Int J Angiol 2024; 33(01): 001-007
DOI: 10.1055/s-0043-1777258
Review Article

Current Evidence and Future Directions of Omega-3 Supplementation and Cardiovascular Disease Risk

1   Deptartment of Cardiology and Vascular Medicine, Faculty of Medicine, Universitas Indonesia - Harapan Kita National Cardiovascular Center, Jakarta, Indonesia
,
Anwar Santoso
1   Deptartment of Cardiology and Vascular Medicine, Faculty of Medicine, Universitas Indonesia - Harapan Kita National Cardiovascular Center, Jakarta, Indonesia
,
Budhi Setianto Purwowiyoto
1   Deptartment of Cardiology and Vascular Medicine, Faculty of Medicine, Universitas Indonesia - Harapan Kita National Cardiovascular Center, Jakarta, Indonesia
,
Basuni Radi
1   Deptartment of Cardiology and Vascular Medicine, Faculty of Medicine, Universitas Indonesia - Harapan Kita National Cardiovascular Center, Jakarta, Indonesia
,
Bashar Adi Wahyu Pandhita
1   Deptartment of Cardiology and Vascular Medicine, Faculty of Medicine, Universitas Indonesia - Harapan Kita National Cardiovascular Center, Jakarta, Indonesia
,
Serlie Fatrin
1   Deptartment of Cardiology and Vascular Medicine, Faculty of Medicine, Universitas Indonesia - Harapan Kita National Cardiovascular Center, Jakarta, Indonesia
,
Ade Meidian Ambari
1   Deptartment of Cardiology and Vascular Medicine, Faculty of Medicine, Universitas Indonesia - Harapan Kita National Cardiovascular Center, Jakarta, Indonesia
› Author Affiliations
Funding None.

Abstract

Omega-3 supplementation has a controversial role in the secondary prevention of cardiovascular diseases. Despite large clinical trials published over the years, the evidence of omega-3 in preventing cardiovascular diseases, especially coronary heart disease, is still inconclusive. However, recent clinical trials using higher dose of omega-3 or highly purified esters of omega-3 shows promising result, with reduction in cardiovascular death and incidence of cardiovascular disease. This review aims to summarize the possible mechanism of omega-3 in preventing cardiovascular disease and future directions of research regarding the benefit of omega-3 in cardiovascular disease.

Authors' Contributions

B.D. and A.S. contributed to study conceptualization and original draft writing. B.S.P. and B.R. contributed as supervisors and manuscript reviewer. D.R.D. and A.M.A. contributed in providing relevant studies and research methodology. B.A.W.P. and S.F. provided relevant figures and tables for the review.




Publication History

Article published online:
24 November 2023

© 2023. International College of Angiology. This article is published by Thieme.

Thieme Medical Publishers, Inc.
333 Seventh Avenue, 18th Floor, New York, NY 10001, USA

