Prevention of sudden cardiac death with omega-3 fatty acids in patients with coronary heart disease: a meta-analysis of randomized controlled trials.

AIM: To systematically review trials concerning the effects of omega-3 fatty acids on sudden cardiac death (SCD), cardiac death, and all-cause mortality in coronary heart disease (CHD) patients. METHODS: PubMed, Embase, and the Cochrane database (1966-2007) were searched. We identified randomized controlled trials that compared dietary or supplementary intake of omega-3 fatty acids with control diet or placebo in CHD patients. Eligible studies had at least 6 months of follow-up data, and cited SCD as an end-point. Two reviewers independently assessed methodological quality. Meta-analysis of relative risk was carried out using the random effect model. RESULTS: Eight trials were identified, comprising 20,997 patients. In patients with prior myocardial infarction (MI), omega-3 fatty acids reduced relative risk (RR) of SCD (RR = 0.43; 95% CI: 0.20-0.91). In patients with angina, omega-3 fatty acids increased RR of SCD (RR = 1.39; 95% CI: 1.01-1.92). Overall, RR for cardiac death and all-cause mortality were 0.71 (95% CI: 0.50-1.00) and 0.77 (95% CI: 0.58-1.01), respectively. CONCLUSIONS: Dietary supplementation with omega-3 fatty acids reduces the incidence of sudden cardiac death in patients with MI, but may have adverse effects in angina patients.

Effects of soluble fiber (Plantago ovata husk) on plasma lipids, lipoproteins, and apolipoproteins in men with ischemic heart disease.

BACKGROUND: New dietary strategies to reduce cardiovascular disease (CVD) risk include the addition of fiber to the diet. The effect of soluble-fiber consumption derived from Plantago ovata husk on lipid risk factors in patients with CVD is unknown. OBJECTIVE: We compared the effects of soluble fiber (P. ovata husk) with those of insoluble fiber (P. ovata seeds) on plasma lipid, lipoprotein, and apolipoprotein (apo) concentrations within a CVD secondary prevention program. DESIGN: In a randomized, crossover, controlled, single-blind design, 28 men with CVD (myocardial infarction or stable angina) and an LDL-cholesterol concentration

Secondary prevention of CHD in UK men: the Diet and Reinfarction Trial and its sequel.

The Diet and Reinfarction Trial (DART) involved 2033 men (mean age 56.5 years) recovering from myocardial infarction. They were randomly allocated to receive advice or to receive no advice on each of three dietary factors: an increase in fatty fish intake; a reduction in fat intake with an increase in polyunsaturated fat:saturated fat; an increased intake of cereal fibre. Compliance was satisfactory with the fish and fibre advice, but less so with the fat advice. The men given fish advice had 29% lower 2-year all-cause mortality; the other forms of advice did not have any significant effects. The Diet and Angina Randomized Trial (DART-2) involved 3114 men (mean age 61.1 years) with stable angina, who were followed up for 3-9 years. Advice to eat oily fish or take fish oil did not affect all-cause mortality, but it was associated with a significant increase in sudden cardiac death (P=0.018), and this effect was largely confined to the subgroup given fish oil capsules. Advice to eat more fruit and vegetables had no effect, probably because of poor compliance. The outcome of DART-2 appears to conflict with that of DART and some other studies; various possible explanations are considered. Nutritional interventions are not equally acceptable and should be tailored to the individuals for whom they are intended. Various distinct groups have a raised risk of CHD, and it cannot be assumed that the same nutritional interventions are appropriate to them all. Nutritional supplements do not necessarily have the same effects as the foods from which they are derived.

[Efficacy of treatment-and-prophylactic diets including soya-based food in elderly patients with atherogenic dislipidemia and glucose intolerance].

47 elderly patients aged 60-74 with stable exertional angina of I-II functional classes and 2a type dislipidemia have been observed. The authors studied the efficacy of hypocholesteremic diet (HD) including soya-based food in comparison with the use of HD without soya-based food. Patients of the main group were prescribed HD, soya-based food (29 g of soya protein per day) and medications of a based therapy during four weeks. Patients of the control group were given HD and medications of a based therapy during the same period. The use of HD with soya-based food decreased considerably frequency and duration of exertional angina attack, increased the tolerance to physical activity resulted in more considerable decrease in concentration of blood serum common cholesterin and cholesterin of low density lipoprotein in comparison with indices of patients of the control group. Soya-based food together with HD in patients with disturbed tolerance to glucose normalized the tolerance test to glucose.

