Albert Marni Joensen

Intake of carbohydrates compared with intake of saturated fatty acids and risk of myocardial infarction: importance of the glycemic index

BACKGROUND Studies have suggested that replacing saturated fatty acids (SFAs) with carbohydrates is modestly associated with a higher risk of ischemic heart disease, whereas replacing SFAs with polyunsaturated fatty acids is associated with a lower risk of ischemic heart disease. The effect of carbohydrates, however, may depend on the type consumed. OBJECTIVES By using substitution models, we aimed to investigate the risk of myocardial infarction (MI) associated with a higher energy intake from carbohydrates and a concomitant lower energy intake from SFAs. Carbohydrates with different glycemic index (GI) values were also investigated. DESIGN Our prospective cohort study included 53,644 women and men free of MI at baseline. RESULTS During a median of 12 y of follow-up, 1943 incident MI cases occurred. There was a nonsignificant inverse association between substitution of carbohydrates with low-GI values for SFAs and risk of MI [hazard ratio (HR) for MI per 5% increment of energy intake from carbohydrates: 0.88; 95% CI: 0.72, 1.07). In contrast, there was a statistically significant positive association between substitution of carbohydrates with high-GI values for SFAs and risk of MI (HR: 1.33; 95% CI: 1.08, 1.64). There was no association for carbohydrates with medium-GI values (HR: 0.98; 95% CI: 0.80, 1.21). No effect modification by sex was observed. CONCLUSION This study suggests that replacing SFAs with carbohydrates with low-GI values is associated with a lower risk of MI, whereas replacing SFAs with carbohydrates with high-GI values is associated with a higher risk of MI.

Obesity, Behavioral Lifestyle Factors, and Risk of Acute Coronary Events

Background— Whether physical activity reduces the impact of obesity on the risk of acute coronary events is much debated. However, little is known about the role of other potentially modifiable lifestyle factors in combination with obesity. Methods and Results— We followed up 54 783 women and men from the prospective Danish Diet, Cancer and Health study who were 50 to 64 years at baseline (1993 to 1997) and free of coronary artery disease and cancer. During a median of 7.7 years, 1127 incident cases of acute coronary syndrome (ACS) occurred. After multivariable adjustments, each unit of body mass index was associated with a 5% and 7% higher risk of ACS among women and men, respectively (both P<0.0001 for trend). Overweight (body mass index, 25 to 29.9 kg/m2) and obesity (body mass index ≥30 kg/m2) were associated with a higher risk of ACS among the physically active and inactive, in nonsmokers and smokers, and among those who adhered more or less to a heart-healthy dietary pattern. Obese individuals who were active 1 to 3.5 h/wk had a lower risk than sedentary, obese individuals. In addition, obese nonsmokers had a lower risk than obese smokers. Adherence to a healthy diet was associated with a lower risk of ACS; however, the relative risk was not different among obese individuals with the most healthy diet versus obese individuals with a less healthy diet. Conclusions— Obesity confers an elevated risk of ACS in both healthy and less healthy subgroups of lifestyle behaviors. Adherence to healthy lifestyle behaviors was associated with a lower risk even among obese individuals.

Validity of the diagnoses atrial fibrillation and atrial flutter in a Danish patient registry

Objectives. To assess the validity of the diagnoses of atrial fibrillation (AF) and atrial flutter (AFL) for men and women recorded in the Danish National Patient Registry, and to assess the relative distribution of AF and AFL. Design. Review of medical records for incident cases of AF and/or AFL in the Diet, Cancer, and Health cohort study. Participants were enrolled in 1993–97 with 13.6 years of follow-up until 30 December, 2009. Results. The positive predictive value of the combined diagnosis of AF and/or AFL was 92.6% (95% CI 88.8%; 95.2%) with no significant difference between sexes (men 93.7% (133/142), women 90.8% (129/142)). The proportion of AFL either alone or in combination with AF was significantly higher in men than in women (13.5% (18/133) vs. 5.4% (7/129), p =0.03). The positive predictive value of the specified diagnosis of AFL was 57.5% for men (46/80) and 29.6% for women (8/27). Conclusions. This study shows that the validity of the diagnosis of AF and/or AFL is high and may be used for registry-based studies. A specified diagnosis of AFL was rarely used and was not reliable to distinguish between cases of AF and AFL.

