Polypill for cardiovascular disease prevention: Systematic review and meta-analysis of randomized controlled trials

Medication Adherence With Polypill in Cardiovascular Disease and High-Risk Patients: A Systematic Review and Meta-Analysis of Randomized Controlled Trials Involving 7364 Participants

Considering the worldwide mortality and morbidity of cardiovascular diseases (CVDs), the necessity of using multiple pills due to the chronicity of this condition, and the importance of medication adherence in these patients, we conducted this systematic review and meta-analysis to assess the polypill effect on adherence in patients with established CVD and at high risk. To accomplish this review, we searched various databases to access grey literature and several electronic databases to find randomized controlled trials (RCTs) assessing polypills compared to individual pills from January 2000 to October 2022. The outcomes were primarily medication adherence, secondarily systolic blood pressure (SBP), low-density lipoprotein cholesterol (LDL-C) serum level, and serious adverse events (SAEs). Ultimately, 2820 studies were detected and narrowed to 8 RCTs based on the eligibility criteria. In this study, involving 7364 patients, there was a significant improvement in medication adherence in the polypill group compared to the individual pills group (Risk Ratio [RR] = 1.29; [95%CI: 1.10; 1.50]). Out of secondary outcomes, SBP was significantly decreased (Mean Difference [MD] = -1.72 mmHg; [95%CI: -2.40; 1.03]), but LDL-C serum level (MD = -0.65 mg/dl; [95%CI: -4.47; 3.16]) and SAE (RR = 1.08; [95%CI: f0.98; 1.20]) did not have a notable difference in polypill compared to individual pills.

Efficacy and Safety of a Polypill to Reduce Cardiovascular Events: A Review of Clinical Trials

ABSTRACT

Cardiovascular disease continues to be the leading cause of mortality globally. Modifiable risk factors, such as hypertension and dyslipidemia, can be managed through lifestyle and pharmacotherapy treatments to reduce the risk of primary and secondary major cardiovascular events in patients with elevated risk. Despite effective and available medications to manage and mitigate cardiovascular risk factors, control rates of hypertension and dyslipidemia are suboptimal, and greater efforts are needed to reduce cardiovascular event rates worldwide. A polypill containing several classes of medications proven to lower cardiovascular risk in a single-dose form has been associated with improved medication adherence over multiple single-ingredient medications and may lead to reduced cardiovascular events. The goal of this article is to review available data from clinical trials assessing the efficacy and safety of polypills compared with placebo or usual care for cardiovascular risk reduction. Three databases were searched (PubMed/MEDLINE, CINAHL, and ScienceDirect) for randomized trials that compared a single polypill with usual care or placebo and reported major adverse cardiovascular events for each study group. A total of 6 trials were selected for inclusion. Several polypill formulations were compared with placebo or usual care with multiple single-ingredient medications in study populations consisting of both primary and secondary prevention patients. Overall, the polypill seems to be associated with reduced major adverse cardiovascular event and comparable safety with usual care treatment with an added benefit of improved adherence over multiple single-ingredient medications. The polypill has potential to be a cost-effective intervention to reduce the global burden of cardiovascular disease.

The Impact of Polypill on Adherence and Cardiovascular Outcomes: A Comprehensive Systematic Review with Meta-Analysis

BACKGROUND

Cardiovascular disease (CVD) remains a leading cause of morbidity and mortality worldwide. Polypills, containing various combinations of medications for primary and secondary CVD prevention, have been developed to enhance medication adherence and reduce the healthcare burden of CVD. However, their effectiveness compared to usual care remains uncertain.

OBJECTIVE

This meta-analysis aimed to evaluate the effects of polypills on cardiovascular risk factors, major adverse cardiovascular events (MACE), and medication adherence.

METHODS

We conducted a comprehensive search for large-scale randomized controlled trials and observational studies comparing the effects of polypills versus usual care on CVD risk factors and events. Outcomes included changes in systolic and diastolic blood pressure (SBP, DBP), lipid profiles, occurrence of MACE, and medication adherence.