 
  • References

  • 1 Djuricic I, Calder PC. Beneficial outcomes of omega-6 and omega-3 polyunsaturated fatty acids on human health: an update for 2021. Nutrients 2021; 13 (07) 2421
  • 2 Kromhout D, Bosschieter EB, de Lezenne Coulander C. The inverse relation between fish consumption and 20-year mortality from coronary heart disease. N Engl J Med 1985; 312 (19) 1205-1209
  • 3 Arnett DK, Blumenthal RS, Albert MA. et al. 2019 ACC/AHA guideline on the primary prevention of cardiovascular disease: executive summary: a report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines. Circulation 2019; 140 (11) e563-e595
  • 4 Mach F, Baigent C, Catapano AL. et al; ESC Scientific Document Group. 2019 ESC/EAS guidelines for the management of dyslipidaemias: lipid modification to reduce cardiovascular risk. Eur Heart J 2020; 41 (01) 111-188
  • 5 Rauch B, Schiele R, Schneider S. et al; OMEGA Study Group. OMEGA, a randomized, placebo-controlled trial to test the effect of highly purified omega-3 fatty acids on top of modern guideline-adjusted therapy after myocardial infarction. Circulation 2010; 122 (21) 2152-2159
  • 6 Heydari B, Abdullah S, Pottala JV. et al. Effect of omega-3 acid ethyl esters on left ventricular remodeling after acute myocardial infarction: the OMEGA-REMODEL randomized clinical trial. Circulation 2016; 134 (05) 378-391
  • 7 Rhee JJ, Kim E, Buring JE, Kurth T. Fish consumption, omega-3 fatty acids, and risk of cardiovascular disease. Am J Prev Med 2017; 52 (01) 10-19
  • 8 Bowman L, Mafham M, Stevens W. et al; ASCEND Study Collaborative Group. ASCEND: A Study of Cardiovascular Events iN Diabetes: characteristics of a randomized trial of aspirin and of omega-3 fatty acid supplementation in 15,480 people with diabetes. Am Heart J 2018; 198: 135-144
  • 9 Simopoulos AP. Evolutionary aspects of diet, the omega-6/omega-3 ratio and genetic variation: nutritional implications for chronic diseases. Biomed Pharmacother 2006; 60 (09) 502-507
  • 10 Schunck W-H, Konkel A, Fischer R, Weylandt K-H. Therapeutic potential of omega-3 fatty acid-derived epoxyeicosanoids in cardiovascular and inflammatory diseases. Pharmacol Ther 2018; 183: 177-204
  • 11 Baumann KH, Hessel F, Larass I. et al. Dietary omega-3, omega-6, and omega-9 unsaturated fatty acids and growth factor and cytokine gene expression in unstimulated and stimulated monocytes. A randomized volunteer study. Arterioscler Thromb Vasc Biol 1999; 19 (01) 59-66
  • 12 Yuan X, Shen G, Hu Q, Xiao H, Qin X. The circulating biomarker fractalkine and platelet-derived growth factor BB are correlated with carotid plaque vulnerability assessed by computed tomography angiography. J Stroke Cerebrovasc Dis 2022; 31 (05) 106422
  • 13 Bays HE, Tighe AP, Sadovsky R, Davidson MH. Prescription omega-3 fatty acids and their lipid effects: physiologic mechanisms of action and clinical implications. Expert Rev Cardiovasc Ther 2008; 6 (03) 391-409
  • 14 Natto ZS, Yaghmoor W, Alshaeri HK, Van Dyke TE. Omega-3 fatty acids effects on inflammatory biomarkers and lipid profiles among diabetic and cardiovascular disease patients: a systematic review and meta-analysis. Sci Rep 2019; 9 (01) 18867
  • 15 Choi HD, Chae SM. Comparison of efficacy and safety of combination therapy with statins and omega-3 fatty acids versus statin monotherapy in patients with dyslipidemia: a systematic review and meta-analysis. Medicine (Baltimore) 2018; 97 (50) e13593
  • 16 Chan DC, Pang J, Barrett PHR. et al. ω-3 fatty acid ethyl esters diminish postprandial lipemia in familial hypercholesterolemia. J Clin Endocrinol Metab 2016; 101 (10) 3732-3739
  • 17 Miyoshi T, Noda Y, Ohno Y. et al. Omega-3 fatty acids improve postprandial lipemia and associated endothelial dysfunction in healthy individuals - a randomized cross-over trial. Biomed Pharmacother 2014; 68 (08) 1071-1077
  • 18 Zhao Y, Liu L, Yang S. et al. Mechanisms of atherosclerosis induced by postprandial lipemia. Front Cardiovasc Med 2021; 8: 636947
  • 19 Jialal I, Devaraj S, Huet BA, Traber M. GISSI-Prevenzione trial. Lancet 1999; 354 (9189) 1554 , author reply 1556–1557
  • 20 Bernasconi AA, Wiest MM, Lavie CJ, Milani RV, Laukkanen JA. Effect of omega-3 dosage on cardiovascular outcomes: an updated meta-analysis and meta-regression of interventional trials. Mayo Clin Proc 2021; 96 (02) 304-313
  • 21 Doi M, Nosaka K, Miyoshi T. et al. Early eicosapentaenoic acid treatment after percutaneous coronary intervention reduces acute inflammatory responses and ventricular arrhythmias in patients with acute myocardial infarction: a randomized, controlled study. Int J Cardiol 2014; 176 (03) 577-582
  • 22 Galan P, Briancon S, Blacher J, Czernichow S, Hercberg S. The SU.FOL.OM3 study: a secondary prevention trial testing the impact of supplementation with folate and B-vitamins and/or omega-3 PUFA on fatal and non fatal cardiovascular events, design, methods and participants characteristics. Trials 2008; 9: 35
  • 23 Bosch J, Gerstein HC, Dagenais GR. et al; ORIGIN Trial Investigators. n-3 fatty acids and cardiovascular outcomes in patients with dysglycemia. N Engl J Med 2012; 367 (04) 309-318
