, Ziemssenstrasse 1, D-80336 Munich, Germany; Omegametrix, Am Klopferspitz 19, 82152 Martinsried, Germany(1).
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30
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Tatsuno I. Omega-3 polyunsaturated fatty acids and cardiovascular disease: an emphasis on omega-3-acid ethyl esters 90 for the treatment of hypertriglyceridemia. Expert Rev Cardiovasc Ther 2014; 12:1261-8. [PMID: 25319059 DOI: 10.1586/14779072.2014.971756] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
A number of epidemiological/observational studies, as well as large-scale randomized intervention studies, have been conducted to provide evidence for the efficacy of ω-3 fatty acids against atherosclerotic diseases. Currently, ω-3 fatty acids are commercially available in many parts of the world containing the same active ingredients as Lotriga(®) (ω-3-acid ethyl esters 90 [O3AE highly concentrated ω-3 fatty acid ethyl esters, consisting of eicosapentaenoic acid-ethyl ester and docosahexaenoic acid-ethyl ester [EPA-E/DHA-E]). A recent head-to-head comparative study of O3AEE90 versus EPA-E demonstrated that O3AEE90 4g/day led to a significantly greater reduction in triglycerides (TG) than EPA-E 1.8g/day and that O3AEE90 2g/day produced comparable effects on TG to those with EPA-E 1.8g/day. While both agents were shown to be useful in lowering TG, the hallmark feature of O3AEE90, that is, the presence of the DHA-E component versus its absence in EPA-E, needs to be further examined for its clinical implications.
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Affiliation(s)
- Ichiro Tatsuno
- Center for Diabetes, Metabolism and Endocrinology, Toho University Sakura Medical Center, 564-1 Shimoshizu, Sakura, Chiba 285-8741, Japan
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Scientific Opinion on health benefits of seafood (fish and shellfish) consumption in relation to health risks associated with exposure to methylmercury. EFSA J 2014. [DOI: 10.2903/j.efsa.2014.3761] [Citation(s) in RCA: 79] [Impact Index Per Article: 7.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
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Sanders TAB. Plant compared with marine n-3 fatty acid effects on cardiovascular risk factors and outcomes: what is the verdict? Am J Clin Nutr 2014; 100 Suppl 1:453S-8S. [PMID: 24898234 DOI: 10.3945/ajcn.113.071555] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Plants provide α-linolenic acid [ALA; 18:3n-3 (18:3ω-3)], which can be converted via eicosapentaenoic acid (EPA; 20:5n-3) to docosahexaenoic acid (DHA; 22:6n-3), which is required for normal visual and cognitive function. Dietary ALA is provided mainly by vegetable oils, especially soybean and rapeseed oils, but is destroyed by partial hydrogenation; it is also present in high amounts in walnuts and flaxseed. Dietary EPA and DHA are provided mainly by fish and so are absent from vegan diets and only present in trace amounts in vegetarian diets. Vegetarians and vegans have lower proportions of DHA in blood and tissue lipids compared with omnivores. High intakes of EPA and DHA (typically in the range of 3-5 g/d) but not ALA have favorable effects on several cardiovascular disease (CVD) risk factors and have been postulated to delay arterial aging and cardiovascular mortality, but these intakes are beyond the range of normal dietary intake. Arterial stiffness, which is a measure of arterial aging, appears to be lower in vegans than in omnivores; and risk of CVD in vegetarians and vegans is approximately one-third that in omnivores. Prospective cohort studies showed higher intakes of EPA+DHA, and less consistently ALA, to be associated with a lower risk of CVD, especially fatal coronary heart disease, but meta-analyses of randomized controlled trials of supplementation of EPA+DHA or ALA in secondary prevention of CVD showed no clear benefit. Current evidence is insufficient to warrant advising vegans and vegetarians to supplement their diets with EPA or DHA for CVD prevention.
