Fish consumption and the risk of developing acute coronary syndromes: the CARDIO2000 study

doi:10.1016/j.ijcard.2004.05.043

International Journal of Cardiology

Volume 102, Issue 3, 20 July 2005, Pages 403-409

https://doi.org/10.1016/j.ijcard.2004.05.043 Get rights and content

Abstract

Objective

The aim of this work was to investigate the association between fish consumption and the development of non-fatal acute coronary syndromes (ACS), in a Mediterranean population.

Methods

During 2000–2001, we randomly and stratified selected, from all Greek regions, 848 hospitalised patients (695 males, 58±10 years old and 153 females, 65±9 years old) who had a first event of ACS and 1078 paired, by region–sex–age, controls without any clinical symptoms or signs of coronary heart disease.

Results

On multivariate logistic regression analysis and, after controlling for several potential confounders, we found that fish consumption less than 150 g/week was associated with 38% lower odds of developing ACS as compared to no consumption (odds ratio=0.62, P-value<0.05). In contrast, moderate (150–300 g/week) and high (>300 g/week) fish consumption was not associated with the developing of the disease (odds ratios=1.10 and 1.01, respectively, P-value>0.1). The benefits from low fish consumption were also significant even amongst current smokers and diabetics.

Conclusion

Moderate fish consumption was independently associated with a significant reduction in the odds of developing ACS. The strength and consistency of this finding has implications for public health and should be explored further.

Introduction

Epidemiological studies have provided conflicting results regarding the effect of fish consumption on the risk of developing cardiovascular diseases. Some observational studies [1], [2], [3] have found an inverse relation between fish consumption and risk of developing coronary heart disease (CHD). For example, in the USA, high consumption of fish was associated with lower risk of CHD in women [4], and with lower CHD incidence and total mortality in diabetic women [5]. In the NHANES I study [6], moderate fish consumption once a week was also found to have a protective effect, but no further reduction in risk was observed in higher fish consumption. In contrast, in Japanese men, fish consumption was not associated with the risk of non-fatal myocardial infarction, in both genders [7]. In a relatively recent review of prospective cohort studies, it was suggested that individuals at low risk of CHD and with healthy life styles do not gain additional protection against CHD from eating fish [8]. However, in the same review, it was suggested that high-risk individuals appear to benefit from increasing their fish consumption up to the optimum of 40–60 g/day. There is also evidence, which suggest that at least in Finland, Italy and the Netherlands, only fatty fish and not lean fish consumption is associated with lower CHD mortality [9]. In Greece, there is some evidence to suggest that, since the early 1960s, fish consumption has been increased from 18 to 34 g/day [10], [11] and this fish consumed is mainly lean rather than fatty [12]. However, there is no data in the Greek population regarding the association of fish consumption and CHD risk. Therefore, we sought to evaluate the association between portion of fish consumed and the risk of developing non-fatal acute coronary events, in a sample of cardiac patients and controls.

Section snippets

Study's population

The CARDIO2000 [13], [14], [15] is a multicentre case-control study that investigates the association between several demographic, nutritional, lifestyle and medical risk factors with the risk of developing non-fatal acute coronary syndromes (ACS). From January 2000 to August 2001, 848 individuals who entered to the selected hospitals for a first event of acute coronary syndromes (stable angina was excluded from the analysis) agreed to participate into the study (response rate 89%). Six hundred

Results

Table 1 presents the distribution of cardiovascular risk factors and other demographic characteristics of the participants.

The portion of fish consumed is presented in Table 2. We can see that the frequency of consumption differed significantly between patients and controls (Table 2). Particularly, male patients seemed to consume more frequently higher quantities of fish during a week than male controls. In contrast, low consumption of fish was more frequent among male controls than patients.

Discussion

In this work, we revealed a J-shape association between fish intake and coronary risk. In particular, low fish consumption (about 150 g or less per week) was independently related with a considerable reduction of the odds of developing acute coronary syndromes, not only in the overall study sample, but also in current smokers and diabetics. This finding is of interest and it is somehow unexpected since the protective effect of fish on acute coronary syndromes was not observed in the groups of

Limitations

In retrospective case-control studies, two main sources of systematic errors may exist, the selection and the recall bias. In order to eliminate selection bias we tried to set objective criteria, both for patients and controls. However, insignificant misclassification may exist, since a small percentage of asymptomatic coronary patients may be wrongly assigned to controls, even if a cardiologist evaluated them. Also, in case-control studies, it is usually observed that patients who had a recent

Conclusion

In conclusion, our findings may state a hypothesis of a beneficial association between low fish consumption and coronary heart disease risk and could suggest a strong public health message for the reduction of cardiovascular morbidity and mortality at population level.

