1. Journal of the American College of Cardiology Vol. 61, No. 4, 2013 Omega-3 Fatty Acids for the Prevention of Recurrent Symptomatic Atrial Fibrillation R3 김진숙 / Prof. 김진배

2. Introduction Atrial fibrillation (AF) - Most common type of arrhythmia in adults : 1/3 of hospital stays for arrhythmia - ↑ risk of death, thromboembolism impaired quality of life, even if asymptomatic - Current treatment : ventricular rate control & anticoagulation : less than satisfactory : limited efficacy & side effects of anti-arrhythmic drugs  contribute these unsatisfactory results

3. Introduction Polyunsaturated fatty acid (n-3 PUFA) - Emerge as attractive candidate to manage AF - Demonstrated benefit by reducing overall mortality (decreased in ventricular arrhythmia) - Anti-arrhythmic properties might be translated also to a decrease of atrial arrhythmias  results of randomized clinical trials : heterogenous Present the results of FORWARD (Randomized Trial to Assess Efficacy of PUFA for the Maintenance of Sinus Rhythm in Persistent Atrial Fibrillation Fish Oil Research with omega-3 for Atrial fibrillation Recurrence Delaying) : assessing the efficacy of n-3 PUFA for the maintenance of sinus rhythm in AF

4. Methods Study design - Independent, double-blind, randomized, controlled trial - Testing the efficacy of n-3 PUFA 1g/day for 1yr for maintenance of NSR in patients with previous persistent AF - Men & women ≥ 21 years diagnosed Outpatient setting Previous symptomatic AF who had recovery NSR

5. Methods Study design Inclusion (must had either) ≥ 2 symptomatic episodes of AF in the 6mon. before & last episode within 3~90 days before (paroxysmal AF) Successful electrical or pharmacological cardioversion within 3~28days before To avoid the inclusion of lone AF < 65years of age : must have ≥ 1 characteristic of mod.~high risk of stroke

6. Methods Primary end point - 1 st recurrence of an AF episode of symptomatic or asymptomatic Secondary outcomes - Hierarchical composite of all cause mortality, nonfatal stroke, nonfatal AMI, systemic embolism - All-cause hospital stays - Survival free of thromboembolic events - Hospital stays for cardiovascular reasons

7. Jan 2008 ~ Mar 2011 (olive oil) (850~882mg eicosapentaenoic acid/ docosahexaenoic acid ethyl esters)

8. Results

9. Jan 2008 ~ Mar 2011 (olive oil) (850~882mg eicosapentaenoic acid/ docosahexaenoic acid ethyl esters)

10. 56 of 297 (18.9%) in placebo 69 of 289 (24.0%) in n-3 PUFA HR: 1.28, 95% CI: 0.90 to 1.83, p(0.17) Results - study outcomes

12. 0.7 0.12

13. Conclusion The FORWARD trial - No significant differences between n-3 PUFA and placebo in prevention of AF recurrence - Pharmacological supplementation with 1g of n-3 PUFA for 1 year did not reduce recurrent AF