Secondary cardiovascular prevention on statin therapy

Patients with established atherosclerotic cardiovascular disease on maximally tolerated statin therapy. Additional interventions aim to reduce residual cardiovascular risk.

ICD-10 I25.91 drug

Also known as: Secondary ASCVD prevention

Drugs used for this condition

COmega-3 triglycerides (EPA and DHA)Case-by-case decision · Lipid-modifying agents. Omega-3 polyunsaturated fatty acidsEvidence is conflicting. REDUCE-IT (NEJM 2019, 8,179 patients) showed a 25% reduction in major cardiovascular events with icosapent ethyl 4 g daily in statin-treated patients with triglycerides 150–500 mg/dL. However, STRENGTH (JAMA 2020, 13,078 patients) with a similar design but a different formulation (EPA+DHA) showed no benefit. The role of the mineral oil placebo in REDUCE-IT is debated. In both trials and in OMEMI (Circulation 2021), high-dose omega-3 therapy increased atrial fibrillation incidence by 30–70% depending on formulation. A meta-analysis of 5 large RCTs (Circulation 2021, Lombardi et al.) confirmed a dose-dependent atrial fibrillation risk. ESC 2021 includes icosapent ethyl for a narrow patient group with residual hypertriglyceridaemia. EPA+DHA mixtures (Omacor) are not indicated for cardiovascular risk reduction when triglycerides are normal.

How to read tiers A–F

Evidence tiers belong to the drug-indication pair, not to the drug as a whole: the same substance can be A for one condition and F for another.

AStrong evidence – first or second line in international guidelines
BRecommended in selected cases
CStudy data contradict each other
DBenefit not proven, no documented harm
FDocumented harm, or risk without benefit