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Diabetes, Race and Effects of Omega-3 Fatty Acids on HF Hospitalization
Quick Takes
- The finding that the combination of 1 g/day of fish oil (EPA 460 mg + 380 mg DHA) reduced hospitalization for heart failure (HF) in type 2 diabetes (T2D) but not in non-T2D participants in a trial designed to assess vitamin D and fish oil on risk of CVD and cancer should be considered interesting and hypothesis generating. This finding, including why the benefit is augmented in Black participants, simply could be higher overall atherosclerotic CVD risk and risk for HF.
- Amongst the issues that need clarity include whether higher doses of omega-3 would reduce admission and readmission for HF in the general population, whether pure EPA would provide a greater benefit as it does in T2D and atherosclerotic CVD in persons with elevated triglycerides, whether the benefit is both HFpEF and HFrEF, and whether omega-3 benefit is independent of treatment for hypertension (e.g., ACE inhibitors or ARBs), lipids with statins, and modern treatment of diabetes which avoids sulfonylurea and advocates metformin, and SGLT-2 inhibitors or GLP1 that lower incident HF.
- Regardless, the findings lend support to increasing dietary fish and seafood high in omega-3 and other nutrients.
Study Questions:
Does prevalent type 2 diabetes (T2D) modify the effects of omega-3 fatty acid supplementation (omega-3) on heart failure (HF) hospitalization, and does race modify the effects of omega-3 on HF risk?
Methods:
This report is an ancillary study of the parent VITAL (Vitamin D and Omega-3 Trial)—a completed randomized trial testing the efficacy of vitamin D (2000 IU/d) and omega-3 fatty acids, 1 g/d (460 mg eicosapentaenoic acid [EPA] and 380 mg docosahexaenoic acid [DHA]), on cardiovascular diseases and cancer. The authors assessed the role of T2D and race on the effects of omega-3 on incident HF hospitalization stratified for age/sex and randomization to vitamin D. The outcome was adjudicated by a review of medical records and supplemented with a query of Centers for Medicare & Medicaid Services data.
Results:
At baseline, of the 25,871 participants in VITAL (5,087 Blacks), about 50% were female and average age was 67 years, with no differences in those with and without T2D. However, Blacks were more likely to have T2D at baseline (24% in Black and 10% in White participants). T2D were more likely on antihypertensive and lipid-lowering drugs, and aspirin. Median follow-up was 5.3 years. When omega-3 was compared with placebo, the hospitalization for HF was 3.6% versus 5.2%, respectively; hazard ratio (HR) for first HF hospitalization was 0.69 (95% confidence interval [CI], 0.50-0.95) for those with T2D and 1.09 (95% CI, 0.88-1.34) in those without T2D (p for interaction = 0.019). T2D also modified the effects of omega-3 on the incidence of recurrent HF hospitalization (HR, 0.53; 95% CI, 0.41-0.69 in participants with T2D vs. HR, 1.07; 95% CI, 0.89-1.28 in those without T2D; p for interaction < 0.0001). In a secondary analysis, omega-3 reduced recurrent HF hospitalization only in Black participants (p for interaction race x omega-3 = 0.0497).
Conclusions:
In an ancillary study from the VITAL trial, a beneficial effect of omega-3 fatty acid supplements was identified on incident HF hospitalization in participants with T2D but not in those without T2D, and such benefit appeared to be stronger in Black participants with T2D.
Perspective:
The finding that the combination of EPA + DHA reduced hospitalization for HF in T2M in the study designed to assess the impact of omega-3 for prevention of cardiovascular disease and cancer should be taken as interesting but far from clinical utility. Omega-3 supplements did not influence hospitalization for HF in White or Black participants. Amongst participants with T2D, omega-3 led to a 31% reduction of initial HF hospitalization and a 47% reduction of recurrent HF hospitalization compared to placebo. The benefit of omega-3 reducing rehospitalization for HF in the entire cohort was limited to Black participants, which is consistent with the findings in the VITAL trial of a significant reduction in myocardial infarction not seen in White participants.
Clinical Topics: Dyslipidemia, Heart Failure and Cardiomyopathies, Prevention, Lipid Metabolism, Nonstatins, Acute Heart Failure, Diet
Keywords: African Americans, Antihypertensive Agents, Aspirin, Atherosclerosis, Diabetes Mellitus, Type 2, Dietary Supplements, Docosahexaenoic Acids, Eicosapentaenoic Acid, Fatty Acids, Omega-3, Heart Failure, Lipids, Myocardial Infarction, Neoplasms, Primary Prevention, Race Factors, Vitamin D
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