Marine n-3 Polyunsaturated Fatty Acids in Adipose Tissue and the Risk of Acute Coronary Syndrome

Background— Marine n-3 polyunsaturated fatty acids may reduce coronary mortality. Previous data in relation to nonfatal coronary disease, however, have been inconsistent, which may be explained by the use of heterogeneous methods to assess the intake of marine n-3 polyunsaturated fatty acids. We investigated the hypothesis that the content of total and individual marine n-3 polyunsaturated fatty acids in adipose tissue is negatively associated with the incidence of acute coronary syndrome (ACS), including both fatal and nonfatal coronary disease. Methods and Results— In the Diet, Cancer and Health, a Danish cohort study, 57 053 subjects were enrolled and had an adipose tissue biopsy taken at inclusion. During a mean follow-up period of 7.6 years, we identified and verified all cases (n=1012) with an incident acute coronary syndrome diagnosis, and a random sample of the cohort (n=1630) had their fatty acid composition in adipose tissue determined by gas chromatography. We found negative dose-response associations between the content of total marine n-3 polyunsaturated fatty acids and individual n-3 polyunsaturated fatty acids in adipose tissue and the risk of acute coronary syndrome. Comparing men in the highest and lowest quintiles gave a hazard ratio of 0.65 (95% confidence interval, 0.45 to 0.95) for total n-3 polyunsaturated fatty acids and 0.51 (95% confidence interval, 0.36 to 0.73) for docosahexaenoic acid. Nonfatal cases constituted >86% of cases, and the association was driven primarily by a reduction in the risk of nonfatal acute coronary syndrome. No consistent associations were found among women. Conclusion— Intake of marine n-3 polyunsaturated fatty acids may protect against acute coronary syndrome in men.

Fish intake and acute coronary syndrome

AIMS To study the effect of fish consumption on the risk of acute coronary syndrome (ACS) in healthy subjects. METHODS AND RESULTS This Danish follow-up study included 57,053 men and women between 50 and 64 years. Intake of lean and fatty fish was estimated from a detailed and validated food frequency questionnaire. Potential cases of ACS were identified through nationwide medical databases. A total of 1122 cases of ACS were verified during a mean follow-up period of 7.6 years. Among men, intake of fatty fish was associated with a lower risk of ACS. For men in the highest quintile of fish intake compared with the lowest quintile, the hazard ratio was 0.67 (95% confidence interval: 0.53-0.85). The inverse association was observed for intakes >6 g of fatty fish per day with no obvious additional benefit observed for higher intakes. Intake of lean fish was not associated with ACS. There were few cases of ACS and results were not consistent in women. CONCLUSION In conclusion, a modest intake of fatty fish was associated with a lower risk of ACS in middle-aged men, whereas no consistent associations were observed among women.

A U-shaped association between consumption of marine n-3 fatty acids and development of atrial fibrillation/atrial flutter—a Danish cohort study

AIMS Previous studies have suggested a lower risk of atrial fibrillation (AF) with higher intakes of fish and marine n-3 polyunsaturated fatty acids (PUFAs), but the results have been inconsistent. The aim was to investigate the association between consumption of marine n-3 PUFA and development of AF. METHODS AND RESULTS A total of 57 053 Danish participants 50-64 years of age were enrolled in the Diet, Cancer, and Health Cohort Study between 1993 and 1997. Dietary intake of fish and marine n-3 PUFA was assessed by a semi-quantitative food frequency questionnaire. In total, 3345 incident cases of AF occurred over 13.6 years. Multivariate Cox regression analyses (3284 cases and 55 246 participants) using cubic splines showed a U-shaped association between consumption of marine n-3 PUFA and risk of incident AF, with the lowest risk of AF at a moderate intake of 0.63 g/day. For quintiles of marine n-3 PUFA intake, a 13% statistically significant lower risk of AF was seen in the middle vs. lowest quintile: Q1 reference, Q2 HR 0.92 (95% CI 0.82-1.03), Q3 HR 0.87 (95% CI 0.78-0.98), Q4 HR 0.96 (95% CI 0.86-1.08), and Q5 HR 1.05 (95% CI 0.93-1.18). Intake of total fish, fatty fish, and the individual n-3 PUFA eicosapentaenoic acid, docosahexaenoic acid, and docosapentaenoic acid also showed U-shaped associations with incident AF. CONCLUSION We found a U-shaped association between consumption of marine n-3 PUFA and risk of incident AF, with the lowest risk close to the median intake of total marine n-3 PUFA (0.63 g/day).

