Marguerite M. Engler

Omega-6 Fatty Acids and Risk for Cardiovascular Disease A Science Advisory From the American Heart Association Nutrition Subcommittee of the Council on Nutrition, Physical Activity, and Metabolism; Council on Cardiovascular Nursing; and Council on Epidemiology and Prevention

A large body of literature suggests that higher intakes of omega-6 (or n-6) polyunsaturated fatty acids (PUFAs) reduce risk for coronary heart disease (CHD). However, for the reasons outlined below, some individuals and groups have recommended substantial reductions in omega-6 PUFA intake.1–4 The purpose of this advisory is to review evidence on the relationship between omega-6 PUFAs and the risk of CHD and cardiovascular disease. Omega-6 PUFAs are characterized by the presence of at least 2 carbon-carbon double bonds, with the first bond at the sixth carbon from the methyl terminus. Linoleic acid (LA), an 18-carbon fatty acid with 2 double bonds (18:2 omega-6), is the primary dietary omega-6 PUFA. LA cannot be synthesized by humans, and although firm minimum requirements have not been established for healthy adults, estimates derived from studies in infants and hospitalized patients receiving total parenteral nutrition suggest that an LA intake of ≈0.5% to 2% of energy is likely to suffice. After consumption, LA can be desaturated and elongated to form other omega-6 PUFAs such as γ-linolenic and dihomo-γ-linolenic acids. The latter is converted to the metabolically important omega-6 PUFA arachidonic acid (AA; 20:4 omega-6), the substrate for a wide array of reactive oxygenated metabolites. Because LA accounts for 85% to 90% of the dietary omega-6 PUFA, this advisory focuses primarily on this fatty acid, recognizing that dietary AA, which can affect tissue AA levels,5 may have physiological sequelae.6–8 LA comes primarily from vegetable oils (eg, corn, sunflower, safflower, soy). The average US intake of LA, according to National Health and Nutrition Examination Survey 2001 to 2002 data for adults ≥19 years of age, is 14.8 g/d.9 On the basis of an average intake of 2000 kcal/d, LA intake is 6.7% of energy. AA (≈0.15 g/d) is consumed preformed in meat, …

Soluble Epoxide Hydrolase Regulates Hydrolysis of Vasoactive Epoxyeicosatrienoic Acids

The cytochrome P450-derived epoxyeicosatrienoic acids (EETs) have potent effects on renal vascular reactivity and tubular sodium and water transport; however, the role of these eicosanoids in the pathogenesis of hypertension is controversial. The current study examined the hydrolysis of the EETs to the corresponding dihydroxyeicosatrienoic acids (DHETs) as a mechanism for regulation of EET activity and blood pressure. EET hydrolysis was increased 5- to 54-fold in renal cortical S9 fractions from the spontaneously hypertensive rat (SHR) relative to the normotensive Wistar-Kyoto (WKY) rat. This increase was most significant for the 14,15-EET regioisomer, and there was a clear preference for hydrolysis of 14,15-EET over the 8,9- and 11,12-EETs. Increased EET hydrolysis was consistent with increased expression of soluble epoxide hydrolase (sEH) in the SHR renal microsomes and cytosol relative to the WKY samples. The urinary excretion of 14,15-DHET was 2.6-fold higher in the SHR than in the WKY rat, confirming increased EET hydrolysis in the SHR in vivo. Blood pressure was decreased 22±4 mm Hg (P <0.01) 6 hours after treatment of SHRs with the selective sEH inhibitor N, N ′-dicyclohexylurea; this treatment had no effect on blood pressure in the WKY rat. These studies identify sEH as a novel therapeutic target for control of blood pressure. The identification of a potent and selective inhibitor of EET hydrolysis will be invaluable in separating the vascular effects of the EET and DHET eicosanoids.

