The impact of omega-3 polyunsaturated fatty acid supplementation on the incidence of cardiovascular events and complications in peripheral arterial disease: a systematic review and meta-analysis

Omega-3 fatty acids for intermittent claudication

BACKGROUND

Peripheral artery disease (PAD) is a progressive disorder characterised by stenosis or occlusion of arteries, or both, due to arteriosclerosis. Intermittent claudication (IC) and diminished walking ability are often present as the main symptoms of PAD. Omega-3 fatty acids have been used in the treatment and prevention of coronary artery disease, although current evidence suggests they may be of limited benefit. Peripheral arterial disease and coronary artery disease share a similar pathogenesis. It is uncertain whether omega-3 fatty acids benefit people with IC. This is an update of the review first published in 2004 and updated in 2013.

OBJECTIVES

To evaluate the benefits and harms of omega-3 fatty acid supplementation in people with intermittent claudication.

SEARCH METHODS

We used standard, extensive Cochrane search methods, and searched the Cochrane Vascular Specialised Register via the Cochrane Register of Studies, CENTRAL, MEDLINE Ovid, Embase Ovid, and two trials registers on 19 April 2024.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) of omega-3 fatty acids versus placebo or non-omega-3 fatty acids in people with intermittent claudication.

DATA COLLECTION AND ANALYSIS

We used standard Cochrane methods. Our primary outcomes were quality of life, pain-free walking distance, and maximal walking distance. Secondary outcomes were ankle-brachial index, revascularisation procedures in the lower limb, amputation rate/frequency, lipid levels, blood pressure, all-cause and vascular mortality, non-fatal vascular events, and adverse effects of therapy. We used GRADE to assess the certainty of the evidence for each outcome.

MAIN RESULTS

We included 15 RCTs (1830 participants) comparing omega-3 fatty acid supplementation with placebo or alternative therapies. The follow-up was four weeks to six years. The majority of the studies had unclear risk of bias, and many could not be included in our meta-analysis, so were reported narratively. The evidence is very uncertain about the effect of omega-3 fatty acids on quality of life. One study measured quality of life but did not present any data. The study authors reported there was no improvement in any of the eight self-reported quality-of-life parameters in the SF-36 questionnaire between entry and 16 weeks for the intervention group. No results were presented for the control group (very low-certainty evidence). Omega-3 fatty acids may result in little to no effect on pain-free walking distance (mean difference (MD) 1.01 metre (m), 95% confidence interval (CI) -34.23 to 36.24; 3 studies, 147 participants; very low-certainty evidence), or maximal walking distance (MD -4.18 m, 95% CI -37.10 to 28.74; 3 studies, 164 participants; very low-certainty evidence). Omega-3 compared with a control may have little to no effect on ankle-brachial index (MD -0.02, 95% CI -0.08 to 0.04; 3 studies, 168 participants; very low-certainty evidence). One study assessed the incidence of revascularisation procedures (lower limb angioplasty/bypass surgery) and rate of amputation (progression of critical limb ischaemia/amputation) in the lower limb. Results showed that omega-3 may have little to no effect on either outcome (very low-certainty evidence). Seven studies reported adverse events. Details of reporting varied amongst studies, and we were unable to combine the results. A total of 47 adverse effects were reported in the intervention groups compared to 33 events in the control groups (7 studies, 488 participants; low-certainty evidence). The evidence suggests that omega-3 results in little to no difference in adverse events. Meta-analyses showed no differences between intervention and placebo groups for cholesterol, triglycerides, or blood pressure. Two studies assessed mortality. All-cause mortality and vascular mortality were reported by one study, and vascular mortality by another. We were unable to pool the studies, but both studies individually reported there were no differences between the omega-3 and the control groups. There was no difference between the intervention and placebo groups for the incidence of non-fatal coronary events (odds ratio (OR) 0.59, 95% CI 0.13 to 2.60; 2 studies, 141 participants), or the incidence of non-fatal stroke/transient ischaemic attack (OR 0.95, 95% CI 0.13 to 6.77; 2 studies, 110 participants).

AUTHORS' CONCLUSIONS

The evidence is very uncertain about the effect of omega-3 fatty acids in people with intermittent claudication on quality of life, walking distance (pain-free or maximal), ankle-brachial index, and the incidence of revascularisation procedures or frequency of amputation in the lower limb. The evidence suggests that omega-3 results in little to no difference in adverse events. Further high-quality research is needed to fully evaluate short- and long-term effects of omega-3 fatty acids on the most clinically relevant outcomes in people with intermittent claudication.

Evaluation of the Effects of Extracorporeal Shockwave Therapy in Patients With Peripheral Arterial Disease: A Meta-Analysis of Randomized Control Trials

The aim of this meta-analysis is to assess the efficacy of extracorporeal shockwave therapy (ESWT) in patients with peripheral arterial disease (PAD). This meta-analysis was performed according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. A systematic search was conducted independently by two authors using PubMed, EMBASE, and Cochrane Central Register of Controlled Trials (CENTRAL) from inception to January 15, 2023. Primary clinical outcomes assessed in this meta-analysis were changes in maximum waking distance (MWD) and pain-free walking distance (PFWD) from baseline. Other outcomes assessed included change in ankle brachial pressure index (ABI) and degree of arterial stenosis. Four RCTs involving a total of 228 patients were included. Change of PFWD and MWD from baseline was significantly higher in patients randomized in the ESWT group as compared to the control group. No significant differences were reported between the two groups in terms of change in ABI from baseline. In conclusion, this meta-analysis of four randomized controlled trials found evidence that ESWT is an effective treatment for patients with PAD in terms of improving PFWD and MWD and reducing stenosis. However, there was no significant difference in the improvement of the ankle-brachial index between the study groups.

Indicators and Recommendations for Assessing Sustainable Healthy Diets

Research coupling human nutrition and sustainability concerns is a rapidly developing field, which is essential to guide governments' policies. This critical and comprehensive review analyzes indicators and approaches to "sustainable healthy diets" published in the literature since this discipline's emergence a few years ago, identifying robust gauges and highlighting the flaws of the most commonly used models. The reviewed studies largely focus on one or two domains such as greenhouse gas emissions or water use, while overlooking potential impact shifts to other sectors or resources. The present study covers a comprehensive set of indicators from the health, environmental and socio-economic viewpoints. This assessment concludes that in order to identify the best food option in sustainability assessments and nutrition analysis of diets, some aspects such as the classification and disaggregation of food groups, the impacts of the rates of local food consumption and seasonality, preservation methods, agrobiodiversity and organic food and different production systems, together with consequences for low-income countries, require further analysis and consideration.

Omega-3 Polyunsaturated Fatty Acid Supplementation in Patients with Lower Extremity Arterial Disease

BACKGROUND

Omega-3 polyunsaturated fatty acid (PUFA) supplements are used to treat lower extremity arterial disease (LEAD), but their effects on patient outcomes remain controversial.

OBJECTIVE

We aimed to investigate the effect of omega-3 PUFA supplements on outcomes in LEAD patients.

