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Tsai HS, Tseng WK, Yin WH, Lin FJ, Hsuan CF, Wu YW, Huang LC, Lin TH, Chang KC, Li YH, Yeh HI, Chen JW, Wu CC. The Correlation between Waist-Hip Ratio and Achieving Therapeutic Lipid Goals in Taiwan. ACTA CARDIOLOGICA SINICA 2019; 35:605-614. [PMID: 31879512 DOI: 10.6515/acs.201911_35(6).20190403a] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
Background Body mass index (BMI), waist circumference (WC) and waist-hip ratio (WHR) are all simple anthropometric tools used to categorize obesity status. This study aimed to determine associations between different anthropometric indices and the attainment of therapeutic lipid goals in patients with atherosclerotic cardiovascular disease (CVD) undergoing secondary prevention. Methods Between 2010 and 2014, this multi-center study enrolled 5718 patients undergoing secondary prevention for CVD. At study enrollment, total cholesterol, high-density lipoprotein protein cholesterol (HDL-C), low-density lipoprotein cholesterol (LDL-C) and triglyceride (TG) were recorded. This cross-sectional study analyzed these three anthropometric obesity indices and correlations with achieving therapeutic lipid goals. Results Among the 5718 patients, multivariate analysis revealed that those with higher BMI or WC tended not to meet their HDL-C and TG therapeutic goals. However, neither BMI nor WC showed a relationship with achieving the LDL-C target. The patients with an elevated WHR (≥ 0.98 for males and ≥ 0.97 for females) were less likely to achieve all three lipid target values, including LDL-C (p = 0.05), HDL-C (p < 0.001) and TG (p < 0.001). Conclusions Among Taiwanese patients undergoing secondary prevention for CVD, the higher the WHR the lower the likelihood of achieving the lipid therapeutic goals.
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Affiliation(s)
- Hsing-Shan Tsai
- Division of Cardiology, Department of Internal Medicine, E-DA Hospital/I-Shou University
| | - Wei-Kung Tseng
- Division of Cardiology, Department of Internal Medicine, E-DA Hospital/I-Shou University.,Department of Medical Imaging and Radiological Sciences, I-Shou University, Kaohsiung
| | - Wei-Hsian Yin
- National Yang-Ming University School of Medicine.,Division of Cardiology, Heart Center, Cheng-Hsin General Hospital
| | - Fang-Ju Lin
- Graduate Institute of Clinical Pharmacy, College of Medicine.,School of Pharmacy, College of Medicine, National Taiwan University.,Department of Pharmacy, National Taiwan University Hospital
| | - Chen-Feng Hsuan
- Division of Cardiology, Department of Internal Medicine, E-DA Hospital/I-Shou University
| | - Yen-Wen Wu
- Departments of Nuclear Medicine, and Internal Medicine, National Taiwan University Hospital and National Taiwan University College of Medicine, Taipei.,Cardiology Division of Cardiovascular Medical Center and Department of Nuclear Medicine, Far Eastern Memorial Hospital, New Taipei City
| | - Lien-Chi Huang
- Division of Cardiology, Taipei City Hospital Heping Fuyou Branch, Taipei
| | - Tsung-Hsien Lin
- Faculty of Medicine, Kaohsiung Medical University, Kaohsiung
| | - Kuan-Cheng Chang
- Graduate Institute of Clinical Medical Science, China Medical University.,Division of Cardiovascular Medicine.,Cardiovascular Research Laboratory, China Medical University Hospital, Taichung
| | - Yi-Heng Li
- Department of Internal Medicine, National Cheng Kung University Hospital and College of Medicine, Tainan
| | - Hung-I Yeh
- Mackay Memorial Hospital, Mackay Medical College, New Taipei City
| | - Jaw-Wen Chen
- Department of Medical Research and Education, Taipei Veterans General Hospital.,Institute of Pharmacology, National Yang-Ming University
| | - Chau-Chung Wu
- Cardiology Division, Department of Internal Medicine, National Taiwan University Hospital.,Graduate Institute of Medical Education & Bioethics, College of Medicine, National Taiwan University, Taipei, Taiwan
