Download Secondary prevention of coronary heart disease

Welcome to today’s webinar…
Omega 3 in Cardiovascular Disease Prevention
New Evidence on an Old Intervention
Deanne Wooden
Nutrition Manager, Heart Foundation
ACRA 2015 ASM
New ACRA Website
ACRA Members Resources
QCRA-Heart Foundation (QLD)
Secondary Prevention in Cardiology
Symposium 2015
• Friday October 16th 8am-4pm
• Russell Strong Auditorium, Princess Alexandra
Hospital, Woolloongabba Qld
• For more details or to register - see ACRA Events
page: http://www.acra.net.au/events/
Welcome to today’s webinar…
Omega 3 in Cardiovascular Disease Prevention
New Evidence on an Old Intervention
Deanne Wooden
Nutrition Manager, Heart Foundation
Omega-3
polyunsaturated fatty
acids and
cardiovascular health
Released: April 2015
©2014 National Heart Foundation of Australia
Overview
• Background
• Development
• Evidence
• Recommendations
• Other Considerations
• Key messages
• Dissemination
• Questions
©2015 National Heart Foundation of Australia
Omega-3 & CVH Slide 8
Released: April 2015
What is dietary fat?
Dietary fat
Saturated
Unsaturated
Polyunsaturated
Trans
n-6 PUFA
Monounsaturated
n-3 PUFA
Sterols
Plant n-3
Dietary
cholesterol
©2015 National Heart Foundation of Australia
Marine n-3
Phytosterols
Omega-3 & CVH Slide 9
Released: April 2015
Background
• n-3 (omega-3) fats are a type of polyunsaturated fat
Marine & animal source
• EPA & DHA: cold water oily fish like Aust. & Atlantic salmon, blueeye trevalla, blue mackerel, herring, canned sardines, canned
salmon and some varieties of canned tuna.
• DPA: beef, lamb and veal converted to EPA & DHA
• DHA: found in eggs + also some DPA
Plant source
• ALA: canola and soybean based fats & oils, nuts (esp. walnuts) &
freshly ground flax seeds (linseed), and chia seeds.
©2015 National Heart Foundation of Australia
Omega-3 & CVH Slide 10
Released: April 2015
Existing Australian Guidelines
Nutrient Reference Values (2006)1
EPA + DPA + DHA
610 mg/day for men & 430 mg/day for women
“…it would seem prudent to encourage increased consumption to the 90th percentile”
Australian Dietary Guidelines (2013)2
“Satisfactory evidence that the consumption of at least two serves a week of fish is
associated with a reduced risk of mortality from cardiovascular disease, and with reduced
incidence of cardiovascular disease, and reduced risk of stroke. (Grade C)”
“Weak evidence that consumption of LCPUFA is associated with reduced mortality from
cardiovascular disease (Grade D)”
Australian Guide to Healthy Eating (2013)2
“Enjoy lean meats and poultry, fish, eggs, tofu, nuts and seeds, and legumes/beans.
(1)
NHMRC. Nutrient Reference Vales for Australia and NZ including Recommended Dietary Intakes, NHMRC September 2006.
(2)
NHMRC. Australian Dietary Guidelines, NHMRC February 2013. Accessed from: www.eatforhealth.gov.au
©2015 National Heart Foundation of Australia
Omega-3 & CVH Slide 11
Released: April 2015
Heart Foundation recommendations
Fish, fish oils, and n-3 polyunsaturated fatty acids and
cardiovascular health (2008)1
“Consume about 500 mg per day of combined docosahexaenoic acid (DHA) and
eicosapentaenoic acid (EPA) through a combination of the following:
-
two or three serves (150 g serve) of oily fish per week
fish oil capsules or liquid
food and drink enriched with marine n-3 polyunsaturated fatty acid (n-3 PUFA).
Dietary fats (1999)2
“… at least 2 serves of fish (preferably oily fish) per week”
“ both plant and marine omega-3 should be consumed since it is possible that
(each)…protect against CHD by different mechanisms”
“plant omega-3 intake should be at least 2g per day.”
(1)
NHFA (2008) Fish, fish oils, and n-3 polyunsaturated fatty acids and cardiovascular health (2008), Melbourne.