DESIGN

We systematically searched for randomized controlled trials (RCTs) published before February 2020 in PubMed, the Cochrane Library, EMBASE, Medline, and ClinicalTrials.gov. Three researchers extracted the study design, sample size, omega-3 PUFA dosage, and patient characteristics. A random-effects model was used. The primary outcomes were the mean change in the ankle-brachial index (ABI) and pain-free and maximal walking distance. The secondary outcomes were the mean changes in triglycerides and other lipid profiles, high-sensitivity C-reactive protein level, blood pressure, flow-mediated vasodilatation, and incidence of cardiovascular events.

RESULTS

Sixteen RCTs and 1,852 patients were analyzed. Most of the included RCTs had a low risk of bias. The grade quality was moderate in ABI, C-reactive protein, and cardiovascular events; very low in triglyceride; and low in the other outcomes. The use of omega-3 PUFAs was not significantly associated with the primary outcomes, but it was significantly associated with a reduced triglyceride level, with a moderate effect size (Hedges' g=-0.34, 95% CI [-0.55-0.13], p < 0.01, I²=32.5%). This significant association was only found for marine-based omega-3 PUFAs. Omega-3 PUFAs and eicosapentaenoic acid dosages >2 g per day were associated with reduced levels of triglycerides. Meta-regression also showed that the use of eicosapentaenoic acid was significantly negatively associated with the triglyceride level in a dosage-dependent manner. No significant association was found in the other secondary outcomes.

CONCLUSION

This meta-analysis showed that the use of marine-based omega-3 PUFAs was significantly associated with a reduced level of triglycerides. The strength of the association depended on the dosage of eicosapentaenoic acid. (CRD42020168416 at PROSPERO.).

Comment on "Optimal Nutritional Status for a Well-Functioning Immune System Is an Important Factor to Protect against Viral Infections. Nutrients 2020, 12, 1181"

The novel coronavirus (COVID-19) pandemic, [...].

Platelet activation and prothrombotic mediators at the nexus of inflammation and atherosclerosis: Potential role of antiplatelet agents

Platelets are central to inflammation-related manifestations of cardiovascular diseases (CVD) such as atherosclerosis. Platelet-activating factor (PAF), thrombin, thromboxane A₂ (TxA₂), and adenosine diphosphate (ADP) are some of the key agonists of platelet activation that are at the intersection between a plethora of inflammatory pathways that modulate pro-inflammatory and coagulation processes. The aim of this article is to review the role of platelets and the relationship between their structure, function, and the interactions of their constituents in systemic inflammation and atherosclerosis. Antiplatelet therapies are discussed with a view to primary prevention of CVD by the clinical reduction of platelet reactivity and inflammation. Current antiplatelet therapies are effective in reducing cardiovascular risk but increase bleeding risk. Novel therapeutic antiplatelet approaches beyond current pharmacological modalities that do not increase the risk of bleeding require further investigation. There is potential for specifically designed nutraceuticals that may become safer alternatives to pharmacological antiplatelet agents for the primary prevention of CVD but there is serious concern over their efficacy and regulation, which requires considerably more research.

Oral Intake of EPA:DHA 6:1 by Middle-Aged Rats for One Week Improves Age-Related Endothelial Dysfunction in Both the Femoral Artery and Vein: Role of Cyclooxygenases

In humans, aging is associated with endothelial dysfunction and an increased risk of venous thromboembolism. Although intake of eicosapentaenoic acid (EPA) and docosahexaenoic acid (DHA) at a ratio of 6:1 by old rats improved the endothelial dysfunction in arteries, the impact on veins remains unclear. Eight-month-old male Wistar rats were either untreated or orally administered corn oil, EPA:DHA 1:1, or EPA:DHA 6:1 (500 mg/kg/d) for seven days. Vascular reactivity was studied by myography. In middle-aged femoral artery rings, acetylcholine caused a partial relaxation at low concentrations and a contractile response at high concentrations, whereas in the old femoral vein only a partial relaxation was observed. The EPA:DHA 6:1 treatment blunted the contractile response to acetylcholine in the middle-aged femoral artery and both EPA:DHA 6:1 and 1:1 increased the relaxation to acetylcholine in the old femoral vein. No such effects were observed with corn oil. Both the non-selective cyclooxygenase inhibitor indomethacin and the COX-1 inhibitor SC-560 increased the relaxation to acetylcholine in the middle-aged femoral artery whereas the COX-2 inhibitor NS-398 increased that in the middle-aged femoral vein. In conclusion, our results indicate that aging is associated with an endothelial dysfunction in the femoral artery and vein, which can be improved by EPA:DHA 6:1 treatment-most likely via a cyclooxygenase-dependent mechanism.

Could Omega 3 Fatty Acids Preserve Muscle Health in Rheumatoid Arthritis?

Rheumatoid arthritis (RA) is a chronic inflammatory disease characterized by a high prevalence of death due to cardiometabolic diseases. As observed during the aging process, several comorbidities, such as cardiovascular disorders (CVD), insulin resistance, metabolic syndrome and sarcopenia, are frequently associated to RA. These abnormalities could be closely linked to alterations in lipid metabolism. Indeed, RA patients exhibit a lipid paradox, defined by reduced levels of total, low-density lipoprotein (LDL) and high-density lipoprotein (HDL) cholesterol whereas the CVD risk is increased. Moreover, the accumulation of toxic lipid mediators (i.e., lipotoxicity) in skeletal muscles can induce mitochondrial dysfunctions and insulin resistance, which are both crucial determinants of CVD and sarcopenia. The prevention or reversion of these biological perturbations in RA patients could contribute to the maintenance of muscle health and thus be protective against the increased risk for cardiometabolic diseases, dysmobility and mortality. Yet, several studies have shown that omega 3 fatty acids (FA) could prevent the development of RA, improve muscle metabolism and limit muscle atrophy in obese and insulin-resistant subjects. Thereby, dietary supplementation with omega 3 FA should be a promising strategy to counteract muscle lipotoxicity and for the prevention of comorbidities in RA patients.

Inflammation and cardiovascular disease: are marine phospholipids the answer?

This review presents the latest research on the cardioprotective effects of n-3 fatty acids (FA) and n-3 FA bound to polar lipids (PL). Overall, n-3 PL may have enhanced bioavailability and potentially bioactivityversusfree FA and ester forms of n-3 FA.