[The treatment of coronary heart disease by beta-adrenoblockers or tiazide diuretics preparation in combination with vegetarian diet].

Work make on 84 patients with coronare heart diseases were divided into two groups, equal quantity. The first groups were given athenolol (50 mg daily), the second--hypotiazide (25 mg daily). In every groupspart patients received an antiatherogenic lactoovovegetetarian diet, part--an standard antiatherogenic diet 10c. Time observation--24 daily. By the end of the treatment period with athenolol in backoground the vegetarian diet the level of total cholesterol decreased by 16%, low-density lipoproteins cholesterol decreased by 18%. In groups patients received an standard antiatherogenic diet these parameters practically did'nt change. In the vegetarian group the atherogenic coefficient (KA) decreased by 31%., while in the patients on standard antiatherogenic diet KA showed only a tendency for decreasing. By the end to the treatment period with hypotiazide the slight decrease in total cholesterol, KA levels and a slight increase in HDL cholesterol were observed only the vegetarian group.

Is fish oil good or bad for heart disease? Two trials with apparently conflicting results.

Two successive randomized trials examined the effect of an increased intake of fatty fish, or the use of fish oil supplements, in reducing mortality in men with heart disease. The Diet and Reinfarction Trial (DART) was conducted in 2033 men who were recovering from acute myocardial infarction (MI). Those who were advised to eat fatty fish (or who opted to take fish oil capsules instead) had a 29% reduction in all-cause mortality over the following two years compared with those not so advised. The effect appeared in the first few months of the trial. The Diet and Angina Randomized Trial (DART 2) involved 3114 men with stable angina. Advice to eat fatty fish did not reduce mortality, and taking fish oil capsules was associated with a higher risk of cardiac and sudden death. The adverse effects of fish or fish oil were restricted to men not taking beta-blockers or dihydropyridine calcium-channel blockers, and were greater in those taking digoxin. Evidence from other sources strongly suggests an anti-arrhythmic action of fish oil, particularly after MI or in the presence of acute ischemia. The apparently conflicting results of the two trials may reflect different actions of n-3 fatty acids in acute and chronic conditions, together with different effects of eating fish and taking fish oil capsules. A mechanism is proposed that could account for these findings.

The long-term effect of dietary advice on the diet of men with angina: the diet and angina randomized trial.

INTRODUCTION: The long-term effects on diet of dietary advice to eat fruit and vegetables or fatty fish are not well described. MATERIALS AND METHODS: From 1990 to 1996 3114 men aged 37-70 with treated angina were recruited from general practices in South Wales. A dietitian randomly allocated the eligible men to receive advice to eat more fruit and vegetables, or advice to eat more fatty fish, or both these types of advice or neither. In 2000, a brief self-completion questionnaire was sent to a sample of 1191 of the men known to be alive at the end of March 1999. RESULTS: The questionnaire was returned by 944 of the 1036 men alive at the time the questionnaire was sent. Those given fish advice were consuming more fatty fish but the difference was modest 21.9 g day(-1) vs. 14.0 g day(-1) (P < 0.01). The differences in fruit and vegetables intake between those given fruit advice and those not given fruit advice were small 373.2 g day(-1) vs. 351.7 g day(-1) (P = 0.05). DISCUSSION: Men of this age group may be particularly resistant to fruit and vegetables advice; population-based interventions or interventions targeted at women might be more effective.

Lack of benefit of dietary advice to men with angina: results of a controlled trial.

OBJECTIVE: To see whether mortality among men with angina can be reduced by dietary advice. DESIGN: A randomized controlled factorial trial. SETTING: Male patients of general practitioners in south Wales. SUBJECTS: A total of 3114 men under 70 y of age with angina. INTERVENTIONS: Subjects were randomly allocated to four groups: (1) advised to eat two portions of oily fish each week, or to take three fish oil capsules daily; (2) advised to eat more fruit, vegetables and oats; (3) given both the above types of advice; and (4) given no specific dietary advice. Mortality was ascertained after 3-9 y. RESULTS: Compliance was better with the fish advice than with the fruit advice. All-cause mortality was not reduced by either form of advice, and no other effects were attributable to fruit advice. Risk of cardiac death was higher among subjects advised to take oily fish than among those not so advised; the adjusted hazard ratio was 1.26 (95% confidence interval 1.00, 1.58; P=0.047), and even greater for sudden cardiac death (1.54; 95% CI 1.06, 2.23; P=0.025). The excess risk was largely located among the subgroup given fish oil capsules. There was no evidence that it was due to interactions with medication. CONCLUSIONS: Advice to eat more fruit was poorly complied with and had no detectable effect on mortality. Men advised to eat oily fish, and particularly those supplied with fish oil capsules, had a higher risk of cardiac death. This result is unexplained; it may arise from risk compensation or some other effect on patients' or doctors' behaviour.

