Dietary fatty acid intake after myocardial infarction: a theoretical substitution analysis of the Alpha Omega Cohort

Abstract

Background: Replacement of saturated fatty acids (SFAs) with unsaturated fatty acids (UFAs), especially polyunsaturated fatty acids (PUFAs), has been associated with a lower risk of ischemic heart disease (IHD). Whether this replacement is beneficial for drug-treated patients with cardiac disease is not yet clear.

Objective: In a prospective study of Dutch patients with cardiac disease (Alpha Omega Cohort), we examined the risk of cardiovascular disease (CVD) and IHD mortality when the sum of SFAs and trans fatty acids (TFAs) was theoretically replaced by total UFAs, PUFAs, or cis monounsaturated fatty acids (MUFAs).

Design: We included 4146 state-of-the-art drug-treated patients aged 60-80 y with a history of myocardial infarction (79% male patients) and reliable dietary data at baseline (2002-2006). Cause-specific mortality was monitored until 1 January 2013. HRs for CVD mortality and IHD mortality for theoretical, isocaloric replacement of dietary fatty acids (FAs) in quintiles (1-5) and continuously (per 5% of energy) were obtained from Cox regression models, adjusting for demographic factors, medication use, and lifestyle and dietary factors.

Results: Patients consumed, on average, 17.5% of energy of total UFAs, 13.0% of energy of SFAs, and <1% of energy of TFAs. During ∼7 y of follow-up, 372 CVD deaths and 249 IHD deaths occurred. Substitution modeling yielded significantly lower risks of CVD mortality when replacing SFAs plus TFAs with total UFAs [HR in quintile 5 compared with quintile 1: 0.45 (95% CI: 0.28, 0.72)] or PUFAs [HR: 0.66 (95% CI: 0.44, 0.98)], whereas HRs in cis MUFA quintiles were nonsignificant. HRs were similar for IHD mortality. In continuous analyses, replacement of SFAs plus TFAs with total UFAs, PUFAs, or cis MUFAs (per 5% of energy) was associated with significantly lower risks of CVD mortality (HRs between 0.68 and 0.75) and IHD mortality (HRs between 0.55 and 0.70).

Conclusion: Shifting the FA composition of the diet toward a higher proportion of UFAs may lower CVD mortality risk in drug-treated patients with cardiac disease. This study was registered at clinicaltrials.gov as NCT03192410.

Keywords: cardiac patients; cardiovascular disease; coronary heart disease; dietary fatty acids; prospective cohort study; substitution analysis.

© 2017 American Society for Nutrition

Figures

FIGURE 1

Associations with CVD mortality (A) and IHD mortality (B) for the theoretical, isocaloric replacement of energy from SFAs plus TFAs with total UFAs in 4146 patients from the Alpha Omega Cohort. Lines are restricted cubic splines, showing the shape of associations on a continuous scale, with 3 knots located at the 5th, 50th, and 95th percentiles (11.9%, 17.2%, and 24.5% of energy intake, respectively). The y-axis shows the predicted HRs for CVD mortality for any value of intake, compared with the reference value set at the 5th percentile. Gray areas indicate 95% CIs. Results are presented for model 3 (details in text). CVD, cardiovascular disease; en%, percentage of total energy intake; IHD, ischemic heart disease; TFA, trans fatty acid; UFA, unsaturated fatty acid.