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Should we use Omega-3 in primary or secondary prevention?

Written By Dr Iqbal Malik, Consultant Cardiologist

Cardiovascular risk reduction

NICE’s clinical guideline ‘Cardiovascular disease: risk assessment and reduction, including lipid modification’ (CG181 published 2014, last updated September 2016) includes:

Omega-3 fatty acid compounds for preventing CVD

1.3.48  Do not offer omega-3 fatty acid compounds for the prevention of CVD to any of the following:

  • people who are being treated for primary prevention
  • people who are being treated for secondary prevention
  • people with CKD
  • people with type 1 diabetes
  • people with type 2 diabetes.

1.3.49 Tell people that there is no evidence that omega-3 fatty acid compounds help to prevent CVD.

Combination therapy for preventing CVD

1.3.50 Do not offer the combination of a bile acid sequestrant (anion exchange resin), fibrate, nicotinic acid or omega-3 fatty acid compound with a statin for the primary or secondary prevention of CVD.

A Cochrane review ‘Omega-3 fatty acids for the primary and secondary prevention of cardiovascular disease ’https://doi.org/10.1002/14651858.CD003177.pub4 (version published 30 November 2018) concludes: “Moderate‐ and high‐quality evidence suggests that increasing EPA and DHA has little or no effect on mortality or cardiovascular health (evidence mainly from supplement trials). Previous suggestions of benefits from EPA and DHA supplements appear to spring from trials with higher risk of bias.”

REDUCE-IT trial

If icosapent ethyl, a highly purified eicosapentaenoic acid ethyl ester is licensed in the UK, the REDUCE-IT trial suggests it may have a role in cardiovascular risk reduction. Is it cost effective? The data is from one trial and not yet main stream in the UK.

In REDUCE-IT,  2g twice a day of  2g of icosapent ethyl was compared to placebo.

  • The risk of the primary composite end point of cardiovascular death, nonfatal myocardial infarction, nonfatal stroke, coronary revascularization, or unstable angina (THAT IS  A LOT OF ENDPOINTS – some of which are hard to be certain about), lower, by 25%,(4.8% lower,  number needed to treat of 21)
  • The risk of the key secondary composite end point of cardiovascular death, nonfatal myocardial infarction, or nonfatal stroke was also significantly lower, by 26%, ( absolute between-group difference of 3.6 percentage points in the rate of the end point and a number needed to treat of 28)
  • AF rates were higher in the treatment group however
  • Cardiovascular death was reduced, but not total mortality.

Written by Dr Iqbal Malik

Reference: https://www.nejm.org/doi/full/10.1056/NEJMoa1812792

Newly initiated prescriptions: 

These  drugs should only be prescribed by, or on the recommendation of, lipid specialists, only for patients who meet all the following criteria:

  • Under the care of a lipid specialist and
  • Taking maximum fibrate and statin and
  • Fasting triglycerides remain >10mmol/l


Thus NOT for everybody- eat oily fish 2x per week instead!