(2)
NHFA (1999) A review of the relationship between dietary fat and cardiovascular disease. Australian Journal of Nutrition and Dietetics, 56:4.
©2015 National Heart Foundation of Australia
Omega-3 & CVH Slide 12
Released: April 2015
Why the update?
Recent meta-analyses reporting neutral effect on cardiovascular
outcomes.
•Kotwal S, Jun M, Sullivan D, Perkovic V, Neal B. Omega 3 fatty acids and cardiovascular outcomes: Systematic
review and meta‐analysis. Circulation: Cardiovascular Quality and Outcomes.2012;5(6):808‐818.
•Rizos EC, Ntzani EE, Bika E, Kostapanos MS, Elisaf MS. Association between omega‐3 fatty acid supplementation
and risk of major cardiovascular disease events: a systematic review and meta‐analysis.
JAMA.2012;308(10):1024‐1033.
•Kwak SM, Myung SK, Lee YJ, Seo HG. Efficacy of omega‐3 fatty acid supplements (eicosapentaenoic acid and
docosahexaenoic acid) in the secondary prevention of cardiovascular disease: a meta‐analysis of randomized,
double‐blind, placebo‐controlled trials. Archives of Internal Medicine.2012;172:E1‐E9
Although it remains possible that fish oil supplements will produce health benefits…the
size of these gains are probably smaller than previously believed, and both physician and
patient expectations may need to be reset.1
(1)Kotwal
et al 2012.
©2015 National Heart Foundation of Australia
Omega-3 & CVH Slide 13
Released: April 2015
Why the update?
Recent guidelines advising a step away from specific omega-3
recommendations
ESC (2013) Guidelines on the management of stable coronary artery disease:
In general, when following the rules for a healthy diet, no dietary supplements are needed. Omega-3
consumption, mainly from fish, is potentially associated with beneficial effects…but not all trials
have sown reduction in CV events. Thus current recommendations are to increase omega-3 intake
through fish consumption, rather than from supplements.
National Institute of Clinical Excellence (2013) Secondary prevention of cardiovascular
and (2010) Primary prevention of cardiovascular disease:
disease
Advise people to eat a Mediterranean-style diet , Do not offer or advise people to use the following to
prevent another MI: omega-3 fatty acid capsules; omega-3 fatty acid supplemented foods; If people
choose to take omega-3 fatty acid capsules or eat omega-3 fatty acid supplemented foods, healthcare
professionals should be aware that there is no evidence of harm.
'People at high risk of or with cardiovascular disease should be advised to consume at least two portions
of fish per week, including a portion of oily fish'
'People should not routinely be recommended to take omega-3 fatty acid supplements for the primary
prevention of cardiovascular disease'.
(1)
European Society of Cardiology (2013) Guidelines on the management of stable coronary artery disease
(2)
National Institute of Clinical Excellence 2010 & 2013
©2015 National Heart Foundation of Australia
Omega-3 & CVH Slide 14
Released: April 2015
Scientific Literature
2007-2013, update to comprehensive 2008 paper
Expert Working Group
NHMRC Evidence Levels & Grades
FNAC & CIC
CVHAC
Conclusions & Recommendations
Summary of
evidence paper
Position statement
w/ recommendations
Nat Brd
Rapid review omega-3
content, mercury,
sustainability
Peer review
Heart Lung Circulation
Healthy eating messages and resources
©2015 National Heart Foundation of Australia
Omega-3 & CVH Slide 15
Released: April 2015
Development
Expert Working Group:
Prof Paul Nestel (Chair), Prof Peter Clifton, A/Prof D Colquhoun,
Dr Trevor Mori, Prof Manny Noakes, Clin A/Prof David Sullivan
Heart Foundation Members:
Ms Beth Thomas, Mrs Melanie Chisholm,
Dr Rob Grenfell (until September 2014), Ms E Nixon (until May 2014)
Heart Foundation governance & approval:
Food and Nutrition Advisory Committee
Clinical Issues Committee
National Cardiovascular Health Advisory Committee
National Board of Heart Foundation
Peer reviewed publication:
Heart, Lung and Circulation Journal
©2015 National Heart Foundation of Australia
Omega-3 & CVH Slide 16
Released: April 2015
What we did...