Intake of omega-3 formulation EPA:DHA 6:1 by old rats for 2 weeks improved endothelium-dependent relaxations and normalized the expression level of ACE/AT1R/NADPH oxidase and the formation of ROS in the mesenteric artery

Omega-3 polyunsaturated fatty acids (PUFAs) including eicosapentaenoic acid (EPA) and docosahexaenoic acid (DHA) have been shown to protect the cardiovascular system, in part, by stimulating the endothelial formation of nitric oxide (NO). EPA:DHA 6:1 has been identified as a potent omega 3 PUFA formulation to induce endothelium-dependent vasorelaxation and activation of endothelial NO synthase (eNOS). This study examined whether intake of EPA:DHA 6:1 (500 mg/kg/day) for 2 weeks improves an established endothelial dysfunction in old rats (20 months old), and, if so, the underlying mechanism was subsequently determined. In the main mesenteric artery rings, an endothelial dysfunction characterized by a blunted NO component, an abolished endothelium-dependent hyperpolarization component, and increased endothelium-dependent contractile responses (EDCFs) are observed in old rats compared to young rats. Age-related endothelial dysfunction was associated with increased vascular formation of reactive oxygen species (ROS) and expression of eNOS, components of the local angiotensin system, senescence markers, and cyclooxygenase-2 (COX-2), and the downregulation of COX-1. The EPA:DHA 6:1 treatment improved the NO-mediated relaxation, reduced the EDCF-dependent contractile response and the vascular formation of ROS, and normalized the expression level of all target proteins in the old arterial wall. Thus, the present findings indicate that a 2-week intake of EPA:DHA 6:1 by old rats restored endothelium-dependent NO-mediated relaxations, most likely, by preventing the upregulation of the local angiotensin system and the subsequent formation of ROS.

Ageing enhances the shedding of splenocyte microvesicles with endothelial pro-senescent effect that is prevented by a short-term intake of omega-3 PUFA EPA:DHA 6:1

BACKGROUND

Ageing is associated with progressive endothelial senescence and dysfunction, and cardiovascular risk. Circulating endothelial microvesicles (MVs) are pro-senescent and pro-inflammatory endothelial effectors in acute coronary syndrome. Omega-3 PUFA intake was claimed beneficial in cardiovascular prevention.

PURPOSE

To investigate whether the intake of the omega-3 formulation EPA:DHA 6:1 by middle-aged and old rats reduces the shedding of pro-senescent microvesicles from cultured spleen leukocytes (SMVs) and clarify the underlying mechanisms in target coronary primary endothelial cells (ECs).

METHODS

Middle-aged male Wistar rats (M, 48-week old) received 500 mg/kg/d of either EPA:DHA 6:1, EPA:DHA 1:1, or vehicle (CTL) for 7 days, old rats (72-week old) for 14 days. Spleen-derived leukocytes were prepared and cultured for 24 h and MVs collected from supernatants (SMVs). Cultured ECs were prepared from freshly isolated porcine coronary arteries. Senescence-associated β-galactosidase activity (SA-β-gal) was assessed by C12FDG, protein expression by Western blot analysis, oxidative stress by dihydroethidium using confocal microscopy, and procoagulant MVs by prothrombinase assay. The pro-senescent potential of SMVs from middle-aged rats (M-SMVs) was analyzed by comparison with young (Y, 12-week) and old (O) rats.

RESULTS

The shedding of SMVs significantly increased with age and was inhibited by EPA:DHA 6:1 intake that also prevented ROS accumulation in spleen. Incubation of ECs with 10 nM SMVs from middle-aged and old but not those from young rats induced premature senescence after 48 h. The pro-senescent effect of M-SMVs was prevented by Losartan and associated with endothelial oxidative stress. M-SMVs induced an up-regulation of senescence markers (p16, p21, p53), pro-atherothrombotic (VCAM-1, ICAM-1, tissue factor) and pro-inflammatory markers (pNF-κB, COX-2) and proteins of the angiotensin system (ACE, AT1-R). Conversely, endothelial NO synthase was down-regulated. Intake of EPA:DHA 1:1 and 6:1 by middle-aged rats decreased SMV shedding by 14% and 24%, respectively. Only EPA:DHA 6:1 intake abolished the M-SMVs-induced endothelial senescence and reduced the pro-senescent action of O-SMVs by 45%. Protection of ECs was not observed in response to SMVs from EPA:DHA 1:1 treated rats.

CONCLUSION

Ingestion of EPA:DHA 6:1 by middle-aged or old rats, respectively abolished or limited both the shedding of SMVs and their pro-senescent, pro-thrombotic and pro-inflammatory effects in ECs, most likely by triggering the local angiotensin system. EPA:DHA 6:1 may help to delay ageing-related endothelial dysfunction.

Clinical Practice Guideline for Cardiac Rehabilitation in Korea: Recommendations for Cardiac Rehabilitation and Secondary Prevention after Acute Coronary Syndrome

Though clinical practice guidelines (CPGs) for cardiac rehabilitation (CR) are an effective and widely used treatment method worldwide, they are as yet not widely accepted in Korea. Given that cardiovascular (CV) disease is the second leading cause of death in Korea, it is urgent that CR programs be developed. In 2008, the Government of Korea implemented CR programs at 11 university hospitals as part of its Regional Cardio-Cerebrovascular Center Project, and 3 additional medical facilities will be added in 2019. In addition, owing to the promotion of CR nationwide and the introduction of CR insurance benefits, 40 medical institutions nationwide have begun CR programs even as a growing number of medical institutions are preparing to offer CR. The purpose of this research was to develop evidence-based CPGs to support CR implementation in Korea. This study is based on an analysis of CPGs elsewhere in the world, an extensive literature search, a systematic analysis of multiple randomized control trials, and a CPG management, development, and assessment committee comprised of thirty-three authors-primarily rehabilitation specialists, cardiologists, and thoracic surgeons in 21 university hospitals and 2 general hospitals. Twelve consultants, primarily rehabilitation, sports medicine, and preventive medicine specialists, CPG experts, nurses, physical therapists, clinical nutritionists, and library and information experts participated in the research and development of these CPGs. After the draft guidelines were developed, 3 rounds of public hearings were held with staff members from relevant academic societies and stakeholders, after which the guidelines were further reviewed and modified. CR involves a more cost-effective use of healthcare resources relative to that of general treatments, and the exercise component of CR lowers CV mortality and readmission rates, regardless of the type of coronary heart disease and type and setting of CR. Individualized CR programs should be considered together with various factors, including differences in heart function and lifestyle, and doing so will boost participation and adherence with the CR program, ultimately meeting the final goals of the program, namely reducing the recurrence of myocardial infarction and mortality rates.

Bioprospecting for Antithrombotic Polar Lipids from Salmon, Herring, and Boarfish By-Products

Marine polar lipids (PLs) have exhibited promising cardioprotection. In this study, marine by-products such as salmon heads (SHs), their brain, eyes and main optic nerves (SBEON), and head-remnants after SBEON removal (RemSH), as well as herring fillets (HFs), herring heads (HHs) and minced boarfish (MB), were evaluated as potential sustainable sources of such bioactive PLs. The antithrombotic bioactivities of PLs derived from these marine by-products were assessed for the first time in human platelets against platelet-activating factor (PAF), thrombin, collagen, and adenosine diphosphate (ADP), while their fatty acid composition was evaluated by gas chromatography–mass spectrometry (GC-MS). PLs from all marine by-products tested possess strong antithrombotic activities against aggregation of human platelets induced by all platelet agonists tested. RemSH, SBEON, HHs, HFs, and MB exhibited strong anti-PAF effects, similar to those previously reported for salmon fillets. PLs from MB had the strongest anti-collagen effects and PLs from SHs and SBEON were the most active against thrombin and ADP. PLs from HHs had similar antithrombotic effects with those from HFs in all agonists. RemSH was less active in all agonists, suggesting that SBEON is the main source of bioactive PLs in SHs. All PLs were rich in omega-3 polyunsaturated fatty acids (ω3PUFA), such as docosahexaenoic acid (DHA) and eicosapentaenoic (EPA) acid, with favourable low values of the ω6/ω3 ratio. Salmon, herring, and boarfish by-products are rich sources of bioactive marine PLs with potent antithrombotic and cardioprotective properties.

