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Question: How might a primary care clinician determine the appropriate role of omega fatty acids in patients at risk for cardiovascular disease?
Answer: The most protective omega-3 fatty acids (omega-3s) for cardiovascular health are eicosapentaenoic acid (EPA) and docosahexaenoic acid (DHA). Sources of EPA and DHA include seafood/fish (especially cold-water fish), supplements, and prescription forms (Omacor, Reliant).
A survey of family physicians in Washington State found that only 17% of respondents recommended fish intake to their patients. Giving the recommendation was associated with having more time available for in-office dietary counseling.1
The primary and secondary preventive benefits of omega-3s in cardiovascular disease (CVD) were reviewed recently and include a 17% reduction in overall mortality and a 36% reduction in coronary death with 200–250 mg daily intake of EPA/DHA.2,3
Patients with known coronary heart disease may benefit from higher daily doses. The GISSI-Prevenzione trial involving more than 11,000 participants with recent myocardial infarction (MI) demonstrated that 1,000 mg/day of combined EPA/DHA reduced risk by 25%, 30%, and 45% for all-cause death, coronary death, and sudden death respectively, establishing the role for omega-3 oils in secondary prevention.4 Higher doses also appear to reduce heart rate and blood pressure and have antithrombotic effects. Additional cardiovascular benefits may include protection against ischemic stroke, nonfatal MI, progression of atherosclerosis, recurrent ventricular tachyarrhythmias, atrial fibrillation, and congestive heart failure.2,3,5,6
One exception to the overall cardiovascular benefits of omega-3 oils may be in patients with implantable defibrillators, in whom strong protective benefits have not been observed.7–9
Isolated case reports have raised concerns about the combination of omega-3 oils with anticoagulants, including aspirin and warfarin (Coumadin, Bristol-Myers Squibb). Although clinical trials testing the impact of omega-3–anticoagulant combinations are limited, significant impact on coagulation parameters has not been reported.10
Primary care providers should consider recommending the use of omega-3 oils
(seafood/fish intake, supplementation, or prescription) to all patients with
and at risk for CVD, with few exceptions. The recommended dose should depend
on the patient's individual clinical goal and health status, but a recent
American Heart Association statement provides more guidelines: consume fish,
especially oily fish, at least twice weekly. Patients with CVD are advised to
consume 
1 g EPA and DHA per day, preferably from oily fish, but EPA and
DHA supplements could be considered in consultation with their physician. In
patients with hypertriglycemia, 2–4 g EPA and DHA daily in capsules may
be recommended.11
Footnotes
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References
2. Mozaffarian D, Rimm EB: Fish intake, contaminants, and human
health: Evaluating the risks and the benefits. JAMA 296: 1885–1899, 2006.
3. Wang C, Harris WS, Chung M, et al.: n-3 Fatty acids from fish or
fish-oil supplements, but not alpha-linolenic acid, benefit cardiovascular
disease outcomes in primary- and secondary-prevention studies: A systematic
review. Am J Clin Nutr 84:5–17, 2006.
4. Marchioli R, Levantesi G, Macchia A, et al.: Antiarrhythmic mechanisms of n-3 PUFA and the results of the GISSI-Prevenzione trial. J Membr Biol 206:117–128, 2005.[Medline]
5. Reiffel JA, McDonald A: Antiarrhythmic effects of omega-3 fatty acids. Am J Cardiol 98:50i–60i, 2006.[Medline]
6. Psota TL, Gebauer SK, Kris-Etherton P: Dietary omega-3 fatty acid intake and cardiovascular risk. Am J Cardiol 98: 3i–18i, 2006.[Medline]
7. Raitt MH, Connor WE, Morris C, et al.: Fish oil supplementation and
risk of ventricular tachycardia and ventricular fibrillation in patients with
implantable defibrillators: A randomized controlled trial.
JAMA 293:2884–2891, 2005.
8. Brouwer IA, Zock PL, Camm AJ, et al.: Effect of fish oil on
ventricular tachyarrhythmia and death in patients with implantable
cardioverter defibrillators: The Study on Omega-3 Fatty Acids and Ventricular
Arrhythmia (SOFA) randomized trial. JAMA 295: 2613–2619, 2006.
9. Leaf A, Albert CM, Josephson M, et al.: Prevention of fatal arrhythmias in high-risk subjects by fish oil n-3 fatty acid intake. Circulation 112:2762–2768, 2005.
10. Eritsland J, Anesen H, Seljeflot I, et al.: Long-term effects of n-3 polyunsaturated fatty acids on haemostatic variables and bleeding episodes in patients with coronary artery disease. Blood Coagul Fibrinolysis 6:17–22, 1995.[Medline]
11. Alice H, Lichtenstein L, Appel M, et al.: Diet and lifestyle recommendations revision 2006: A scientific statement from the American Heart Association nutrition committee. Circulation 14: 82–96, 2006.
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