Abstract
Background
Methods
Results
Conclusion
Keywords
- •Fish consumption is beneficial for the primary prevention of acute coronary syndrome.
- •Each additional 100-g serving of fish per week is associated with a 5% reduced risk of acute coronary syndrome.
- •Age and sex do not appear to influence the association between fish consumption and acute coronary syndrome.
Methods
Study Selection
- •Prospective cohort or case-control study design.
- •Fish consumption as exposure of interest.
- •Acute coronary syndrome as outcome of interest.
- •The most adjusted relative risk (RR) and 95% confidence interval (CI) were reported.
- •The study population consisted of general adult populations without preexisting disease or without a previous acute coronary syndrome event.
- •For dose-response analysis, the number of cases and participants or person-years for each category of fish consumption were reported (or data were available to calculate them).
Data Extraction
Quality Assessment
Wells GA, Shea B, O’Connell D, et al. The Newcastle-Ottawa Scale (NOS) for assessing the quality of nonrandomised studies in meta-analyses. Available at: http://www.ohri.ca/programs/clinical_epidemiology/oxford.asp. Accessed on June 10, 2013.
Statistical Analysis
Results
Literature Search

Study Characteristics
- Yamagishi K.
- Iso H.
- Date C.
- et al.
First Author, Year of Publication (Country) | Years & Duration of Follow-Up | Number of Participants | Mean Age (Range), Years | Number of Cases (Outcome) | Dietary Assessment Tool | Categories of Fish Consumption | Covariates |
---|---|---|---|---|---|---|---|
Ascherio, 1995 (US) 16 | 1986-1992 6 | 44,895 men | 57.5 (40-75) | 547 (nonfatal MI) | Self-administered FFQ | <1/mo, 1-3/mo, 1/wk, 2-3/wk, 4-5/wk, ≥6/wk | Age, BMI, smoking, alcohol consumption, history of hypertension, history of diabetes, history of hypercholesterolemia, family history of MI before 60 years, profession, intake of n-3 fatty acids |
Bjerregaard, 2010 (Denmark) 17 | 1993-2003 7.6 | 25,573 men 28,653 women | 56 (50-64) | 854 (nonfatal MI) | Self-administered FFQ | 0-24 g/d, 25-35 g/d, 36-47 g/d, 48-64 g/d, >64 g/d (men); 0-22 g/d, 23-31 g/d, 32-41 g/d, 42-54 g/d, >55 g/d (women) | Education, smoking, alcohol intake, BMI, history of diabetes, systolic blood pressure, serum cholesterol, physical activity, dietary intake of fruits and vegetables, total energy intake, dietary intake of SFA, MUFA and PUFA, menopausal status |
Daviglus, 1997 (US) 18 | 1957-1959 30 | 1822 men | 47.6 (40-55) | 293 (fatal MI) | Questionnaire-based interview by nutritionists | 0 g/d, 1-17 g/d, 18-34 g/d, ≥35 g/d | Age, education, religion, systolic pressure, serum cholesterol, number of cigarettes smoked, BMI, diabetes, electrocardiographic abnormalities, intake of energy, cholesterol, SFA, MUFA, PUFA, total protein, carbohydrate, alcohol, iron, thiamine, riboflavin, niacin, vitamin C, beta carotene and retinol |
de Goede, 2010 (Netherlands) 19 | 1993-2007 11.3 | 9604 men 11,738 women | 42.1 (20-65) | 64 (fatal MI) 252 (nonfatal MI) | Self-administered FFQ | <3.3 g/d, 3.3-7.3 g/d, 7.4-14 g/d, >14 g/d | Age, sex, BMI, total energy intake, ethanol intake, smoking, SES, vitamin or mineral supplement use, use of drugs for hypertension or hypercholesterolemia, family history of cardiovascular diseases, SFA intake, fruit and vegetable intake |
