Consider discontinuing fish oil in CV patients

Fish oil supplements MIGHT slightly decrease CV events in patients with a previous MI and MIGHT modestly reduce death and hospitalizations....
Mahitab Hany, BS Pharm, PGDipClinPharm, PGDipClinNutrition

What are omega-3 fatty acids? ─ Eicosapentaenoic acid (EPA) and docosahexaenoic acid (DHA) are omega-3 fatty acids. They are found in fish and sometimes called "fish oil". Alpha-linolenic acid (ALA) is also an omega-3 fatty acid. It is found in soy, canola oil, flaxseed, and walnuts.

Foods that have omega-3 fatty acids, mainly fish, MIGHT prevent heart disease and stroke in some patients. Omega-3 fatty acids appear to have a dose-response hypotensive effect in patients with hypertension and have little to no effect in normotensive patients.There is less proof that fish oil helps other problems. The best source is fatty fish. Salmon is a fatty fish. The best source is fatty fish. Salmon is a fatty fish.

AHA recommendations

Debate will continue about whether fish oil supplements improve cardiovascular outcomes. The American Heart Association continues to say it's reasonable for CV patients to take about 1 g/day of omega-3 fatty acids for secondary prevention. Now they also suggest some patients with heart failure may benefit.

Fish oil supplements MIGHT slightly decrease CV events in patients with a previous MI and MIGHT modestly reduce death and hospitalizations in certain heart failure patients. But evidence for fish oil supplements or prescribed fish oil is conflicting and most of the newer trials show no benefit. Fish oil supplements likely don't add much benefit for secondary-prevention patients already on statins and other meds that lower CV risk. Plus evidence suggests that fish oil supplements are NOT effective for primary prevention of CV disease. And there's no proof that using higher doses of fish oil to lower triglycerides improves CV outcomes.

Evaluate the need for fish oil supplements, Super Omega-3, and Vascepa or Icosalip 1 gm when patients are admitted or when restarting home medications at discharge from hospital. In many cases, these can be permanently stopped.

Table (1). Summary of AHA Recommendations for Omega-3 Fatty Acid Intake
PATIENT POPULATION RECOMMENDATION
No documented history of CHD Eat a variety of fish (preferably oily) at least twice per week. Include oils and foods rich in alphalinolenic acid (flaxseed, canola, and soybean oils; flaxseeds and walnuts).
Documented history of CHD Consume approximately 1 g of EPA plus DHA daily, preferably from oily fish. EPA plus DHA capsule supplements may be used in consultation with a physician.
Needs to lower triglyceride level Consume 2 to 4 g of EPA plus DHA daily in capsules in consultation with a physician.
AHA = American Heart Association; CHD = coronary heart disease; EPA = eicosapentaenoic acid; DHA = docosahexaenoic acid.

Adapted with permission from Kris-Etherton PM, Harris WS, Appel LJ; American Heart Association. Nutrition Committee. Fish consumption, fish oil, omega-3 fatty acids, and cardiovascular disease. Circulation 2002;106:2755.

Side effects and interactions

Gastrointestinal side effects include unpleasant taste, fishy burp, bad breath, heartburn, nausea, indigestion, and diarrhea. Taking supplements with meals or freezing them may help.

  • (US: Omega-3 and Vascepa should not be stored below 15 C; Canada: Vascepa should not be stored below 20 C).

Enteric-coated products may help. People with seafood allergy might theoretically be allergic to fish oil supplements. Omega-3 and Vascepa labeling advises caution in fish- or shellfish-allergic patients.

Increased LDL. DHA-containing products can increase LDL by over 40% in patients with triglycerides ≥ 500 mg/dL. This may be due to an increase in larger, potentially less atherogenic LDL particles. Vascepa (icosapent ethyl [ethyl esters of EPA]) does not adversely affect LDL.

Doses of fish oil > 3 g/day may inhibit platelet aggregation. Monitor patients taking fish oils and drugs that affect bleeding (e.g., anticoagulants, antiplatelets). Continue to emphasize usual measures such as adherence to statins and antihypertensive medications, exercise, and quitting smoking.

Table (2). Key Points About Fish Oil Supplements
POINTS COMMENTS
Efficacy Reduces risk for sudden death
Reduces all-cause mortality
Lowers serum triglyceride levels
Modest effect on lowering blood pressure in patients with hypertension
Reduces morning stiffness and number of tender, swollen joints in patients with rheumatoid arthritis
Adverse effects Generally well tolerated. Side effects may include fishy aftertaste, gastrointestinal disturbances (e.g., nausea, bloating, belching), prolonged bleeding time, elevations in LDL-C, and exposure to environmental contaminants with certain fish species
Interactions No significant drug interactions
Dosage Capsules: 1 g generally contains 180 mg of EPA and 120 mg of DHA
Liquid concentrate: 1 tsp contains approximately 1 to 3 g of EPA plus DHA
For cardiac health, approximately 1 g of EPA plus DHA daily
For lowering triglycerides, 2 to 4 g of EPA plus DHA daily
For rheumatoid arthritis, ≥ 3 g of EPA plus DHA daily
Types of fish oil supplements Cod liver oil (rich in vitamin A)
Standard fish body oil (e.g., salmon)
Omega-3 fatty acid concentrate
LDL-C = low-density lipoprotein cholesterol; EPA = eicosapentaenoic acid; DHA = docosahexaenoic acid.

References