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Agarwal A, Mehta PM, Jacobson T, Shah NS, Ye J, Zhu J, Wafford QE, Bahiru E, de Cates AN, Ebrahim S, Prabhakaran D, Rodgers A, Huffman MD. Fixed-dose combination therapy for the prevention of atherosclerotic cardiovascular disease. Nat Med 2024; 30:1199-1209. [PMID: 38532223 PMCID: PMC11031293 DOI: 10.1038/s41591-024-02896-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2023] [Accepted: 03/01/2024] [Indexed: 03/28/2024]
Abstract
Fixed-dose combination (FDC) therapy, also known as polypill therapy, targets risk factors for atherosclerotic cardiovascular disease (ASCVD) and has been proposed as a strategy to reduce global ASCVD burden. Here we conducted a systematic search for relevant studies from 2016-2022 to assess the effects of FDC therapy for prevention of ASCVD. The studies selected include randomized trials evaluating FDC therapy with at least one blood pressure-lowering drug and one lipid-lowering drug. The study data were independently extracted, the quality of evidence was appraised by multiple reviewers and effect estimates were pooled using a fixed-effect meta-analysis when statistical heterogeneity was low to moderate. The main outcomes of the analysis were all-cause mortality, fatal and nonfatal ASCVD events, adverse events, systolic blood pressure, low-density lipoprotein cholesterol and adherence. Among 26 trials (n = 27,317 participants, 43.2% female and mean age range 52.9-76.0), FDC therapy was associated with lower low-density lipoprotein cholesterol and systolic blood pressure, with higher rates of adherence and adverse events in both primary and mixed secondary prevention populations. For studies with a mostly primary prevention population, FDC therapy was associated with lower risk of all-cause mortality by 11% (5.6% versus 6.3%; relative risk (risk ratio) of 0.89; 95% confidence interval 0.78 to 1.00; I2 = 0%; four trials and 16,278 participants) and risk of fatal and nonfatal ASCVD events by 29% (6.1% versus 8.4%; relative risk (risk ratio) of 0.71; 95% confidence interval 0.63 to 0.79; I2 = 0%; five trials and 15,503 participants). One adequately powered trial in an exclusively secondary prevention population showed that FDC therapy reduced the risk of major adverse cardiovascular events by 24%. These findings support adoption and implementation of polypills to lower risk for all-cause mortality and ASCVD.
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Affiliation(s)
- Anubha Agarwal
- Department of Medicine and Global Health Center, Washington University in St. Louis, St. Louis, MO, USA.
| | - Priya M Mehta
- Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Tyler Jacobson
- Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Nilay S Shah
- Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | | | - JingJing Zhu
- Department of Medicine and Global Health Center, Washington University in St. Louis, St. Louis, MO, USA
| | - Q Eileen Wafford
- Galter Health Sciences Library and Learning Center, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Ehete Bahiru
- Desert Cardiology Consultants, Eisenhower Medical Center, Rancho Mirage, CA, USA
| | | | - Shah Ebrahim
- Department of Non-communicable Disease Epidemiology, London School of Hygiene and Tropical Medicine, London, UK
| | - Dorairaj Prabhakaran
- Centre for Chronic Disease Control, New Delhi, India
- Public Health Foundation of India, Gurgaon, India
| | - Anthony Rodgers
- The George Institute for Global Health, University of New South Wales, Sydney, New South Wales, Australia
| | - Mark D Huffman
- Department of Medicine and Global Health Center, Washington University in St. Louis, St. Louis, MO, USA
- The George Institute for Global Health, University of New South Wales, Sydney, New South Wales, Australia
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2
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Sedhom R, Hamed M, Tan W, Mansoor H, Stoletniy L, Mamas M, Abramov D, Elgendy IY, Elbadawi A. Meta-Analysis on the Clinical Outcomes With Polypills for Cardiovascular Disease Prevention. Am J Cardiol 2023; 201:211-218. [PMID: 37385176 DOI: 10.1016/j.amjcard.2023.06.001] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/18/2023] [Revised: 05/30/2023] [Accepted: 06/01/2023] [Indexed: 07/01/2023]
Abstract
Randomized controlled trials (RCTs) examining the outcomes of "polypill" therapy in cardiovascular disease prevention have yielded mixed results. We performed an electronic search through January 2023 for RCTs that examined the use of polypills for cardiovascular disease primary or secondary prevention. The primary outcome was the incidence of major adverse cardiac and cerebrovascular events (MACCEs). The final analysis included 11 RCTs with 25,389 patients; 12,791 patients were in the polypill arm, and 12,598 patients were in the control arm. The follow-up period ranged from 1 to 5.6 years. Polypill therapy was associated with a lower risk of MACCE (5.8% vs 7.7%; risk ratio [RR] 0.78, 95% confidence interval [CI] 0.67 to 0.91). The reduction of MACCE risk was consistent in both primary and secondary prevention. Polypill therapy was associated with a lower incidence of cardiovascular mortality (2.1% vs 3%; RR 0.69, 95% CI 0.55 to 0.87), myocardial infarction (2.3% vs 3.2%; RR 0.72, 95% CI 0.61 to 0.84) and stroke (0.9% vs 1.6%; RR 0.62, 95% CI 0.42 to 0.90). Polypill therapy was associated with a higher degree of adherence. There was no difference between both groups in the incidence of serious adverse events (16.1% vs 15.9%; RR 1.12, 95% CI 0.93 to 1.36). In conclusion, we found that a polypill strategy was associated with a lower incidence of cardiac events and higher adherence, without an increased incidence of adverse events. This benefit was consistent for both primary and secondary prevention.
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Affiliation(s)
- Ramy Sedhom
- Division of Cardiology, Loma Linda University Medical Center, Loma Linda, California
| | - Mohamed Hamed
- Department of Internal Medicine, Florida Atlantic University, Boca Raton, Florida
| | - Weiyi Tan
- Division of Cardiology, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Hend Mansoor
- Department of Pharmacy, Practice and Science, College of Pharmacy and
| | - Liset Stoletniy
- Division of Cardiology, Loma Linda University Medical Center, Loma Linda, California
| | - Mamas Mamas
- Keele Cardiovascular Research Group, Center for Prognosis Research, Keele University, Keele, United Kingdom; Department of Cardiology, Royal Stoke University Hospital, Stoke-on-Trent, United Kingdom
| | - Dmitry Abramov
- Division of Cardiology, Loma Linda University Medical Center, Loma Linda, California
| | - Islam Y Elgendy
- Division of Cardiovascular Medicine, Gill Heart Institute, University of Kentucky, Lexington, Kentucky
| | - Ayman Elbadawi
- Division of Cardiology, University of Texas Southwestern Medical Center, Dallas, Texas.
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3
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Di Fusco SA, Aquilani S, Spinelli A, Alonzo A, Matteucci A, Castello L, Imperoli G, Colivicchi F. The polypill strategy in cardiovascular disease prevention: It's time for its implementation. Prog Cardiovasc Dis 2023; 79:37-40. [PMID: 36931543 DOI: 10.1016/j.pcad.2023.03.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/13/2023] [Accepted: 03/13/2023] [Indexed: 03/19/2023]
Abstract
A polypill strategy has been demonstrated to improve treatment adherence in several cardiovascular disease (CVD) settings. However, data on the prognostic impact in the secondary prevention setting have been scarce. The Secondary Prevention of Cardiovascular Disease in the Elderly trial, the results of which have been recently published, has demonstrated a benefit in terms of major adverse CVD event reduction. This finding, in addition to previous evidence, should lead to a broader polypill implementation in CVD prevention.