  • 24 Kromhout D, Giltay EJ, Geleijnse JM. Alpha Omega Trial Group. n-3 fatty acids and cardiovascular events after myocardial infarction. N Engl J Med 2010; 363 (21) 2015-2026
  • 25 Popoff F, Balaciano G, Bardach A. et al. Omega 3 fatty acid supplementation after myocardial infarction: a systematic review and meta-analysis. BMC Cardiovasc Disord 2019; 19 (01) 136
  • 26 Yokoyama M, Origasa H, Matsuzaki M. et al; Japan EPA lipid intervention study (JELIS) Investigators. Effects of eicosapentaenoic acid on major coronary events in hypercholesterolaemic patients (JELIS): a randomised open-label, blinded endpoint analysis. Lancet 2007; 369 (9567) 1090-1098
  • 27 Bhatt DL, Miller M, Brinton EA. et al; REDUCE-IT Investigators. REDUCE-IT USA: results from the 3146 patients randomized in the United States. Circulation 2020; 141 (05) 367-375
  • 28 Wan Y, Zheng J, Wang F, Li D. Fish, Long Chain Omega-3 Polyunsaturated Fatty Acids Consumption, and Risk of All-Cause Mortality: A Systematic Review and Dose-Response Meta-Analysis from 23 Independent Prospective Cohort Studies. Asia Pac J Clin Nutr 2017; 939-956
  • 29 Hu Y, Hu FB, Manson JE. Marine omega-3 supplementation and cardiovascular disease: an updated meta-analysis of 13 randomized controlled trials involving 127 477 participants. J Am Heart Assoc 2019; 8 (19) e013543
  • 30 Lombardi M, Carbone S, Del Buono MG. et al. Omega-3 fatty acids supplementation and risk of atrial fibrillation: an updated meta-analysis of randomized controlled trials. Eur Heart J Cardiovasc Pharmacother 2021; 7 (04) e69-e70
  • 31 Kapoor K, Alfaddagh A, Al Rifai M. et al. Association between omega-3 fatty acid levels and risk for incident major bleeding events and atrial fibrillation: MESA. J Am Heart Assoc 2021; 10 (11) e021431
  • 32 Jeansen S, Witkamp RF, Garthoff JA, van Helvoort A, Calder PC. Fish oil LC-PUFAs do not affect blood coagulation parameters and bleeding manifestations: analysis of 8 clinical studies with selected patient groups on omega-3-enriched medical nutrition. Clin Nutr 2018; 37 (03) 948-957
  • 33 Mozaffarian D, Lemaitre RN, King IB. et al. Plasma phospholipid long-chain ω-3 fatty acids and total and cause-specific mortality in older adults: a cohort study. Ann Intern Med 2013; 158 (07) 515-525
  • 34 Chang C-H, Tseng P-T, Chen N-Y. et al. Safety and tolerability of prescription omega-3 fatty acids: a systematic review and meta-analysis of randomized controlled trials. Prostaglandins Leukot Essent Fatty Acids 2018; 129: 1-12
  • 35 Mozaffarian D, Wu JHY. (n-3) fatty acids and cardiovascular health: are effects of EPA and DHA shared or complementary?. J Nutr 2012; 142 (03) 614S-625S
  • 36 Sun Q, Ma J, Campos H. et al. Blood concentrations of individual long-chain n-3 fatty acids and risk of nonfatal myocardial infarction. Am J Clin Nutr 2008; 88 (01) 216-223
  • 37 Mozaffarian D, Lemaitre RN, King IB. et al. Circulating long-chain ω-3 fatty acids and incidence of congestive heart failure in older adults: the cardiovascular health study: a cohort study. Ann Intern Med 2011; 155 (03) 160-170
  • 38 Kohashi K, Nakagomi A, Saiki Y. et al. 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 (07) 712-729
  • 39 Golzari MH, Javanbakht MH, Ghaedi E, Mohammadi H, Djalali M. Effect of eicosapentaenoic acid (EPA) supplementation on cardiovascular markers in patients with type 2 diabetes mellitus: a randomized, double-blind, placebo-controlled trial. Diabetes Metab Syndr 2018; 12 (03) 411-415
  • 40 Patel PN, Patel SM, Bhatt DL. Cardiovascular risk reduction with icosapent ethyl. Curr Opin Cardiol 2019; 34 (06) 721-727
  • 41 Budoff MJ, Bhatt DL, Kinninger A. et al. Effect of icosapent ethyl on progression of coronary atherosclerosis in patients with elevated triglycerides on statin therapy: final results of the EVAPORATE trial. Eur Heart J 2020; 41 (40) 3925-3932
  • 42 Bays HE, Ballantyne CM, Kastelein JJ, Isaacsohn JL, Braeckman RA, Soni PN. Eicosapentaenoic acid ethyl ester (AMR101) therapy in patients with very high triglyceride levels (from the Multi-center, plAcebo-controlled, Randomized, double-blINd, 12-week study with an open-label Extension [MARINE] trial). Am J Cardiol 2011; 108 (05) 682-690
  • 43 Ballantyne CM, Bays HE, Kastelein JJ. et al. Efficacy and safety of eicosapentaenoic acid ethyl ester (AMR101) therapy in statin-treated patients with persistent high triglycerides (from the ANCHOR study). Am J Cardiol 2012; 110 (07) 984-992
  • 44 GISSI-Prevenzione Investigators (Gruppo Italiano per lo Studio della Sopravvivenza nell’Infarto miocardico). Dietary supplementation with n-3 polyunsaturated fatty acids and vitamin E after myocardial infarction: results of the GISSI-Prevenzione trial. The Lancet 1999; Aug; 354 (9177) 447-455
  • 45 Nicholls SJ, Lincoff AM, Garcia M. et al. Effect of High-Dose Omega-3 Fatty Acids vs Corn Oil on Major Adverse Cardiovascular Events in Patients at High Cardiovascular Risk: The STRENGTH Randomized Clinical Trial. JAMA 2020; 324 (22) 2268-2280