Clinical Practice Guideline for Cardiac Rehabilitation in Korea

BACKGROUND

Though clinical practice guidelines (CPGs) for cardiac rehabilitation (CR) are an effective and widely used treatment method worldwide, they are as yet not widely accepted in Korea. Given that cardiovascular disease is the second leading cause of death in Korea, it is urgent that CR programs be developed. In 2008, the Government of Korea implemented CR programs at 11 university hospitals as part of its Regional Cardio-Cerebrovascular Center Project, and 3 additional medical facilities will be added in 2019. In addition, owing to the promotion of CR nationwide and the introduction of CR insurance benefits, 40 medical institutions nationwide have begun CR programs even as a growing number of medical institutions are preparing to offer CR. The purpose of this research was to develop evidence-based CPGs to support CR implementation in Korea.

METHODS

This study is based on an analysis of CPGs elsewhere in the world, an extensive literature search, a systematic analysis of multiple randomized control trials, and a CPG management, development, and assessment committee comprised of 33 authors-primarily rehabilitation specialists, cardiologists, and thoracic surgeons in 21 university hospitals and 2 general hospitals. Twelve consultants, primarily rehabilitation, sports medicine, and preventive medicine specialists, CPG experts, nurses, physical therapists, clinical nutritionists, and library and information experts participated in the research and development of these CPGs. After the draft guidelines were developed, 3 rounds of public hearings were held with staff members from relevant academic societies and stakeholders, after which the guidelines were further reviewed and modified.

RESULTS

CR involves a more cost-effective use of healthcare resources relative to that of general treatments, and the exercise component of CR lowers cardiovascular mortality and readmission rates, regardless of the type of coronary heart disease and type and setting of CR.

CONCLUSION

Individualized CR programs should be considered together with various factors, including differences in heart function and lifestyle, and doing so will boost participation and adherence with the CR program, ultimately meeting the final goals of the program, namely reducing the recurrence of myocardial infarction and mortality rates.

Effects of basal insulin glargine and omega-3 on lower limb arterial disease outcome in patients with dysglycaemia: An analysis of the Outcome Reduction with an Initial Glargine INtervention (ORIGIN) trial

The impact of insulin or omega-3 supplements on the incidence and progression of peripheral artery disease (PAD) in patients with dysglycaemia has not been well studied. The Outcome Reduction with an Initial Glargine INtervention (ORIGIN) trial randomized participants with dysglycaemia and cardiovascular risk factors to titrated insulin glargine vs standard care, and to either 1 g of omega-3 per day or placebo. We assessed incident PAD, defined as the composite of either asymptomatic or symptomatic PAD according to the randomized interventions in the 11 119 ORIGIN participants whose baseline ankle-brachial index (ABI) was >0.9 (no PAD), and PAD progression in the 971 ORIGIN participants whose baseline ABI was ≤0.9. Hazard ratios (HR) were adjusted for confounders. During a 6.2-year follow-up period, allocation to insulin glargine vs standard care had a neutral effect on the composite of PAD incidence (HR, 0.99; 95% CI, 0.86-1.15) and progression (HR, 0.88; 95% CI, 0.63-1.22). Similar findings were noted for allocation to omega-3 vs placebo for PAD incidence (HR, 1.02; 95% CI, 0.89-1.18) and progression (HR, 0.93; 95% CI, 0.67-1.28). In this large study, neither insulin glargine nor omega-3 affected the incidence or progression of PAD.

Clinical Practice Guideline for Cardiac Rehabilitation in Korea

OBJECTIVE

Though clinical practice guidelines (CPGs) for cardiac rehabilitation (CR) are an effective and widely used treatment method worldwide, they are as yet not widely accepted in Korea. Given that cardiovascular disease is the second leading cause of death in Korea, it is urgent that CR programs be developed. In 2008, the Government of Korea implemented CR programs at 11 university hospitals as part of its Regional Cardio-Cerebrovascular Center Project, and three additional medical facilities will be added in 2019. In addition, owing to the promotion of CR nationwide and the introduction of CR insurance benefits, 40 medical institutions nationwide have begun CR programs even as a growing number of medical institutions are preparing to offer CR. The purpose of this research was to develop evidence-based CPGs to support CR implementation in Korea.

METHODS

This study is based on an analysis of CPGs elsewhere in the world, an extensive literature search, a systematic analysis of multiple randomized control trials, and a CPG management, development, and assessment committee comprised of 33 authors-primarily rehabilitation specialists, cardiologists, and thoracic surgeons in 21 university hospitals and two general hospitals. Twelve consultants, primarily rehabilitation, sports medicine, and preventive medicine specialists, CPG experts, nurses, physical therapists, clinical nutritionists, and library and information experts participated in the research and development of these CPGs. After the draft guidelines were developed, three rounds of public hearings were held with staff members from relevant academic societies and stakeholders, after which the guidelines were further reviewed and modified.

PRINCIPAL CONCLUSIONS

CR involves a more cost-effective use of healthcare resources relative to that of general treatments, and the exercise component of CR lowers cardiovascular mortality and readmission rates, regardless of the type of coronary heart disease and type and setting of CR. Individualized CR programs should be considered together with various factors, including differences in heart function and lifestyle, and doing so will boost participation and adherence with the CR program, ultimately meeting the final goals of the program, namely reducing the recurrence of myocardial infarction and mortality rates.