Effect of an Indo-Mediterranean diet on progression of coronary artery disease in high risk patients (Indo-Mediterranean Diet Heart Study): a randomised single-blind trial.

BACKGROUND: The rapid emergence of coronary artery disease (CAD) in south Asian people is not explained by conventional risk factors. In view of cardioprotective effects of a Mediterranean style diet rich in alpha-linolenic acid, we assessed the benefits of this diet for patients at high risk of CAD. METHODS: We did a randomised, single-blind trial in 1000 patients with angina pectoris, myocardial infarction, or surrogate risk factors for CAD. 499 patients were allocated to a diet rich in whole grains, fruits, vegetables, walnuts, and almonds. 501 controls consumed a local diet similar to the step I National Cholesterol Education Program (NCEP) prudent diet. FINDINGS: The intervention group consumed more fruits, vegetables, legumes, walnuts, and almonds than did controls (573 g [SD 127] vs 231 g [19] per day p<0.001). The intervention group had an increased intake of whole grains and mustard or soy bean oil. The mean intake of alpha-linolenic acid was two-fold greater in the intervention group (1.8 g [SD 0.4] vs 0.8 g [0.2] per day, p<0.001). Total cardiac end points were significantly fewer in the intervention group than the controls (39 vs 76 events, p<0.001). Sudden cardiac deaths were also reduced (6 vs 16, p=0.015), as were non-fatal myocardial infarctions (21 vs 43, p<0.001). We noted a significant reduction in serum cholesterol concentration and other risk factors in both groups, but especially in the intervention diet group. In the treatment group, patients with pre-existing CAD had significantly greater benefits compared with such patients in the control group. INTERPRETATION: An Indo-Mediterranean diet that is rich in alpha-linolenic acid might be more effective in primary and secondary prevention of CAD than the conventional step I NCEP prudent diet.

The development of a nurse-led angina management programme.

The anxiety caused by living with angina can be very debilitating and affects patients' quality of life. In one trust an angina management programme was set up to provide educational and psychosocial support, with an emphasis on cardiac risk factor modification. Regular monitoring of patients at nurse-led clinics and multidisciplinary teamwork were important elements.

Nutritional advice to increase soluble fibre intake does not change plasma folate or homocysteine in men with angina: a randomised controlled trial.

OBJECTIVE: To study the effect of advice to increase dietary soluble fibre, including fruit and vegetables, on plasma folate and homocysteine in men with angina. DESIGN: Data were collected on a subset of subjects from the Diet and Angina Randomised Trial (DART II). In a randomised (2 x 2) factorial design, subjects received advice on either, neither or both interventions to: (1) increase soluble fibre intake to 8.0 g day(-1) (fruit, vegetables and oats); (2) increase oily fish intake to 2 portions week(-1). Those who received soluble fibre advice were compared with those who did not. Subjects were genotyped for C677T variant 5,10-methylenetetrahydrofolate reductase (MTHFR). SETTING/SUBJECTS: Seven hundred and fifty-three male angina patients were recruited from general practice. RESULTS: Plasma homocysteine concentrations were at the upper end of the normal range (median 11.5, 25% 9.4, 75% 14.0 micromol l(-1)). Baseline intake of fruit and vegetables was positively correlated with plasma folate (r(s) = 0.29, P < 0.01). Smokers had lower intakes of fruit and vegetables, lower plasma folate and higher homocysteine (all P < 0.01). Homozygotes for variant MTHFR had higher homocysteine concentrations at low plasma folate (P < 0.01). Reported intakes of fruit and vegetables and estimated dietary folate increased in the intervention group (ca. +75 g day(-1), P < 0.01 and ca. +20 g day(-1), P < 0.05, respectively). However, neither plasma folate (baseline/follow-up 4.5 vs. 4.4 microg l(-1), P = 0.40) nor homocysteine (baseline/follow-up 11.7 vs. 11.7 micromol l(-1), P = 0.31) changed. CONCLUSIONS: Plasma homocysteine, a cardiovascular risk factor, is influenced by MTHFR genotype, plasma folate and smoking status. Dietary advice successfully led to changes in fruit and vegetable intake, but not to changes in plasma folate or homocysteine, possibly because the fruits and vegetables that were chosen were not those richest in folate.

