Polypills for the prevention of Cardiovascular diseases

PoLA/CFPiP/PCS/PSLD/PSD/PSH guidelines on diagnosis and therapy of lipid disorders in Poland 2021

In Poland there are still nearly 20 million individuals with hypercholesterolaemia, most of them are unaware of their condition; that is also why only ca. 5% of patients with familial hypercholesterolaemia have been diagnosed; that is why other rare cholesterol metabolism disorders are so rarely diagnosed in Poland. Let us hope that these guidelines, being an effect of work of experts representing 6 main scientific societies, as well as the network of PoLA lipid centers being a part of the EAS lipid centers, certification of lipidologists by PoLA, or the growing number of centers for rare diseases, with a network planned by the Ministry of Health, improvements in coordinated care for patients after myocardial infarction (KOS-Zawał), reimbursement of innovative agents, as well as introduction in Poland of an effective primary prevention program, will make improvement in relation to these unmet needs in diagnostics and treatment of lipid disorders possible.

The value of the polypill in cardiovascular disease: an Italian multidisciplinary Delphi panel consensus

The purpose of this work was to reach the consensus of a multidisciplinary and multistakeholder Italian panel on the value of polypill in cardiovascular disease, with respect to the clinical, technological, economic and organizational dimension. A three-step modified Delphi method was used to establish consensus. Eleven experts in the area of cardiology, pharmaceutical technology, general practice, hospital pharmacy, pharmacology, and health economics participated in the expert panel. To identify existing evidence concerning the value of polypill in the prevention of patients with cardiovascular disease, a systematic literature review was carried out according to the Preferred Reporting Items for Systematic reviews and Meta-Analyses statement guidelines. In the first round, 22 statements were distributed to the panel. Panel members were asked to mark 'agree' or 'disagree' for each statement and provide any comments. The same voting method was again used for the second round. In the first round nine statements met consensus. In the second round, 10 statements reached consensus. Overall, consensus was reached for 19 statements representing five value polypill domains: clinical, technological, economic and organizational. During a final web meeting with all panel members consensus document open points were discussed. Panel members agreed to recognize polypill as effective in reducing cardiovascular events, blood pressure and lipids, cardiovascular risk and the weight of therapy, in therapeutic adherence improvement, in the absence of differences in bioavailability between drugs administered in fixed or free combinations and the better cost-effectiveness profile compared with standard care. This document represents a knowledge framework to inform decision makers of the value of polypill in cardiovascular prevention.

Polypill eligibility and equivalent intake in a Swiss population-based study

The polypill has been advocated for cardiovascular disease (CVD) management. The fraction of the population who could benefit from the polypill in Switzerland is unknown. Assess (1) the prevalence of subjects (a) eligible for the polypill and (b) already taking a polypill equivalent; and (2) the determinants of polypill intake in the first (2009–2012) and second follow-ups (2014–2017) of a population-based prospective study conducted in Lausanne, Switzerland. The first and the second follow-ups included 5038 and 4596 participants aged 40–80 years, respectively. Polypill eligibility was defined as having a high CVD risk as assessed by an absolute CVD risk ≥ 5% with the SCORE equation for Switzerland and/or presenting with CVD. Four polypill equivalents were defined: statin + any antihypertensive with (A) or without (B) aspirin; statin + calcium channel blocker (CCB) (C); and statin + CCB + angiotensin-converting enzyme inhibitor (D). The prevalence of polypill eligibility was 20.6% (95% CI 19.5–21.8) and 27.7% (26.5–29.1) in the first and second follow-up, respectively. However, only around one-third of the eligible 29.5% (95% CI 26.7–32.3) and 30.4% (27.9–33.0) respectively, already took the polypill equivalents. All polypill equivalents were more prevalent among men, elderly and in presence of CVD. After multivariable adjustment, in both periods, male gender was associated with taking polypill equivalent A (OR: 1.93; 95% CI 1.45–2.55 and OR: 1.67; 95% CI 1.27–2.19, respectively) and polypill equivalent B (OR: 1.52; 95% CI 1.17–1.96 and OR: 1.41; 95% CI 1.07–1.85, respectively). Similarly, in both periods, age over 70 years, compared to middle-age, was associated with taking polypill equivalent A (OR: 11.71; CI 6.74–20.33 and OR: 9.56; CI 4.13–22.13, respectively) and equivalent B (OR: 13.22; CI 7.27–24.07 and OR: 20.63; CI 6.51–56.36, respectively). Former or current smoking was also associated with a higher likelihood of taking polypill equivalent A in both periods. A large fraction of the population is eligible for the polypill, but only one-third of them actually benefits from an equivalent, and this proportion did not change over time.