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Shams T, Auchus AP, Oparil S, Wright CB, Wright J, Furlan AJ, Sila CA, Davis BR, Pressel S, Yamal JM, Einhorn PT, Lerner AJ. Baseline Quality of Life and Risk of Stroke in the ALLHAT Study (Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack Trial). Stroke 2017; 48:3078-3085. [PMID: 28954920 DOI: 10.1161/strokeaha.117.016062] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2016] [Revised: 08/09/2017] [Accepted: 08/11/2017] [Indexed: 11/16/2022]
Abstract
BACKGROUND AND PURPOSE The visual analogue scale is a self-reported, validated tool to measure quality of life (QoL). Our purpose was to determine whether baseline QoL predicted strokes in the ALLHAT study (Antihypertensive and Lipid Lowering Treatment to Prevent Heart Attack Trial) and evaluate determinants of poststroke change in QoL. In the ALLHAT study, among the 33 357 patients randomized to treatment arms, 1525 experienced strokes; 1202 (79%) strokes were nonfatal. This study cohort includes 32 318 (97%) subjects who completed the baseline visual analogue scale QoL estimate. METHODS QoL was measured on a visual analogue scale and adjusted using a Torrance transformation (transformed QoL [TQoL]). Kaplan-Meier curves and adjusted proportional hazards analyses were used to estimate the effect of TQoL on the risk of stroke, on a continuous scale (0-1) and by quartiles (≤0.81, >0.81≤0.89, >0.89≤0.95, >0.95). We analyzed the change from baseline to first poststroke TQoL using adjusted linear regression. RESULTS After adjusting for multiple stroke risk factors, the hazard ratio for stroke events for baseline TQoL was 0.93 (95% confidence interval, 0.89-0.98) per 0.1 U increase. The lowest baseline TQoL quartile had a 20% increased stroke risk (hazard ratio=1.20 [95% confidence interval, 1.00-1.44]) compared with the reference highest quartile TQoL. Poststroke TQoL change was significant within all treatment groups (P≤0.001). Multivariate regression analysis revealed that baseline TQoL was the strongest predictor of poststroke TQoL with similar results for the untransformed QoL. CONCLUSIONS The lowest baseline TQoL quartile had a 20% higher stroke risk than the highest quartile. Baseline TQoL was the only factor that predicted poststroke change in TQoL. CLINICAL TRIAL REGISTRATION URL: http://www.clinicaltrials.gov. Unique identifier: NCT00000542.
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Affiliation(s)
- Tanzila Shams
- From the Departments of Neurology (T.S., A.J.F., C.A.S., A.J.L.) and Medicine (J.W.), University Hospitals Case Medical Center, Cleveland, OH; Department of Neurology, University of Mississippi Medical Center, Jackson (A.P.A.); Department of Medicine, University of Alabama, Birmingham (S.O.); National Institute of Neurological Disorders and Stroke, Bethesda, MD (C.B.W.); Case Western Reserve University, Cleveland, OH (J.W., A.J.F., C.A.S., A.J.L.); University of Texas School of Public Health, Houston (B.R.D., S.P., J.-M.Y.); and Division of Cardiovascular Sciences, National Heart, Lung, and Blood Institute, Bethesda, MD (P.T.E.).
| | - Alexander P Auchus
- From the Departments of Neurology (T.S., A.J.F., C.A.S., A.J.L.) and Medicine (J.W.), University Hospitals Case Medical Center, Cleveland, OH; Department of Neurology, University of Mississippi Medical Center, Jackson (A.P.A.); Department of Medicine, University of Alabama, Birmingham (S.O.); National Institute of Neurological Disorders and Stroke, Bethesda, MD (C.B.W.); Case Western Reserve University, Cleveland, OH (J.W., A.J.F., C.A.S., A.J.L.); University of Texas School of Public Health, Houston (B.R.D., S.P., J.-M.Y.); and Division of Cardiovascular Sciences, National Heart, Lung, and Blood Institute, Bethesda, MD (P.T.E.)