Eight Research Questions
1. Are omega-3 LCPUFA supplements effective in the primary prevention of coronary
heart disease?
2. Is the reported consumption of omega-3 LCPUFA from fish, or dietary patterns high in
omega-3 LCPUFA (measured through plasma or red blood cell LCPUFA) associated
with lower incidence of coronary heart disease events in primary prevention?
3. Are omega-3 LCPUFA supplements an effective intervention for the secondary
prevention of coronary heart disease?
4. Is the reported consumption of fish, or dietary patterns high in omega-3 LCPUFA
(measured through plasma or red blood cell LCPUFA) associated with a lower
incidence of coronary heart disease in patients with existing CHD (i.e. secondary
prevention)?
5. Are omega-3 LCPUFA supplements effective in the prevention or treatment of heart
failure?
6. Is the reported consumption of fish, or dietary patterns high in omega-3 LCPUFA
(measured through plasma or red blood cell LCPUFA) associated with lower
incidence of heart failure?
7. Are omega-3 LCPUFA supplements an effective intervention for lowering plasma
triglycerides in hypertriglyceridaemic patients?
8. Is the intervention with the plant omega-3 fatty acid (alpha-linolenic acid) or its
consumption effective in the prevention of coronary heart disease?
©2015 National Heart Foundation of Australia
Omega-3 & CVH Slide 17
Released: April 2015
What we did...
©2015 National Heart Foundation of Australia
Omega-3 & CVH Slide 18
Released: April 2015
What we found...
©2015 National Heart Foundation of Australia
Omega-3 & CVH Slide 19
Released: April 2015
NHMRC Grades for Assessment of Evidence
Levels of Evidence
Level of evidence
Study design (Intervention)
I
A systematic review of Level II studies
II
Evidence obtained from at least one properly designed RCT.
III-1
III-2
III-3
IV
Evidence obtained from well-designed, pseudo RCTs (alternate allocation or some other
method).
Evidence obtained from comparative studies with concurrent controls and allocation, not
randomised cohort studies, case-control studies or interrupted time series with a control
group.
Evidence obtained from comparative studies with historical control, two or more single-arm
studies, or interrupted time series without a parallel control group.
Evidence obtained from case series, either post-test or pre-test and post-test.
1
©2015 National Heart Foundation of Australia
Omega-3 & CVH Slide 20
Released: April 2015
NHMRC Grades for Assessment of Evidence
Matrix for Grading Evidence
Component
Evidence Base
A
Excellent
B
Good
C
Satisfactory
One or two level II
studies with a low risk
of bias or a
SR/several level III
studies with a low risk
of bias
Most studies
consistent and
inconsistency may be
explained
substantial
One or two level III
studies with a low
risk of bias, or level
I or II studies with a
moderate risk of
bias
Some inconsistency
reflecting genuine
uncertainty around
clinical question
moderate
Population/s studied
in body of evidence
are the same as the
target population for
the guideline
Population/s studied
in the body of
evidence are similar
to the target
population for the
guideline
Population/s studied
in the body of
evidence differ to
target population for
guideline but it is
clinically sensible to
apply this evidence
to target population
Directly applicable to
Australian healthcare
context
Applicable to
Australian healthcare
context with few
caveats
Probably applicable
to Australian
healthcare context
with some caveats
One or more level I
studies with a low risk
of bias or several
level II studies with a
low risk of bias
Consistency
All studies consistent
Clinical Impact
Generalisability
Applicability
Very large
D
Poor
Level IV studies, or
level I to III
studies/SRs with a
high risk of bias
Evidence is
inconsistent
Slight or restricted
Population/s
studied in body of
evidence differ to
target population
and hard to judge
whether it is
sensible to
generalise to target
population
Not applicable to
Australian
healthcare context
1
©2015 National Heart Foundation of Australia
Omega-3 & CVH Slide 21
Released: April 2015
NHMRC Grades for Assessment of Evidence
Matrix for Grading Evidence - example
©2015 National Heart Foundation of Australia
Omega-3 & CVH Slide 22
Released: April 2015
NHMRC Grades for Assessment of Evidence
Description for grades of evidence
Grade of
Description
Recommendation
A
B
C
D
Body of evidence can be trusted to guide practice
Body of evidence can be trusted to guide practice in most situations
Body of evidence provides some support for recommendation(s) but care should be taken in
its application
Body of evidence is weak and recommendation must be applied with caution
1
Adapted from source:
https://www.nhmrc.gov.au/_files_nhmrc/file/guidelines/developers/nhmrc_levels_grades_evidence_120423.pdf
©2015 National Heart Foundation of Australia
Omega-3 & CVH Slide 23
Released: April 2015
Evidence informed conclusions 1/2
©2015 National Heart Foundation of Australia
Omega-3 & CVH Slide 24
Released: April 2015
Evidence informed conclusions 2/2
©2015 National Heart Foundation of Australia
Omega-3 & CVH Slide 25
Released: April 2015
Heart Foundation recommendations 2015
As part of a heart healthy diet based on a variety of foods including plenty of vegetables, legumes,
fruit, wholegrain cereal, lean meats and their alternatives, reduced fat milk, cheese and yoghurt and
alternatives, nuts, seeds, healthier oils and limiting salt, the following recommendations are made:
Primary prevention of coronary heart disease
Eat two to three serves of fish (150-200g), including oily fish, per week to achieve about 250-500mg
per day of combined docosahexaenoic acid (DHA) and eicosapentaenoic acid (EPA).