The Use of Aspirin in Contemporary Primary Prevention of Atherosclerotic Cardiovascular Diseases Revisited: The Increasing Need and Call for a Personalized Therapeutic Approach

The use of aspirin has been widely accepted for the secondary prevention of atherosclerotic cardiovascular disease (ASCVD) in all patient populations, as the benefits linked to the reduction of clinical events outweigh the risk of major bleeding. However, despite the undisputable, though modest, potential of aspirin to reduce atherothrombotic events, its overall efficacy and safety in primary ASCVD prevention remains debatable, despite being used for this purpose for decades. The net clinical benefit of aspirin was brought into question by three recent large contemporary randomized controlled trials evaluating its role in various primary prevention populations (individuals with diabetes [ASCEND], an elderly population [ASPREE], and middle-aged adults at high estimated cardiovascular risk [ARRIVE]) and numerous large meta-analyses published during the past year. As a result, the usual generalized recommendations for the use of aspirin in patients with estimated intermediate to high ASCVD risk but without overt ASCVD have already been removed from most international guidelines. Since the primary prevention framework encompasses heterogenous groups of subjects with variable absolute ASCVD risk, a more individualized approach based on the best possible estimated ratio between the potential health benefits from fewer atherothrombotic events and harms because of potential increases in major bleeding is warranted in clinical practice. With this compromise, clinicians can better decide on the personalized use of aspirin in patients at high risk of major adverse cardiovascular events.

The feasibility of polypill for cardiovascular disease prevention in Asian Population

Polypill is a fixed‐dose combination of medications with proven benefits for the prevention of cardiovascular disease (CVD). Its role in CVD prevention has been extensively debated since the inception of this concept in 2003. There are two major kinds of polypills in clinical studies. The first is polypill that combines multiple low‐dose medications for controlling only one CVD risk factor (such as high blood pressure or high serum cholesterol). These “single‐purpose” polypills were mostly developed from original producers and have higher cost. The polypill that combines 3‐4 pharmaceutical components, each with potential to reduce one major cardiovascular risk factors is “multi‐purpose” or “cardiovascular” polypill. Using data from various clinical trials and from meta‐analysis, Wald and Law claimed that this “cardiovascular” polypill when administered to every individual older than 55 years could reduce the incidence of CVD by more than 80%. Several short and intermediate to long‐term studies with different cardiovascular polypills in phase II and III trials showed that they could provide better adherence, equivalent, or better risk factor control and quality of life among users as compared to usual care. One recently published randomized controlled clinical trial demonstrated the effectiveness and safety of a four‐component polypill for both primary and secondary CVD prevention with acceptable number needed to treat (NNT) to prevent one major cardiovascular event. Considering the slow achievement of CVD prevention in many poor‐ and middle‐income Asian countries and also the need to further improve compliance of antihypertensive and lipid lowering medications in many high‐income Asian countries, the concept of “cardiovascular polypill” could be very useful. With further support from ongoing polypill cardiovascular outcome trials, polypill could be the foundation of the population‐based strategies for CVD prevention.