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Affiliation(s)
- Stefania Angela Di Fusco
- Clinical and Rehabilitation Cardiology Unit, Emergency Department, San Filippo Neri Hospital, ASL Rome 1, Rome, Italy.
| | - Stefano Aquilani
- Clinical and Rehabilitation Cardiology Unit, Emergency Department, San Filippo Neri Hospital, ASL Rome 1, Rome, Italy
| | - Antonella Spinelli
- Clinical and Rehabilitation Cardiology Unit, Emergency Department, San Filippo Neri Hospital, ASL Rome 1, Rome, Italy
| | - Alessandro Alonzo
- Clinical and Rehabilitation Cardiology Unit, Emergency Department, San Filippo Neri Hospital, ASL Rome 1, Rome, Italy
| | - Andrea Matteucci
- Clinical and Rehabilitation Cardiology Unit, Emergency Department, San Filippo Neri Hospital, ASL Rome 1, Rome, Italy
| | - Lorenzo Castello
- Clinical and Rehabilitation Cardiology Unit, Emergency Department, San Filippo Neri Hospital, ASL Rome 1, Rome, Italy
| | - Giuseppe Imperoli
- Internal Medicine Unit, Emergency Department, San Filippo Neri Hospital, ASL Rome 1, Rome, Italy
| | - Furio Colivicchi
- Clinical and Rehabilitation Cardiology Unit, Emergency Department, San Filippo Neri Hospital, ASL Rome 1, Rome, Italy
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4
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Shen Q, Zhang H, Huang Y, Li M, Zhao H, Yang Z, Zhao H, Liu Q, Fu Z, Di Y, Liu L, Bai H, Lv F, Chen Y, Liu Y, Wang S. Sensitive detection of single-nucleotide polymorphisms by conjugated polymers for personalized treatment of hypertension. Sci Transl Med 2023; 15:eabq5753. [PMID: 36888697 DOI: 10.1126/scitranslmed.abq5753] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/10/2023]
Abstract
Genetic variants among individuals have been associated with ineffective control of hypertension. Previous work has shown that hypertension has a polygenic nature, and interactions between these loci have been associated with variations in drug response. Rapid detection of multiple genetic loci with high sensitivity and specificity is needed for the effective implementation of personalized medicine for the treatment of hypertension. Here, we used a cationic conjugated polymer (CCP)-based multistep fluorescence resonance energy transfer (MS-FRET) technique to qualitatively analyze DNA genotypes associated with hypertension in the Chinese population. Assessment of 10 genetic loci using this technique successfully identified known hypertensive risk alleles in a retrospective study of whole-blood samples from 150 patients hospitalized with hypertension. We then applied our detection method in a prospective clinical trial of 100 patients with essential hypertension and found that personalized treatment of patients with hypertension based on results from the MS-FRET technique could effectively improve blood pressure control rate (94.0% versus 54.0%) and shorten the time duration to controlling blood pressure (4.06 ± 2.10 versus 5.82 ± 1.84 days) as compared with conventional treatment. These results suggest that CCP-based MS-FRET genetic variant detection may assist clinicians in rapid and accurate classification of risk in patients with hypertension and improve treatment outcomes.
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Affiliation(s)
- Qi Shen
- Beijing National Laboratory for Molecular Sciences, Key Laboratory of Organic Solids, Institute of Chemistry, Chinese Academy of Sciences, Beijing 100190, P.R. China.,College of Chemistry, University of Chinese Academy of Sciences, Beijing 100049, P. R. China
| | - Honghong Zhang
- Cardiac Department, Sixth Center of Chinese PLA General Hospital; Cardiac Department, First Center of Chinese PLA General Hospital, National Key Laboratory of Kidney Diseases; Department of Cardiology & National Clinical Research Center of Geriatric Disease; Beijing Key Laboratory of Chronic Heart Failure Precision Medicine, First Center of Chinese PLA General Hospital, Beijing 100141, P.R. China
| | - Yiming Huang
- Beijing National Laboratory for Molecular Sciences, Key Laboratory of Organic Solids, Institute of Chemistry, Chinese Academy of Sciences, Beijing 100190, P.R. China
| | - Mingyu Li
- Beijing National Laboratory for Molecular Sciences, Key Laboratory of Organic Solids, Institute of Chemistry, Chinese Academy of Sciences, Beijing 100190, P.R. China.,College of Chemistry, University of Chinese Academy of Sciences, Beijing 100049, P. R. China
| | - Hao Zhao
- Beijing National Laboratory for Molecular Sciences, Key Laboratory of Organic Solids, Institute of Chemistry, Chinese Academy of Sciences, Beijing 100190, P.R. China
| | - Zhiwen Yang
- Beijing National Laboratory for Molecular Sciences, Key Laboratory of Organic Solids, Institute of Chemistry, Chinese Academy of Sciences, Beijing 100190, P.R. China.,College of Chemistry, University of Chinese Academy of Sciences, Beijing 100049, P. R. China
| | - Haijing Zhao
- Cardiac Department, Sixth Center of Chinese PLA General Hospital; Cardiac Department, First Center of Chinese PLA General Hospital, National Key Laboratory of Kidney Diseases; Department of Cardiology & National Clinical Research Center of Geriatric Disease; Beijing Key Laboratory of Chronic Heart Failure Precision Medicine, First Center of Chinese PLA General Hospital, Beijing 100141, P.R. China
| | - Qi Liu
- Cardiac Department, Sixth Center of Chinese PLA General Hospital; Cardiac Department, First Center of Chinese PLA General Hospital, National Key Laboratory of Kidney Diseases; Department of Cardiology & National Clinical Research Center of Geriatric Disease; Beijing Key Laboratory of Chronic Heart Failure Precision Medicine, First Center of Chinese PLA General Hospital, Beijing 100141, P.R. China
| | - Zihao Fu
- Cardiac Department, Sixth Center of Chinese PLA General Hospital; Cardiac Department, First Center of Chinese PLA General Hospital, National Key Laboratory of Kidney Diseases; Department of Cardiology & National Clinical Research Center of Geriatric Disease; Beijing Key Laboratory of Chronic Heart Failure Precision Medicine, First Center of Chinese PLA General Hospital, Beijing 100141, P.R. China
| | - Yufei Di
- Beijing National Laboratory for Molecular Sciences, Key Laboratory of Organic Solids, Institute of Chemistry, Chinese Academy of Sciences, Beijing 100190, P.R. China.,College of Chemistry, University of Chinese Academy of Sciences, Beijing 100049, P. R. China
| | - Libing Liu
- Beijing National Laboratory for Molecular Sciences, Key Laboratory of Organic Solids, Institute of Chemistry, Chinese Academy of Sciences, Beijing 100190, P.R. China
| | - Haotian Bai
- Beijing National Laboratory for Molecular Sciences, Key Laboratory of Organic Solids, Institute of Chemistry, Chinese Academy of Sciences, Beijing 100190, P.R. China
| | - Fengting Lv
- Beijing National Laboratory for Molecular Sciences, Key Laboratory of Organic Solids, Institute of Chemistry, Chinese Academy of Sciences, Beijing 100190, P.R. China
| | - Yundai Chen
- Cardiac Department, Sixth Center of Chinese PLA General Hospital; Cardiac Department, First Center of Chinese PLA General Hospital, National Key Laboratory of Kidney Diseases; Department of Cardiology & National Clinical Research Center of Geriatric Disease; Beijing Key Laboratory of Chronic Heart Failure Precision Medicine, First Center of Chinese PLA General Hospital, Beijing 100141, P.R. China
| | - Yuqi Liu
- Cardiac Department, Sixth Center of Chinese PLA General Hospital; Cardiac Department, First Center of Chinese PLA General Hospital, National Key Laboratory of Kidney Diseases; Department of Cardiology & National Clinical Research Center of Geriatric Disease; Beijing Key Laboratory of Chronic Heart Failure Precision Medicine, First Center of Chinese PLA General Hospital, Beijing 100141, P.R. China
| | - Shu Wang
- Beijing National Laboratory for Molecular Sciences, Key Laboratory of Organic Solids, Institute of Chemistry, Chinese Academy of Sciences, Beijing 100190, P.R. China.,College of Chemistry, University of Chinese Academy of Sciences, Beijing 100049, P. R. China
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Brogi S, Tabanelli R, Calderone V. Combinatorial approaches for novel cardiovascular drug discovery: a review of the literature. Expert Opin Drug Discov 2022; 17:1111-1129. [PMID: 35853260 DOI: 10.1080/17460441.2022.2104247] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
INTRODUCTION In this article, authors report an inclusive discussion about the combinatorial approach for the treatment of cardiovascular diseases (CVDs) and for counteracting the cardiovascular risk factors. The mentioned strategy was demonstrated to be useful for improving the efficacy of pharmacological treatments and in CVDs showed superior efficacy with respect to the classical monotherapeutic approach. AREAS COVERED According to this topic, authors analyzed the combinatorial treatments that are available on the market, highlighting clinical studies that demonstrated the efficacy of combinatorial drug strategies to cure CVDs and related risk factors. Furthermore, the review gives an outlook on the future perspective of this therapeutic option, highlighting novel drug targets and disease models that could help the future cardiovascular drug discovery. EXPERT OPINION The use of specifically designed and increasingly rational and effective drug combination therapies can therefore be considered the evolution of polypharmacy in cardiometabolic and CVDs. This approach can allow to intervene on multiple etiopathogenetic mechanisms of the disease or to act simultaneously on different pathologies/risk factors, using the combinations most suitable from a pharmacodynamic, pharmacokinetic, and toxicological perspective, thus finding the most appropriate therapeutic option.