Dietary intake of total marine n-3 polyunsaturated fatty acids, eicosapentaenoic acid, docosahexaenoic acid and docosapentaenoic acid and the risk of acute coronary syndrome - a cohort study

Dietary intake of marine n-3 PUFA has been negatively associated with the risk of CHD among subjects with known CHD, whereas an effect in healthy subjects is less documented. We assessed the hypothesis that dietary intake of marine n-3 PUFA is negatively associated with the risk of acute coronary syndrome (ACS) in healthy subjects. In the Danish Diet, Cancer and Health cohort study, 57 053 participants were enrolled. Dietary intake of total n-3 PUFA, including EPA, docosapentaenoic acid (DPA) and DHA, was assessed. During a mean follow-up period of 7.6 years, we identified all cases (n 1150) from this cohort with an incident ACS diagnosis in the Danish National Patient Registry or the Cause of Death Registry. Diagnoses were verified through medical record review. In Cox proportional hazard models, we adjusted for established risk factors for CHD. Men in the four highest quintiles of n-3 PUFA intake (>0.39 g n-3 PUFA per d) had a lower incidence of ACS compared with men in the lowest quintile. The hazard ratio was 0.83 (95 % CI 0.67, 1.03) when we compared men in the second lowest and lowest quintile of n-3 PUFA intake. Higher intake of n-3 PUFA did not strengthen this association. Associations for EPA, DPA and DHA were all negative, but less consistent. No convincing associations were found among women. In conclusion, we found borderline significant negative associations between the intake of marine n-3 PUFA and ACS among healthy men.

Marine n-3 fatty acids in adipose tissue and development of atrial fibrillation: a Danish cohort study

Objective Consumption of fish and marine n-3 polyunsaturated fatty acids (PUFA) may be associated with a lower risk of atrial fibrillation (AF), but results have been inconsistent. The aim was to investigate this further by measurements of marine n-3 PUFA in adipose tissue. Design Cohort study. Setting A total of 57 053 Danish participants 50–64 years of age were enrolled into the Diet, Cancer and Health Cohort Study. Patients A randomly drawn subcohort of 3440 participants with available data from baseline adipose tissue biopsies. Interventions Exposure was the adipose tissue content of marine n-3 PUFA, which reflects the endogenous exposure and is also an objective marker of the long-term dietary intake. Main outcome measures Incident AF during follow-up. Results 179 cases of AF occurred over 13.6 years. Multivariate, sex-stratified Cox proportional hazards regression analyses using cubic splines showed a monotonic, negative, dose-response trend, but not statistically significant association, between total marine n-3 PUFA in adipose tissue and incident AF. A similar trend towards a lower risk of AF was seen in the second (HR 0.87, 95% CI 0.60 to 1.24) and third tertiles (HR 0.77, 95% CI 0.53 to 1.10) of marine n-3 PUFA compared with the lowest tertile. Similar trends, but also not statistically significant, were found separately for eicosapentaenoic, docosahexaenoic and docosapentaenoic acids. Conclusions There was no statistically significant association between the content of marine n-3 PUFA in adipose tissue and the development of AF; however, data showed a monotonic, negative dose-response trend suggestive of a negative association.

Short and long-term outcome in diabetic patients with acute myocardial infarction in the invasive era.

Objectives. To investigate the outcome after acute myocardial infarction in diabetic patients compared with non-diabetic patients in a period with invasive treatment as the preferred treatment for acute myocardial infarction (MI). Design. Patient records for all patients admitted with an acute MI in a two-year period from July 1, 2001 to June 30, 2003 were reviewed. Results. A total of 334 patients entered the study: 48 with diabetes mellitus (DM) and 286 without diabetes. ST-elevation infarction occurred in 49% of non-diabetic patients and 36% of diabetic patients. In-hospital mortality was 23% among diabetic patients compared to 5% among non-diabetic patients (p < 0.001). Long-term mortality (median 2 years and 10 months) was 44% in diabetic-patients and 23% in non-diabetic patients (p = 0.001). Diabetic patients were older, more frequently had hypertension and three-vessel disease, but DM was found to be an independent risk factor for death after MI (p = 0.005). Conclusions. In an era of invasive therapy as the preferred therapy for acute MI, DM is still associated with considerably increased mortality after an acute MI.

Alcohol drinking habits, alcohol dehydrogenase genotypes and risk of acute coronary syndrome

Aims: The risk of myocardial infarction is lower among light-to-moderate drinkers compared with abstainers. Results from some previous studies, but not all, suggest that this association is modified by variations in genes coding for alcohol dehydrogenase (ADH). We aimed to test this hypothesis, including alcohol as both the amount of alcohol and the frequency of drinking. Methods: we conducted a nested case-cohort study within the Danish Diet, Cancer and Health study, including 1,645 men (770 incident cases of acute coronary syndrome from 1993—1997 through 2004 and 875 randomly selected controls). Results: Higher alcohol intake (measured as amount or drinking frequency) was associated with lower risk of acute coronary syndrome; however, there was no evidence that these finding were modified by ADH1B or ADH1C genotypes. Conclusions: The importance of functional variation in alcohol dehydrogenase for the association between alcohol drinking habits and the risk of developing acute coronary syndrome, if any, is very limited.