| | - Suzanne Oparil
- From the Departments of Neurology (T.S., A.J.F., C.A.S., A.J.L.) and Medicine (J.W.), University Hospitals Case Medical Center, Cleveland, OH; Department of Neurology, University of Mississippi Medical Center, Jackson (A.P.A.); Department of Medicine, University of Alabama, Birmingham (S.O.); National Institute of Neurological Disorders and Stroke, Bethesda, MD (C.B.W.); Case Western Reserve University, Cleveland, OH (J.W., A.J.F., C.A.S., A.J.L.); University of Texas School of Public Health, Houston (B.R.D., S.P., J.-M.Y.); and Division of Cardiovascular Sciences, National Heart, Lung, and Blood Institute, Bethesda, MD (P.T.E.)
| | - Clinton B Wright
- From the Departments of Neurology (T.S., A.J.F., C.A.S., A.J.L.) and Medicine (J.W.), University Hospitals Case Medical Center, Cleveland, OH; Department of Neurology, University of Mississippi Medical Center, Jackson (A.P.A.); Department of Medicine, University of Alabama, Birmingham (S.O.); National Institute of Neurological Disorders and Stroke, Bethesda, MD (C.B.W.); Case Western Reserve University, Cleveland, OH (J.W., A.J.F., C.A.S., A.J.L.); University of Texas School of Public Health, Houston (B.R.D., S.P., J.-M.Y.); and Division of Cardiovascular Sciences, National Heart, Lung, and Blood Institute, Bethesda, MD (P.T.E.)
| | - Jackson Wright
- From the Departments of Neurology (T.S., A.J.F., C.A.S., A.J.L.) and Medicine (J.W.), University Hospitals Case Medical Center, Cleveland, OH; Department of Neurology, University of Mississippi Medical Center, Jackson (A.P.A.); Department of Medicine, University of Alabama, Birmingham (S.O.); National Institute of Neurological Disorders and Stroke, Bethesda, MD (C.B.W.); Case Western Reserve University, Cleveland, OH (J.W., A.J.F., C.A.S., A.J.L.); University of Texas School of Public Health, Houston (B.R.D., S.P., J.-M.Y.); and Division of Cardiovascular Sciences, National Heart, Lung, and Blood Institute, Bethesda, MD (P.T.E.)
| | - Anthony J Furlan
- From the Departments of Neurology (T.S., A.J.F., C.A.S., A.J.L.) and Medicine (J.W.), University Hospitals Case Medical Center, Cleveland, OH; Department of Neurology, University of Mississippi Medical Center, Jackson (A.P.A.); Department of Medicine, University of Alabama, Birmingham (S.O.); National Institute of Neurological Disorders and Stroke, Bethesda, MD (C.B.W.); Case Western Reserve University, Cleveland, OH (J.W., A.J.F., C.A.S., A.J.L.); University of Texas School of Public Health, Houston (B.R.D., S.P., J.-M.Y.); and Division of Cardiovascular Sciences, National Heart, Lung, and Blood Institute, Bethesda, MD (P.T.E.)
| | - Cathy A Sila
- From the Departments of Neurology (T.S., A.J.F., C.A.S., A.J.L.) and Medicine (J.W.), University Hospitals Case Medical Center, Cleveland, OH; Department of Neurology, University of Mississippi Medical Center, Jackson (A.P.A.); Department of Medicine, University of Alabama, Birmingham (S.O.); National Institute of Neurological Disorders and Stroke, Bethesda, MD (C.B.W.); Case Western Reserve University, Cleveland, OH (J.W., A.J.F., C.A.S., A.J.L.); University of Texas School of Public Health, Houston (B.R.D., S.P., J.-M.Y.); and Division of Cardiovascular Sciences, National Heart, Lung, and Blood Institute, Bethesda, MD (P.T.E.)