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Affiliation(s)
- Simone Brogi
- Department of Pharmacy, University of Pisa, Pisa, Italy
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6
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Fixed-Dose Combination (Polypill) for Cardiovascular Disease Prevention: A Meta-Analysis. Am J Prev Med 2022; 63:440-449. [PMID: 35613977 DOI: 10.1016/j.amepre.2022.03.027] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/17/2022] [Revised: 03/28/2022] [Accepted: 03/29/2022] [Indexed: 12/12/2022]
Abstract
INTRODUCTION This meta-analysis was performed to assess the efficacy of fixed-dose combination (polypill) in reducing the risk of mortality and cardiovascular events. METHODS Medline, Scopus, Web of Science, and Cochrane Central were searched during May 2021. All randomized trials investigating the efficacy of antihypertensive and lipid-lowering ± antiplatelet drug combinations in patients at cardiovascular risk were included. Outcomes were presented as risk ratios or standardized mean differences with 95% CIs. RESULTS A total of 16 trials (N = 26,567 participants) were included. The risk reduction for all-cause mortality (risk ratio = 0.90; 95% CI = 0.79, 1.01; I2 = 0%; moderate certainty) and major adverse cardiac events (risk ratio=0.84; 95% CI=0.68, 1.04; I2=51%; very low certainty) did not reach statistical significance in comparison with those of the control group. Subgroup analysis of studies that used an active control yielded similar results. However, significant reductions in major adverse cardiac event risk were observed in studies that exclusively targeted primary prevention, followed patients for ≥4 years, and had a low risk of bias. The polypill group had significantly higher adherence (risk ratio=1.18; 95% CI=1.06, 1.32; I2=96%; very low certainty) and comprable rates of adverse side effects (risk ratio=1.10; 95% CI=0.98, 1.23; I2=58%; moderate certainty) with those of the control group. Patients randomized to the polypill had significant reductions in systolic and diastolic blood pressure as well as in total and low-density lipoprotein cholesterol. DISCUSSION Despite reductions in cardiovascular risk factors, the observed mortality benefit for the polypill did not reach statistical significance. Further studies are needed to validate its clinical benefits and determine the patient populations likely to achieve such benefits.
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Perrone-Filardi P, Minghetti P, Menditto E, Bianchi S, Scaglione F, Trifirò G, Piccinocchi G, Corona T, Gambarelli G, Izzi C, Misciagna V, Putignano D, Lopatriello S, Cafiero D. The value of the polypill in cardiovascular disease: an Italian multidisciplinary Delphi panel consensus. J Cardiovasc Med (Hagerstown) 2021; 22:246-258. [PMID: 33633039 DOI: 10.2459/jcm.0000000000001159] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
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.
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Affiliation(s)
- Pasquale Perrone-Filardi
- Department of Advanced Biomedical Sciences, Federico II University of Naples
- Mediterranea Cardiocentro, Napoli
| | - Paola Minghetti
- Department of Pharmaceutical Sciences, Università degli Studi di Milano, Milano
| | - Enrica Menditto
- Department of Pharmacy, CIRFF, Centre of Pharmacoeconomics, University of Naples Federico II, Napoli
| | - Stefano Bianchi
- U.O. Assistenza Farmaceutica Ospedaliera, Territoriale e Ricerca clinica, Ferrara
| | - Francesco Scaglione
- Department of Oncology and Hemato-oncology, Postgraduate School of Clinical Pharmacology and Toxicology, University of Milan
- Clinical Pharmacology Unit, ASST Grande Ospedale Metropolitano Niguarda, Milano
| | - Gianluca Trifirò
- Department of Biomedical and Dental Sciences and Morphofunctional Imaging, University of Messina, Messina
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An J, Derington CG, Luong T, Olson KL, King JB, Bress AP, Jackevicius CA. Fixed-Dose Combination Medications for Treating Hypertension: A Review of Effectiveness, Safety, and Challenges. Curr Hypertens Rep 2020; 22:95. [DOI: 10.1007/s11906-020-01109-2] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
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9
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Sosa-Liprandi Á, Sosa Liprandi MI, Alexánderson E, Avezum Á, Lanas F, López-Jaramillo JP, Martínez F, Ponte-Negretti N CI, Wyss F, González Juanatey JR, Perel P. Clinical Impact of the Polypill for Cardiovascular Prevention in Latin America: A Consensus Statement of the Inter-American Society of Cardiology. Glob Heart 2018; 14:3-16.e1. [PMID: 30502220 DOI: 10.1016/j.gheart.2018.10.001] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2018] [Revised: 06/20/2018] [Accepted: 10/16/2018] [Indexed: 01/22/2023] Open
Abstract
The burden of cardiovascular diseases (CVD) is increasing, particularly in low-middle-income countries such as most of Latin America. This region presents specific socioeconomic characteristics, generating a high incidence of CVD despite efforts to control the problem. A consensus statement has been developed by Inter-American Society of Cardiology with the aim of answering some important questions related to CVD in this region and the role of the polypill in cardiovascular (CV) prevention as an intervention to address these issues. A multidisciplinary team composed of Latin American experts in the prevention of CVD was convened by the Inter-American Society of Cardiology and participated in the process and the formulation of statements. To characterize the prevailing situation in Latin American countries, we describe the most significant CV risk factors in the region. The barriers that impair the use of CV essential medications are also reviewed. The role of therapeutic adherence in CV prevention and how the polypill emerges as an effective strategy for optimizing adherence, accessibility, and affordability in the treatment of CVDs are discussed in detail. Clinical scenarios in which the polypill could represent an effective intervention in primary and secondary CV prevention are described. This initiative is expected to help professionals involved in the management of CVD and public health policymakers develop optimal strategies for the management of CVDs.
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Affiliation(s)
| | | | - Erick Alexánderson
- Department of Physiology, Faculty of Medicine, Universidad Nacional Autónoma de México, Instituto Nacional de Cardiología Ignacio Chávez, Mexico City, Mexico
| | - Álvaro Avezum
- Instituto Dante Pazzanese de Cardiología, Saõ Paulo, Brazil
| | | | - José Patricio López-Jaramillo
- Clínica Fundación Oftalmologica de Santander/Clínica Carlos Ardila Lulle, Bucaramanga, Colombia; Eugenio Espejo Faculty of Health Sciences, Universidad Tecnológica Equinoccial, Quito, Ecuador
| | | | | | - Fernando Wyss
- Servicios y Tecnología Cardiovascular de Guatemala S.A., CARDIOSOLUTIONS, Guatemala, Guatemala
| | | | - Pablo Perel
- Centre for Global Chronic Conditions, London School of Hygiene and Tropical Medicine, London, United Kingdom
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Li B, Montbriand J, Eisenberg N, Roche-Nagle G, Tan KT, Byrne J. Pre-operative Aneurysm Thrombus Volume, But Not Density, Predicts Type 2 Endoleak Rate Following Endovascular Aneurysm Repair. Ann Vasc Surg 2018; 57:98-108. [PMID: 30500629 DOI: 10.1016/j.avsg.2018.09.012] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2018] [Revised: 07/25/2018] [Accepted: 09/21/2018] [Indexed: 11/17/2022]
Abstract
BACKGROUND The impact of aneurysm thrombus characteristics on type 2 endoleak rate following endovascular aneurysm repair (EVAR) for abdominal aortic aneurysm (AAA) is unclear. The purpose of this study is to determine the impact of pre-operative aneurysm thrombus volume and density on the incidence of type 2 endoleak following EVAR for infrarenal AAA. METHODS A retrospective analysis was completed on all patients who underwent standard EVAR at an academic medical institution between May 1, 2010 and June 1, 2016 with a minimum follow-up period of 12 months. The final analysis included 170 patients. Thrombus volume and density were determined by analyzing pre-operative computed tomography angiography (CTA) scans using the TeraRecon plaque analysis module. The number and diameter of patent infrarenal aortic branch vessels were also identified. Type 2 endoleak was diagnosed by post-operative CTA, duplex ultrasound, or angiography. RESULTS Over a median follow-up period of 29 months, 88 (51.8%) of 170 patients had a type 2 endoleak. The thrombus volume as a proportion of the infrarenal aorta volume was significantly lower in patients with type 2 endoleak (odds ratio [OR] 0.034, 95% confidence interval [CI] 0.005-0.291, P = 0.002). The number of patent lumbar arteries was significantly greater in patients with type 2 endoleak (OR 1.45, 95% CI 1.16-1.56, P < 0.0005). Both variables independently predicted the incidence of type 2 endoleak in a multivariate analysis. Thrombus density was not related to the incidence of type 2 endoleak. CONCLUSIONS A lower ratio of thrombus volume/infrarenal aorta volume and a higher number of patent lumbar arteries were associated with an increased incidence of type 2 endoleak. A multivariate logistic regression model was generated to pre-operatively predict the risk of type 2 endoleak. This model can guide the stratification of patients for intensity of endoleak surveillance following EVAR and consideration of pre-operative treatment.