Flavonoid-Rich Dark Chocolate Improves Endothelial Function and Increases Plasma Epicatechin Concentrations in Healthy Adults

Background: Dark chocolate derived from the plant (Theobroma cacao) is a rich source of flavonoids. Cardioprotective effects including antioxidant properties, inhibition of platelet activity, and activation of endothelial nitric oxide synthase have been ascribed to the cocoa flavonoids. Objective: To investigate the effects of flavonoid-rich dark chocolate on endothelial function, measures of oxidative stress, blood lipids, and blood pressure in healthy adult subjects. Design: The study was a randomized, double-blind, placebo-controlled design conducted over a 2 week period in 21 healthy adult subjects. Subjects were randomly assigned to daily intake of high-flavonoid (213 mg procyanidins, 46 mg epicatechin) or low-flavonoid dark chocolate bars (46 g, 1.6 oz). Results: High-flavonoid chocolate consumption improved endothelium-dependent flow-mediated dilation (FMD) of the brachial artery (mean change = 1.3 ± 0.7%) as compared to low-flavonoid chocolate consumption (mean change = −0.96 ± 0.5%) (p = 0.024). No significant differences were noted in the resistance to LDL oxidation, total antioxidant capacity, 8-isoprostanes, blood pressure, lipid parameters, body weight or body mass index (BMI) between the two groups. Plasma epicatechin concentrations were markedly increased at 2 weeks in the high-flavonoid group (204.4 ± 18.5 nmol/L, p ≤ 0.001) but not in the low-flavonoid group (17.5 ± 9 nmol/L, p = 0.99). Conclusion: Flavonoid-rich dark chocolate improves endothelial function and is associated with an increase in plasma epicatechin concentrations in healthy adults. No changes in oxidative stress measures, lipid profiles, blood pressure, body weight or BMI were seen.

Antioxidant Vitamins C and E Improve Endothelial Function in Children With Hyperlipidemia: Endothelial Assessment of Risk from Lipids in Youth (EARLY) Trial

Background—Hyperlipidemia is associated with endothelial dysfunction, an early event in atherosclerosis and predictor of risk for future coronary artery disease. Epidemiological studies suggest that increased dietary intake of antioxidants reduces the risk of coronary artery disease. The purpose of this study was to determine whether antioxidant vitamin therapy improves endothelial function and affects surrogate biomarkers for oxidative stress and inflammation in hyperlipidemic children. Methods and Results—In a randomized, double-blind, placebo-controlled trial, the effects of antioxidant vitamins C (500 mg/d) and E (400 IU/d) for 6 weeks and the National Cholesterol Education Program Step II (NCEP-II) diet for 6 months on endothelium-dependent flow-mediated dilation (FMD) of the brachial artery were examined in 15 children with familial hypercholesterolemia (FH) or the phenotype of familial combined hyperlipidemia (FCH). Antioxidant vitamin therapy improved FMD of the brachial artery compared with baseline (P <0.001) without an effect on biomarkers for oxidative stress (autoantibodies to epitopes of oxidized LDL, F2-isoprostanes, 8-hydroxy-2′-deoxyguanosine), inflammation (C-reactive protein), or levels of asymmetric dimethylarginine, an endogenous inhibitor of nitric oxide. Conclusions—Antioxidant therapy with vitamins C and E restores endothelial function in hyperlipidemic children. Early detection and treatment of endothelial dysfunction in high-risk children may retard the progression of atherosclerosis.

Why patients in critical care do not receive adequate enteral nutrition? A review of the literature

Enteral nutrition is frequently used to provide nutrients for critically ill patients. However, only about half of critically ill enterally fed patients receive their energy requirements. Underfeeding is associated with detrimental clinical outcomes including infection, pressure ulcers, impaired wound healing, prolonged hospital stays, and increased morbidity and mortality. This literature review was conducted to identify major barriers to adequate enteral nutrition intake in critically ill adults and to identify gaps in the research literature. Studies (n = 30) reviewed addressed adult patients in critical care, published since 1999, and written in English. Findings showed that factors that explain inadequate enteral nutritional intake include delayed initiation of enteral nutrition and slow advancement of infusion rate, underprescription, incomplete delivery of prescribed nutrition, and frequent interruption of enteral nutrition. Frequent interruption was caused by diagnostic tests, surgical procedures, gastrointestinal intolerance, feeding tube problems, and routine nursing procedures. There are no standardized protocols that address these barriers to receiving adequate enteral intake. Such protocols must be developed, implemented, and tested to address undernutrition and mitigate the negative consequences of inadequate enteral intake.