RESULTS

The use of polypills led to a statistically significant yet clinically modest reduction in SBP (mean difference -1.47 mmHg, 95% CI: -2.50 to -0.44, p<0.01) and DBP (mean difference- 1.10 mmHg, 95% CI: -1.68 to -0.51, p< 0.01) compared to usual care. Polypills also showed a significant reduction in the risk of MACE (RR: 0.86, 95% CI: 0.77 -0.95, p<0.01). There was a non-significant reduction in LDL and HDL levels. Adherence to medication improved by up to 17% in polypill users compared to those on usual care (p < 0.01). A multivariable metaregression analysis suggested that adherence may be the underlying factor responsible for the observed effect of the polypills on blood pressure.

CONCLUSION

Polypills were found to significantly reduce SBP, DBP and MACE. An improvement in medication adherence was also observed among polypill users, which might be responsible for the significant reduction in SBP observed users. Future research might benefit from exploring a more personalized approach to the composition of polypills, which could reveal a more clinically significant impact of increased adherence on CVD outcomes.

Polypill-based strategy vs. usual care for secondary prevention of cardiovascular disease: a meta-analysis of randomized controlled trials

AIMS

We aimed to perform a systematic review and meta-analysis of randomized controlled trials (RCTs) to determine the impact of a polypill-based strategy (PBS) on therapeutic adherence and cardiovascular outcomes compared with usual care for secondary prevention of cardiovascular diseases (CVDs).

METHODS AND RESULTS

We systematically searched PubMed, Cochrane, and Scopus databases from inception to January 2023, including RCTs comparing PBS with usual care in patients with prior CVD. We assessed efficacy outcomes of therapeutic adherence, systolic blood pressure (SBP), and LDL-cholesterol (LDL-C) and safety outcomes of all-cause and cardiovascular mortality. Statistical analysis was performed with Review Manager 5.4.1 and R Version 4.2.1. A total of 8 RCTs with a population of 6541 individuals were included, of whom 3318 (50.7%) were treated with the PBS. Follow-up ranged from 6 to 60 months. The polypill-based strategy was associated with a significantly increased therapeutic adherence [risk ratio (RR) 1.22; 95% confidence interval (CI) 1.10-1.34; P < 0.001]. Cardiovascular mortality (RR 0.61; 95% CI 0.44-0.85; P = 0.004), SBP [mean difference (MD) -1.47 mmHg; 95% CI -2.86 to -0.09; P = 0.04], and LDL-C (MD -3.83 mg/dL; 95% CI -6.99 to -0.67; P = 0.02) were significantly lower in the PBS group. The incidence of all-cause mortality was similar between groups (RR 0.83; 95% CI 0.54-1.29; P = 0.41).

CONCLUSION

In patients with pre-existing CVD, a PBS is associated with lower cardiovascular mortality and improved therapeutic adherence, along with a modest decrease in SBP and LDL-C compared with usual care. Thus, a PBS may be considered a preferred option for this patient population.

The Effectiveness of Polypill for the Prevention of Cardiovascular Disease: A Meta-Analysis of Randomized Controlled Trials

A significant global health concern, cardiovascular disease (CVD) is characterized by a rising prevalence and accompanying mortality rates. It is crucial to implement primary and secondary prevention strategies, particularly in resource-scarce settings. Polypills, which combine blood pressure, cholesterol, and homocysteine drugs, hold significant potential for lowering the risk of CVD. This study follows PRISMA meta-analysis guidelines. Two researchers conducted an extensive literature search. Inclusion criteria encompassed RCT design, polypill use, a four-week duration, and one meta-analysis outcome. Primary outcomes included MACE and CV mortality, while secondary outcomes encompassed SBP and LDL-C changes. Data extraction was performed independently, and conflicts were resolved. Review Manager 5.4 with random effects was employed for statistical analysis, and ROB 2.0 bias evaluation was conducted. The study reported CVD mortality and MACE risk ratios (RRs) with 95% CIs, as well as SBP and LDL-C weighted mean differences (MD). A total of 24 trials were included in this meta-analysis. The results revealed that the polypill was associated with a decreased risk of CVD mortality and major adverse cardiovascular events (MACE). Additionally, a significant reduction in systolic blood pressure (SBP) and low-density lipoprotein cholesterol (LDL-C) was observed. This meta-analysis showed that polypill is a viable medication for reducing the risk of CVD mortality and MACE. It is also a beneficial medication for lowering LDL-C levels and SBP.