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Affiliation(s)
- Thomas A B Sanders
- From the Diabetes and Nutritional Sciences Division, School of Medicine, King's College London, London, United Kingdom
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Kohashi K, Nakagomi A, Saiki Y, Morisawa T, Kosugi M, Kusama Y, Atarashi H, Shimizu W. Effects of eicosapentaenoic acid on the levels of inflammatory markers, cardiac function and long-term prognosis in chronic heart failure patients with dyslipidemia. J Atheroscler Thromb 2014; 21:712-29. [PMID: 24670266 DOI: 10.5551/jat.21022] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022] Open
Abstract
AIMS The effects of eicosapentaenoic acid (EPA) on the levels of inflammatory markers, cardiac function and long-term prognosis in chronic heart failure (CHF) patients with dyslipidemia remain unclear. METHODS A total of 139 CHF patients with a mean left ventricular ejection fraction (LVEF) of 37.6± 8.0% were divided into two groups based on whether EPA was included in their treatment regimen: the EPA group (n=71) and the no EPA group (n=68). Only patients with dyslipidemia at baseline (entry) were treated with EPA. The monocyte chemoattractant protein (MCP)-1 and asymmetric dimethylarginine (ADMA) levels were measured at baseline and after 12 months of treatment. RESULTS At 12 months, in the EPA group, the LVEF had improved and the MCP-1 and ADMA levels had decreased (respectively, p<0.001); however, in the no EPA group, the LVEF had worsened, while the MCP-1 and ADMA levels had increased (respectively, p<0.001). Fifty-five patients experienced cardiac events, including 15 cardiac deaths and 40 readmissions for worsening of CHF during a median follow-up period of 28.0 months. The percent change in LVEF from baseline was found to be significantly associated with the percent change in ADMA (r=-0.462, p<0.001). A multivariate Cox hazard analysis showed EPA treatment (hazard ratio: 0.21, 95% confidence interval: 0.05-0.93, p=0.031) to be an independent predictor of cardiac events. CONCLUSIONS These data indicate that EPA treatment may improve the cardiac function and long-term prognosis of CHF patients with dyslipidemia, at least in part, due to reductions in inflammation and improvements in the endothelial function.
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Affiliation(s)
- Keiichi Kohashi
- Department of Internal Medicine and Cardiology, Tama-Nagayama Hospital, Nippon Medical School
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von Schacky C. Omega-3 index and cardiovascular health. Nutrients 2014; 6:799-814. [PMID: 24566438 PMCID: PMC3942733 DOI: 10.3390/nu6020799] [Citation(s) in RCA: 98] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2014] [Revised: 02/12/2014] [Accepted: 02/13/2014] [Indexed: 12/14/2022] Open
Abstract
Recent large trials with eicosapentaenoic acid (EPA) and docosahexaenoic acid (DHA) in the cardiovascular field did not demonstrate a beneficial effect in terms of reductions of clinical endpoints like total mortality, sudden cardiac arrest or other major adverse cardiac events. Pertinent guidelines do not uniformly recommend EPA + DHA for cardiac patients. In contrast, in epidemiologic findings, higher blood levels of EPA + DHA were consistently associated with a lower risk for the endpoints mentioned. Because of low biological and analytical variability, a standardized analytical procedure, a large database and for other reasons, blood levels of EPA + DHA are frequently assessed in erythrocytes, using the HS-Omega-3 Index® methodology. A low Omega-3 Index fulfills the current criteria for a novel cardiovascular risk factor. Neutral results of intervention trials can be explained by issues of bioavailability and trial design that surfaced after the trials were initiated. In the future, incorporating the Omega-3 Index into trial designs by recruiting participants with a low Omega-3 Index and treating them within a pre-specified target range (e.g., 8%-11%), will make more efficient trials possible and provide clearer answers to the questions asked than previously possible.
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Affiliation(s)
- Clemens von Schacky
- Preventive Cardiology, Medical Clinic and Poli-Clinic I, Ludwig Maximilians-University Munich, Ziemssenstr. 1, Munich 80336, Germany.
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Abstract
PURPOSE OF REVIEW The fish fatty acids eicosapentaenoic acid (EPA) and docosahexaenoic acid (DHA) may promote cardiometabolic health. This review summarizes the results of recent meta-analyses of prospective studies on cardiovascular diseases, diabetes type 2 and markers of atherosclerosis and thrombosis. RECENT FINDINGS The results of recently published meta-analyses of prospective cohort studies showed that eating fish once a week was associated with a 16% lower risk of fatal coronary heart disease (CHD) and a 14% lower risk of stroke incidence, but was not related to heart failure. Fish consumption may be associated with a higher risk of diabetes in Western countries and a lower risk in Asian countries. Recent meta-analyses of randomized controlled trials showed that EPA-DHA supplementation reduced the risk of fatal CHD and sudden death by 10% of which the latter was not significant. Extra EPA-DHA did not reduce the risk of heart failure, stroke and cardiac arrhythmias. ω-3 fatty acid (FA) supplementation did reduce markers of ventricular fibrillation, inflammation and endothelial dysfunction and platelet aggregation. SUMMARY There is strong evidence for a protective effect of ω-3 FA on fatal CHD and for some markers of atherosclerosis and thrombosis. Consistent results were not obtained for other vascular diseases and diabetes. ω-3 FA reduced markers of ventricular fibrillation but did not reduce the risk of atrial fibrillation.