Mechanisms of vasorelaxation induced by eicosapentaenoic acid (20:5n-3) in WKY rat aorta

The vasorelaxant activity of eicosapentaenoic acid (EPA, 20:5n‐3), the omega‐3 polyunsaturated fatty acid, was investigated in isolated Wistar Kyoto (WKY) rat aortae by measuring isometric tension. Eicosapentaenoic acid (1–100 μM) relaxed rat aortae contracted with high K+ (80 mM) or noradrenaline (NA, 1 μM) in a concentration‐dependent manner. Contractions induced by Bay K 8644 or increasing concentrations of calcium were unaffected by EPA. The relaxant effect of EPA (3–100 μM) was significantly inhibited by indomethacin (10 μM), the cyclo‐oxygenase inhibitor, but not by the nitric oxide (NO) synthesis inhibitor, Nω‐nitro‐L‐arginine methyl ester hydrochloride (L‐NAME, 100 μM). Removal of the endothelium did not alter EPA‐induced relaxations. In Ca2+‐free, EGTA 2 mM solution, EPA (10–30 μM significantly inhibited NA‐sustained contractions. Incubation with EPA (5, 10 μM) diminished both NA‐induced (1 μM) phasic and sustained contractions. The vasorelaxant effects of EPA (30 μM) on NA‐induced (1 μM) contractions were significantly inhibited by the K+ channel blocker, glibenclamide (10 μM), but not tetraethylammonium (1 mM). Moreover, indomethacin and glibenclamide combined significantly inhibited EPA‐induced (1–100 μM) responses. These results indicate EPA exerts its endothelium‐independent vasorelaxant effects in WKY rat aortae through production of prostanoids which activate K+ATP channels. Inhibition of Ca2+ mobilization from intracellular pools and influx through the non‐L‐type, but not the L‐type, Ca2+ channel are also possible mechanisms action of EPAs.

Omega-6 Fatty Acids and Risk for Cardiovascular Disease

The long-chain marine n–3 fatty acids have been reported to be cardio protective over many years and many mechanisms of action have been proposed. Up through the first decade of the 21st century, nearly all n–3 randomized trials were positive, but beginning in 2010 several trials were published that did not show a benefit of these fatty acids on clinical cardiovascular endpoints. There is a wealth of epidemiologic evidence for a cardiac benefit for the n–3 fatty acids that appears to contradict the findings of the randomized trials. This chapter will review both trial and prospective cohort study data which, in the aggregate, continues to support the view that n–3 fatty acids are heart healthy.

Perceived learning needs of patients with coronary artery disease using a questionnaire assessment tool

OBJECTIVE To determine the perceived learning needs and their level of importance in patients with angina pectoris or myocardial infarction at hospitalization and follow-up clinic visit and to assess the reliability of a self-administered questionnaire. DESIGN Longitudinal, exploratory. SETTING West Coast university-affiliated medical center and clinics that serve primarily a veteran population. PATIENTS Twenty-eight adults who were admitted with a diagnosis of angina pectoris or myocardial infarction. Age range was 31 to 80 years (mean 61 years). OUTCOME MEASURES Learning needs, questionnaire. INTERVENTION Data collection was initiated at hospitalization and continued at the first clinic visit after discharge. A self-administered questionnaire and personal data sheet were completed by the patients. RESULTS Matched-pair t-tests and Pearsons correlation were used for data analysis. No statistical differences were demonstrated between learning needs at hospitalization and clinic visit. Three content areas including symptom recognition, cardiac anatomy and physiology, and medications were ranked as the most important learning needs of patients at hospitalization and follow-up clinic visit. The least important learning needs at both times were content areas of smoking, work, and sex. No correlation was found between the importance of perceived learning needs and age, occupation, smoking, and marital status. The questionnaire contains 38 items and is self-administered. It was developed on the basis of a previous tool and preliminary study results. Content and validity were supported by clinical experts. The internal consistency reliability alpha coefficients of the questionnaire were 0.96 at hospitalization and 0.93 at the clinic visit. CONCLUSIONS The findings of this study suggest that the most important perceived learning needs of patients at hospitalization and follow-up clinic visit are those that affect survival. A self-administered questionnaire can be used as a practical and reliable tool to determine the perceived learning needs of patients with coronary artery disease during the recovery phase of illness. Cardiac educational programs for patients with coronary artery disease can focus on the content areas that patients consider most important.