Secondary prevention of coronary heart disease
Eat two to three serves of fish (150-200g), including oily fish, per week to achieve about 250-500mg
per day of combined DHA/EPA.
Consider omega-3 LCPUFA supplementation of ≥1000mg combined EPA/DHA as an additional
therapy for patients with heart failure.
Hypertriglyceridaemia
Consider up to 4000 – 5000 mg combined EPA/DHA as the highest dose alone or with a fibrate for
moderately sever hypertriglyceridaemia.
Alpha-Linolenic Acid
Consume at least 1 g per day of alpha-linolenic acid (ALA) from food, consistent with NHMRC
recommendations.
©2015 National Heart Foundation of Australia
Omega-3 & CVH Slide 26
Released: April 2015
2008 recommendations
2015 recommendations
To lower their risk of coronary heart disease
(CHD), all adult Australians should:
Primary prevention of coronary heart disease


Consume about 500 mg per day of combined
docosahexaenoic acid (DHA) and
eicosapentaenoic acid (EPA) through a
combination of the following:
two or three serves (150 g serve) of oily fish per
week
Consume between 250-500mg per day of
combined docosahexaenoic acid (DHA) and
eicosapentaenoic acid (EPA) through the
consumption of two to three servings of fish
(around 150-200g serve), including oily fish, per
week.
fish oil capsules or liquid
food and drink enriched with marine n-3
polyunsaturated fatty acid (n-3 PUFA).
Adult Australians with documented CHD
To lower their risk of further disease progression,
Australian adults with documented CHD should:
 Consume about 1000 mg per day of combined
DHA and EPA through a combination of the
following:
two or three serves (150 g serve) of oily fish per
week
fish oil capsules or liquid
Secondary prevention of coronary heart disease

Consume about 250-500mg per day of combined
DHA & EPA through the consumption of two to
three serves of fish (150-200g), including oily fish,
per week.

Provide omega-3 LCPUFA supplementation as an
additional therapy for patients with heart failure.
food and drink enriched with marine n-3 PUFA.
©2015 National Heart Foundation of Australia
Omega-3 & CVH Slide 27
Released: April 2015
2008 recommendations
2015 recommendations
Hypertriglyceridaemia
Australians with lipid abnormalities
For Australians with elevated triglyceride (TG)
 Consider use of supplements to achieve up to
levels, first-line therapy could be fish oil capsules
4000 – 5000mg in addition to standard therapy
or liquid and marine n-3 PUFA enriched foods and
drink. They should:
 start with a dose of 1200 mg per day of DHA
and EPA; and if appropriate increase the dose
to 4000 mg per day of DHA and EPA and
check their response every 3 to 4 weeks when
the dose is changed, until target TG levels are
reached.
Alpha-Linolenic Acid

Consume at least 2 g per day of ALA.
©2015 National Heart Foundation of Australia
Alpha-Linolenic Acid

Consume at least 1 g per day of alpha-linolenic
acid (ALA) consistent with NHMRC
recommendations
Omega-3 & CVH Slide 28
Released: April 2015
Recommendations (detailed)
Adult Australians…..