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Affiliation(s)
- Daan Kromhout
- Division of Human Nutrition, Wageningen University, Wageningen, The Netherlands
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Flock MR, Fleming JA, Kris-Etherton PM. Macronutrient replacement options for saturated fat: effects on cardiovascular health. Curr Opin Lipidol 2014; 25:67-74. [PMID: 24345985 DOI: 10.1097/mol.0000000000000039] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
PURPOSE OF REVIEW The purpose of this review is to discuss macronutrient replacement options for saturated fatty acids (SFAs) to optimize cardiovascular disease (CVD) risk reduction. RECENT FINDINGS Dietary recommendations advise decreasing SFAs. There is convincing evidence that replacing SFAs with unsaturated fat, both omega-6 and omega-3 polyunsaturated fatty acids, reduces CVD risk. Monounsaturated fatty acid substitution for SFAs also decreases CVD risk. Replacing SFAs with refined carbohydrate does little to alter CVD risk, whereas whole-grain CHO or lean protein substitutions beneficially affect CVD risk. SUMMARY Modifying the macronutrient composition of the diet by replacing SFAs with unsaturated fatty acids, as well as lean protein and carbohydrate from whole grains, all lower CVD risk. Research is needed to identify food sources of macronutrients that optimize CVD risk reduction.
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Affiliation(s)
- Michael R Flock
- Department of Nutritional Sciences, The Pennsylvania State University, Pennsylvania, USA
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Harris WS, Dayspring TD, Moran TJ. Omega-3 fatty acids and cardiovascular disease: new developments and applications. Postgrad Med 2014; 125:100-13. [PMID: 24200766 DOI: 10.3810/pgm.2013.11.2717] [Citation(s) in RCA: 55] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
The omega-3 fatty acids (FA) found in fish oils, eicosapentaenoic and docosahexaenoic acids (EPA and DHA, respectively), have been extensively studied therapeutically in a wide variety of disease conditions, but in none more than cardiovascular disease (CVD). Our review summarizes mechanisms of action, recent meta-analyses of CVD outcome trials, sources (fish and supplements), and recommendations for use of omega-3 FA in clinical practice. With the ability to now measure the omega-3 FA biostatus through blood tests, patients can achieve cardioprotective levels by either taking fish oil supplements or simply eating more oily fish. Two omega-3 FA formulations (both in the ethyl ester form) have been approved by the US Food and Drug Administration (FDA) for the treatment of patients with very high triglyceride levels (> 500 mg/dL); one contains both EPA and DHA, whereas the other contains only EPA. The agents have been extensively tested in 2 patient populations, those with very high triglycerides and those with triglycerides between 200 and 500 mg/dL while on background statin therapy. In general, treatment with EPA+DHA appears to lower patient triglycerides more effectively, but in those patients with very high triglyceride levels, use of EPA+DHA also raised low-density lipoprotein cholesterol levels, whereas EPA alone did not. Both formulations, at doses that do not lower triglycerides, have been shown to reduce CVD events in some, but not all, studies. Given the favorable risk-to-benefit ratio for these essentially nutritional agents, use is expected to continue to expand.
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Affiliation(s)
- William S Harris
- Professor of Medicine, Sanford School of Medicine, University of South Dakota, Sioux Falls, SD; President, OmegaQuant Analytics, LLC, Sioux Falls, SD; Senior Research Scientist, Health Diagnostic Laboratory, Inc, Richmond, VA.