Omega-3 fatty acids: role in cardiovascular health and disease.

Dietary omega-3 polyunsaturated fatty acids, eicosapentaenoic and docosahxaenoic acids, play an important role in cardiovascular health and disease. Clinical trials provide substantial evidence to support current dietary recommendations for omega-3 fatty acids in cardiovascular disease management. The cardioprotective benefits of omega-3 fatty acids may be attributed to multiple physiological effects on lipids, blood pressure, vascular function, cardiac rhythms, platelet function, and inflammatory responses. The metabolism of omega-3 fatty acids, physiological effects, and clinical considerations with current dietary recommendations and sources of omega-3 fatty acids are presented.

Calcium-mediated mechanisms of eicosapentaenoic acid-induced relaxation in hypertensive rat aorta*

We have previously demonstrated the vasorelaxant properties of the omega-3 fatty acid, eicosapentaenoic acid (EPA), in normotensive and spontaneously hypertensive rat (SHR) aorta, although the mechanism(s) of action are not fully understood. Because endothelial dysfunction and increased intracellular free calcium concentration ([Ca2+]i) are seen in hypertensive rat aorta, we investigated the potential role of Ca2+ signaling, endothelium and derived factors, and the opening of potassium (K+) channels in EPA-induced relaxation. In the presence of extracellular Ca2+, EPA induced significant relaxations at >10 micromol/L (P<.01) in norepinephrine (NE) (10(-6) mol/L)-contracted aortic rings and at 30 micromol/L (P<.001) in high K+ (80 mmol/L)-contracted aortic rings. In the absence of extracellular Ca2+, EPA (10 to 30 micromol/L) inhibits the tonic component of NE-induced contraction (P<.0001). The relaxant properties of EPA in SHR aorta appear specific to Ca2+ release from an internal storage site associated with NE-induced tonic contraction. Further studies with the use of fura-2 to measure [Ca2+]i in cultured vascular smooth muscle (VSM) cells from SHR aorta indicated that EPA (30 micromol/ L)-pretreatment attenuated angiotensin II (50 nmol/ L)-induced Ca2+ transient by 95%, suggesting that an inhibitory effect on the Ca2+ signaling may underlie EPA-induced relaxation of the vessel preparation. In addition, EPA per se induced an increase in [Ca2+li with a duration of approximately 20 min in VSM cells, and the effect was not altered by removal of extracellular Ca2+. There was no increase in the level of inositol-1,4,5-trisphosphate in response to EPA (30 micromol/L). The actions of EPA are independent of endothelium-derived factors, cyclooxygenase metabolites, and activation of K+ channels since endothelium removal, N(omega)-nitro-L-arginine methyl ester hydrochloride, (L-NAME, 100 micromol/L), indomethacin (10 micromol/L), tetraethylammonium (1 mmol/L), and glibenclamide (10 micromol/L) did not affect EPA-induced vasodilation in NE-precontracted aortic rings. These results suggest that EPA directly modulates intracellular Ca2+ signaling in VSM cells, and that this may contribute to the vasorelaxant effect and, at least in part, the blood pressure-lowering effect of fish oil.