Hu, 2002 (US) 20 | 1980-1994 16 | 84,688 women | 46.5 (34-59) | 1029 (nonfatal MI) | Self-administered FFQ | <1/mo, 1-3/mo, 1/wk, 2-4/wk, ≥5/wk | Age, time periods, smoking, BMI, alcohol intake, menopausal status, postmenopausal hormone use, vigorous to moderate activity, use of aspirin, multivitamin use, vitamin E supplement use, history of hypertension, hypercholesterolemia, diabetes, intake of trans fat, ratio PUFA:SFA, dietary fiber |
Iso, 2006 (Japan) 21 | 1990-2001 10 | 19,985 men 21,593 women | 49.5 (40-59) | 198 (total MI) | Self-administered FFQ | median 23 g/d, 51 g/d, 78 g/d, 114 g/d, 180 g/d | Age, sex, smoking, alcohol intake, BMI, history of hypertension and diabetes, medication use for hypercholesterolemia, education, sports at leisure time, dietary intake of fruits, vegetables, SFA, MUFA, n-6 PUFA, cholesterol and total energy, public health centers |
Kuhn, 2013 (Germany) 22 | 1994-1998 8.1 | 20,292 men 28,023 women | 50.5 (35-65) | 605 (total MI) | Self-administered FFQ | <7.5 g/d, 7.5-14.5 g/d, 14.5-21.5 g/d, 21.5-31.1 g/d, >31.1 g/d | Age, sex, study centers, energy intake, alcohol intake, BMI, waist circumference, physical activity, education, smoking, diabetes |
Morris, 1995 (US) 23 | 1982-1988 4 | 21,185 men | 62 (40-84) | 281 (total MI) | Self-administered FFQ | <1/wk, 1/wk, 2-4/wk, ≥5/wk | Age, level of fish consumption, aspirin and beta-carotene assignment, smoking, alcohol consumption, obesity, diabetes, vigorous exercise, parental history of MI before 60, history of hypertension, history of hypercholesterolemia, vitamin supplement use, SFA intake |
Mozaffarian, 2003 (US) 24 | 1989-2000 9.3 | 1526 men 2384 women | 72.7 (≥65) | 363 (nonfatal MI) | Self-administered FFQ picture-sort version | 1/mo, 1-3/mo, 1/wk, 2/wk, ≥3/wk | Age, sex, education, diabetes, smoking, pack-years of smoking, tuna/other fish and fried fish/fish sandwich consumption, BMI, systolic blood pressure, LDL cholesterol, HDL cholesterol, triglycerides, C-reactive protein, intake of SFA, alcohol, beef/pork, fruits and vegetables |
Yamagishi, 2008 (Japan) 25
Fish, omega-3 polyunsaturated fatty acids, and mortality from cardiovascular diseases in a nationwide community-based cohort of Japanese men and women the JACC (Japan Collaborative Cohort Study for Evaluation of Cancer Risk) Study. J Am Coll Cardiol. 2008; 52: 988-996 | 1988-2003 12.7 | 22,881 men 35,091 women | 56.1 (40-79) | 329 (fatal MI) | Self-administered FFQ | Median 20 g/d, 33 g/d, 45g/d, 62 g/d, 86 g/d (men); 21 g/d, 33 g/day, 46g/d, 62 g/d, 85 g/d (women) | Age, sex, history of hypertension and diabetes, smoking, alcohol consumption, BMI, mental stress, walking, sports, education, total energy, dietary intake of cholesterol, SFA, n-6 PUFA, vegetables and fruits |
Yuan, 2001 (China) 26 | 1986-1989 12 | 18,244 men | 55.8 (45-64) | 113 (fatal MI) | Questionnaire-based interview | <30 g/wk, 30-<60 g/wk, 60-<100 g/wk, 100-<150 g/wk, ≥150 g/wk | Age, total energy intake, level of education, BMI, smoking, number of cigarettes smoked, number of alcoholic drinks consumed, history of diabetes, history of hypertension |
First Author, Year of Publication (Country) | Years | Number of Participants | Mean Age (Range), Years | Number of Cases (Outcome) | Dietary Assessment Tool | Categories of Fish Consumption | Covariates |
---|---|---|---|---|---|---|---|
Gramenzi, 1990 (Italy) 27 | 1983-1989 | 936 women | 49 (21-69) | 287 (total MI) | Questionnaire-based interview | <1/wk, 1/wk, >1/wk | Age, area of residence, education, smoking, hyperlipidemia, diabetes, hypertension, BMI, intake of carrots, green vegetables, fresh fruit, meat, ham and salami, butter, total fat score, coffee consumption, alcohol consumption |