Fixed dose drug combinations - are they pharmacoeconomically sound? Findings and implications especially for lower- and middle-income countries

Introduction: There are positive aspects regarding the prescribing of fixed dose combinations (FDCs) versus prescribing the medicines separately. However, these have to be balanced against concerns including increased costs and their irrationality in some cases. Consequently, there is a need to review their value among lower- and middle-income countries (LMICs) which have the greatest prevalence of both infectious and noninfectious diseases and issues of affordability.Areas covered: Review of potential advantages, disadvantages, cost-effectiveness, and availability of FDCs in high priority disease areas in LMICs and possible initiatives to enhance the prescribing of valued FDCs and limit their use where there are concerns with their value.Expert commentary: FDCs are valued across LMICs. Advantages include potentially improved response rates, reduced adverse reactions, increased adherence rates, and reduced costs. Concerns include increased chances of drug:drug interactions, reduced effectiveness, potential for imprecise diagnoses and higher unjustified prices. Overall certain FDCs including those for malaria, tuberculosis, and hypertension are valued and listed in the country's essential medicine lists, with initiatives needed to enhance their prescribing where currently low prescribing rates. Proposed initiatives include robust clinical and economic data to address the current paucity of pharmacoeconomic data. Irrational FDCs persists in some countries which are being addressed.

Is type 2 diabetes mellitus a coronary heart disease equivalent or not? Do not just enjoy the debate and forget the patient!

In the last several years there has been a large debate whether patients with type 2 diabetes (T2DM) should be treated as those with high or very high cardiovascular risk, and whether T2DM should be considered as equivalent to coronary heart disease (CHD). It all started in the 2001 in National Cholesterol Education Program - Adult Treatment Panel III recommendations, and the knowledge has changed on this issue at least several times. But the main problem is that due to these inconsistencies and different approaches to the cardiovascular risk of T2DM patients, we have more and more patients with T2DM not effectively treated, and diabetologists mostly focus on glucose (glucocentric approach), often forgetting about the overall cardiovascular risk of those patients. In this review we discuss the above-mentioned topic, try to give some practical suggestions, and raise the issue of whether we should start a discussion on treating all patients with T2DM as those at very high cardiovascular risk, or to at least to try to unify the definition and find such variables/risk factors which are easy to measure to help physicians to treat those patients optimally. We have obviously discussed these issues in the context of new European Society of Cardiology (ESC)/European Association for the Study of Diabetes (EASD) Guidelines 2019.

Improvement of arterial wall phenotype in subjects at moderate cardiovascular risk induced by very low-dose fluvastatin/valsartan combination: a pilot study

BACKGROUND

The largest population that suffers from cardiovascular events are subjects at moderate cardiovascular risk. However, no effective and safe preventive treatment is available for this population. We investigated whether their arterial wall phenotype could be turned to a lower risk direction by low-dose fluvastatin/valsartan combination (low-flu/val).

METHODS

Twenty males at moderate cardiovascular risk (as classified by SCORE) were blindly randomized into the intervention group (N.=10, low-flu/val: 10 mg/20 mg) or control group (N.=10, placebo). At inclusion and after 30 days of treatment, brachial flow-mediated dilatation (FMD), β-stiffness coefficient, carotid pulse wave velocity (c-PWV), carotid-femoral PWV, Reactive Hyperemia Index, high-sensitivity C-reactive protein (hs-CRP), interleukin 6, vascular cell adhesion molecule 1, total antioxidant status and expression of several protective genes (SIRT1, mTOR, NF-κB1, NFE2L2, PRKAA1) were followed.

RESULTS

Treatment resulted in improved FMD (from 3% to 4.2%, P=0.008), c-PWV (from 6.7 to 6.2 m/s, P=0.006), hs-CRP (from 5.39 to 3.35 mg/L, P=0.041) and SIRT1 expression (3.34-fold difference, P=0.047). No other vascular, inflammation and genetic parameters changed. The hs-CRP values after intervention correlated significantly with SIRT1 expression. The improved FMD persisted even 10 weeks after treatment discontinuation. The obtained changes were not followed by changes of lipids or blood pressure. Overall, the results revealed improvement in three different, although interrelated preventive arterial wall characteristics.

