Which alternative is best if my main goal is preventing heart death?

The short version: for preventing heart death specifically, icosapent ethyl is the only non-statin here with a trial showing fewer cardiovascular deaths. Everything else cut combined events, not death.

The question is narrower than last time: not "which alternative works," but "which one prevents heart death." On that outcome, the evidence separates cleanly. In REDUCE-IT, icosapent ethyl 4 g/day on top of a statin cut cardiovascular death from 5.2% to 4.3% over a median 4.9 years, HR 0.80 [1]. That is roughly 1 fewer cardiovascular death per 100 people treated. It is a prespecified secondary endpoint, not the primary one, so weigh it as a real but secondary finding.

The rest failed on death. Ezetimibe added to simvastatin after acute coronary syndrome: 6.9% vs 6.8%, HR 1.0 [1]. Alirocumab: 2.5% vs 2.9%, HR 0.88, not significant [1]. Evolocumab: 1.8% vs 1.7%, HR 1.05 [1]. Bempedoic acid in statin-intolerant patients: 3.8% vs 3.7%, HR 1.04 [1]. Bempedoic acid did cut the composite endpoint by 13% in that same statin-intolerant group [2], but not death. Inclisiran has no completed outcome trial at all [2].

Two caveats. Every one of these trials added the drug to a statin, so none of them tests a statin-free regimen, which is the situation you actually described. And REDUCE-IT enrolled people with elevated triglycerides and either established heart disease or diabetes with an extra risk factor [1]; if your triglycerides are normal, that result may not transfer to you. The review is a narrative summary, not a pooled analysis, and I cannot see its funding or the full trial data behind it.

My call: icosapent ethyl is the best-evidenced choice for preventing heart death, but only if your triglycerides are in the 150 to 499 range and you are already at high risk. Confidence: moderate.