| | - Barry R Davis
- From the Departments of Neurology (T.S., A.J.F., C.A.S., A.J.L.) and Medicine (J.W.), University Hospitals Case Medical Center, Cleveland, OH; Department of Neurology, University of Mississippi Medical Center, Jackson (A.P.A.); Department of Medicine, University of Alabama, Birmingham (S.O.); National Institute of Neurological Disorders and Stroke, Bethesda, MD (C.B.W.); Case Western Reserve University, Cleveland, OH (J.W., A.J.F., C.A.S., A.J.L.); University of Texas School of Public Health, Houston (B.R.D., S.P., J.-M.Y.); and Division of Cardiovascular Sciences, National Heart, Lung, and Blood Institute, Bethesda, MD (P.T.E.)
| | - Sara Pressel
- From the Departments of Neurology (T.S., A.J.F., C.A.S., A.J.L.) and Medicine (J.W.), University Hospitals Case Medical Center, Cleveland, OH; Department of Neurology, University of Mississippi Medical Center, Jackson (A.P.A.); Department of Medicine, University of Alabama, Birmingham (S.O.); National Institute of Neurological Disorders and Stroke, Bethesda, MD (C.B.W.); Case Western Reserve University, Cleveland, OH (J.W., A.J.F., C.A.S., A.J.L.); University of Texas School of Public Health, Houston (B.R.D., S.P., J.-M.Y.); and Division of Cardiovascular Sciences, National Heart, Lung, and Blood Institute, Bethesda, MD (P.T.E.)
| | - Jose-Miguel Yamal
- From the Departments of Neurology (T.S., A.J.F., C.A.S., A.J.L.) and Medicine (J.W.), University Hospitals Case Medical Center, Cleveland, OH; Department of Neurology, University of Mississippi Medical Center, Jackson (A.P.A.); Department of Medicine, University of Alabama, Birmingham (S.O.); National Institute of Neurological Disorders and Stroke, Bethesda, MD (C.B.W.); Case Western Reserve University, Cleveland, OH (J.W., A.J.F., C.A.S., A.J.L.); University of Texas School of Public Health, Houston (B.R.D., S.P., J.-M.Y.); and Division of Cardiovascular Sciences, National Heart, Lung, and Blood Institute, Bethesda, MD (P.T.E.)
| | - Paula T Einhorn
- From the Departments of Neurology (T.S., A.J.F., C.A.S., A.J.L.) and Medicine (J.W.), University Hospitals Case Medical Center, Cleveland, OH; Department of Neurology, University of Mississippi Medical Center, Jackson (A.P.A.); Department of Medicine, University of Alabama, Birmingham (S.O.); National Institute of Neurological Disorders and Stroke, Bethesda, MD (C.B.W.); Case Western Reserve University, Cleveland, OH (J.W., A.J.F., C.A.S., A.J.L.); University of Texas School of Public Health, Houston (B.R.D., S.P., J.-M.Y.); and Division of Cardiovascular Sciences, National Heart, Lung, and Blood Institute, Bethesda, MD (P.T.E.)
| | - Alan J Lerner
- From the Departments of Neurology (T.S., A.J.F., C.A.S., A.J.L.) and Medicine (J.W.), University Hospitals Case Medical Center, Cleveland, OH; Department of Neurology, University of Mississippi Medical Center, Jackson (A.P.A.); Department of Medicine, University of Alabama, Birmingham (S.O.); National Institute of Neurological Disorders and Stroke, Bethesda, MD (C.B.W.); Case Western Reserve University, Cleveland, OH (J.W., A.J.F., C.A.S., A.J.L.); University of Texas School of Public Health, Houston (B.R.D., S.P., J.-M.Y.); and Division of Cardiovascular Sciences, National Heart, Lung, and Blood Institute, Bethesda, MD (P.T.E.)