CONCLUSIONS

This pilot study revealed that intervention with low-flu/val importantly shifts the arterial wall phenotype in a lower risk direction. This improvement could be interpolated into clinical benefits that remain to be further studied.

Mandatory Reporting of Coronary Artery Calcifications Incidentally Noted on Chest Multi-Detector Computed Tomography: A Multicentre Experience

BACKGROUND

Coronary Artery Calcifications (CACs) are associated with coronary atherosclerosis and Cardiovascular (CV) events. In "non-cardiovascular" settings, CACs can be easily detected on chest Multi-Detector Computed Tomography (MDCT). Their evaluation may help to better stratify CV risk in the general population, especially for primary prevention.

AIMS

We retrospectively evaluated the relationship between CAC distribution and CV risk, determined by Framingham Risk Score (FRS), in a cohort of patients who underwent chest MDCT performed for several clinical indications.

METHOD

We retrospectively recruited 305 patients (194 men, 111 women; mean age 70.5 years) from 3 different Italian centres. Patients with coronary stent, pacemaker and/or CV devices were excluded from the study. Circumflex Artery (LCX), Left Main Coronary Artery (LMCA), left Anterior Descending artery (LAD) and right coronary artery (RCA) were analysed.

RESULTS

From a total population of 305 patients, 119 (39%) had low FRS (<10%), 115 (38%) had intermediate FRS (10-20%), and 71 (23%) had high FRS (>20%). The study identified 842 CACs located in decreasing order as follows: RCA (34.5%), LAD (32.3%), LCX (28%) and LMCA (13%). Statistical two-step analysis subdivided patients into two clusters according to FRS (risk threshold = 12.38%): cluster I (mean 9.34) and cluster II (mean 15.09). A significant association between CAC distribution and cluster II was demonstrated. CACs were mostly detected in patients with intermediate FRS. All patients (100%) with the highest CV risk showed intermediate RCA and LMCA involvement.

CONCLUSION

Radiologists can note the distribution of CACs on a chest MDCT and should mandatorily record them in their reports. Depending on CAC presence and location, these findings may have important clinical implications, mostly in asymptomatic patients with intermediate FRS. This information may reclassify a patients' CV risk and improve clinical management.

Effects of resveratrol supplementation on risk factors of non-communicable diseases: A meta-analysis of randomized controlled trials

The results of randomized controlled trials (RCTs) investigating resveratrol supplementation on risk factors of non-communicable diseases (NCDs) have been inconsistent. The present meta-analysis aimed to quantitatively evaluate the effects of resveratrol intervention on risk factors of NCDs. PubMed and Scopus databases were searched up to June 2017. Weighted mean differences were calculated for net changes in risk factors of NCDs by using a random-effects model. Pre-specified subgroup and univariate meta-regression analyses were carried out to explore the sources of heterogeneity. Twenty-nine studies (30 treatment arms) with 1069 participants were identified. Resveratrol supplementation significantly reduced the concentrations of fasting glucose (-4.77 mg/dL; 95% CI: -9.33 to -0.21 mg/dL; P = 0.040), total cholesterol (TC) (-9.75 mg/dL; 95% CI: -17.04 to -2.46 mg/dL; P = 0.009), and C-reactive protein (CRP) (-0.81 mg/L; 95% CI: -1.42 to -0.21 mg/L; P = 0.009). Resveratrol intervention exerted significant reductions in systolic blood pressure (SBP) and diastolic blood pressure (DBP) in subjects with type 2 diabetes mellitus (T2DM). Subgroup analysis also showed that the trials with resveratrol intervention ≥3 months significantly reduced the low-density lipoprotein cholesterol (LDL-C), DBP, and glycated hemoglobin (HbA1c) values. The results did not support that resveratrol intervention had favorable effects in altering high-density lipoprotein cholesterol (HDL-C), triglyceride (TAG), and homeostasis model assessment of insulin resistance (HOMA-IR). The present study provides substantial evidence that resveratrol supplementation has favorable effects on several risk factors of NCDs.