What is the recommended treatment for reducing cardiovascular risk with omega-3 fatty acids, such as Lovaza (icosapent ethyl) or Vascepa (icosapent ethyl)?

From the Guidelines

For reducing cardiovascular risk with omega-3 fatty acids, the recommended treatment is icosapent ethyl (Vascepa) at a dose of 4 grams daily, as it has shown significant cardiovascular benefits in high-risk patients, particularly those with elevated triglycerides, as demonstrated in the REDUCE-IT trial 1. The use of prescription-grade omega-3 fatty acids, specifically icosapent ethyl, has been supported by recent studies for its efficacy in lowering cardiovascular risk. Key points to consider include:

• The REDUCE-IT trial, a randomized, placebo-controlled study, found that 4 grams of icosapent ethyl daily reduced the primary composite endpoint of cardiovascular death, nonfatal MI, nonfatal stroke, coronary revascularization, or unstable angina by 25% 1.
• Icosapent ethyl is a pure EPA formulation, which has been shown to be more effective than mixtures of EPA and DHA for cardiovascular risk reduction, as evidenced by the lack of significant benefits seen in trials using low-dose mixtures of EPA and DHA, such as the ASCEND and VITAL trials 1.
• The recommended patient population for icosapent ethyl includes those with established cardiovascular disease or diabetes plus additional risk factors, who are already on statin therapy with controlled LDL cholesterol but elevated triglycerides (135-499 mg/dL) 1.
• Lifestyle modifications should be implemented in conjunction with icosapent ethyl therapy as part of a comprehensive approach to reducing cardiovascular risk.
• Potential side effects of icosapent ethyl include joint pain, peripheral edema, and a small increased risk of atrial fibrillation and bleeding, necessitating regular monitoring 1.

From the Research

Cardiovascular Benefits of Prescribed Omega-3's

The question of whether prescribed omega-3's offer cardiovascular benefits compared to over-the-counter alternatives is complex and has been the subject of numerous studies.

• The REDUCE-IT trial demonstrated that a purified form of EPA ethyl esters (icosapent ethyl) at 4 g daily reduced cardiovascular events and death in patients with ASCVD (or diabetes and multiple cardiovascular risk factors) and elevated triglycerides on background statin therapy 2, 3.
• However, other large trials like STRENGTH, which used different formulations of prescription omega-3 fatty acids, did not note significant cardiovascular risk reduction 2, 3.
• Clinical guideline statements now recommend icosapent ethyl use for selected individuals with hypertriglyceridemia to reduce cardiovascular events given recent evidence from the REDUCE-IT trial 3.

Comparison of Prescribed and Over-the-Counter Omega-3's

• Alternative versions of omega-3 fatty acids should not be considered equivalent to icosapent ethyl, as the evidence for their cardiovascular benefit is not as compelling 2.
• Patients taking an omega-3 fatty acid supplement should be monitored for potential adverse effects, including gastrointestinal disorders or bleeding, in addition to a possible increased risk of atrial fibrillation 2.
• The American Heart Association recommends consumption of two servings of fish per week for persons with no history of coronary heart disease and at least one serving of fish daily for those with known coronary heart disease 4.

Recommended Treatment for Reducing Cardiovascular Risk

• Icosapent ethyl has the most compelling evidence to support a cardiovascular benefit and should be considered in select patients who meet the REDUCE-IT criteria 2, 3.
• Increasing LCn3 (long-chain omega-3) slightly reduces risk of coronary heart disease mortality and events, and reduces serum triglycerides (evidence mainly from supplement trials) 5, 6.
• Moderate- and low-certainty evidence suggests that increasing LCn3 slightly reduces risk of coronary heart disease mortality and events, and reduces serum triglycerides 5.