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Din JN, Sarma J, Harding SA, Lyall K, Newby DE, Flapan AD. Effect of ω-3 fatty acid supplementation on endothelial function, endogenous fibrinolysis and platelet activation in patients with a previous myocardial infarction: a randomised controlled trial. BMJ Open 2013; 3:e003054. [PMID: 24071458 PMCID: PMC3787492 DOI: 10.1136/bmjopen-2013-003054] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/14/2013] [Revised: 07/05/2013] [Accepted: 07/10/2013] [Indexed: 12/30/2022] Open
Abstract
OBJECTIVE The mechanisms through which ω-3 fatty acids reduce adverse cardiac events remain uncertain. We aimed to investigate the effect of ω-3 fatty acid supplementation on endothelial vasomotor function, endogenous fibrinolysis, and platelet and monocyte activation in patients with coronary heart disease. DESIGN Randomised, double-blind, placebo-controlled, cross-over trial. SETTING Academic cardiac centre. PARTICIPANTS 20 male patients with a previous myocardial infarction. INTERVENTION ω-3 Fatty acid supplementation (2 g/day for 6 weeks) versus olive oil placebo. OUTCOME MEASURES Peripheral blood was taken for analysis of platelet and monocyte activation, and forearm blood flow (FBF) was assessed in a subset of 12 patients during intrabrachial infusions of acetylcholine, substance P and sodium nitroprusside. Stimulated plasma tissue plasminogen activator (t-PA) concentrations were measured during substance P infusion. RESULTS All vasodilators caused dose-dependent increases in FBF (p<0.0001). ω-3 Fatty acid supplementation did not affect endothelium-dependent vasodilation with acetylcholine and substance P compared with placebo (p=0.5 and 0.9). Substance P caused a dose-dependent increase in plasma t-PA concentrations (p<0.0001), which was not affected by ω-3 fatty acid supplementation (p=0.9). ω-3 Fatty acids did not affect platelet-monocyte aggregation, platelet P-selectin or CD40L, or monocyte CD40. CONCLUSIONS We have demonstrated that dietary supplementation with ω-3 fatty acids does not affect endothelial vasomotor function, endothelial t-PA release, or platelet and monocyte activation in patients with coronary heart disease. Cardiac benefits conferred by ω-3 fatty acids in coronary heart disease are unlikely to be mediated through effects on these systems.
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Affiliation(s)
- Jehangir N Din
- Centre for Cardiovascular Sciences, University of Edinburgh, Edinburgh, UK
| | - Jaydeep Sarma
- North West Heart Centre, Wythenshawe Hospital, Manchester, UK
| | - Scott A Harding
- Department of Cardiology, Wellington Hospital, Wellington, New Zealand
| | - Karin Lyall
- Centre for Cardiovascular Sciences, University of Edinburgh, Edinburgh, UK
| | - David E Newby
- Centre for Cardiovascular Sciences, University of Edinburgh, Edinburgh, UK
| | - Andrew D Flapan
- Edinburgh Heart Centre, Royal Infirmary of Edinburgh, Edinburgh, UK
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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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Affiliation(s)
| | - S. Coe
- British Nutrition Foundation; London; UK
| | | | - S. Stanner
- British Nutrition Foundation; London; UK
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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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Greene J, Ashburn SM, Razzouk L, Smith DA. Fish oils, coronary heart disease, and the environment. Am J Public Health 2013; 103:1568-76. [PMID: 23409906 DOI: 10.2105/ajph.2012.300959] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
Clinical trials continue to produce conflicting results on the effectiveness of fish oils for the primary and secondary prevention of coronary heart disease. Despite many large, well-performed studies, questions still remain, made even more complex by the addition of early revascularization and statins in our coronary heart disease armamentarium. This is complicated by the reality that fish oil production has a measureable impact on reducing fish populations, which in turn has a negative impact on creating a sustainable product. We review the current data for fish oil usage in the primary and secondary prevention of coronary heart disease with an eye toward future studies, and the effects fish oil production has on the environment and efforts that are currently under way to mitigate these effects.