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Affiliation(s)
- Ben Li
- Division of Vascular Surgery, Department of Surgery, Toronto General Hospital, University Health Network, University of Toronto, Toronto, ON, Canada
| | - Janice Montbriand
- Division of Vascular Surgery, Department of Surgery, Toronto General Hospital, University Health Network, University of Toronto, Toronto, ON, Canada
| | - Naomi Eisenberg
- Division of Vascular Surgery, Department of Surgery, Toronto General Hospital, University Health Network, University of Toronto, Toronto, ON, Canada
| | - Graham Roche-Nagle
- Division of Vascular Surgery, Department of Surgery, Toronto General Hospital, University Health Network, University of Toronto, Toronto, ON, Canada; Division of Vascular and Interventional Radiology, Department of Medical Imaging, Toronto General Hospital, University Health Network, University of Toronto, Toronto, ON, Canada
| | - Kong Teng Tan
- Division of Vascular and Interventional Radiology, Department of Medical Imaging, Toronto General Hospital, University Health Network, University of Toronto, Toronto, ON, Canada
| | - John Byrne
- Division of Vascular Surgery, Department of Surgery, Toronto General Hospital, University Health Network, University of Toronto, Toronto, ON, Canada.
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11
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Abstract
BACKGROUND Treatment non-adherence in randomised trials refers to situations where some participants do not receive their allocated treatment as intended. For cluster randomised trials, where the unit of randomisation is a group of participants, non-adherence may occur at the cluster or individual level. When non-adherence occurs, randomisation no longer guarantees that the relationship between treatment receipt and outcome is unconfounded, and the power to detect the treatment effects in intention-to-treat analysis may be reduced. Thus, recording adherence and estimating the causal treatment effect adequately are of interest for clinical trials. OBJECTIVES To assess the extent of reporting of non-adherence issues in published cluster trials and to establish which methods are currently being used for addressing non-adherence, if any, and whether clustering is accounted for in these. METHODS We systematically reviewed 132 cluster trials published in English in 2011 previously identified through a search in PubMed. RESULTS One-hundred and twenty three cluster trials were included in this systematic review. Non-adherence was reported in 56 cluster trials. Among these, 19 reported a treatment efficacy estimate: per protocol in 15 and as treated in 4. No study discussed the assumptions made by these methods, their plausibility or the sensitivity of the results to deviations from these assumptions. LIMITATIONS The year of publication of the cluster trials included in this review (2011) could be considered a limitation of this study; however, no new guidelines regarding the reporting and the handling of non-adherence for cluster trials have been published since. In addition, a single reviewer undertook the data extraction. To mitigate this, a second reviewer conducted a validation of the extraction process on 15 randomly selected reports. Agreement was satisfactory (93%). CONCLUSION Despite the recommendations of the Consolidated Standards of Reporting Trials statement extension to cluster randomised trials, treatment adherence is under-reported. Among the trials providing adherence information, there was substantial variation in how adherence was defined, handled and reported. Researchers should discuss the assumptions required for the results to be interpreted causally and whether these are scientifically plausible in their studies. Sensitivity analyses to study the robustness of the results to departures from these assumptions should be performed.
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Affiliation(s)
- Schadrac C Agbla
- Department of Medical Statistics, London School of Hygiene and Tropical Medicine (LSHTM), London, UK
| | - Karla DiazOrdaz
- Department of Medical Statistics, London School of Hygiene and Tropical Medicine (LSHTM), London, UK
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Chen L, Xiao T, Chen L, Xie S, Deng M, Wu D. The Association of ADRB1 and CYP2D6 Polymorphisms With Antihypertensive Effects and Analysis of Their Contribution to Hypertension Risk. Am J Med Sci 2018; 355:235-239. [PMID: 29549925 DOI: 10.1016/j.amjms.2017.11.002] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2017] [Revised: 11/07/2017] [Accepted: 11/09/2017] [Indexed: 10/18/2022]
Abstract
BACKGROUND Genetic factors have a vital influence on the pathogenesis of hypertension. In this retrospective study, we aimed to evaluate the association of ADRB1 and CYP2D6 polymorphisms with antihypertensive effects and perform an analysis of their contribution to hypertension risk. METHODS A total of 261 healthy individuals and 261 essential hypertension patients treated with metoprolol for 12 weeks were enrolled. ADRB1 and CYP2D6 genotypes were identified by xTAG liquid chip technology. We used multivariate logistic regression and a generalized linear mixed model to assess hypertension-related risk factors. RESULTS The allele frequencies of ADRB1 and CYP2D6 variants were 59.8% and 64.6% in the essential hypertension group and 70.3% and 65.9% in the controls, respectively. The genotype and allele distribution of ADRB1 were significantly different between the 2 groups (P < 0.05), but there was no significant difference in CYP2D6 distribution (P = 0.91 and 0.88). By logistic regression analysis, high fasting plasma glucose, smoking, high triglyceride and the Gly/Gly polymorphism in Arg389Gly ADRB1 all emerged as independent risk factors for hypertension. Additionally, the ADRB1 genotype played a major role in the antihypertensive effect of metoprolol and the patients with the Gly389Gly genotype showed a significantly better response to metoprolol than did those with a heterozygous ADRB1 mutation (Arg389Gly) (P = 0.027). CONCLUSIONS The results demonstrate that Gly/Gly polymorphism in Arg389Gly ADRB1 was an independent risk factor together with high fasting plasma glucose, smoking and high triglyceride; moreover, the patients who carried the Gly389Gly genotype had a significantly improved metoprolol antihypertensive effect than those with ADRB1.
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Affiliation(s)
- Liping Chen
- Department of Laboratory Medicine, Fujian Longyan First Hospital, Longyan First Affiliated Hospital of Fujian Medical University, Longyan, Fujian, PR China
| | - Ting Xiao
- Department of Laboratory Medicine, Fujian Longyan First Hospital, Longyan First Affiliated Hospital of Fujian Medical University, Longyan, Fujian, PR China
| | - Liling Chen
- Department of Cardiovascular Medicine, Fujian Longyan First Hospital, Longyan First Affiliated Hospital of Fujian Medical University, Longyan, Fujian, PR China
| | - Shanshan Xie
- Department of Laboratory Medicine, Fujian Longyan First Hospital, Longyan First Affiliated Hospital of Fujian Medical University, Longyan, Fujian, PR China
| | - Maoqing Deng
- Department of Laboratory Medicine, Fujian Longyan First Hospital, Longyan First Affiliated Hospital of Fujian Medical University, Longyan, Fujian, PR China
| | - Dingchang Wu
- Department of Laboratory Medicine, Fujian Longyan First Hospital, Longyan First Affiliated Hospital of Fujian Medical University, Longyan, Fujian, PR China.