Lockheart, 2007 (Norway) 28 | 1995-1997 | 211 men and women | 62.4 (45-75) | 106 (total MI) | Interview using FFQ | Median 32 g/d, 99 g/d (low-fat); 12 g/d, 52 g/d (high-fat) | Age, marital status, education, family history of heart disease, smoking, energy intake |
Martinez-Gonzalez, 2002 (Spain) 29 | 1999-2001 | 277 men 65 women | 61.6 (<80) | 171 (total MI) | Self-administered FFQ | <60 g/d, >77 g/d | Age, sex, hospital, smoking, BMI, high blood pressure, high blood cholesterol, diabetes, leisure-time physical activity, SES, intake of olive oil, fiber, fruits, vegetables, alcohol, meat/meat products and white bread/rice/pasta |
Oliveira, 2010 (Portugal) 30 | 1999-2003 | 1460 men 1556 women | 52 (33-69) | 820 (nonfatal MI) | Interview using FFQ | Median <35.5 g/d, ≥35.5 g/d (excluding cod); <13.5 g/d, ≥13.5 g/d (cod) | Sex, age, education, total energy intake, intake of fruit, refined cereals and white meat, smoking, regular physical activity, family history of MI, BMI, menopause, hormone replacement therapy |
Panagiotakos, 2005 (Greece) 31 | 2000-2001 | 1562 men 364 women | 60.1 (49-75) | 848 (nonfatal ACS) | Questionnaire-based interview | Never, <150 g/wk, 150-300 g/wk, >300 g/wk | Age, sex, smoking, hypertension, hypercholesterolemia, HDL cholesterol, LDL cholesterol, diabetes, physical inactivity, BMI, food items consumed |
Sasazuki, 2001 (Japan) 32 | 1996-1998 | 1340 men 506 women | 59.5 (40-79) | 458 (nonfatal MI) | Questionnaire-based interview | <2/wk, 2-3/wk, ≥4/wk | Smoking, alcohol use, sedentary job, leisure-time physical activity, hyperlipidemia, hypertension, diabetes, angina pectoris, obesity, tofu consumption, fruit consumption |
Tavani, 2001 (Italy) 33 | 1995-1999 | 675 men 310 women | 60 (25-79) | 507 (nonfatal MI) | Interview using FFQ | <1/wk, 1-<2/wk, ≥2/wk | Age, sex, education, BMI, cholesterol, smoking, coffee, alcohol, meat, vegetables, fruit, calorie intakes, physical activity, hyperlipidemia, diabetes, hypertension, family history of MI in first-degree relatives |
Wennberg, 2011 (Sweden) 34 | 1987-1999 | 648 men 218 women | 58.7 (34-77) | 392 (total MI) | Self-administered FFQ | <1/mo, 1/mo-<1/wk, 1-2/wk, >2/wk | Apolipoprotein B/apolipoprotein A-I, smoking, systolic blood pressure, diabetes, education, consumption of fruit and vegetables, consumption of wine, consumption of strong beer, level of physical activity |
Fish Consumption and Acute Coronary Syndrome
RR (95% CI) per Category of Fish Consumption | |||||
---|---|---|---|---|---|
<Once per Month | 1 to <4 Times per Month | 1 to <2 Times per Week | 2 to <4 Times per Week | ≥4 Times per Week | |
Prospective cohort | 1.00 | 0.82 (0.72-0.92) | 0.85 (0.72-1.01) | 0.83 (0.71-0.96) | 0.79 (0.70-0.89) |
Highest quality studies | 1.00 | 0.84 (0.74-0.95) | 0.81 (0.73-0.91) | 0.84 (0.73-0.95) | 0.79 (0.70-0.89) |
Hazard ratio only | 1.00 | 0.83 (0.73-0.95) | 0.81 (0.72-0.90) | 0.81 (0.70-0.95) | 0.79 (0.69-0.90) |
Largest study excluded | 1.00 | 0.82 (0.72-0.92) | 0.85 (0.72-1.01) | 0.80 (0.67-0.96) | 0.76 (0.66-0.88) |
Case-control | 1.00 | – | 0.76 (0.67-0.87) | 0.84 (0.64-1.10) | 0.73 (0.49-1.09) |

Dose-Response Analysis
Effect of Sex and Age
Publication Bias
Discussion
Acknowledgments
Appendix


References
- Fish consumption, fish oil, omega-3 fatty acids, and cardiovascular disease.Arterioscler Thromb Vasc Biol. 2003; 23: e20-e30