Acknowledgements

This study was supported by research grants from the Hellenic Heart Foundation (11/1999-11/2002). The authors would like to thank the physicians (field investigators) and the other specialists that coordinated this study: Dr. Ê. Tzioumis (Athens, Crete, Pelloponisos), Dr. Í. Papaioannou (Athens, Thessalia), Dr. P. Stravopodis (Ionian Islands), Dr. L. Karra (Aegean Islands), Dr. D. Antoniades (Macedonia), Dr. G. Rembelos (Aegean Islands), Dr. D. Markou (Athens), A. Moraiti (Athens), D. Evagelou

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Thus, the final set of studies consisted of 19 studies (Figure 1). The combined studies included 11 prospective cohort16-26 and 8 case-control27-34 studies, totaling 408,305 participants (398,177 for prospective cohort and 10,128 for case-control studies), with 47.1% being male. The mean age was 55.8 years (age range 20-84 years).
Findings on the association between fish consumption and acute coronary syndrome are inconsistent. We assessed the role of fish consumption in acute coronary syndrome by conducting a dose-response meta-analysis.
We conducted a literature search of MEDLINE and Embase databases from 1966 to June 2013 for prospective cohort and case-control studies that evaluated the association between fish consumption and acute coronary syndrome among general populations without cardiovascular disease history. Additional studies were identified via hand search of references of relevant articles. Estimates of relative risk (RR) were pooled using random-effects model. Sex and age effects were also evaluated.
Our search retrieved 11 prospective cohort and 8 case-control studies, totaling 408,305 participants. Among prospective cohort studies, the highest category of fish consumption (ie, ≥4 times per week) was associated with the greatest risk reduction in acute coronary syndrome (RR 0.79; 95% confidence interval [CI], 0.70-0.89). In dose-response analysis, each additional 100-g serving of fish per week was associated with a 5% reduced risk (RR per serving 0.95; 95% CI, 0.92-0.97). Subgroup analysis and meta-regression suggested that the risk reduction did not differ across sex or age groups. No heterogeneity was observed among prospective cohort (P = .73) and case-control (P = .29) studies. There was no evidence of publication bias.
Our meta-analysis demonstrated that there is an inverse association between fish consumption and the risk of acute coronary syndrome. Fish consumption appears beneficial in the primary prevention of acute coronary syndrome, and higher consumption is associated with greater protection.
Comparative analysis of a-priori and a-posteriori dietary patterns using state-of-the-art classification algorithms: A case/case-control study
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Among them, a healthy diet has been acknowledged as the cornerstone of CVD prevention [2]. Thus, it is of paramount importance to gain further insights into the assessment of dietary habits [3–8]. In nutritional epidemiology, two basic methodologies have been proposed for the holistic assessment of dietary habits (i.e., dietary patterns analysis): the a-priori and the a-posteriori analyses.
To compare the accuracy of a-priori and a-posteriori dietary patterns in the prediction of acute coronary syndrome (ACS) and ischemic stroke. This is actually the first study to employ state-of-the-art classification methods for this purpose.
During 2009–2010, 1000 participants were enrolled; 250 consecutive patients with a first ACS and 250 controls (60 ± 12 years, 83% males), as well as 250 consecutive patients with a first stroke and 250 controls (75 ± 9 years, 56% males). The controls were population-based and age-sex matched to the patients. The a-priori dietary patterns were derived from the validated MedDietScore, whereas the a-posteriori ones were extracted from principal components analysis. Both approaches were modeled using six classification algorithms: multiple logistic regression (MLR), naïve Bayes, decision trees, repeated incremental pruning to produce error reduction (RIPPER), artificial neural networks and support vector machines. The classification accuracy of the resulting models was evaluated using the C-statistic.
For the ACS prediction, the C-statistic varied from 0.587 (RIPPER) to 0.807 (MLR) for the a-priori analysis, while for the a-posteriori one, it fluctuated between 0.583 (RIPPER) and 0.827 (MLR). For the stroke prediction, the C-statistic varied from 0.637 (RIPPER) to 0.767 (MLR) for the a-priori analysis, and from 0.617 (decision tree) to 0.780 (MLR) for the a-posteriori.
Both dietary pattern approaches achieved equivalent classification accuracy over most classification algorithms. The choice, therefore, depends on the application at hand.
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Dietary supplementation of alpha-linolenic acid in an enriched rapeseed oil diet protects from stroke
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Populations of Western countries are severely deficient in omega-3 intake, both in the form of alpha-linolenic acid (ALA) and the Long Chain derivatives (LC-n-3), Eicosa-Pentaenoic-Acid and Docosa-Hexaenoic-Acid. Omega-3 insufficiency is a risk factor for cardiovascular and cerebral diseases such as coronary heart disease and stroke. Stroke is a major cause of mortality and morbidity, and induces a significant socioeconomic cost and a marked increase in patient/family burden. To date, preventive treatments and neuroprotective drugs identified in preclinical studies failed in clinical trials, in part because of an inability to tolerate drugs at neuroprotective concentrations. Therefore testing alternative protective strategies, such as functional foods/nutraceuticals, are of considerable interest.
We have previously demonstrated that a single injection of ALA reduced ischemic damage by limiting glutamate-mediated neuronal death, whereas repeated injections displayed additive protective benefits as a result of increased neurogenesis, synaptogenesis and neurotrophin expression. Because intravenous injections are not a suitable long-term strategy in humans, the present study investigated the effect of ALA supplementation by an experimental diet containing rapeseed oil (RSO, a rich source of ALA) as the only source of lipids for stroke prevention. We tested several experimental diets which included 5, 10, and 20% RSO-enriched diet and feeding paradigms (fresh diet was provided once or twice a week for 4 or 6 weeks). Our results showed that ALA supplemented diets are more sensitive to lipid peroxidation than a regular chow diet. Because the diet affected feeding behavior and animal growth, we defined concrete guidelines to investigate the effect of omega-3 supplementation on neuropathology. Among the different sets of experiments, animals fed with 10% and 20% RSO-enriched diet displayed a reduced mortality rate, infarct size and increased probability of spontaneous reperfusion in the post-ischemic period. In addition, a drastic reduction of lipid peroxidation levels was observed in the ischemic brain of RSO-fed animals. Overall, our findings provide new insights into the potential of employing rapeseed oil as a functional food/nutraceutical aiding in stroke prevention and protection.
Long-term fish consumption is associated with lower risk of 30-day cardiovascular disease events in survivors from an acute coronary syndrome
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This study aimed to assess the relationship between long-term fish consumption and short-term prognosis of patients who had an acute coronary syndrome. The multi-adjusted data analysis from a total of 214 men and 79 women patients showed that intake of fish, n−3 and n−6 fatty acids above 7 portions, 8.8 g and 13.2 g per week correspondingly, is associated with 83%, 83% and 79% reduction on the likelihood of recurrent events in a 30-day period after hospitalisation hospitalization (OR = 0.17, 95%CI 0.04–0.80, OR = 0.17, 95%CI 0.04–0.81, OR = 0.21, 95%CI 0.05–0.97). Conclusively, an inverse relationship between long-term fish and fish oils consumption and short-term prognosis of patients who had had an ACS was observed, irrespective of various potential confounders.