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Lee HY, Kim SY, Choi KJ, Yoo BS, Cha DH, Jung HO, Ryu DR, Choi JH, Lee KJ, Park TH, Oh JH, Kim SM, Choi JY, Kim KH, Shim J, Kim WS, Choi SW, Park DG, Song PS, Hong TJ, Rhee MY, Rha SW, Park SW. A Randomized, Multicenter, Double-blind, Placebo-controlled Study to Evaluate the Efficacy and the Tolerability of a Triple Combination of Amlodipine/Losartan/Rosuvastatin in Patients With Comorbid Essential Hypertension and Hyperlipidemia. Clin Ther 2017; 39:2366-2379. [DOI: 10.1016/j.clinthera.2017.10.013] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2017] [Revised: 10/06/2017] [Accepted: 10/14/2017] [Indexed: 01/01/2023]
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Huffman MD, Xavier D, Perel P. Uses of polypills for cardiovascular disease and evidence to date. Lancet 2017; 389:1055-1065. [PMID: 28290995 DOI: 10.1016/s0140-6736(17)30553-6] [Citation(s) in RCA: 70] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/16/2017] [Revised: 02/12/2017] [Accepted: 02/13/2017] [Indexed: 12/11/2022]
Abstract
Polypills have been approved in more than 30 countries, but worldwide experience with and availability of polypills remain limited, unlike fixed-dose combinations in other diseases such as HIV, tuberculosis, and malaria. In this Series review, we aim to propose a guide for the use of polypills in future research and clinical activities and to synthesise contemporary evidence supporting the use of polypills for prevention of atherosclerosis. Polypill uses can be categorised by population and indication, both of which influence the balance between benefits and risks. Populations include secondary prevention, high-risk primary prevention based on formal risk assessment, and primary prevention based on single risk factor measurement, such as age, also known as mass treatment. For each population, potential indications are initiation, step-up of current drug therapy, and straight substitution of individual drug components. We summarise efficacy and safety results from 13 polypill trials (9059 participants) done in 32 countries. Polypills improve adherence, are generally well tolerated, and reduce risk factor levels, although heterogeneity limits the certainty of the effect on risk factors. Trials published to date have not been designed to detect differences in clinical outcomes, and thus no significant differences between polypill and comparator groups have been reported. Polypill therapy could be one of the most scalable strategies to reduce the risk of premature mortality from atherosclerosis by 25% by 2025 by improving medication adherence and access, but further trial data and clinical experience will be useful to determine how polypills can best be implemented to achieve this goal.
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Affiliation(s)
- Mark D Huffman
- Department of Preventive Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL, USA.
| | - Denis Xavier
- Department of Pharmacology and Division of Clinical Research, St John's Medical College and Research Institute, St John's National Academy of Health Sciences, Bangalore, India
| | - Pablo Perel
- Centre for Global Non-communicable Disease Epidemiology, London School of Hygiene & Tropical Medicine, London, UK
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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: 37] [Impact Index Per Article: 5.3] [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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Kim SH, Jo SH, Lee SC, Lee SY, Yoon MH, Lee HL, Lee NH, Ha JW, Lee NH, Kim DW, Han GR, Hyon MS, Cho DG, Park CG, Kim YD, Ryu GH, Kim CH, Kim KS, Chung MH, Chae SC, Seung KB, Oh BH. Blood Pressure and Cholesterol-lowering Efficacy of a Fixed-dose Combination With Irbesartan and Atorvastatin in Patients With Hypertension and Hypercholesterolemia: A Randomized, Double-blind, Factorial, Multicenter Phase III Study. Clin Ther 2016; 38:2171-2184. [DOI: 10.1016/j.clinthera.2016.09.005] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2016] [Revised: 09/10/2016] [Accepted: 04/24/2016] [Indexed: 10/20/2022]
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Kolte D, Aronow WS, Banach M. Polypills for the prevention of Cardiovascular diseases. Expert Opin Investig Drugs 2016; 25:1255-1264. [PMID: 27645895 DOI: 10.1080/13543784.2016.1236912] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
INTRODUCTION Cardiovascular diseases (CVD) remain the leading cause of death worldwide with an estimated 17.5 million deaths per year. Since its initial conception over a decade ago, the use of cardiovascular polypills has gained increasing momentum as a strategy to lower risk factor levels and prevent CVD. Several new data have emerged including the recent publication of the first outcomes trial using polypills. Areas covered: In this review, the authors summarize the current literature on the safety, efficacy, and cost-effectiveness of polypills for primary and secondary prevention of CVD, describe the current controversies in this field, and identify important areas for future research. The authors searched PubMed, CENTRAL, and ClinicalTrials.gov from inception till 25 June 2016 using the search term 'polypill.' Expert opinion: Cardiovascular polypills containing aspirin, statin, and one or more anti-hypertensive medications, along with lifestyle interventions, represent an attractive, safe, and cost-effective strategy for primary and secondary prevention of CVD. Future research efforts should focus on identifying patients who will benefit the most from the use of polypills, marketing several polypills with different components and doses, and developing novel regulatory strategies for making polypills more readily available in all countries worldwide.
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Affiliation(s)
- Dhaval Kolte
- a Division of Cardiology , Brown University , Providence , RI
| | - Wilbert S Aronow
- b Division of Cardiology , New York Medical College , Valhalla , NY , USA
| | - Maciej Banach
- c Department of Hypertension , Medical University of Lodz , Lodz , Poland
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Pragmatic trial design elements showed a different impact on trial interpretation and feasibility than explanatory elements. J Clin Epidemiol 2016; 77:95-100. [DOI: 10.1016/j.jclinepi.2016.04.010] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2015] [Revised: 01/19/2016] [Accepted: 04/29/2016] [Indexed: 11/19/2022]
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Selak V, Harwood M, Raina Elley C, Bullen C, Wadham A, Parag V, Rafter N, Arroll B, Bramley D, Crengle S. Polypill-based therapy likely to reduce ethnic inequities in use of cardiovascular preventive medications: Findings from a pragmatic randomised controlled trial. Eur J Prev Cardiol 2016; 23:1537-45. [DOI: 10.1177/2047487316637196] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/04/2015] [Accepted: 02/15/2016] [Indexed: 11/16/2022]
Affiliation(s)
- Vanessa Selak
- Department of Epidemiology and Biostatistics, University of Auckland, New Zealand
| | - Matire Harwood
- Te Kupenga Hauora Māori, University of Auckland, New Zealand
| | - C Raina Elley
- Department of General Practice and Primary Health Care, University of Auckland, New Zealand
| | - Chris Bullen
- National Institute for Health Innovation, University of Auckland, New Zealand
| | - Angela Wadham
- National Institute for Health Innovation, University of Auckland, New Zealand
| | - Varsha Parag
- National Institute for Health Innovation, University of Auckland, New Zealand
| | - Natasha Rafter
- National Institute for Health Innovation, University of Auckland, New Zealand
- Royal College of Surgeons in Ireland, Ireland
| | - Bruce Arroll
- Department of General Practice and Primary Health Care, University of Auckland, New Zealand
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Li X, Xie P, He J, Cai H, Yang R, Zhang Q, Li B, Qi W, Ma H. CYP11B2 gene polymorphism and essential hypertension among Tibetan, Dongxiang and Han populations from northwest of China. Clin Exp Hypertens 2016; 38:375-80. [PMID: 27149293 DOI: 10.3109/10641963.2015.1131287] [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] [Indexed: 02/05/2023]
Abstract
Essential hypertension (EH) is a complex multifactorial condition influenced by both genetic and environmental factors; aldosterone synthase (CYP11B2) is a key enzyme which involves in the terminal steps of aldosterone synthesis. The result of relationship between C-344T of CYP11B2 polymorphism and EH was controversial. This study was undertaken to investigate the association of C-344T polymorphism with EH in the populations of Tibetan, Dongxiang and Han from northwest of China. A total of 2115 participants aged 18-70 years were enrolled in this study. In total, 1776 blood samples, including 545 Tibetan (305 hypertensive and 240 normotensive), 530 Dongxiang (254 hypertensive and 276 normotensive) and 701 Han (338 hypertensive and 363 normotensive), were analyzed successfully by using Snapshot minisequencing method, 30 samples were also performed by direct sequencing (5 hypertensive and 5 normotensive in each population, respectively). The frequencies of genotype and allele of CYP11B2 (C-344T) were not significantly different between EH group and control group in every ethnic population (p > 0.05). However, in female population of Tibetan, the frequencies of CC and CT genotype and C allele in EH group were higher than in control (p < 0.05) group. The frequencies of CC genotype and C allele in both the normotensive controls and EH patients in Tibetan population were higher than in Dongxiang and Han populations. Our study suggests that there is lack of association between C-344T polymorphism of CYP11B2 gene and EH in Dongxiang and Han populations, whereas the polymorphism was correlated with EH in female population of Tibetan.