• ~ 250 - 500 mg/day DHA and
EPA (n-3 marine source)
• 2-3 serves of oily fish/week (150g
serve)
• At least 1 g/day ALA (n-3 plant source)
• Observe local safety recommendations
©2015 National Heart Foundation of Australia
Omega-3 & CVH Slide 29
Released: April 2015
Pregnant, breastfeeding &
children
• As per adult Australians
• Limit some fish species (FSANZ Guidelines)
– High methylmercury: 1 serve per fortnight
– Medium methylmercury: 1 serves per week
– No recommendation for low methylmercury
©2015 National Heart Foundation of Australia
Omega-3 & CVH Slide 30
Released: April 2015
Health professionals…..
Adults with CHD:
• 250-500 mg/day DHA and EPA
• 2-3 serves of oily fish/week (150 g
serve)
• At least 1 g/day ALA
• Observe local safety
recommendations
• Consider use of omega-3
supplements to achieve 1g/day in
those with heart failure
©2015 National Heart Foundation of Australia
Omega-3 & CVH Slide 31
Released: April 2015
Health professionals…..
Adults with elevated triglycerides:
• As per adult Australians and in
addition – Consider use of supplements to
achieve up to 4000 – 5000mg in
addition to standard therapy
Note, no prescriptive recommendations.
©2015 National Heart Foundation of Australia
Omega-3 & CVH Slide 32
Released: April 2015
Risks and cautions
• Biological Pathogens
• Viral
• Bacteria
• Ciguatera
• Chemical Pollutant
• Mercury
• Dioxin and PCBs
Health benefits >>>
©2015 National Heart Foundation of Australia
potential risks
Omega-3 & CVH Slide 33
Released: April 2015
Other considerations
• Omega-3 content in Australian Foods
– EPA & DHA
– ALA
• Chemical Pollutants
• Mercury
• Sustainability
• Australian seafood stocks
• Canned fish
©2015 National Heart Foundation of Australia
Omega-3 & CVH Slide 34
Released: April 2015
ALA composition of foods
• The most up-to-date and highest quality data is from the
FSANZ AUSNUT 2011-13 food nutrient database.
• No significant changes to ALA composition of foods since
2008 review.
• Best dietary sources of ALA are: walnuts,
linseeds/flaxseeds, chia seeds, and oils such as
vegetable, canola, soybean and linseed/flaxseed.
• Given reduction in recommendations for consumption of
ALA to 1 g/day, there is now a wider variety of foods that
can reasonably meet this level.
©2015 National Heart Foundation of Australia
Omega-3 & CVH Slide 35
Released: April 2015
EPA and DHA in seafood
• The most up-to-date and highest quality data is from the
FSANZ AUSNUT 2011-13 food nutrient database.
• There is significant new data on EPA and DHA composition of
seafood which has required significant re-categorisation of
seafood composition in consumer resources.
• This reflects variable nature of food composition, improvements
in sampling/analytical methods over time, and perhaps changes
in composition of foods due to varying environmental conditions
and other factors.
• Given reduction of consumption recommendation to 250-500
mg/day of EPA and DHA, there is now a wider variety of
seafood which can realistically meet this level.
• Reductions in fatty acid composition of farmed fish (related to
reduced use of marine LC omega 3s in fish feed), could have
significant implications in future and this should be closely
monitored.
©2015 National Heart Foundation of Australia
Omega-3 & CVH Slide 36
Released: April 2015
Mercury in seafood
• Heart Foundation recommendations align with FSANZ
recommendations to limit the risks of mercury
contamination.
• Heart Foundation consumer resources do not refer to any
higher risk species (e.g. Flake, Orange Roughy etc),
which also have sustainability concerns.
• It may be useful to make specific reference to these
species in consumer resources to increase awareness of
contamination risks and sustainability concerns.
– Eg. Flake is commonly sold in takeaway seafood restaurants and
many may be unaware that it has a higher risk of mercury
contamination (and sustainability issues)
©2015 National Heart Foundation of Australia
Omega-3 & CVH Slide 37
Released: April 2015
Sustainable seafood choices
• There is a serious disconnect between current seafood
consumption recommendations for health, and
sustainability of current seafood supply.