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Bahiru E, de Cates AN, Farr MRB, Jarvis MC, Palla M, Rees K, Ebrahim S, Huffman MD. Fixed-dose combination therapy for the prevention of atherosclerotic cardiovascular diseases. Cochrane Database Syst Rev 2017; 3:CD009868. [PMID: 28263370 PMCID: PMC6464321 DOI: 10.1002/14651858.cd009868.pub3] [Citation(s) in RCA: 30] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
BACKGROUND Atherosclerotic cardiovascular disease (ASCVD) is the leading cause of death and disability worldwide, yet ASCVD risk factor control and secondary prevention rates remain low. A fixed-dose combination of blood pressure- and cholesterol-lowering and antiplatelet treatments into a single pill, or polypill, has been proposed as one strategy to reduce the global burden of ASCVD. OBJECTIVES To determine the effect of fixed-dose combination therapy on all-cause mortality, fatal and non-fatal ASCVD events, and adverse events. We also sought to determine the effect of fixed-dose combination therapy on blood pressure, lipids, adherence, discontinuation rates, health-related quality of life, and costs. SEARCH METHODS We updated our previous searches in September 2016 of CENTRAL, MEDLINE, Embase, ISI Web of Science, and DARE, HTA, and HEED. We also searched two clinical trials registers in September 2016. We used no language restrictions. SELECTION CRITERIA We included randomised controlled trials of a fixed-dose combination therapy including at least one blood pressure-lowering and one lipid-lowering component versus usual care, placebo, or an active drug comparator for any treatment duration in adults 18 years old or older, with no restrictions on presence or absence of pre-existing ASCVD. DATA COLLECTION AND ANALYSIS Three review authors independently selected studies for inclusion and extracted the data for this update. We evaluated risk of bias using the Cochrane 'Risk of bias' assessment tool. We calculated risk ratios (RR) for dichotomous data and mean differences (MD) for continuous data with 95% confidence intervals (CI) using fixed-effect models when heterogeneity was low (I2 < 50%) and random-effects models when heterogeneity was high (I2 ≥ 50%). We used the GRADE approach to evaluate the quality of evidence. MAIN RESULTS In the initial review, we identified nine randomised controlled trials with a total of 7047 participants and four additional trials (n = 2012 participants; mean age range 62 to 63 years; 30% to 37% women) were included in this update. Eight of the 13 trials evaluated the effects of fixed-dose combination (FDC) therapy in populations without prevalent ASCVD, and the median follow-up ranged from six weeks to 23 months. More recent trials were generally larger with longer follow-up and lower risk of bias. The main risk of bias was related to lack of blinding of participants and personnel, which was inherent to the intervention. Compared with the comparator groups (placebo, usual care, or active drug comparator), the effects of the fixed-dose combination treatment on mortality (FDC = 1.0% versus control = 1.0%, RR 1.10, 95% CI 0.64 to 1.89, I2 = 0%, 5 studies, N = 5300) and fatal and non-fatal ASCVD events (FDC = 4.7% versus control = 3.7%, RR 1.26, 95% CI 0.95 to 1.66, I2 = 0%, 6 studies, N = 4517) were uncertain (low-quality evidence). The low event rates for these outcomes and indirectness of evidence for comparing fixed-dose combination to usual care versus individual drugs suggest that these results should be viewed with caution. Adverse events were common in both the intervention (32%) and comparator (27%) groups, with participants randomised to fixed-dose combination therapy being 16% (RR 1.16, 95% CI 1.09 to 1.25, 11 studies, 6906 participants, moderate-quality evidence) more likely to report an adverse event . The mean differences in systolic blood pressure between the intervention and control arms was -6.34 mmHg (95% CI -9.03 to -3.64, 13 trials, 7638 participants, moderate-quality evidence). The mean differences (95% CI) in total and LDL cholesterol between the intervention and control arms were -0.61 mmol/L (95% CI -0.88 to -0.35, 11 trials, 6565 participants, low-quality evidence) and -0.70 mmol/L (95% CI -0.98 to -0.41, 12 trials, 7153 participants, moderate-quality evidence), respectively. There was a high degree of statistical heterogeneity in comparisons of blood pressure and lipids (I2 ≥ 80% for all) that could not be explained, so these results should be viewed with caution. Fixed-dose combination therapy improved adherence to a multidrug strategy by 44% (26% to 65%) compared with usual care (4 trials, 3835 participants, moderate-quality evidence). AUTHORS' CONCLUSIONS The effects of fixed-dose combination therapy on all-cause mortality or ASCVD events are uncertain. A limited number of trials reported these outcomes, and the included trials were primarily designed to observe changes in ASCVD risk factor levels rather than clinical events, which may partially explain the observed differences in risk factors that were not translated into differences in clinical outcomes among the included trials. Fixed-dose combination therapy is associated with modest increases in adverse events compared with placebo, active comparator, or usual care but may be associated with improved adherence to a multidrug regimen. Ongoing, longer-term trials of fixed-dose combination therapy will help demonstrate whether short-term changes in risk factors might be maintained and lead to expected differences in clinical events based on these changes.
