Randomized Trial for Evaluation in Secondary Prevention Efficacy of Combination Therapy-Statin and Eicosapentaenoic Acid (RESPECT-EPA).

Background: Low plasma levels of eicosapentaenoic acid (EPA) are associated with cardiovascular events. This trial aimed to assess the clinical benefits of icosapent ethyl in patients with coronary artery disease, a low EPA/arachidonic acid (AA) ratio, and statin treatment.
Methods: In this prospective, multicenter, randomized, open-label, blinded end-point study, patients with stable coronary artery disease and a low EPA/AA ratio (<0.4) were randomized to EPA (1800 of icosapent ethyl administered daily) or control group. The primary end point was a composite of cardiovascular death, nonfatal myocardial infarction, nonfatal ischemic stroke, unstable angina pectoris, and coronary revascularization. The secondary composite end points of coronary events included sudden cardiac death, fatal and nonfatal myocardial infarction, unstable angina requiring emergency hospitalization and coronary revascularization, or coronary revascularization.
Results: Overall, 3884 patients were enrolled at 95 sites in Japan. Among them, 2506 patients had a low EPA/AA ratio, and 1249 and 1257 patients were randomized to the EPA and control group, respectively. The median EPA/AA ratio was 0.243 (interquartile range, 0.180-0.314) and 0.235 (interquartile range, 0.163-0.310) in the EPA and control group, respectively. Over a median period of 5 years, the primary end point occurred in 112 of 1225 patients (9.1%) and 155 of 1235 patients (12.6%) in the EPA and control group, respectively (hazard ratio, 0.79 [95% CI, 0.62-1.00]; P =0.055). Meanwhile, the secondary composite end point of coronary events in the EPA group was significantly lower (81/1225 [6.6%] versus 120/1235 [9.7%] patients; hazard ratio, 0.73 [95% CI, 0.55-0.97]). Adverse events did not differ between the groups, but the rate of new-onset atrial fibrillation was significantly higher in the EPA group (3.1% versus 1.6%; P =0.017).
Conclusions: Icosapent ethyl treatment resulted in a numerically lower risk of cardiovascular events that did not reach statistical significance in patients with chronic coronary artery disease, a low EPA/AA ratio, and statin treatment.
Registration: URL: https://www.umin.ac.jp/ctr/; Unique identifier: UMIN000012069.
Competing Interests: Dr Miyauchi has received lecture fees from Amgen Astellas BioPharma, Astellas Pharma, MSD, Bayer Yakuhin, Sanofi, Takeda Pharmaceutical, Daiichi-Sankyo, Nippon Boehringer Ingelheim, and Bristol-Myers Squibb. Dr Iwata has received lecture fees from Kowa, Daiichi-Sankyo, Sumitomo Pharma, MSD, Novo Nordisk, Mochida Pharmaceutical, and Bayer Yakuhin. Dr Hirayama has received lecture fees from Bayer Yakuhin and Daiichi-Sankyo. Dr Kimura has received grants from Bayer Yakuhin, consulting fees from Idorsia Pharmaceuticals Japan, and lecture fees from Bayer Yakuhin and Daiichi-Sankyo. Dr Ozaki has received grants from Takeda Pharmaceutical, Daiichi-Sankyo, and Otsuka Pharmaceutical. Dr Murohara has received from Daiichi-Sankyo, Jansen Pharmaceutical, Bayer Yakuhin, Ono Pharmaceutical, Mochida Pharmaceutical, Pfizer, AstraZeneca, and Boehringer Ingelheim Japan. Dr Daida has received grants from Philips Japan, FUJIFILM Holdings Corp, Asahi Kasei Corp, Inter Reha, TOHO HOLDINGS, GLORY, Bristol-Myers Squibb, Abbott Japan, Boehringer Ingelheim Japan, Eisai, Bayer Yakuhin, and Daiichi-Sankyo, as well as lecture fees from Novartis Pharma, Bayer Yakuhin, Sanofi, Kowa, Taisho Pharmaceutical, Abbott Medical Japan, Otsuka Pharmaceutical, Amgen, MSD, Daiichi-Sankyo, Pfizer Japan, FUKUDA DENSHI, Tsumura, and TOA EIYO. The other authors report no conflicts.