- Omega 3 fatty acids and cardiovascular outcomes: systematic review and meta-analysis.Circ Cardiovasc Qual Outcomes. 2012; 5: 808-818
- Association between omega-3 fatty acid supplementation and risk of major cardiovascular disease events: a systematic review and meta-analysis.JAMA. 2012; 308: 1024-1033
- Association between fish consumption, long chain omega 3 fatty acids, and risk of cerebrovascular disease: systematic review and meta-analysis.BMJ. 2012; 345: e6698
- Fish consumption, omega-3 fatty acids and risk of heart failure: a meta-analysis.Clin Nutr. 2012; 31: 846-853
- Fish consumption and incidence of stroke: a meta-analysis of cohort studies.Stroke. 2004; 35: 1538-1542
- Fish consumption and the risk of stroke: a dose-response meta-analysis.Stroke. 2011; 42: 3621-3623
- Fish intake, contaminants, and human health: evaluating the risks and the benefits.JAMA. 2006; 296: 1885-1899
- Meta-analysis of observational studies in epidemiology: a proposal for reporting. Meta-analysis Of Observational Studies in Epidemiology (MOOSE) group.JAMA. 2000; 283: 2008-2012
Wells GA, Shea B, O’Connell D, et al. The Newcastle-Ottawa Scale (NOS) for assessing the quality of nonrandomised studies in meta-analyses. Available at: http://www.ohri.ca/programs/clinical_epidemiology/oxford.asp. Accessed on June 10, 2013.
- Methods for trend estimation from summarized dose-response data, with applications to meta-analysis.Am J Epidemiol. 1992; 135: 1301-1309
- Meta-analysis in clinical trials.Control Clin Trials. 1986; 7: 177-188
- Quantifying heterogeneity in a meta-analysis.Stat Med. 2002; 21: 1539-1558
- Bias in meta-analysis detected by a simple, graphical test.BMJ. 1997; 315: 629-634
- A measure to aid in the interpretation of published clinical trials.Stat Med. 1985; 4: 1-9
- Dietary intake of marine n-3 fatty acids, fish intake, and the risk of coronary disease among men.N Engl J Med. 1995; 332: 977-982
- Fish intake and acute coronary syndrome.Eur Heart J. 2010; 31: 29-34
- Fish consumption and the 30-year risk of fatal myocardial infarction.N Engl J Med. 1997; 336: 1046-1053
- Marine (n-3) fatty acids, fish consumption, and the 10-year risk of fatal and nonfatal coronary heart disease in a large population of Dutch adults with low fish intake.J Nutr. 2010; 140: 1023-1028
- Fish and omega-3 fatty acid intake and risk of coronary heart disease in women.JAMA. 2002; 287: 1815-1821
- Intake of fish and n3 fatty acids and risk of coronary heart disease among Japanese: the Japan Public Health Center-Based (JPHC) Study Cohort I.Circulation. 2006; 113: 195-202
- Fish consumption and the risk of myocardial infarction and stroke in the German arm of the European Prospective Investigation into Cancer and Nutrition (EPIC-Germany).Br J Nutr. 2013; 110: 1118-1125
- Fish consumption and cardiovascular disease in the physicians' health study: a prospective study.Am J Epidemiol. 1995; 142: 166-175
- Cardiac benefits of fish consumption may depend on the type of fish meal consumed: the Cardiovascular Health Study.Circulation. 2003; 107: 1372-1377
- Fish, omega-3 polyunsaturated fatty acids, and mortality from cardiovascular diseases in a nationwide community-based cohort of Japanese men and women the JACC (Japan Collaborative Cohort Study for Evaluation of Cancer Risk) Study.J Am Coll Cardiol. 2008; 52: 988-996
- Fish and shellfish consumption in relation to death from myocardial infarction among men in Shanghai, China.Am J Epidemiol. 2001; 154: 809-816