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Affiliation(s)
- Ehete Bahiru
- Northwestern UniversityInternal Medicine; Division of Cardiology201 E. Huron St. Galter 19‐100ChicagoIllinoisUSA60611
| | - Angharad N de Cates
- Warwick Medical School, University of WarwickDivision of Health SciencesCoventryUKCV4 7AL
| | - Matthew RB Farr
- Warwick Medical School, University of WarwickDivision of Health SciencesCoventryUKCV4 7AL
| | - Morag C Jarvis
- Warwick Medical School, University of WarwickDivision of Health SciencesCoventryUKCV4 7AL
| | - Mohan Palla
- Wayne State UniversityDepartment of Medicine540 E Canfield StDetroitMichiganUSA48201
| | - Karen Rees
- Warwick Medical School, University of WarwickDivision of Health SciencesCoventryUKCV4 7AL
| | - Shah Ebrahim
- London School of Hygiene & Tropical MedicineDepartment of Non‐communicable Disease EpidemiologyKeppel StreetLondonUKWC1E 7HT
| | - Mark D Huffman
- Northwestern University Feinberg School of MedicineDepartments of Preventive Medicine and Medicine (Cardiology)680 N. Lake Shore Drive, Suite 1400ChicagoILUSA60611
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de Cates AN, Farr MRB, Wright N, Jarvis MC, Rees K, Ebrahim S, Huffman MD. Fixed-dose combination therapy for the prevention of cardiovascular disease. Cochrane Database Syst Rev 2014; 4:CD009868. [PMID: 24737108 PMCID: PMC4083498 DOI: 10.1002/14651858.cd009868.pub2] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
BACKGROUND Cardiovascular disease (CVD) is the leading cause of death and disability worldwide, yet CVD risk factor control and secondary prevention rates remain low. A fixed-dose combination of blood pressure and cholesterol lowering and antiplatelet treatments into a single pill, or polypill, has been proposed as one strategy to reduce the global burden of CVD by up to 80% given its potential for better adherence and lower costs. OBJECTIVES To determine the effectiveness of fixed-dose combination therapy on reducing fatal and non-fatal CVD events and on improving blood pressure and lipid CVD risk factors for both primary and secondary prevention of CVD. We also aimed to determine discontinuation rates, adverse events, health-related quality of life, and costs of fixed-dose combination therapy. SEARCH METHODS We searched the Cochrane Central Register of Controlled Trials (CENTRAL) in The Cochrane Library (2013, Issue 6), MEDLINE Ovid (1946 to week 2 July 2013), EMBASE Ovid (1980 to Week 28 2013), ISI Web of Science (1970 to 19 July 2013), and the Database of Abstracts of Reviews of Effects (DARE), Health Technology Assessment Database (HTA), and Health Economics Evaluations Database (HEED) (2011, Issue 4) in The Cochrane Library. We used no language restrictions. SELECTION CRITERIA We included randomised controlled trials of a fixed-dose combination therapy including at least one blood pressure lowering and one lipid lowering component versus usual care, placebo, or a single drug active component for any treatment duration in adults ≥ 18 years old with no restrictions on presence or absence of pre-existing cardiovascular disease. DATA COLLECTION AND ANALYSIS Three review authors independently selected studies for inclusion and extracted the data. We evaluated risk of bias using the Cochrane risk of bias assessment tool. We sought to include outcome data on all-cause mortality, fatal and non-fatal CVD events, adverse events, changes in systolic and diastolic blood pressure, total and low density lipoprotein (LDL) cholesterol concentrations, discontinuation rates, quality of life, and costs. We calculated risk ratios (RR) for dichotomous data and weighted mean differences (MD) for continuous data with 95% confidence intervals (CI) using fixed-effect models when heterogeneity was low (I(2) < 50%) and random-effects models when heterogeneity was high (I(2) > 50%). MAIN RESULTS We found nine randomised controlled trials with a total of 7047 participants. Seven