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Affiliation(s)
- Xinghui Li
- a Department of Cardiology , Gansu Provincial Hospital , LanZhou , PR China
| | - Ping Xie
- a Department of Cardiology , Gansu Provincial Hospital , LanZhou , PR China
| | - Jin He
- a Department of Cardiology , Gansu Provincial Hospital , LanZhou , PR China
| | - Hui Cai
- a Department of Cardiology , Gansu Provincial Hospital , LanZhou , PR China
| | - Ruixuan Yang
- a Department of Cardiology , Gansu Provincial Hospital , LanZhou , PR China
| | - Qing Zhang
- b Department of Cardiology , West China Hospital of Sichuan University , Chengdu , PR China
| | - Baojuan Li
- c Department of Cardiology , Gannan District People's Hospital of Gansu Province , He Zuo , PR China
| | - Wenhua Qi
- c Department of Cardiology , Gannan District People's Hospital of Gansu Province , He Zuo , PR China
| | - Haizhong Ma
- a Department of Cardiology , Gansu Provincial Hospital , LanZhou , PR China
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Du Q, Zhang M, Li Y, Luan H, Liang S, Ren F. Spatial Patterns of Ischemic Heart Disease in Shenzhen, China: A Bayesian Multi-Disease Modelling Approach to Inform Health Planning Policies. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2016; 13:436. [PMID: 27104551 PMCID: PMC4847098 DOI: 10.3390/ijerph13040436] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/19/2016] [Revised: 03/31/2016] [Accepted: 04/13/2016] [Indexed: 11/26/2022]
Abstract
Incorporating the information of hypertension, this paper applies Bayesian multi-disease analysis to model the spatial patterns of Ischemic Heart Disease (IHD) risks. Patterns of harmful alcohol intake (HAI) and overweight/obesity are also modelled as they are common risk factors contributing to both IHD and hypertension. The hospitalization data of IHD and hypertension in 2012 were analyzed with three Bayesian multi-disease models at the sub-district level of Shenzhen. Results revealed that the IHD high-risk cluster shifted slightly north-eastward compared with the IHD Standardized Hospitalization Ratio (SHR). Spatial variations of overweight/obesity and HAI were found to contribute most to the IHD patterns. Identified patterns of IHD risk would benefit IHD integrated prevention. Spatial patterns of overweight/obesity and HAI could supplement the current disease surveillance system by providing information about small-area level risk factors, and thus benefit integrated prevention of related chronic diseases. Middle southern Shenzhen, where high risk of IHD, overweight/obesity, and HAI are present, should be prioritized for interventions, including alcohol control, innovative healthy diet toolkit distribution, insurance system revision, and community-based chronic disease intervention. Related health resource planning is also suggested to focus on these areas first.
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Affiliation(s)
- Qingyun Du
- School of Resources and Environmental Science, Wuhan University, 129 Luoyu Road, Wuhan 430079, China.
- Key Laboratory of GIS, Ministry of Education, Wuhan University, 129 Luoyu Road, Wuhan 430079, China.
- Key Laboratory of Digital Mapping and Land Information Application Engineering, National Administration of Surveying, Mapping and Geoinformation, Wuhan University, 129 Luoyu Road, Wuhan 430079, China.
- Collaborative Innovation Center of Geospatial Technology, Wuhan University, 129 Luoyu Road, Wuhan 430079, China.
| | - Mingxiao Zhang
- School of Resources and Environmental Science, Wuhan University, 129 Luoyu Road, Wuhan 430079, China.
| | - Yayan Li
- School of Resources and Environmental Science, Wuhan University, 129 Luoyu Road, Wuhan 430079, China.
| | - Hui Luan
- School of Planning, Faculty of Environment, University of Waterloo, 200 University Avenue West, Waterloo, ON N2L 3G1, Canada.
| | - Shi Liang
- Shenzhen Prevention and Treatment Center for Occupational Diseases, Guiyuan Street North 70, Luohu District, Shenzhen 518001, China.
| | - Fu Ren
- School of Resources and Environmental Science, Wuhan University, 129 Luoyu Road, Wuhan 430079, China.
- Key Laboratory of GIS, Ministry of Education, Wuhan University, 129 Luoyu Road, Wuhan 430079, China.
- Key Laboratory of Digital Mapping and Land Information Application Engineering, National Administration of Surveying, Mapping and Geoinformation, Wuhan University, 129 Luoyu Road, Wuhan 430079, China.
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Wu D, Li G, Deng M, Song W, Huang X, Guo X, Wu Z, Wu S, Xu J. Associations between ADRB1 and CYP2D6 gene polymorphisms and the response to β-blocker therapy in hypertension. J Int Med Res 2015; 43:424-34. [PMID: 25823457 DOI: 10.1177/0300060514563151] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2014] [Accepted: 11/13/2014] [Indexed: 11/15/2022] Open
Abstract
OBJECTIVE To investigate the associations between β1-adrenergic receptor (ADRB1) and cytochrome P450 2D6 (CYP2D6) gene polymorphisms and β-blocker treatment outcomes in patients with hypertension. METHODS Chinese patients with essential hypertension were treated with the β-blocker metoprolol and followed up for 12 weeks. xTAG® liquid-chip technology was used for CYP2D6 100 C > T and ADRB1 1165G > C genotyping. Associations between gene polymorphisms and antihypertensive therapy outcomes were assessed by generalized linear model fitting. A decrease of ≥ 10 mmHg in systolic blood pressure indicated an effective treatment outcome. RESULTS A total of 93 patients were included in the study. Mutant allele frequencies of 61.29% and 58.60% were obtained for ADRB1 and CYP2D6, respectively. There was no significant interaction between the effects of ADRB1 and CYP2D6 gene polymorphisms on treatment outcome. Patients homozygous for the mutant ADRB1 genotype (CC) had better treatment outcomes than those heterozygous for the mutation (GC). Interestingly, β-blocker treatment duration was an independent factor associated with treatment outcome. CONCLUSIONS The ADRB1 1165G > C gene polymorphism and β-blocker treatment duration are independent factors associated with β-blocker treatment outcome. These findings suggest that the selection of antihypertensive therapy should take into consideration the patient's genotype.
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Affiliation(s)
- Dingchang Wu
- Department of Laboratory Medicine, First Affiliated Hospital of Fujian Medical University, Longyan, China
| | - Ganyang Li
- Department of Cardiovascular Medicine, First Affiliated Hospital of Fujian Medical University, Longyan, China
| | - Maoqing Deng
- Department of Laboratory Medicine, First Affiliated Hospital of Fujian Medical University, Longyan, China
| | - Wei Song
- Department of Cardiovascular Medicine, First Affiliated Hospital of Fujian Medical University, Longyan, China
| | - Xiaohua Huang
- Department of Laboratory Medicine, First Affiliated Hospital of Fujian Medical University, Longyan, China
| | - Xiaoru Guo
- Department of Laboratory Medicine, First Affiliated Hospital of Fujian Medical University, Longyan, China
| | - Zhengzheng Wu
- SurExam Bio-Tech Co. Ltd, Guangzhou Technology Innovation Base, Guangzhou, China
| | - Shiyang Wu
- SurExam Bio-Tech Co. Ltd, Guangzhou Technology Innovation Base, Guangzhou, China
| | - Jiasen Xu
- SurExam Bio-Tech Co. Ltd, Guangzhou Technology Innovation Base, Guangzhou, China
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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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Cho YK, Nam CW, Park HS, Yoon HJ, Kim H, Hur SH, Kim YN, Lee JH, Yang DH, Lee BR, Jung BC, Kim W, Park JS, Lee JB, Kim KS, Kim KB. Efficacy and safety of antiplatelet-combination therapy after drug-eluting stent implantation. Korean J Intern Med 2014; 29:210-6. [PMID: 24648804 PMCID: PMC3956991 DOI: 10.3904/kjim.2014.29.2.210] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/13/2013] [Revised: 06/28/2013] [Accepted: 08/05/2013] [Indexed: 11/27/2022] Open
Abstract
BACKGROUND/AIMS Combination single-pill therapy can improve cost-effectiveness in a typical medical therapy. However, there is a little evidence about the efficacy and tolerability of combination single-pill antiplatelet therapy after percutaneous coronary intervention (PCI) with drug-eluting stents (DES). METHODS From June to November 2012, in total, 142 patients who met the following criteria were enrolled: at least 18 years old; successful PCI with DES at least 3 months earlier; and regular medication of aspirin and clopidogrel with no side effects. After VerifyNow P2Y12 and aspirin assays, the combination single pill of aspirin and clopidogrel was given and laboratory tests were repeated 6 weeks later. RESULTS At baseline, the incidence of aspirin resistance, defined as aspirin reaction unit (ARU) ≥ 550, was 9.2%, that of clopidogrel resistance, defined as P2Y12 reaction unit (PRU) ≥ 230, was 46.5%, and that of percent inhibition of PRU < 20% was 32.4%. At follow-up, the incidence of resistance by ARU value was 7.0%, 50.0% by PRU value, and 35.9% by percentage inhibition of PRU, respectively. The mean values of ARU (431.5 ± 63.6 vs. 439.8 ± 55.2; p = 0.216) and PRU (227.5 ± 71.4 vs. 223.3 ± 76.0; p = 0.350) were not significantly different before versus after antiplatelet-combination single-pill therapy. Five adverse events (3.5%) were observed during the study period. CONCLUSIONS Combination single-pill antiplatelet therapy, which may reduce daily pill burden for patients after PCI with DES, demonstrated similar efficacy to separate dual-pill antiplatelet therapy.