- Association between certain foods and risk of acute myocardial infarction in women.BMJ. 1990; 300: 771-773
- Dietary patterns, food groups and myocardial infarction: a case-control study.Br J Nutr. 2007; 98: 380-387
- Mediterranean diet and reduction in the risk of a first acute myocardial infarction: an operational healthy dietary score.Eur J Nutr. 2002; 41: 153-160
- Adherence to the Southern European Atlantic Diet and occurrence of nonfatal acute myocardial infarction.Am J Clin Nutr. 2010; 92: 211-217
- Fish consumption and the risk of developing acute coronary syndromes: the CARDIO2000 study.Int J Cardiol. 2005; 102: 403-409
- Case-control study of nonfatal myocardial infarction in relation to selected foods in Japanese men and women.Jpn Circ J. 2001; 65: 200-206
- n-3 Polyunsaturated fatty acids, fish, and nonfatal acute myocardial infarction.Circulation. 2001; 104: 2269-2272
- Fish consumption and myocardial infarction: a second prospective biomarker study from northern Sweden.Am J Clin Nutr. 2011; 93: 27-36
- A quantitative analysis of fish consumption and stroke risk.Am J Prev Med. 2005; 29: 347-352
- A quantitative analysis of fish consumption and coronary heart disease mortality.Am J Prev Med. 2005; 29: 335-346
- Meta-analysis of observational studies on fish intake and coronary heart disease.Am J Cardiol. 2004; 93: 1119-1123
- Fish consumption and risk of stroke and its subtypes: accumulative evidence from a meta-analysis of prospective cohort studies.Eur J Clin Nutr. 2012; 66: 1199-1207
- Fish consumption and CHD mortality: an updated meta-analysis of seventeen cohort studies.Public Health Nutr. 2012; 15: 725-737
- Effects of changes in fat, fish, and fibre intakes on death and myocardial reinfarction: diet and reinfarction trial (DART).Lancet. 1989; 2: 757-761
- N-3 fatty acids: food or supplements?.J Am Diet Assoc. 2008; 108: 1125-1130
- Dietary intake of fish vs. formulations leads to higher plasma concentrations of n-3 fatty acids.Lipids. 2003; 38: 415-418
- Comparison of the effects of fish and fish-oil capsules on the n 3 fatty acid content of blood cells and plasma phospholipids.Am J Clin Nutr. 2007; 86: 1621-1625
- The percentage of DHA in erythrocytes can detect non-adherence to advice to increase EPA and DHA intakes.Br J Nutr. 2014; 111: 270-278
- Vitamin D levels for preventing acute coronary syndrome and mortality: evidence of a nonlinear association.J Clin Endocrinol Metab. 2013; 98: 2160-2167
- The omega-3 index as a risk factor for coronary heart disease.Am J Clin Nutr. 2008; 87: 1997S-2002S
- EPA and DHA in blood cell membranes from acute coronary syndrome patients and controls.Atherosclerosis. 2008; 197: 821-828
- Blood omega-3 and trans fatty acids in middle-aged acute coronary syndrome patients.Am J Cardiol. 2007; 99: 154-158
- Marine n-3 polyunsaturated fatty acids in adipose tissue and the risk of acute coronary syndrome.Circulation. 2011; 124: 1232-1238
- The Omega-3 Index as a risk factor for cardiovascular diseases.Prostaglandins Other Lipid Mediat. 2011; 96: 94-98
- Predictors of omega-3 index in patients with acute myocardial infarction.Mayo Clin Proc. 2011; 86: 626-632
Article info
Publication history
Footnotes
Funding: SSLLY is supported by a health professional training award from the Fonds de la Recherche en Santé du Québec. LP is funded by a James McGill Chair at McGill University.
Conflict of Interest: None.
Authorship: All authors had access to the data and played a role in writing this manuscript.