Clinical Impact of the Polypill for Cardiovascular Prevention in Latin America: A Consensus Statement of the Inter-American Society of Cardiology

World Heart Federation Roadmap for Secondary Prevention of Cardiovascular Disease: 2023 Update

Background

Secondary prevention lifestyle and pharmacological treatment of atherosclerotic cardiovascular disease (ASCVD) reduce a high proportion of recurrent events and mortality. However, significant gaps exist between guideline recommendations and usual clinical practice.

Objectives

Describe the state of the art, the roadblocks, and successful strategies to overcome them in ASCVD secondary prevention management.

Methods

A writing group reviewed guidelines and research papers and received inputs from an international committee composed of cardiovascular prevention and health systems experts about the article's structure, content, and draft. Finally, an external expert group reviewed the paper.

Results

Smoking cessation, physical activity, diet and weight management, antiplatelets, statins, beta-blockers, renin-angiotensin-aldosterone system inhibitors, and cardiac rehabilitation reduce events and mortality. Potential roadblocks may occur at the individual, healthcare provider, and health system levels and include lack of access to healthcare and medicines, clinical inertia, lack of primary care infrastructure or built environments that support preventive cardiovascular health behaviours. Possible solutions include improving health literacy, self-management strategies, national policies to improve lifestyle and access to secondary prevention medication (including fix-dose combination therapy), implementing rehabilitation programs, and incorporating digital health interventions. Digital tools are being examined in a range of settings from enhancing self-management, risk factor control, and cardiac rehab.

Conclusions

Effective strategies for secondary prevention management exist, but there are barriers to their implementation. WHF roadmaps can facilitate the development of a strategic plan to identify and implement local and national level approaches for improving secondary prevention.

Benefits of the Polypill on Medication Adherence in the Primary and Secondary Prevention of Cardiovascular Disease: A Systematic Review

Background

Higher medication adherence reduces the risk of new cardiovascular events. However, there are individual and health system barriers that lead to lower adherence. The polypill has demonstrated benefits in cardiovascular morbidity and mortality mainly driven by an increase in adherence. We aim to evaluate the impact of the polypill on adherence to cardiovascular medication, its efficacy and safety in cardiovascular disease (CVD) prevention.

Methods

A systematic review following PRISMA guidelines was conducted. Databases were searched from January 2003 to December 2022. We included randomized, pragmatic, or real-world clinical trials and observational studies. The primary outcome was medication adherence, secondary outcomes were efficacy in cardiovascular disease in primary and secondary prevention and safety.

Results

From the 490 publications screened, 13 met the inclusion criteria and were incorporated into a comparative table Of those included, 70% were randomized controlled trials (RCTs) and 53.8% focused on secondary prevention. Most of the studies received a high and moderate quality rating. Self-report, pill counting and, the Morisky scale were the most frequent methods to evaluate adherence (84.6%). Compared with standard medication, the polypill improved overall medication adherence by 13%, with percentages ranging from 7.6% to 34.9%. Moreover, a potential benefit was also observed in reducing Major Adverse Cardiovascular Events (MACE), particularly in secondary prevention studies, with hazard ratios ranged between 0.43 to 0.76. Compared to standard care, the profile of side effects was similar.

Conclusion

The polypill is an effective, safe, and practical strategy to improve adherence in people at risk of CVD. Although there is a demonstrated benefit in reducing MACE, predominantly in secondary prevention, there are still gaps in its efficacy in primary prevention and reducing total mortality. Therefore, the importance of obtaining long-term results of the polypill effect and how this strategy can be implemented in real practice.

Impact of a Telemedicine Program After a Heart Failure Hospitalization on 12 Months Follow-Up Events

The aim of this study was to describe the safety, effectiveness, and usability of a mobile-app based follow up platform after a heart failure (HF) hospitalization. It was a pilot, prospective implementation study. 55 consecutive patients were included. Over 12 months, a significant increase in the use of renin angiotensin system inhibitors was observed (91% vs 76%, P < 0.04). Medication adherence, assessed by daily patient validation in the app was 96%. No relevant changes were found in biochemical evaluations. The parameters of app usability showed a high value. At 12 months follow-up one patient was hospitalized for HF (1/55 [1,8%]), there was no cardiovascular death, and 5 patients had non-cardiovascular deaths (5/55 [9.1%]). In patients recently discharged from HF hospitalization, the implementation of non-invasive telemedicine follow-up was feasible, safe and an effective strategy to increase the adherence to medical therapy. A high degree of clinical stability and a low rate of events were observed over 1-year.

El control de la hipertensión arterial, una asignatura pendiente

El adecuado diagnóstico, tratamiento y control de la hipertensión arterial (HTA) continúa siendo una asignatura pendiente en nuestro intento de reducir la incidencia de mortalidad cardiovascular prematura y discapacidades, siendo esta una realidad a nivel mundial y particularmente cierta en la región de las Américas.

A pesar de contar con adecuados algoritmos diagnósticos y eficientes esquemas de tratamiento, la brecha entre el conocimiento médico y la realidad nos muestra la gran dificultad para que nuestras recomendaciones sean adoptadas por nuestros pacientes. La adherencia representa un gran desafío y la adecuada comprensión de sus dimensiones resulta básico al momento de diseñar estrategias para mejorar el control de la HTA.

Es claro que disponer y diseminar información adecuada es una parte de la solución, pero no menos importante son las acciones que garanticen su implementación. Es por lo que damos la bienvenida a guías de práctica clínica que intenten abordar esta problemática. La reciente publicación de guía de la Organización Mundial de la Salud en hipertensión arterial es un claro ejemplo de este tipo de iniciativas.