Genomic, Transcriptomic, and Epigenomic Features Differentiate Genes That Are Relevant for Muscular Polyunsaturated Fatty Acids in the Common Carp

Polyunsaturated fatty acids (PUFAs) are a set of important nutrients that mainly include arachidonic acid (ARA4), docosahexaenoic acid (DHA), eicosapentaenoic acid (EPA), and α-linolenic acid (ALA). Recently, fish-derived PUFAs have been associated with cardiovascular health, fetal development, and improvement of brain functions. Studies have shown that fish muscular tissues are rich in PUFAs, which are influenced by various factors, including genetic variations, regulatory profiles, and methylation status of desaturase genes during fatty acid desaturation and elongation processes. However, the genetic mechanism and the pathways involved in fatty acid metabolism in fishes remain unclear. The overall aim of this study was to assess differences in gene expression responses among fishes with different fatty acid levels. To achieve this goal, we conducted genome-wide association analysis (GWAS) using a 250K SNP array in a population of 203 samples of common carp (Cyprinus carpio) and identified nine SNPs and 15 genes associated with muscular PUFA content. Then, RNA-Seq and whole genome bisulfite sequencing (WGBS) of different groups with high and low EPA, DHA, ARA4, and ALA contents in muscle, liver and brain tissues were conducted, resulting in 6,750 differentially expressed genes and 5,631 genes with differentially methylated promoters. Gene ontology and KEGG pathway enrichment analyses of RNA-Seq and WGBS results identified enriched pathways for fatty acid metabolism, which included the adipocytokine signaling pathway, ARA4 and linoleic acid metabolism pathway, and insulin signaling pathway. Integrated analysis indicated significant correlations between gene expression and methylation status among groups with high and low PUFA contents in muscular tissues. Taken together, these multi-level results uncovered candidate genes and pathways that are associated with fatty acid metabolism and paved the way for further genomic selection and carp breeding for PUFA traits.

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

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.

In Vitro Antithrombotic Properties of Salmon (Salmo salar) Phospholipids in a Novel Food-Grade Extract

Marine and salmon polar lipids (PLs) extracted by conventional extractions with non-food-grade solvents (CE-salmon-PLs) possess antithrombotic bioactivities against platelet-activating factor (PAF) and thrombin. Similar effects of food-grade-extracted (FGE) marine PLs have not yet been reported. In this study, food-grade solvents were used to extract PLs from Irish organic farmed salmon (Salmo salar) fillets (FGE-salmon-PLs), while their antithrombotic bioactivities were assessed in human platelets induced by platelet aggregation agonists (PAF/thrombin). FGE-salmon-PLs were further separated by thin layer chromatography (TLC) into lipid subclasses, and the antithrombotic bioactivities of each subclass were also assessed. LC-MS was utilized to elucidate the structure-activity relationships. FGE-salmon-PLs strongly inhibited PAF-induced platelet aggregation, while their relevant anti-thrombin effects were at least three times more potent than the previously reported activities of CE-salmon-PLs. TLC-derived lipid fractions corresponding to phosphatidylcholines (PC) and phosphatidylethanolamines (PE) were the most bioactive lipid subclasses obtained, especially against thrombin. Their LC-MS analysis elucidated that they are diacyl- or alkyl-acyl- PC and PE moieties baring ω3 polyunsaturated fatty acids (PUFA) at their sn-2 position, such as eicosapentaenoic acid (EPA) or docosahexaenoic acid (DHA). Our results concerning the potent antithrombotic effects of FGE-salmon-PLs against both PAF and thrombin pathways strongly suggest that such food-grade extracts are putative candidates for the development of novel cardioprotective supplements and nutraceuticals.

Omega-3 fatty acids for the primary and secondary prevention of cardiovascular disease

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.

Omega-3 fatty acids for the primary and secondary prevention of cardiovascular disease

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.

Structural Elucidation of Irish Organic Farmed Salmon (Salmo salar) Polar Lipids with Antithrombotic Activities

While several marine polar lipids (PL) have exhibited cardioprotective properties through their effects on the platelet-activating factor (PAF) pathways, salmon PL have not been tested so far. In this study, the antithrombotic activities of salmon PL were assessed in human platelets and the structural characterisation of bioactive salmon PL was performed by GC-MS and LC-MS analyses. PL from fillets of Irish organic farmed salmon (Salmo salar) were extracted and separated into several lipid subclasses by thin-layer chromatography (TLC), while their fatty acid profile was fully characterised by GC-MS. Salmon total lipids (TL), total neutral lipids (TNL), total polar lipids (TPL), and each PL subclass obtained by TLC were further assessed for their in vitro effects towards PAF-induced and thrombin-induced platelet aggregation in human platelets. Salmon PL exhibited antithrombotic effects on human platelet aggregation, mostly through their strong inhibitory effects against the PAF pathway with IC50 values comparable to other marine PL, but with lower effects towards the thrombin pathway. PL fractions corresponding to phosphatidylcholine and phosphatidylethanolamine derivatives exhibited the most potent anti-PAF effects, while LC-MS analysis putatively elucidated their structure/function relationship. Several diacyl-PC/PE and alkyl-acyl-PC/PE species containing mostly docosahexaenoic acid at their sn-2 glycerol-backbone may be responsible for the bioactivity. The data presented suggests that salmon contains PL with strong antithrombotic bioactivities.

Integrative Medicine and Cardiovascular Disorders

Integrative medicine (IM) has developed an increasingly significant role in health care worldwide, including cardiovascular diseases (CVD). This review describes the commonly used IM in CVD, with particular attention placed with dietary supplements and mind-body therapies. More rigorous research continues to be needed to determine the mechanisms and efficacy of IM cardiovascular morbidity and mortality. Health care providers will need to develop skills in open communication and nonjudgmental dialogue around IM use in discussing treatment plans with their patients.

Omega-3 Polyunsaturated Fatty Acids and Cardiovascular Health: A Comprehensive Review

The potential cardiovascular (CV) disease (CVD) benefits of Omega-3 Polyunsaturated Fatty Acids (OM3) have been intensely studied and debated for decades. Initial trials were performed in patients with low use of maximal medical therapy for CVD, and reported significant mortality benefits with the use of 1 g/day OM3 intervention following myocardial infarction (MI). More recent studies, including cohorts of patients receiving modern guideline directed medical therapy for CVD, have often not shown similar benefits with OM3 use. We conducted a literature review using PubMed, professional society guidelines, specific journal databases including New England Journal of Medicine and Journal of the American College of Cardiology from January 1, 2007 to December 31, 2017. References from selected articles were also reviewed, as well as key articles outside of the selected time-frame for their important findings or historical perspectives. Currently, there are no Class I recommendations from the American Heart Association (AHA) for the use of OM3, however, considering the safety of this therapy and beneficial findings of some modern studies (including patients with current maximal medical therapy for CVD), the AHA has recently expanded their list of Class II recommendations, in which treatment with OM3 for CVD benefit is reasonable. This review discusses the current state of the evidence, summarizes current professional recommendations, and provides recommendations for future research.

Phospholipids of Animal and Marine Origin: Structure, Function, and Anti-Inflammatory Properties

In this review paper, the latest literature on the functional properties of phospholipids in relation to inflammation and inflammation-related disorders has been critically appraised and evaluated. The paper is divided into three sections: Section 1 presents an overview of the relationship between structures and biological activities (pro-inflammatory or anti-inflammatory) of several phospholipids with respect to inflammation. Section 2 and Section 3 are dedicated to the structures, functions, compositions and anti-inflammatory properties of dietary phospholipids from animal and marine sources. Most of the dietary phospholipids of animal origin come from meat, egg and dairy products. To date, there is very limited work published on meat phospholipids, undoubtedly due to the negative perception that meat consumption is an unhealthy option because of its putative associations with several chronic diseases. These assumptions are addressed with respect to the phospholipid composition of meat products. Recent research trends indicate that dairy phospholipids possess anti-inflammatory properties, which has led to an increased interest into their molecular structures and reputed health benefits. Finally, the structural composition of phospholipids of marine origin is discussed. Extensive research has been published in relation to ω-3 polyunsaturated fatty acids (PUFAs) and inflammation, however this research has recently come under scrutiny and has proved to be unreliable and controversial in terms of the therapeutic effects of ω-3 PUFA, which are generally in the form of triglycerides and esters. Therefore, this review focuses on recent publications concerning marine phospholipids and their structural composition and related health benefits. Finally, the strong nutritional value of dietary phospholipids are highlighted with respect to marine and animal origin and avenues for future research are discussed.

