In a recent poll, most responders opted to prescribe icosapent ethyl (EPA only) to a 70-year-old patient with a recent ST-segment elevation myocardial infarction. The second most common answer was to not recommend any n-3 polyunsaturated fatty acids due to insufficient evidence. Few responders chose to add an EPA/DHA combination or over-the-counter fish oil supplement.

In the recently published OMEMI (Omega-3 Fatty Acids in Elderly With Myocardial Infarction) trial, n-3 polyunsaturated fatty acids (EPA/DHA combination) failed to reduce adverse cardiovascular events in elderly patients with a recent myocardial infarction. Furthermore, a higher incidence of atrial fibrillation was observed among recipients of n-3 polyunsaturated fatty acids, consistent with data from other omega-3 fatty acid studies.

Similarly, in STRENGTH (Long-Term Outcomes Study to Assess Statin Residual Risk With Epanova in High Cardiovascular Risk Patients With Hypertriglyceridemiatrial), the use of n-3 polyunsaturated fatty acids (EPA/DHA combination) did not result in a reduction of cardiovascular events in patients with hypertriglyceridemia and high cardiovascular risk. On the other hand, two randomized studies using the highly purified icosapent ethyl (EPA only) showed a significant reduction in cardiovascular events. In the open-label JELIS (Japan EPA Lipid Intervention Study), moderate dose EPA (1.8 g/day) resulted in a 19% reduction in adverse events mainly driven by unstable angina and revascularization. In REDUCE-IT (Reduction of Cardiovascular Events With Icosapent Ethyl–Intervention Trial), high-dose EPA (4 g/day) was compared with mineral oil placebo resulting in a 25% reduction in the primary cardiovascular outcome. The study was criticized for the use of mineral oil as it appears to have resulted in an increase in low-density lipoprotein cholesterol levels in the placebo group. When reviewed by the US Food and Drug Administration, this increase in low-density lipoprotein cholesterol was thought to be insufficient to fully explain the observed benefits of high-dose EPA, and the medication was granted approval.

At the present time, current evidence does not support the use of combination EPA/DHA omega-3 fatty acids in patients with prior myocardial infarction or at high cardiovascular risk. There may, however, be a benefit from EPA-only compounds such as those used in the JELIS and REDUCE-IT trials.

Clinical Topics: Acute Coronary Syndromes, Diabetes and Cardiometabolic Disease, Dyslipidemia, Geriatric Cardiology, Invasive Cardiovascular Angiography and Intervention, Noninvasive Imaging, Stable Ischemic Heart Disease, Vascular Medicine, Lipid Metabolism, Nonstatins, Novel Agents, Statins, Interventions and ACS, Interventions and Imaging, Interventions and Vascular Medicine, Angiography, Nuclear Imaging, Chronic Angina

Keywords: Acute Coronary Syndrome, Dyslipidemias, Geriatrics, Coronary Angiography, Fatty Acids, Unsaturated, Fatty Acids, Omega-3, Myocardial Infarction, ST Elevation Myocardial Infarction, Drug-Eluting Stents, Cholesterol, LDL, Hydroxymethylglutaryl-CoA Reductase Inhibitors

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