What is the current recommendation for using omega 3 fatty acids (EPA and DHA) in patients with cardiovascular disease or hypertriglyceridemia?

Current Recommendations for Omega-3 Fatty Acids in Cardiovascular Disease and Hypertriglyceridemia

For patients with cardiovascular disease or hypertriglyceridemia, omega-3 fatty acids are recommended both through dietary sources (2+ servings of fatty fish weekly) and as prescription supplements (4g/day of EPA+DHA) for those with severe hypertriglyceridemia (≥500 mg/dL). 1, 2

Dietary Recommendations

• General cardiovascular health:

  • Consume at least 2 servings (8+ ounces total) of fatty fish per week 1, 2
  • Focus on fatty fish high in EPA/DHA: salmon, mackerel, rainbow trout, sardines, anchovies 1
  • Choose fish low in mercury: salmon, anchovies, sardines, trout, tilapia, shrimp, catfish 1
  • Avoid high-mercury fish: king mackerel, marlin, shark, swordfish, tilefish, bigeye tuna 1

• For patients with triglycerides 200-499 mg/dL:

  • Prioritize fatty fish like salmon and tuna 1
  • Choose fresh or frozen fish rather than canned, smoked, or cured options (which are high in sodium) 1

• For patients with triglycerides 500-999 mg/dL:

  • May need to limit overall fat intake; consider lean fish options (cod, tilapia, haddock, flounder) 1

Supplementation Recommendations

• For general cardiovascular health:

  • 1g/day of EPA+DHA for patients with documented coronary heart disease 2

• For hypertriglyceridemia management:

  • Severe hypertriglyceridemia (≥500 mg/dL): 4g/day of EPA+DHA (requires prescription) 1, 3
  • Prescription omega-3 fatty acids (Lovaza) are FDA-approved for treating severe hypertriglyceridemia 3
  • At 4g/day, can reduce triglycerides by approximately 45% and VLDL-C by >50% 4

Clinical Evidence and Benefits

• Omega-3 fatty acids reduce risk of:

  • Major cardiovascular events (RR 0.95% CI 0.91-0.99) 5
  • Myocardial infarction (RR 0.90,95% CI 0.83-0.98) 5
  • Cardiovascular death (RR 0.94,95% CI 0.88-0.99) 5

• Regular fish consumption (2 servings/week) is associated with a 30% reduction in coronary heart disease risk 2

• Cardiovascular benefits appear primarily attributable to prescription EPA ethyl ester formulations 5

Important Considerations and Cautions

• Potential risks:

  • Increased risk of atrial fibrillation (RR 1.25,95% CI 1.10-1.41) with high-dose supplementation 5
  • Possible increased bleeding risk with prescription EPA ethyl ester formulations 5
  • LDL-C levels may increase with EPA+DHA in patients with very high triglycerides, while EPA alone does not raise LDL-C 6

• Safety profile:

  • Generally well-tolerated with minimal side effects 4
  • Common side effects include mild gastrointestinal symptoms that can be minimized by taking with food 2
  • No significant drug interactions with most medications, but caution advised with blood thinners 2
  • Patients receiving ibrutinib should avoid fish oil supplements due to association with epistaxis 2

• Special populations:

  • Pregnant/nursing women: At least 300mg DHA daily recommended 2
  • Black individuals: May experience greater cardiovascular benefits (77% reduction in MI in VITAL trial) 2

Prescription vs. Non-Prescription Options

• Prescription omega-3 products:

  • Provide consistent quality, purity, and dosing 4
  • FDA-approved for severe hypertriglyceridemia (≥500 mg/dL) 3
  • Available as EPA+DHA combination or EPA-only formulations 6

• Over-the-counter supplements:

  • Variable quality and concentration
  • American Heart Association advises that treatment for very high triglycerides should be under physician supervision 4

For patients requiring triglyceride reduction, prescription-grade omega-3 supplements are recommended to ensure consistent dosing and quality, particularly when treating severe hypertriglyceridemia.