Omega-3 Fatty Acids Supplementation Differentially Modulates the SDF-1/CXCR-4 Cell Homing Axis in Hypertensive and Normotensive Rats

BACKGROUND

We assessed the effect of acute and chronic dietary supplementation of ω-3 on lipid metabolism and cardiac regeneration, through its influence on the Stromal Derived Factor-1 (SDF-1) and its receptor (CXCR4) axis in normotensive and hypertensive rats.

METHODS

Male Wistar Kyoto (WKY) and spontaneously hypertensive rats (SHR) were allocated in eight groups (of eight animals each), which received daily orogastric administration of ω-3 (1 g) for 24 h, 72 h or 2 weeks. Blood samples were collected for the analysis of the lipid profile and SDF-1 systemic levels (ELISA). At the end of the treatment period, cardiac tissue was collected for CXCR4 expression analysis (Western blot).

RESULTS

The use of ω-3 caused a reduction in total cholesterol levels (p = 0.044), and acutely activated the SDF-1/CXCR4 axis in normotensive animals (p = 0.037). In the presence of the ω-3, after 72 h, SDF-1 levels decreased in WKY and increased in SHR (p = 0.017), and tissue expression of the receptor CXCR4 was higher in WKY than in SHR (p = 0.001).

CONCLUSION

The ω-3 fatty acid supplementation differentially modulates cell homing mediators in normotensive and hypertensive animals. While WKY rats respond acutely to omega-3 supplementation, showing increased release of SDF-1 and CXCR4, SHR exhibit a weaker, delayed response.

Inflammatory Markers Are Positively Associated with Serum trans-Fatty Acids in an Adult American Population

BACKGROUND AND AIM

The relationship between serum trans-fatty acids (TFAs) and systemic inflammation markers is unclear. We investigated the association of serum TFAs with high sensitivity C-reactive protein (hs-CRP) and fibrinogen in adult Americans.

METHODS

The 1999 to 2000 National Health and Nutrition Examination Survey (NHANES) participants with measured data on hs-CRP and fibrinogen were included. TFAs were measured via capillary gas chromatography and mass spectrometry using negative chemical ionization. Analysis of covariance and multivariable-adjusted linear regression models were used to investigate the associations between these parameters, accounting for the survey design.

RESULTS

Of the 5446 eligible participants, 46.8% (n = 2550) were men. The mean age was 47.1 years overall: 47.8 years in men and 46.5 years in women (p = 0.085). After adjustment for age and sex, mean serum TFAs rose with the increasing quarters of hs-CRP and fibrinogen (both p < 0.001). In linear regression models adjusted for age, sex, race, education, marital status, body mass index, and smoking, serum TFAs were an independent predictor of plasma hs-CRP and fibrinogen levels.

CONCLUSION

A high level of TFAs appears to be a contributor to an unfavourable inflammatory profile. Because serum TFAs concentrations are affected by dietary TFA intake, these data suggest a possible contribution of TFAs intake modulation in the prevention of inflammation-related chronic diseases.

Recommendations of the Spanish Menopause Society on the consumption of omega-3 polyunsaturated fatty acids by postmenopausal women

The consumption of long-chain omega-3 polyunsaturated fatty acids (LCO3-PUFAs) has shown a great variety of beneficial effects, including cardiovascular, metabolic and inflammatory effects, which make them interesting for the postmenopausal woman. Because LCO3-PUFAs could be effective and safe during this period, a panel of experts from the Spanish Menopause Society met to establish a set of recommendations for their use in postmenopausal women based on the best available evidence. The decrease in triglycerides is the most consistent effect observed with LCO3-PUFAs (at doses greater than 3g/day). In addition, LCO3-PUFAs have antiarrhythmic effects, reduce blood pressure, improve depressive and psychotic symptoms, and do not increase the risk of cancer. However, further studies are needed to confirm the benefit of LCO3-PUFAs in the relief of menopause symptoms and osteoporosis.

Nutrition, Pharmacological and Training Strategies Adopted by Six Bodybuilders: Case Report and Critical Review

The purpose of this study was to report and analyze the practices adopted by bodybuilders in light of scientific evidence and to propose evidence-based alternatives. Six (four male and two female) bodybuilders and their coaches were directly interviewed. According to the reports, the quantity of anabolic steroids used by the men was 500-750 mg/week during the bulking phase and 720-1160 mg during the cutting phase. The values for women were 400 and 740 mg, respectively. The participants also used ephedrine and hydrochlorothiazide during the cutting phase. Resistance training was designed to train each muscle once per week and all participants performed aerobic exercise in the fasted state in order to reduce body fat. During the bulking phase, bodybuilders ingested ~2.5 g of protein/kg of body weight. During the cutting phase, protein ingestion increased to ~3 g/kg and carbohydrate ingestion decreased by 10-20%. During all phases, fat ingestion corresponded to ~15% of the calories ingested. The supplements used were whey protein, chromium picolinate, omega 3 fatty acids, branched chain amino acids, poly-vitamins, glutamine and caffeine. The men also used creatine in the bulking phase. In general, the participants gained large amounts of fat-free mass during the bulking phase; however, much of that fat-free mass was lost during the cutting phase along with fat mass. Based on our analysis, we recommend an evidence-based approach by people involved in bodybuilding, with the adoption of a more balanced and less artificial diet. One important alert should be given for the combined use of anabolic steroids and stimulants, since both are independently associated with serious cardiovascular events. A special focus should be given to revisiting resistance training and avoiding fasted cardio in order to decrease the reliance on drugs and thus preserve bodybuilders' health and integrity.

The pro- or antiarrhythmic actions of polyunsaturated fatty acids and of cholesterol

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.

Nutraceutical therapies for atherosclerosis

Atherosclerosis is a chronic inflammatory disease affecting large and medium arteries and is considered to be a major underlying cause of cardiovascular disease (CVD). Although the development of pharmacotherapies to treat CVD has contributed to a decline in cardiac mortality in the past few decades, CVD is estimated to be the cause of one-third of deaths globally. Nutraceuticals are natural nutritional compounds that are beneficial for the prevention or treatment of disease and, therefore, are a possible therapeutic avenue for the treatment of atherosclerosis. The purpose of this Review is to highlight potential nutraceuticals for use as antiatherogenic therapies with evidence from in vitro and in vivo studies. Furthermore, the current evidence from observational and randomized clinical studies into the role of nutraceuticals in preventing atherosclerosis in humans will also be discussed.