Redefining the polypill: pros and cons in cardiovascular precision medicine

Polypill is a multi-drug formulation in a single pill intended to simplify the drug regimen and reduce medication-induced adverse effects. The most common multidrug combinations in a polypill are used to treat cardiovascular diseases and are targeted against key modifiable risk factors such as hypertension and hyperlipidemia. These contain blood-pressure lowering agents, statins, and anti-platelet agents usually in a fixed dose. Polypills can be an affordable therapeutic intervention for treating high-risk patients, as these are proven to increase patients' adherence to medication and improve clinical outcomes. Over the previous years, randomized clinical trials of several polypills have yielded contradictory findings, raising skepticism regarding their widespread use in primary disease prevention. Here, we have reviewed the concept of polypills, the evidence-based strengths, the limitations of this polypharmacy intervention strategy, and discussed future directions for their use in the primary and secondary preventive management of cardiovascular diseases and associated risk factors.

Hypertension therapy using fixed-dose polypills that contain at least three medications

Fixed-dose combination (FDC) therapy may provide a solution to treatment gaps by overcoming reasons for therapeutic inertia. To synthesise and report on available evidence on standard or low-dose combination medicines that combine at least three antihypertensive medicines. A literature search was conducted via Scopus, Embase, PubMed and the Cochrane clinical trials database. Studies were eligible for inclusion if they were randomised clinical trials that included adults (>18 years) and examined the impact of at least three antihypertensive medications on blood pressure (BP). A total of 18 trials (n=14 307) were identified that examined combinations of three or four antihypertensive medicines. Ten trials investigated the effect of a standard dose triple combination polypill, four the effect of a low-dose triple and four the effect of a low-dose quadruple combination polypill. The mean difference (MD) in systolic BP ranged from -10.6 to -41.4 for the standard dose triple combination polypill in comparison with 2.1 to -34.5 for dual combination; -9.8 to -20.6 for a low-dose combination polypill in comparison with a MD of -0.9 to -5.2 for placebo; -9.0 to -29.3 for a low-dose combination polypill compared with -2.0 to -20.6 for monotherapy or usual care. All trials reported similar rates of adverse events. Ten studies reported medication adherence, six reported >95% adherence. Triple and quadruple combination antihypertensive medications are effective. Studies of low-dose triple and quadruple combinations involving treatment naïve populations suggest initiating such combinations are safe and effective as first-line therapy for stage 2 hypertension (BP >140/90 mm Hg).

Risk Amplifiers for Vascular Disease and CKD in South Asians: When Intrinsic β-Cell Dysfunction Meets a High-Carbohydrate Diet

South Asians, comprising almost one fourth of the world population, are at higher risk of type 2 diabetes mellitus, hypertension, cardiovascular disease, and CKD compared with other ethnic groups. This has major public health implications in South Asia and in other parts of the world to where South Asians have immigrated. The interplay of various modifiable and nonmodifiable risk factors confers this risk. Traditional models of cardiometabolic disease progression and CKD evaluation may not be applicable in this population with a unique genetic predisposition and phenotype. A wider understanding of dietary and lifestyle influences, genetic and metabolic risk factors, and the pitfalls of conventional equations estimating kidney function in this population are required in providing care for kidney diseases. Targeted screening of this population for metabolic and vascular risk factors and individualized management plan for disease management may be necessary. Addressing unhealthy dietary patterns, promoting physical activity, and medication management that adheres to cultural factors are crucial steps to mitigate the risk of cardiovascular disease and CKD in this population. In South Asian countries, a large rural and urban community-based multipronged approach using polypills and community health workers to decrease the incidence of these diseases may be cost-effective.