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View full text

Fish consumption and the risk of developing acute coronary syndromes: the CARDIO2000 study

Abstract

Objective

Methods

Results

Conclusion

Introduction

Section snippets

Study's population

Results

Discussion

Limitations

Conclusion

Acknowledgements

J. Clin. Epidemiol.

Am. J. Clin. Nutr.

Int. J. Cardiol.

Nutrition

J. Clin. Epidemiol.

Biomed. Pharmacother.

Atherosclerosis

The inverse relation between fish consumption and 20-year mortality from coronary heart disease

N. Engl. J. Med.

Fish intake may limit the increase in risk of coronary heart disease morbidity and mortality among heavy smokers

Circulation

Fish consumption and mortality from coronary heart disease

Br. Med. J.

Fish and omega-3 fatty acid intake and risk of coronary heart disease in women

JAMA

Fish and long-chain omega-3 fatty acid intake and risk of coronary heart disease and total mortality in diabetic women

Circulation

Case-control study of nonfatal myocardial infarction in relation to selected foods in Japanese men and women

Jpn. Circ. J.

Fish consumption and coronary heart disease mortality. A systematic review of prospective cohort studies

Eur. J. Clin. Nutr.

Fish consumption and coronary heart disease mortality in Finland, Italy, and the Netherlands

Am. J. Epidemiol.