Should a patient with an Atherosclerotic Cardiovascular Disease (ASCVD) risk of 7.8% be started on Lovaza (omega-3 fatty acids) or a statin, such as atorvastatin or rosuvastatin?

Start a Statin, Not Lovaza

A patient with a 7.8% 10-year ASCVD risk should be started on a moderate-intensity statin, not Lovaza (omega-3 fatty acids). 1, 2

Why Statins Are the Clear Choice

Primary Prevention Evidence Base

• The ACC/AHA guidelines identify patients aged 40-75 years with LDL-C 70-189 mg/dL and 10-year ASCVD risk ≥7.5% as one of four major statin benefit groups with proven mortality and morbidity reduction. 1
• At 7.8% 10-year risk, this patient meets the threshold where randomized controlled trials have demonstrated clear ASCVD event reduction with statin therapy. 1
• Large-scale RCTs in primary prevention demonstrated that moderate-intensity statin therapy significantly reduces cardiovascular death, nonfatal myocardial infarction, and stroke compared to placebo. 1

Omega-3 Fatty Acids Lack Primary Prevention Evidence

• Lovaza (omega-3 fatty acids) has no established role in primary prevention for patients at this risk level. 1
• The REDUCE-IT trial, which showed cardiovascular benefit with high-dose icosapent ethyl (4g/day), enrolled only patients already on statin therapy with persistent hypertriglyceridemia (≥150 mg/dL) and either established ASCVD or diabetes plus additional risk factors. 3
• Low-dose omega-3 formulations (≤1.8 g/day) show minimal to no cardiovascular benefit in clinical trials. 3
• Omega-3 fatty acids are considered adjunctive therapy to statins for residual triglyceride-mediated risk, not a replacement for statin therapy. 4, 3

Recommended Statin Regimen

Initial Therapy

• Start moderate-intensity statin therapy targeting ≥30% LDL-C reduction. 1, 2
• Appropriate moderate-intensity options include:
  • Atorvastatin 10-20 mg daily 1, 2
  • Rosuvastatin 5-10 mg daily 1, 2
  • Simvastatin 20-40 mg daily 1, 2

Consider High-Intensity Statin If:

• The patient desires maximal ASCVD risk reduction after risk discussion. 1
• Risk-enhancing factors are present (family history of premature ASCVD, metabolic syndrome, chronic inflammatory disorders, chronic kidney disease, persistently elevated LDL-C ≥160 mg/dL, high-sensitivity CRP ≥2 mg/L, or coronary artery calcium score ≥100 or ≥75th percentile). 1, 2
• High-intensity options include atorvastatin 40-80 mg or rosuvastatin 20-40 mg daily, targeting ≥50% LDL-C reduction. 1, 5, 6

Critical Implementation Points

Before Starting Therapy

• Engage in a clinician-patient risk discussion reviewing major risk factors, potential benefits of lifestyle and statin therapy, potential adverse effects, drug-drug interactions, and patient preferences. 1
• Obtain baseline lipid panel (fasting preferred) and assess for contraindications to statin therapy. 1
• Routine baseline liver enzymes or creatine kinase testing is not required unless clinically indicated. 2

After Starting Therapy

• Assess adherence and LDL-C response 4-12 weeks after statin initiation. 2
• The goal is achieving appropriate statin intensity (percent LDL-C reduction), not targeting specific LDL-C goals in primary prevention. 1
• If the patient cannot tolerate the intended intensity, use the maximum tolerated dose rather than discontinuing therapy completely. 2

Common Pitfalls to Avoid

• Do not delay statin initiation in patients with 7.8% 10-year ASCVD risk, as this level has robust RCT evidence supporting treatment. 2
• Do not substitute omega-3 fatty acids for statin therapy in primary prevention—they address different lipid parameters and have different evidence bases. 1, 3
• Do not use age alone as a reason to withhold statins in appropriate candidates aged 40-75 years. 2
• Do not target specific LDL-C goals in primary prevention; instead, focus on achieving appropriate statin intensity based on risk category. 1