of the nine trials evaluated the effects of fixed-dose combination therapy on primary CVD prevention, and the trial length ranged from six weeks to 15 months. We found a moderate to high risk of bias in the domains of selection, performance, detection, attrition, and other types of bias in five of the nine trials. Compared with the comparator groups, the effects of the fixed-dose combination treatment on mortality (1.2% versus 1.0%, RR 1.26, 95% CI 0.67 to 2.38, N = 3465) and cardiovascular events (4.0% versus 2.9%, RR 1.38, 95% CI 0.91 to 2.10, N = 2479) were uncertain (low quality evidence). The low event rates for these outcomes, limited availability of data as only two out of nine trials reported on these outcomes, and a high risk of bias in at least one domain suggest that these results should not be viewed with confidence. Adverse events were common in both the intervention (30%) and comparator (24%) groups, with participants randomised to fixed-dose combination therapy being 20% (95% CI 9% to 30%) more likely to report an adverse event. Notably, no serious adverse events were reported. Compared with placebo, the rate of discontinuation among participants randomised to fixed-dose combination was higher (14% versus 11%, RR 1.26 95% CI 1.02 to 1.55). The weighted mean differences in systolic and diastolic blood pressure between the intervention and control arms were -7.05 mmHg (95% CI -10.18 to -3.87) and -3.65 mmHg (95% CI -5.44 to -1.85), respectively. The weighted mean differences (95% CI) in total and LDL cholesterol between the intervention and control arms were -0.75 mmol/L (95% CI -1.05 to -0.46) and -0.81 mmol/L (95% CI -1.09 to -0.53), respectively. There was a high degree of statistical heterogeneity in comparisons of blood pressure and lipids (I(2) ≥ 70% for all) that could not be explained, so these results should be viewed with caution. Fixed-dose combination therapy improved adherence to a multi-drug strategy by 33% (26% to 41%) compared with usual care, but this comparison was reported in only one study. The effects of fixed-dose combination therapy on quality of life are uncertain, though these results were reported in only one trial. No trials reported costs. AUTHORS' CONCLUSIONS Compared with placebo, single drug active component, or usual care, the effects of fixed-dose combination therapy on all-cause mortality or CVD events are uncertain; only few trials report these outcomes and the included trials were primarily designed to observe changes in CVD risk factor levels rather than clinical events. Reductions in blood pressure and lipid parameters are generally lower than those previously projected, though substantial heterogeneity of results exists. Fixed-dose combination therapy is associated with modest increases in adverse events compared with placebo, single drug active component, or usual care but may be associated with improved adherence to a multidrug regimen. Ongoing trials of fixed-dose combination therapy will likely inform key outcomes.
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Affiliation(s)
- Angharad N de Cates
- Division of Health Sciences, Warwick Medical School, University of Warwick, Coventry, UK
| | - Matthew RB Farr
- Division of Health Sciences, Warwick Medical School, University of Warwick, Coventry, UK
| | - Nicola Wright
- Public Health Department, NHS Warwickshire, Warwick, UK
| | - Morag C Jarvis
- Division of Health Sciences, Warwick Medical School, University of Warwick, Coventry, UK
| | - Karen Rees
- Division of Health Sciences, Warwick Medical School, University of Warwick, Coventry, UK
| | - Shah Ebrahim
- Department of Non-communicable Disease Epidemiology, London School of Hygiene & Tropical Medicine, London, UK
| | - Mark D Huffman
- Departments of Preventive Medicine and Medicine (Cardiology), Northwestern University Feinberg School of Medicine, Chicago, USA
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