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Affiliation(s)
- Yun-Kyeong Cho
- Division of Cardiology, Keimyung University Dongsan Medical Center, Daegu, Korea
| | - Chang-Wook Nam
- Division of Cardiology, Keimyung University Dongsan Medical Center, Daegu, Korea
| | - Hyoung-Seob Park
- Division of Cardiology, Keimyung University Dongsan Medical Center, Daegu, Korea
| | - Hyuck-Jun Yoon
- Division of Cardiology, Keimyung University Dongsan Medical Center, Daegu, Korea
| | - Hyungseop Kim
- Division of Cardiology, Keimyung University Dongsan Medical Center, Daegu, Korea
| | - Seung-Ho Hur
- Division of Cardiology, Keimyung University Dongsan Medical Center, Daegu, Korea
| | - Yoon-Nyun Kim
- Division of Cardiology, Keimyung University Dongsan Medical Center, Daegu, Korea
| | - Jang-Hoon Lee
- Division of Cardiology, Kyungpook National University Hospital, Daegu, Korea
| | - Dong-Heon Yang
- Division of Cardiology, Kyungpook National University Hospital, Daegu, Korea
| | - Bong-Ryeol Lee
- Division of Cardiology, Daegu Fatima Hospital, Daegu, Korea
| | | | - Woong Kim
- Division of Cardiology, Yeungnam University Hospital, Daegu, Korea
| | - Jong-Seon Park
- Division of Cardiology, Yeungnam University Hospital, Daegu, Korea
| | - Jin-Bae Lee
- Division of Cardiology, Daegu Catholic University Hospital, Daegu, Korea
| | - Kee-Sik Kim
- Division of Cardiology, Daegu Catholic University Hospital, Daegu, Korea
| | - Kwon-Bae Kim
- Division of Cardiology, Keimyung University Dongsan Medical Center, Daegu, Korea
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25
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Cho EJ, Kim JH, Sutradhar S, Yunis C, Westergaard M. Proactive multifactorial intervention strategy reduces the risk of cardiovascular disease estimated with region-specific risk assessment models in Pacific Asian patients participating in the CRUCIAL trial. J Korean Med Sci 2013; 28:1741-8. [PMID: 24339703 PMCID: PMC3857369 DOI: 10.3346/jkms.2013.28.12.1741] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/14/2013] [Accepted: 09/30/2013] [Indexed: 12/03/2022] Open
Abstract
Despite race, ethnic, and regional differences in cardiovascular disease risk, many worldwide hypertension management guidelines recommend the use of the Framingham coronary heart disease (CHD) risk equation to guide treatment decisions. This subanalysis of the recently published CRUCIAL trial compared the treatment-related reductions in calculated CHD and stroke risk among Pacific Asian (PA) patients using a variety of region-specific risk assessment models. As a result, greater reductions in systolic and diastolic blood pressure, low-density lipoprotein cholesterol, and triglycerides were observed in the proactive multifactorial intervention (PMI) arm compared with the usual care arm at Week 52 for PA patients. The relative percentage change in 10-yr CHD risk between baseline and Week 52 in the PMI versus usual care arms was greatest using the NIPPON DATA80 fatal CHD model (LS [least square] mean difference -42.6%), and similar in the SCORE fatal CHD and Framingham total CHD models (LS mean difference -29.4% and -30.8%, respectively). The single-pill based PMI approach is consistently effective in reducing cardiovascular disease risk, evaluated using a variety of risk assessment models. (ClinicalTrials.gov registration number: NCT00407537).
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Affiliation(s)
- Eun Joo Cho
- Department of Cardiology, St Paul's Hospital, The Catholic University of Korea, Seoul, Korea
| | - Jae Hyung Kim
- Department of Cardiology, St Paul's Hospital, The Catholic University of Korea, Seoul, Korea
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Abstract
Cardiovascular diseases are the leading cause of death worldwide. Risk factors are rarely seen individually, and the 2 most common and most frequently associated risk factors are hypertension and dyslipidemia (DL). Studies conducted in different parts of the world uniquely point out insufficient efficacy of hypertension and DL treatment, which is reflected in blood pressure and low-density lipoprotein levels higher than target values. A reason of this therapeutic failure is the reduced adherence, which is mainly caused by multidrug therapy. A possible solution for this problem is the use of fixed combinations. The main advantages of amlodipine/atorvastatin fixed combination are synergistic effect of these 2 components, a single-dose treatment, high safety profile, and good tolerance.
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Affiliation(s)
- Branislava Ivanovic
- Clinical Centre of Serbia, Clinic for Cardiology, Belgrade, Serbia
- Medical School of Belgrade, University of Belgrade, Belgrade, Serbia
| | - Marijana Tadic
- University Clinical Hospital Center “Dr Dragisa Misovic”, Belgrade, Serbia
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27
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Hradec J, Zamorano J, Sutradhar S. Post hoc analysis of the Cluster Randomized Usual Care versus Caduet Investigation Assessing Long-term risk (CRUCIAL) trial. Curr Med Res Opin 2013; 29:589-96. [PMID: 23464930 DOI: 10.1185/03007995.2013.783795] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
OBJECTIVE A proactive, multifactorial intervention strategy incorporating single-pill amlodipine/atorvastatin (SPAA) (5-10/10 mg up-titrated to 5-10/20 mg, where approved) is more effective than physician's usual care (UC) for reducing calculated 10 year coronary heart disease (CHD) risk, in patients with hypertension and additional risk factors (CRUCIAL trial: Curr Med Res Opin 2011;27:821--33). As SPAA combinations containing atorvastatin 20 mg are not approved in some countries, this post hoc analysis investigated the efficacy and safety of a proactive intervention strategy incorporating low-dose SPAA (5/10 or 10/10 mg) only (low-dose PI) versus UC. METHODS Of 1461 CRUCIAL participants (35-79 years; hypertension and ≥3 additional risk factors; no CHD; total cholesterol ≤6.5 mmol/L), 105 were prescribed SPAA containing 20 mg atorvastatin and excluded. The primary endpoint was difference between treatment arms in Framingham 10 year CHD risk after 52 weeks; secondary assessments included difference in calculated CHD risk at Week 16; SCORE cardiovascular mortality (Week 16 and 52); blood pressure (BP)/lipid parameters; adverse events (AEs). RESULTS Baseline BP (149.2/89.2 vs. 144.3/86.5 mmHg) and calculated CHD risk (19.6% vs. 18.1%) were higher for low-dose PI (n = 655) versus UC (n = 657) patients. Least-squares mean treatment difference (low-dose PI vs. UC) in calculated 10 year CHD risk was -26.8 (95% CI: -31.7, -22.0; p < 0.001) after 52 weeks' follow-up and -24.8 (-29.8, -19.9; p < 0.001) after 16 weeks' follow-up. Treatment difference in SCORE mortality was -20.1 (-24.7, -15.6; p < 0.001) and -22.4 (-26.8, -18.0; p < 0.001) after 16 and 52 weeks' follow-up. Risk calculations are surrogate endpoints and may not translate into actual reductions in cardiovascular events. Overall, 49.1% (low-dose PI) and 44.0% (UC) reported AEs. CONCLUSION A proactive, multifactorial approach to cardiovascular management based on low-dose SPAA led to statistically significant improvements in calculated 10 year CHD risk versus physician's UC, comparable to that reported in the full CRUCIAL trial. These data will inform healthcare providers in countries where SPAA (5/10 or 10/10 mg) only are licensed.
