Updates on Atrial Fibrillation Causation: Omega-3 Fatty Acids, Diabetes, and More

In this commentary, Mark Munger, PharmD, discusses recently published studies related to atrial fibrillation and advises pharmacists to be cognizant of patient risk factors.

The Link Between Omega-3 Fatty Acid Supplements and Atrial Fibrillation

The global omega-3 market was estimated to be worth $4 billion in 2019 and is expected to reach $9 billion by 2026.¹ Taking these supplements regularly has been linked to cardiovascular benefits, expanding the marketplace growth.²

However, research suggests that these products may increase the risk for atrial fibrillation.³ In a meta-analysis of 4 randomized clinical trials on omega-3 fatty acid supplementation, a random effect model indicated a link to an increased incident of atrial fibrillation compared to placebo (IRR 1.37, 95% CI: 1.22-1.54, P<.001).

This effect appears to be dose dependent. At a dose of 4 g/day, there was nearly double the risk of atrial fibrillation. At an intermediate dose, the risk was a hazard ratio of 1.84, which did not achieve statistical significance. There was no apparent increase in risk at the standard daily dose of 840 mg/day.

There was no significant heterogeneity between studies and no publication bias. Individuals with the highest risk had underlying cardiovascular disease and elevated plasma triglyceride levels. The mechanism of this effect remains elusive and requires further investigation.

The above data, with the limitations of a meta-analysis, does support warning patients about increased doses for the development of atrial fibrillation, which is a potentially lethal arrhythmia.

Screening for Atrial Fibrillation in Patients With Diabetes

Additional new data suggests that patients with type 1 or 2 diabetes should be screened frequently for atrial fibrillation.⁴

Diabetes is a major risk factor for atrial fibrillation.⁵ The underlying mechanisms involve electrical and structural remodeling of the atria.⁶ Participants in Swiss-AF study (2411) with atrial fibrillation (median age of 73.6 years) were studied against patients without diabetes.

Paroxysmal atrial fibrillation (defined as atrial fibrillation that terminates spontaneously or with intervention within 7 days of onset with variable frequency) was not associated with diabetes. Patients with diabetes were less often able to perceive atrial fibrillation symptoms but had more cardiac disease, as well as more neurological (39% increase in stroke risk) and cognitive impairment comorbidities.

This data supports screening older adults regularly for atrial fibrillation. Perhaps more frequent electrocardiograms, Holter-monitoring, and monitoring of presyncope or falls may be prudent.

Evaluating Self-Selected Triggers for Paroxysmal Atrial Fibrillation

A study recently published in the Journal of the American Medical Association was related to whether self-selected triggers of paroxysmal atrial fibrillation such as caffeine, exercise, reduced sleep, dehydration, large meals, cold food or drink, specific diets, and other triggers influence atrial fibrillation quality of life.⁷

In 446 participants, no significant differences were observed for the triggers. However, alcohol exposure was associated with an increased risk of atrial fibrillation events. Caution on frequent or excessive alcohol intake in patients with paroxysmal atrial fibrillation should be considered.

References:

1. Global Omega 3 Fatty Acid Market Size Will Grow to USD 9 Billion By 2026: Facts & Factors. Globe Newswire. Accessed November 2021. https://www.globenewswire.com/en/news-release/2021/01/29/2166566/0/en/Global-Omega-3-Fatty-Acid-Market-Size-Will-Grow-to-USD-9-Billion-By-2026-Facts-Factors.html
2. Bhatt DL, Steg PG, Miller M, et al. Cardiovascular risk reduction with ciosapent ethyl for hypertriglyceridemia. N Engl J Med. 2019;380(1):11-22. doi:10.1056/NEJMoa1812792.
3. Lombardi M, Carbone S, Del Buono MG, et al. Omega-3 fatty acids supplementation and risk of atrial fibrillation: an updated meta-analysis of randomized controlled trials. Eur Heart J Cardiovasc Pharmacother. 2021;7(4):e69-e70. doi:10.1093/ehjcvp/pvab008
4. Bano A, Rodondi N, Beer JH, et al. Association of diabetes with atrial fibrillation phenotype and cardiac and neurological comorbidities: insights from the Swiss-AF study. J Am Heart Assoc. 2021;10(22):e021800. doi:10.1161/JAHA.121.021800
5. Huxley RR, Filion KB, Konety S, Alonso A. Meta-analysis of cohort and case-control studies of type 2 diabetes mellitus and risk of atrial fibrillation. Am J Cardiol. 2011;108(1):56-62. doi:10.1016/j.amjcard.2011.03.004
6. Bohne LJ, Johnson D, Rose RA, Wilton SB, Gillis AM. The association between diabetes mellitus and atrial fibrillation: clinical and mechanistic insights. Front Physiol. 2019;10:135. doi:10.3389/fphys.2019.00135
7. Marcus GM, Modrow M-F, Schmid CH,e t al. Individualized studies of triggers of paroxysmal atrial fibrillation: the I-STOP-AFib randomized clinical trial [published online ahead of print November 14, 2021]. JAMA Cardiol. doi:10.1001/jamacardio.2021.5010