[Six-month xenical (orlistat) therapy of patients with stable angina pectoris concomitant with obesity and hyperlipidemia]. / Opyt 6-mesiachnogo primeneniia ksenikala (orlistata) u bol'nykh stabil'noi stenokardiei s ozhireniem i giperlipidemiei.

AIM: To evaluate the efficiency of 6-month therapy with xenical (gastrointestinal lipase inhibitor) in combination with diet in patients with stable angina pectoris associated with obesity and hyperlipemia. MATERIAL AND METHODS: An open comparative randomized study of the efficiency of xenical in combination with diet was carried out in patients with stable angina pectoris concomitant with obesity and hyperlipemia. Thirty coronary patients aged 45-65 years with stable angina of effort (functional class I-II) with body weight index 28.1-45.6 kg/m2 (mean 33.5 kg/m2) were examined. All patients presented with dyslipemia (low density lipoprotein (LDL) cholesterol more than 4.14 mmol/liter, triglycerides (TG) more than 2.2 mmol/liter). Controls (n = 15) were treated with diets alone for 6 months. In the main group diets were supplemented by xenical in a dose of 360 mg/day. RESULTS: Body weight index decreased in both groups (by 9.9% in the main group and by 4.2% in the control). Body weight stabilization during 6 months of treatment and the fact that it was slow and gradual were essential. In patients treated with xenical total cholesterol level decreased by 10.9% and of LDL cholesterol by 12.2% after 6 months (p < 0.05). Changes in the levels of high density lipoprotein cholesterol and TG were insignificant. The drug did not affect the incidence of angina attacks and improved exercise tolerance after 6-month therapy. Blood biochemistry (transaminases, alkaline phosphatase, glucose, and creatinine) changed negligibly. No side effects were observed; all patients received a complete 6-month course. CONCLUSION: The results confirm that xenical (orlistat) can be used for long therapy of patients with stable angina of effort concomitant with obesity and hyperlipemia.

Randomized trial of a medical food for the dietary management of chronic, stable angina.

OBJECTIVES: We determined the electrocardiographic, vascular and clinical effects of a medical food bar enriched with L-arginine and a combination of other nutrients known to enhance endothelium-derived nitric oxide (NO) in patients with stable angina. BACKGROUND: Enhancement of vascular NO by supplementation with L-arginine and other nutrients has been shown to have clinical benefits in patients with angina secondary to atherosclerotic coronary artery disease (CAD). However, the amounts and combinations of these nutrients required to achieve a clinical effect make traditional delivery by capsules and pills less suitable than alternative delivery methods such as a specially formulated nutrition bar. METHODS: Thirty-six stable outpatients with CAD and class II or III angina participated in a randomized, double-blind, placebo-controlled, crossover trial with two treatment periods each of two weeks' duration (two active bars or two placebo bars per day). Flow-mediated brachial artery dilation was measured by ultrasound. Electrocardiographic measures of ischemia, exercise capacity and angina onset time were measured by treadmill exercise testing and by Holter monitor during routine daily activities. Quality of life was assessed by SF-36 and Seattle Angina Questionnaires and by diary. RESULTS: The medical food improved flow-mediated vasodilation (from 5.5 +/- 4.5 to 8.0 +/- 4.9, p = 0.004), treadmill exercise time (by 20% over placebo, p = 0.05) and quality-of-life scores (SF-36 summary score; 68 +/- 13 vs. 63 +/- 21 after placebo, p = 0.04, Seattle Angina Questionnaire summary score; 67 +/- 10 vs. 62 +/- 18, p = 0.04) without affecting electrocardiographic manifestations of ischemia or angina onset time. CONCLUSIONS: These findings reveal that this arginine-rich medical food, when used as an adjunct to traditional therapy, improves vascular function, exercise capacity and aspects of quality of life in patients with stable angina.

A review of recent dietary intervention trials in the United Kingdom to reduce blood cholesterol levels.

A review of 14 UK studies conducted between 1980 and January 1997 showed that blood cholesterol levels can be reduced through screening followed by dietary and behavioural intervention in both general population and high risk individuals (hyperlipidaemic and angina patients). In most studies cholesterol levels were lowered moderately while changes in other risk factors were also in a positive direction. However, it is unclear whether the cholesterol reductions are sufficiently large to have a significant impact in lowering the risk of heart disease in the whole population.