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de Lorgeril M, Salen P, Defaye P, Rabaeus M. Recent findings on the health effects of omega-3 fatty acids and statins, and their interactions: do statins inhibit omega-3? BMC Med 2013; 11:5. [PMID: 23289647 PMCID: PMC3571733 DOI: 10.1186/1741-7015-11-5] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/04/2012] [Accepted: 01/04/2013] [Indexed: 12/23/2022] Open
Abstract
Early randomized controlled trials (RCTs) demonstrated the health benefits of omega-3 fatty acids (n-3), whereas recent RCTs were negative. We now address the issue, focusing on the temporal changes having occurred: most patients in recent RCTs are no longer n-3 deficient and the vast majority are now treated with statins. Recent RCTs testing n-3 against arrhythmias suggest that n-3 reduce the risk only in patients not taking a statin. Other recent RCTs in secondary prevention were negative although, in a post-hoc analysis separating statin users and non-users, non-significant protection of n-3 was observed among statin non-users whereas statin users had no effect. Recent RCTs testing statins - after the implementation of the New Clinical Trial Regulation in 2007 - are negative (or flawed) suggesting that the lack of effect of n-3 cannot be attributed to a parallel protection by statins. Finally, statins favor the metabolism of omega-6 fatty acids (n-6), which in turn inhibits n-3 and, contrary to n-3, they increase insulin resistance and the risk of diabetes. Thus, n-3 and statins are counteractive at several levels and statins appear to inhibit n-3.
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Affiliation(s)
- Michel de Lorgeril
- Laboratoire Coeur et Nutrition, TIMC-IMAG CNRS 5525, Université Joseph Fourier, Faculté de Médecine de Grenoble, 38054 La Tronche, France.
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Kazemian P, Kazemi-Bajestani SMR, Alherbish A, Steed J, Oudit GY. The use of ω-3 poly-unsaturated fatty acids in heart failure: a preferential role in patients with diabetes. Cardiovasc Drugs Ther 2012; 26:311-20. [PMID: 22644698 DOI: 10.1007/s10557-012-6397-x] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
PURPOSE To review the evidence for a beneficial effect of ω-3 PUFAs in heart failure (HF) and its co-morbidities, their possible preferential effect in diabetes and the potential mechanism for their benefit. METHODS We summarize the clinical studies which investigated the use of ω-3 PUFAs in patients with HF with an emphasis on diabetes. We briefly summarize the evidence for an effect of ω-3 PUFAs in patients with coronary artery disease (CAD), atrial fibrillation (AF) and ventricular arrhythmias. We also discuss the proposed mechanisms of ω-3 PUFA action in cardiovascular diseases. RESULTS While there is emerging evidence for a beneficial effect of ω-3 PUFA supplementation in patients with HF, the evidence for other indications have been variable and conflicting. In HF patients with diabetes, ω-3 PUFAs may have a preferential therapeutic benefit. Randomized controlled trials did not show considerable beneficial effects of ω-3 PUFAs in other conditions such as CAD and AF. In a diabetic and insulin-resistant state, ω-3 PUFAs bind to the G-protein coupled receptor, GPR120, resulting in reduced cytokine production from inflammatory macrophages and improved signaling in adipocytes, leading to a reduction in insulin resistance. CONCLUSIONS There is promising evidence showing that use of ω-3 PUFA supplementation improves clinical outcomes of HF patients with diabetes. Further clinical trials are needed in this regard.
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Affiliation(s)
- Pedram Kazemian
- Division of Cardiology, Department of Medicine, Mazankowski Alberta Heart Institute, University of Alberta, Edmonton, Canada
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Aarsetoey H, Grundt H, Nygaard O, Nilsen DWT. The role of long-chained marine N-3 polyunsaturated Fatty acids in cardiovascular disease. Cardiol Res Pract 2012; 2012:303456. [PMID: 23304630 PMCID: PMC3532917 DOI: 10.1155/2012/303456] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/10/2012] [Revised: 10/11/2012] [Accepted: 10/25/2012] [Indexed: 01/27/2023] Open
Abstract
This paper reviews the current evidence regarding long-chained marine omega-3 polyunsaturated fatty acids (PUFAs) and cardiovascular disease (CVD), their possible mechanisms of action, and results of clinical trials. Also, primary and secondary prevention trials as studies on antiarrhythmic effects and meta-analyses are summarized. However, the individual bioavailability of n-3 PUFAs along with the highly different study designs and estimations of FAs intake or supplementation dosages in patient populations with different background intake of n-3 PUFAs might be some of the reasons for the inconsistent findings of the studies evaluating the impact of n-3 PUFAs on CVD. The question of an optimum dose of n-3 PUFAs or whether there exists a dose-response relation for n-3 PUFA supplementation is widely discussed. Moreover, the difficulties in interpreting meta-analyses are clearly demonstrated by two recently published meta-analyses (Rizos et al. and Delgado Lista et al.), evaluating the efficacy of n-3 PUFAs on CVD, including 12 common studies, but drawing opposite conclusions. We definitely need more large-scale, randomized clinical trials of long duration, also reporting harmful effects of n-3 PUFAs.