Lack of effect of supplementation with EPA or DHA on platelet-monocyte aggregates and vascular function in healthy men

BACKGROUND AND AIMS

Eicosapentaenoic acid (EPA) and docosahexaenoic acid (DHA) found in fish oil are postulated to have favourable effects on platelet, endothelial and vascular function. We investigated whether EPA has differential effects on in vivo platelet aggregation and other markers of cardiovascular risk compared to DHA.

METHODS AND RESULTS

Following a 2 wk run-in taking encapsulated refined olive oil, 48 healthy young men were randomly allocated using a parallel design to receive EPA-rich (3.1 g EPA/d) or DHA-rich (2.9 g DHA/d) triglyceride concentrates or refined olive oil (placebo), for a total supplementary lipid intake of 5 g/d. The specified primary outcome was change in platelet monocyte aggregates (PMA); secondary outcomes were capillary density, augmentation index, digital pulse volume measurements, 24 h ambulatory BP, plasma 8-isoprostanes-F2α. Changes in the proportions of DHA and EPA in erythrocytes and non-esterified fatty acid composition indicated compliance to the intervention. There was no significant treatment effect on PMA (P = 0.382); mean changes (%) (95% CI) were placebo -0.5 (-2.0, 1.04), EPA 0.4 (-0.8, 1.6), DHA 0.3 (-1.5, 2.0). R-QUICKI, an index of insulin sensitivity, was greater following EPA compared to placebo (P < 0.05). No other significant differences were noted.

CONCLUSION

Neither EPA- nor DHA-rich fish oil supplementation influence platelet-monocyte aggregation or several markers of vascular function after 6 wk in healthy young males. This trial was registered at clinicaltrials.gov as NCT01735357.

Cytokines: roles in atherosclerosis disease progression and potential therapeutic targets

Atherosclerosis, the primary cause of cardiovascular disease (CVD), is a chronic inflammatory disorder in the walls of medium and large arteries. CVD is currently responsible for about one in three global deaths and this is expected to rise in the future due to an increase in the prevalence of obesity and diabetes. Current therapies for atherosclerosis mainly modulate lipid homeostasis and while successful at reducing the risk of a CVD-related death, they are associated with considerable residual risk and various side effects. There is, therefore, a need for alternative therapies aimed at regulating inflammation in order to reduce atherogenesis. This review will highlight the key role cytokines play during disease progression as well as potential therapeutic strategies to target them.

Mixture of Peanut Skin Extract and Fish Oil Improves Memory in Mice via Modulation of Anti-Oxidative Stress and Regulation of BDNF/ERK/CREB Signaling Pathways

Long-term use of fish oil (FO) is known to induce oxidative stress and increase the risk of Alzheimer’s disease in humans. In the present study, peanut skin extract (PSE), which has strong antioxidant capacity, was mixed with FO to reduce its side effects while maintaining its beneficial properties. Twelve-week Institute of Cancer Research (ICR) mice were used to conduct animal behavior tests in order to evaluate the memory-enhancing ability of the mixture of peanut skin extract and fish oil (MPF). MPF significantly increased alternations in the Y-maze and cognitive index in the novel object recognition test. MPF also improved performance in the water maze test. We further sought to understand the mechanisms underlying these effects. A significant decrease in superoxide dismutase (SOD) activity and an increase in malonyldialdehyde (MDA) in plasma were observed in the FO group. The MPF group showed reduced MDA level and increased SOD activity in the plasma, cortex and hippocampus. Furthermore, the gene expression levels of brain-derived neurotrophic factor (BDNF) and cAMP responsive element-binding protein (CREB) in the hippocampus were increased in the MPF group, while phosphorylation of protein kinase B (AKT), extracellular signal-regulated kinase (ERK) and CREB in the hippocampus were enhanced. MPF improves memory in mice via modulation of anti-oxidative stress and activation of BDNF/ERK/CREB signaling pathways.

The role of free fatty acids in the inflammatory and cardiometabolic profile in adolescents with metabolic syndrome engaged in interdisciplinary therapy

The purpose of the present study was to evaluate if interdisciplinary therapy can influence the cardiometabolic and serum free fatty acid profile. The second aim was to evaluate if there is an association between serum free fatty acids, inflammation and cardiometabolic biomarkers in obese adolescents with and without metabolic syndrome submitted to a long-term interdisciplinary therapy. The study involved 108 postpuberty obese adolescents, who were divided according to metabolic syndrome (MetS) diagnosis: MetS (n=32) and Non-MetS (n=76). The interdisciplinary therapy consisted of a 1-year period of nutrition, psychology, physical exercise and clinical support. After therapy, both groups improved metabolic, inflammatory (leptin, adiponectin, leptin/adiponectin ratio, adiponectin/leptin ratio and C-reactive protein) and cardiometabolic profile (PAI-1 and ICAM). Metabolic syndrome prevalence reduced from 28.70% to 12.96%. Both groups reduced myristic acid (C14:0) and increased docosahexaenoic acid (DHA, C22:6n3), heneicosapentaenoic acid (HPA, C21:5n3) and arachidonic acid (C20:4n6). After adjustment for metabolic syndrome and the number of metabolic syndrome parameters, multiple regression analysis showed that changes in VCAM and PAI-1 were negatively associated with changes in cis-linoleic acid (C18:2n6c). Additionally, changes in trans-linoleic acid (C18:2n6t) were also positively associated with these biomarkers. Moreover, leptin and leptin/adiponectin ratio were negatively associated with changes in docosapentaenoic acid (DPA, C22:5n3) and stearidonic acid (SDA, C18:4n3). Adiponectin/leptin ratio was positively associated with docosapentaenoic acid (DPA, C22:5n3). Changes in adiponectin were positively correlated with changes in omega 3, such as heneicosapentaenoic acid (HPA, C21:5n3) and docosapentaenoic acid (DPA, C22:5n3). Results support that interdisciplinary therapy can control inflammatory and cardiometabolic profile in obese adolescents. Moreover, serum fatty acids can be influenced by lifestyle changes and are able to modulate these biomarkers.

Conducting omega-3 clinical trials with cardiovascular outcomes: Proceedings of a workshop held at ISSFAL 2014

In contrast to earlier long-chain (LC) omega-3 (i.e. EPA and DHA) investigations, some recent studies have not demonstrated significant effects of EPA and DHA on cardiovascular disease (CVD) outcomes. The neutral findings may have been due to experimental design issues, such as: maintenance on aggressive cardiovascular drug treatment overshadowing the benefits of LC omega-3s, high background LC omega-3 intake, too few subjects in the study, treatment duration too short, insufficient LC omega-3 dosage, increase in omega-6 fatty acid intake during the study, failure to assess the LC omega-3 status of the subjects prior to and during treatment and lack of clarity concerning which mechanisms were expected to produce benefits. At the 11th ISSFAL Congress, a workshop was held on conducting LC omega-3 clinical trials with cardiovascular outcomes, with the goal of gaining a better understanding concerning aspects of experimental design that should be considered when planning clinical studies related to EPA and DHA and potential cardiovascular benefits.