Los programas de implementación posiblemente sean uno de los mayores desafíos de la medicina contemporánea. El desarrollo de intervenciones multimodales en el primer nivel de atención con el objetivo de mejorar su capacidad resolutiva y promover el desarrollo de redes integradas de servicios de salud, impresiona ser el camino mas adecuado para alcanzar niveles adecuados de control de la HTA.

Estamos convencidos del importante rol que nuestras sociedades científicas tienen con estas iniciativas dando apoyo, soporte y articulando la interacción con los diferentes actores involucrados.

Practical Decision Algorithms for the Use of the Cardiovascular Polypill in Secondary Prevention in Europe

The main objective of cardiovascular disease (CVD) prevention is to reduce morbidity and mortality. Despite recommendations on evidence-based pharmacological treatment and lifestyle changes, the control of CV risk factors such as hypertension or dyslipidaemia is not optimal. The use of a CV polypill, including guideline-recommended drugs, as a baseline therapy, may contribute to improving risk factors control either by improving the treatment adherence or by the synergistic effect of its components. The CNIC-Polypill is the first CV polypill approved in Europe as an effective strategy for secondary prevention, which contains acetylsalicylic acid, atorvastatin (in two optional doses), and ramipril (in three optional doses) in a single pill. The present practical clinical document aims to provide a guide for patient management after an acute coronary syndrome (ACS) or with chronic CVD (CCVD) with a strategy based on the CNIC-Polypill, also considering the need to add other therapies for a personalized treatment. The most suitable clinical scenarios for the CNIC-Polypill use are discussed: (a) in patients after an ACS at discharge, (b) in patients with CCVD (chronic coronary syndrome, stroke, or peripheral artery disease) with uncontrolled low-density lipoprotein cholesterol (LDL-c) and/or blood pressure levels and (c) in patients with CCVD with well-controlled risk factors to simplify treatment and reduce polypharmacy in the context of CCVD prevention.

Considerations and Guidance for the Structure, Organisation, and Operation of Cardiometabolic Prevention Units: A Consensus Statement of the Inter-American Society of Cardiology

Cardiovascular diseases (CVDs) remain the leading cause of death worldwide, particularly in low- and middle-income regions such as Latin America. This is because of the combination and interaction in different proportions of a high prevalence of cardiometabolic risk factors and socio-economic and cultural characteristics. This reality brings about the need to change paradigms to consistently and systematically boost cardiovascular prevention as the most cost-effective medium- to long-term strategy to reduce their prevalence in medium- and low-resource countries, not only in Latin America but also in other global regions.

To achieve the therapeutic goals in various diseases, including CVD, the current literature demonstrates that the most effective way is to carry out the patient’s diagnosis and treatment in multidisciplinary units. For this reason, the Inter American Society of Cardiology (IASC) proposes the creation of cardiometabolic prevention units (CMPUs) as a regional initiative exportable throughout the world to standardise cardiovascular prevention based on the best available evidence. This ensures homogeneity in the global management of cardiometabolic risk factors and access to quality medicine independently of the population’s social situation. These guidelines, written by a panel of experts in cardiovascular prevention, defines what a CMPU is, its objectives and the minimum requirements for it, as well as proposing three categories and suggesting an operational scheme. It must be used as a guide for all individuals or centres that, aware of the need for multidisciplinary and standardised work, want to create a unit for the comprehensive management of cardiometabolic risk established as an international research network.

Lastly, the document makes meaningful points on the determination of cardiovascular risk and its importance. These guidelines do not cover specific targets and therapeutic schemes, as these topics will be extensively discussed in another SIAC publication, namely a statement on residual cardiometabolic risk.

Innovative Implementation Strategies for Hypertension Control in Low- and Middle-Income Countries: a Narrative Review

PURPOSE OF REVIEW

This review summarizes the most recent and innovative implementation strategies for hypertension control in low- and middle-income countries (LMICs).

RECENT FINDINGS

Implementation strategies from Latin America, Africa, and Asia were organized across three levels: community, health system, and policy/population. Multicomponent interventions involving task-shifting strategies, with or without mobile health tools, had the most supporting evidence, with policy or population-level interventions having the least, focused only on salt reduction with mixed results. More research is needed to better understand how context affects intervention implementation. There is an emerging evidence base for implementation strategies for hypertension control and CVD risk reduction in LMICs at the community and health system levels, but further research is needed to determine the most effective policy and population-level strategies. How to best account for local context in adapting and implementing these evidence-based interventions in LMICs still remains largely unknown. Accelerating the translation of this implementation research into policy and practice is imperative to improve health and save lives globally.

Reaching blood pressure guideline targets with the CNIC polypill in patients with a previous cardiovascular event in Mexico: a post hoc analysis of the SORS study

Aim: To determine the effectiveness of Centro Nacional de Investigaciones Cardiovasculares (CNIC)-polypill (acetylsalicylic acid 100 mg, ramipril 5/10 mg, simvastatin 40 mg) in achieving blood pressure (BP) goals. Patients & methods: A multicenter, observational, one cohort, prospective study. BP targets were analyzed in patients with cardiovascular disease after 12-months treatment with the CNIC polypill. Results: A total of 572 patients (59.4 ± 13.9 years, 57.3% men) were analyzed. At baseline, BP was 147.1 ± 18.1/88.3 ± 10.6 mmHg, 97.1% of patients were taken renin-angiotensin system inhibitors, 5.4% calcium antagonists, 1.9% diuretics and 13.1% β-blockers. The proportion of patients who achieved BP targets increased from 20.1 to 55.4% (p < 0.001). Conclusion: In routine practice, switching from usual care to the CNIC-polypill in patients with cardiovascular disease could facilitate achieving BP goals.