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Affiliation(s)
- Hildegunn Aarsetoey
- Department of Medicine, Stavanger University Hospital, 4011 Stavanger, Norway
| | - Heidi Grundt
- Department of Medicine, Stavanger University Hospital, 4011 Stavanger, Norway
- Institute of Medicine, University of Bergen, 5020 Bergen, Norway
| | - Ottar Nygaard
- Institute of Medicine, University of Bergen, 5020 Bergen, Norway
- Department of Heart Disease, Haukeland University Hospital, 5021 Bergen, Norway
| | - Dennis W. T. Nilsen
- Institute of Medicine, University of Bergen, 5020 Bergen, Norway
- Department of Cardiology, Stavanger University Hospital, 4011 Stavanger, Norway
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Billman GE. Omega-3 polyunsaturated fatty acids and cardiac rhythm: an introduction. Front Physiol 2012; 3:457. [PMID: 23230422 PMCID: PMC3515776 DOI: 10.3389/fphys.2012.00457] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2012] [Accepted: 11/19/2012] [Indexed: 11/30/2022] Open
Affiliation(s)
- George E. Billman
- Department of Physiology and Cell Biology, The Ohio State UniversityColumbus, OH, USA
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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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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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Jump DB, Depner CM, Tripathy S. Omega-3 fatty acid supplementation and cardiovascular disease. J Lipid Res 2012; 53:2525-45. [PMID: 22904344 DOI: 10.1194/jlr.r027904] [Citation(s) in RCA: 143] [Impact Index Per Article: 11.9] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
Epidemiological studies on Greenland Inuits in the 1970s and subsequent human studies have established an inverse relationship between the ingestion of omega-3 fatty acids [C(20-22) ω 3 polyunsaturated fatty acids (PUFA)], blood levels of C(20-22) ω 3 PUFA, and mortality associated with cardiovascular disease (CVD). C(20-22) ω 3 PUFA have pleiotropic effects on cell function and regulate multiple pathways controlling blood lipids, inflammatory factors, and cellular events in cardiomyocytes and vascular endothelial cells. The hypolipemic, anti-inflammatory, anti-arrhythmic properties of these fatty acids confer cardioprotection. Accordingly, national heart associations and government agencies have recommended increased consumption of fatty fish or ω 3 PUFA supplements to prevent CVD. In addition to fatty fish, sources of ω 3 PUFA are available from plants, algae, and yeast. A key question examined in this review is whether nonfish sources of ω 3 PUFA are as effective as fatty fish-derived C(20-22) ω 3 PUFA at managing risk factors linked to CVD. We focused on ω 3 PUFA metabolism and the capacity of ω 3 PUFA supplements to regulate key cellular events linked to CVD. The outcome of our analysis reveals that nonfish sources of ω 3 PUFA vary in their capacity to regulate blood levels of C(20-22) ω 3 PUFA and CVD risk factors.
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Affiliation(s)
- Donald B Jump
- Nutrition Program, School of Biological and Population Health Sciences, The Linus Pauling Institute, Oregon State University, Corvallis, OR 97331, USA.
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How Are n-3 LCPUFAs Antiarrhythmic? A Reassessment of n-3 LCPUFAs in Cardiac Disease. Cardiol Res Pract 2012; 2012:746709. [PMID: 22953156 PMCID: PMC3431072 DOI: 10.1155/2012/746709] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/05/2012] [Revised: 06/01/2012] [Accepted: 06/12/2012] [Indexed: 12/05/2022] Open
Abstract
Long-chain n-3-polyunsaturated fatty acids (n-3 LCPUFAs), referring particularly to marine-derived eicosapentaenoic acid (EPA) and docosahexaenoic acid (DHA), have been shown to be effective in treating arrhythmias in some clinical trials and animal studies. The mechanism for this effect of n-3 LCPUFAs is not well understood. Experimental studies and clinical trials published in the 1980s and 1990s suggested that n-3 LCPUFAs may be antiarrhythmic drugs, but more recent trials have not confirmed this. In this paper, we examine evidence for, and against, the direct antiarrhythmic action of n-3 LCPUFAs and suggest that antistructural remodeling effects of n-3 LCPUFAs may be more relevant in accounting for their clinical effects.
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