Krill oil reduces plasma triacylglycerol level and improves related lipoprotein particle concentration, fatty acid composition and redox status in healthy young adults - a pilot study

Background

Lipid abnormalities, enhanced inflammation and oxidative stress seem to represent a vicious circle in atherogenesis, and therapeutic options directed against these processes seems like a reasonable approach in the management of atherosclerotic disorders. Krill oil (RIMFROST Sublime®) is a phospholipid-rich oil with eicosapentaenoic acid (EPA): docosahexaenoic acid (DHA) ratio of 1.8:1. In this pilot study we determined if krill oil could favourable affect plasma lipid parameters and parameters involved in the initiation and progression of atherosclerosis.

Methods

The study was conducted as a 28 days intervention study examining effect-parameters of dietary supplementation with krill oil (832.5 mg EPA and DHA per day). 17 healthy volunteers in the age group 18–36 (mean age 23 ± 4 years) participated. Plasma lipids, lipoprotein particle sizes, fatty acid composition in plasma and red blood cells (RBCs), plasma cytokines, antioxidant capacity, acylcarntines, carnitine, choline, betaine, and trimethylamine-N-oxide (TMAO) were measured before and after supplementation.

Results

Plasma triacylglycerol (TAG) and large very-low density lipoprotein (VLDL) & chylomicron particle concentrations decreased after 28 days of krill oil intake. A significant reduction in the TAG/HDL cholesterol resulted. Krill oil supplementation decreased n-6/n-3 polyunsaturated fatty acids (PUFA) ratio both in plasma and RBCs. This was due to increased EPA, DHA and docosapentaenoic acid (DPA) and reduced amount of arachidonic acid (AA). The increase of n-3 fatty acids and wt % of EPA and DHA in RBC was of smaller magnitude than found in plasma. Krill oil intake increased the antioxidant capacity, double bond index (DBI) and the fatty acid anti-inflammatory index. The plasma atherogenicity index remained constant whereas the thrombogenicity index decreased. Plasma choline, betaine and the carnitine precursor, γ-butyrobetaine were increased after krill oil supplementation whereas the TMAO and carnitine concentrations remained unchanged.

Conclusion

Krill oil consumption is considered health beneficial as it decreases cardiovascular disease risk parameters through effects on plasma TAGs, lipoprotein particles, fatty acid profile, redox status and possible inflammation. Noteworthy, no adverse effects on plasma levels of TMAO and carnitine were found.

Effect of Dietary Docosahexaenoic Acid Supplementation on the Participation of Vasodilator Factors in Aorta from Orchidectomized Rats

Benefits of n-3 polyunsaturated fatty acids (PUFAs) against cardiovascular diseases have been reported. Vascular tone regulation is largely mediated by endothelial factors whose release is modulated by sex hormones. Since the incidence of cardiovascular pathologies has been correlated with decreased levels of sex hormones, the aim of this study was to analyze whether a diet supplemented with the specific PUFA docosahexaenoic acid (DHA) could prevent vascular changes induced by an impaired gonadal function. For this purpose, control and orchidectomized rats were fed with a standard diet supplemented with 5% (w/w) sunflower oil or with 3% (w/w) sunflower oil plus 2% (w/w) DHA. The lipid profile, the blood pressure, the production of prostanoids and nitric oxide (NO), and the redox status of biological samples from control and orchidectomized rats, fed control or DHA-supplemented diet, were analyzed. The vasodilator response and the contribution of NO, prostanoids and hyperpolarizing mechanisms were also studied. The results showed that orchidectomy negatively affected the lipid profile, increased the production of prostanoids and reactive oxygen species (ROS), and decreased NO production and the antioxidant capacity, as well as the participation of hyperpolarizing mechanisms in the vasodilator responses. The DHA-supplemented diet of the orchidectomized rats decreased the release of prostanoids and ROS, while increasing NO production and the antioxidant capacity, and it also improved the lipid profile. Additionally, it restored the participation of hyperpolarizing mechanisms by activating potassium. Since the modifications induced by the DHA-supplemented diet were observed in the orchidectomized, but not in the healthy group, DHA seems to exert cardioprotective effects in physiopathological situations in which vascular dysfunction exists.

Nonstatin therapies for management of dyslipidemia: a review

PURPOSE

Cardiovascular disease (CVD) is the leading cause of morbidity and mortality in the United States. Recently published cholesterol treatment guidelines emphasize the use of statins as the preferred treatment strategy for both primary and secondary prevention of CVD. However, the optimal treatment strategy for patients who cannot tolerate statin therapy or those who need additional lipid-lowering therapy is unclear in light of recent evidence that demonstrates a lack of improved cardiovascular outcomes with combination therapy. The purpose of this review is to summarize and interpret evidence that evaluates nonstatin drug classes in reducing cardiovascular outcomes, to provide recommendations for use of nonstatin therapies in clinical practice, and to review emerging nonstatin therapies for management of dyslipidemia.

METHODS

Relevant articles were identified through searches of PubMed, International Pharmaceutical Abstracts, and the Cochrane Database of Systematic Reviews by using the terms niacin, omega-3 fatty acids (FAs), clofibrate, fibrate, fenofibrate, fenofibric acid, gemfibrozil, cholestyramine, colestipol, colesevelam, ezetimibe, proprotein convertase subtilisin/kexin 9 (PCSK9), cholesteryl ester transfer protein (CETP), and cardiovascular outcomes. Only English language, human clinical trials, meta-analyses, and systematic reviews were included. Additional references were identified from citations of published articles.

FINDINGS

Niacin may reduce cardiovascular events as monotherapy; however, recent trials in combination with statins have failed to show a benefit. Trials with omega-3 FAs have failed to demonstrate significant reductions in cardiovascular outcomes. Fibrates may improve cardiovascular outcomes as monotherapy; however, trials in combination with statins have failed to show a benefit, except in those with elevated triglycerides (>200 mg/dL) or low HDL-C (<40 mg/dL). There is a lack of data that evaluates bile acid sequestrant in combination with statin therapy on reducing cardiovascular events. Ezetimibe-statin combination therapy can reduce cardiovascular outcomes in those with chronic kidney disease and following vascular surgery or acute coronary syndrome. Long-term effects of emerging nonstatin therapies (CETP and PCSK9 inhibitors) are currently being evaluated in ongoing Phase III trials.

IMPLICATIONS

Nonstatin therapies have a limited role in reducing cardiovascular events in those maintained on guideline-directed statin therapy. In certain clinical situations, such as patients who are unable to tolerate statin therapy or recommended intensities of statin therapy, those with persistent severe elevations in triglycerides, or patients with high cardiovascular risk, some nonstatin therapies may be useful in reducing cardiovascular events. Future research is needed to evaluate the role of nonstatin therapies in those who are unable to tolerate guideline-directed statin doses.