Adoption and scale-up of the cardiovascular Polypill: a realist institutional analysis

Efforts to promote the adoption and scale-up of health system innovations must contend with the existing institutional context. But there are no commonly used frameworks to ensure that the insights of actors involved in such institutional efforts connect to one another. To test and modify a potential framework-the 'four-by-four' framework-we interviewed researcher-entrepreneurs involved in the unfolding story of the cardiovascular Polypill. The framework has four types/levels of institutions that affect adoption and scale-up: (1) informal institutions (L1, e.g. social norms), (2) formal institutions (L2, e.g. government policies and regulation), (3) organizational structures (L3, e.g. organizational boards and mission) and (4) everyday exchange (L4, e.g. service delivery), vis-à-vis four potential entrepreneurial strategies in response: (1) abide by existing institutions, (2) evade them, (3) alter them and/or (4) exit entrepreneurial action. Using this framework, we conducted a realist-informed analysis to understand how context (i.e. institutions) and mechanism (i.e. entrepreneurial strategies) influence each other to shape outcomes (i.e. adoption and scale-up). We found that researcher-entrepreneurs began with efforts to abide with existing institutions but encountered institutional obstacles at each level. Efforts to abide were followed by seeking to evade and/or alter unfavourable institutions, with greater success evading and/or altering lower (L3 and L4) than upper (L1 and L2) institutions. Exit considerations followed the failure of the evade or alter strategy. Shifts between strategies were propelled by 'learning'. The 'four-by-four' framework can be used as a scaffold to generate narratives of adoption or scale-up efforts, a sensitizing tool to prospectively map out contingencies and a matrix to synthesize narratives and experiences across multiple innovations or settings. Used in these ways, the 'four-by-four' framework can help to optimize the transferability and cumulation of insights on how to promote the adoption and scale-up of health system innovations.

Multimorbidity, polypharmacy and inappropriate prescribing in elderly patients with atrial fibrillation: A report from the China Atrial Fibrillation Registry Study

Background

Multimorbidity, polypharmacy and inappropriate prescribing is common in elderly patients worldwide. We aimed to explore the current status of multimorbidity, polypharmacy and the appropriateness of pharmacological therapy among elderly patients with atrial fibrillation (AF) in China.

Materials and methods

We randomly selected 500 patients aged 65 years or older from the China AF Registry study. Multimorbidity was defined as ≥2 comorbidities and polypharmacy was defined as ≥5 long-term prescribed drugs. Appropriateness of prescribing was evaluated using the Screening Tool of Older People’s Prescriptions/Screening Tool to Alert to Right Treatment (STOPP/START) criteria version 2. Patients’ attitudes toward polypharmacy were evaluated by the Patients’ Attitudes Towards Deprescribing (PATD) questionnaire.

Results

Among the 500 patients included (mean age 75.2 ± 6.7 years, 49.0% male), 98.0% had multimorbidity and 49.4% had polypharmacy. The prevalence of potentially inappropriate medications (PIMs) and potential prescribing omissions (PPOs) was 43.6% (n = 218) and 71.6% (n = 358), respectively. Traditional Chinese medicine attributed largely to PIMs. Anticoagulants were the most common PPOs. Many clinical factors increased the risk of PIMs and PPOs. However, polypharmacy increased the risk of PIMs (OR 2.70, 95%CI 1.78–4.11; p &lt; 0.0001), but not PPOs. In addition, 73.7% patients with polypharmacy were willing to have one or more of their medications prescribed if advised by their doctor.

Conclusion

Multimorbidity and polypharmacy were highly prevalent in elderly patients with AF in China. A high prevalence of inappropriate prescribing was also observed. Therefore, much more attention should be paid to the serious health problem in the elderly population.