• Sustainability assessments must include a variety of
indicators including fish stocks, fishing practices, by-catch,
ecosystem impacts etc, and must cover imported seafood
(>70% of seafood consumed in Australia is imported)
• Current government reports only report on fish stocks (so
inadequate as an assessment of sustainability).
©2015 National Heart Foundation of Australia
Omega-3 & CVH Slide 38
Released: April 2015
Sustainable seafood choices
• Useful consumer resources on sustainable seafood
options include:
– Australian Marine Conservation Foundation Sustainable Seafood
Guide (online)
– Greenpeace Canned Tuna Guide (online)
• Heart Foundation should de-list known overfished species
(Gemfish), and link consumers to appropriate resources
on sustainable seafood options.
©2015 National Heart Foundation of Australia
Omega-3 & CVH Slide 39
Released: April 2015
What about supplements?
Eating fish is the recommended way to consume
essential Omega-3 nutrients for heart health, however
supplements will provide people who do not eat fish
with some level of marine-sourced Omega-3s.
There is no evidence to suggest that Omega-3
supplements are harmful in any way;
Omega-3 supplements can play a beneficial role in
the treatment of those with high triglycerides and in
the secondary prevention of heart disease (specifically
heart failure).
©2015 National Heart Foundation of Australia
Omega-3 & CVH Slide 40
Released: April 2015
Key messages
Top line
• The Heart Foundation recommends all Australians should aim to eat 2-3 serves of fish
(including oily fish) per week, which provides about 250-500 milligrams of Omega-3s
(marine source) per day. In addition, the Heart Foundation recommends that all
Australians consume at least 1 gram of omega-3 (plant source) every day.
And the detail…
• For heart health, the best available evidence supports including 2-3 serves of fish per
week as part of a heart healthy diet.
•
Eating fish is the recommended way to consume essential Omega-3 nutrients for heart
health, however supplements will provide people who do not eat fish with some level of
marine-sourced Omega-3s.
•
For people with high triglycerides, omega-3s (marine source) can help lower
triglycerides.
For people with heart failure, your health professional may consider using omega-3s
(marine source) in addition to standard medications.
•
©2015 National Heart Foundation of Australia
Omega-3 & CVH Slide 41
Released: April 2015
Key messages
•
Making small changes can be as easy as
– including a serve of canned salmon or sardines
– adding serves of oily fish or seafood (either caught or bought)
– Good sources of marine omega-3 include: Atlantic and Australian salmon (fresh or
canned), gemfish, blue-eye trevalla, blue mackerel, oysters, arrow squid, canned
sardines and some varieties of canned tuna
•
Not eating enough fish or seafood?
– Check out our meal plans and recipes for simple ideas.
•
What about supplements?
– Eating fish is the recommended way to consume essential Omega-3 nutrients
– However supplements will provide people who do not eat fish with some level of
marine-sourced Omega-3s.
– There is no evidence to suggest that Omega-3 supplements are harmful in any way
– Omega-3 supplements can play a beneficial role in the treatment of those with high
triglycerides and in the secondary prevention of heart disease (specifically heart
failure).
©2015 National Heart Foundation of Australia
Omega-3 & CVH Slide 42
Released: April 2015
Sneak peek…
……. Down to 200- 300 mg/150 g
©2015 National Heart Foundation of Australia
Omega-3 & CVH Slide 43
Released: April 2015
©2015 National Heart Foundation of Australia
Omega-3 & CVH Slide 44
Released: April 2015
Eating Plans
Weekly plan 1 = 3 fish serves
EPA & DHA = ~506 mg /d
Weekly plan 4 = 3 fish serves
EPA & DHA = ~289 mg /d
©2015 National Heart Foundation of Australia
Omega-3 & CVH Slide 45
Released: April 2015
Coming soon…
New position statement…
©2015 National Heart Foundation of Australia
Omega-3 & CVH Slide 46
Released: April 2015
Coming soon…
©2015 National Heart Foundation of Australia
Omega-3 & CVH Slide 47
Released: April 2015
Questions???
©2015 National Heart Foundation of Australia
Omega-3 & CVH Slide 48
Released: April 2015