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Affiliation(s)
- Jaromír Hradec
- University General Hospital, Charles University, Prague, Czech Republic.
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28
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Kim JH, Zamorano J, Erdine S, Pavia A, Al-Khadra A, Sutradhar S, Yunis C. Reduction in cardiovascular risk using proactive multifactorial intervention versus usual care in younger (< 65 years) and older (≥ 65 years) patients in the CRUCIAL trial. Curr Med Res Opin 2013; 29:453-63. [PMID: 23448581 DOI: 10.1185/03007995.2013.781503] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
OBJECTIVE To compare the reduction in calculated Framingham 10 year coronary heart disease (CHD) risk after 52 weeks' intervention with a proactive multifactorial intervention (PMI) strategy (based on single-pill amlodipine/atorvastatin [SPAA]) versus continuing usual care (UC) (based on investigators' best clinical judgment) among younger (<65 years) and older (≥ 65 years) patients. RESEARCH DESIGN AND METHODS Sub-analysis of the Cluster Randomized Usual Care versus Caduet Investigation Assessing Long-term risk (CRUCIAL) trial. Eligible patients had hypertension and ≥ 3 cardiovascular risk factors. MAIN OUTCOME MEASURE Treatment-related reduction in calculated Framingham 10 year CHD risk between baseline and Week 52 in younger and older patients. RESULTS Nine hundred patients (63.5%) were <65 years (mean age 54.2 years, 57.4% men) and 517 patients (36.5%) were ≥ 65 years (mean age 70.5 years, 42.7% men). Younger patients had lower mean baseline CHD risk versus older patients (17.1% vs. 22.6%). A greater reduction in calculated CHD risk at Week 52 was observed in the PMI versus the UC arm in both younger (-33.2% vs. -2.9%, p < 0.001) and older (-32.7% vs. -5.7%, p < 0.001) patients. Least-squares mean treatment differences (PMI vs. UC) in percentage change from baseline in calculated CHD risk were similar in younger and older patients (-26.3% vs. -25.7%, age interaction p = 0.887). CHD risk reduction was slightly greater among younger men than younger women (-29.3 vs. -23.9, gender interaction p = 0.062). A low proportion of patients discontinued the PMI strategy due to adverse events in both age groups (5.8% vs. 6.1%, respectively). Study limitations included ad-hoc (not pre-specified) sub-group analysis and short duration of follow-up. CONCLUSIONS The PMI strategy based on the inclusion of SPAA in the treatment regimen is more effective than UC in reducing calculated CHD risk. This strategy may be considered as the treatment of choice in younger and older hypertensive patients with additional cardiovascular risk factors.
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Affiliation(s)
- Jae-Hyung Kim
- St. Paul's Hospital, The Catholic University of Korea, Seoul, Republic of Korea.
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29
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Delgado-Montero A, Zamorano JL. Atorvastatin calcium plus amlodipine for the treatment of hypertension. Expert Opin Pharmacother 2012; 13:2673-85. [DOI: 10.1517/14656566.2012.742064] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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30
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Pavia A, Zamorano J, Sutradhar S, Yunis C. Changes in calculated coronary heart disease risk using proactive multifactorial intervention versus continued usual care in Latin-American and non-Latin-American patients enrolled in the CRUCIAL trial. Curr Med Res Opin 2012; 28:1667-76. [PMID: 22991979 DOI: 10.1185/03007995.2012.725391] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
OBJECTIVE To compare the change in calculated coronary heart disease (CHD) risk using a proactive multifactorial intervention (PMI) versus usual care (UC), among Latin-American (LA) and non-LA patients enrolled in the CRUCIAL trial. RESEARCH DESIGN AND METHODS This is a sub-analysis of the Cluster Randomized Usual Care versus Caduet Investigation Assessing Long-term-risk (CRUCIAL) trial. CRUCIAL was a prospective, multinational, open-label, cluster-randomized trial. Eligible patients had hypertension and ≥3 additional cardiovascular risk factors, but no history of CHD and baseline total cholesterol ≤6.5 mmol/l (250 mg/dl). The PMI strategy was implemented by the inclusion of single-pill amlodipine/atorvastatin (SPAA) in the patients' treatment regimen. Overall, 20% of patients resided in the LA region. MAIN OUTCOME MEASURE Treatment-related change in calculated Framingham 10-year CHD risk between baseline and Week 52 in the LA and non-LA regions. RESULTS A greater relative reduction in calculated CHD risk after 52 weeks' follow-up was observed for patients in the PMI arm compared with UC arm in both LA (-32.8% vs. -7.5%, p = 0.003) and non-LA regions (-33.1% vs. -3.3%, p < 0.001), region interaction p = 0.316. The proportion of patients discontinuing treatment in the PMI arm due to adverse events (AEs) was low in both regions (both 5.9%). CONCLUSIONS The PMI approach based on the inclusion of SPAA in the patients' treatment regimen may improve the management of CHD risk among patients residing in LA and non-LA regions. Clinicians may be reassured by the low rate of AEs leading to discontinuation of SPAA in both regions.
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Affiliation(s)
- Abel Pavia
- Hospital General de México, Ciudad de México, México.
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31
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Kim JH, Zamorano J, Erdine S, Pavia A, Al-Khadra A, Sutradhar S, Yunis C. Proactive cardiovascular risk management versus usual care in patients with and without diabetes mellitus: CRUCIAL trial subanalysis. Postgrad Med 2012; 124:41-53. [PMID: 22913893 DOI: 10.3810/pgm.2012.07.2565] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
UNLABELLED Patients with diabetes mellitus (DM) and additional cardiovascular (CV) risk factors are at very high risk for future CV events. This study investigated the efficacy and safety of a proactive, multifactorial CV risk factor-management strategy based on single-pill amlodipine/atorvastatin (SPAA) versus continuing physicians' usual care (UC) over 52 weeks in patients with and without DM. Patients with hypertension and ≥ 3 additional CV risk factors from the Cluster Randomized Usual Care vs Caduet Investigation Assessing Long-Term-Risk (CRUCIAL) trial--an open-label, cluster-randomized trial conducted in 19 countries--were enrolled and randomized to receive proactive intervention (based on SPAA 5/10 to 10/20 mg) or UC (based on investigators' best clinical judgment). Patients were analyzed according to baseline DM status. Six hundred patients had DM. Patients with DM in the SPAA and UC arms had mean ages of 61.8 and 61.5 years, respectively, and an absolute coronary heart disease (CHD) risk of 25.2% and 21.5%, respectively. Among non-DM patients, mean ages were 58.6 and 59.5 years, respectively, and CHD risk was 16.0% vs 15.7%, respectively. Least-squares mean treatment differences in percentage change from baseline in calculated 10-year Framingham CHD risk were -26.3% vs -27.3% among DM and non-DM patients (adjusted for respective baseline values) (both P < 0.0001). Among DM and non-DM patients, adverse events were reported in 52.8% versus 45.6% in the SPAA and 49.6% versus 41.6% in the UC arms, respectively. This global risk-management approach, simultaneously targeting blood pressure and lipids, was more effective for reducing calculated 10-year Framingham CHD risk than UC in patients with DM. While blood pressure changes were of smaller magnitude among patients with DM, this strategy reduced overall risk to an extent comparable with that observed in non-DM patients. Further studies are thus warranted to study this proactive risk factor intervention on CV or mortality endpoints in patients with and without DM. TRIAL REGISTRATION www.ClinicalTrials.gov identifier NCT00407537.
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Affiliation(s)
- Jae-Hyung Kim
- St Paul's Hospital, The Catholic University of Korea, Seoul, Republic of Korea.
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Zamorano J, Edwards J. Combining antihypertensive and antihyperlipidemic agents - optimizing cardiovascular risk factor management. Integr Blood Press Control 2011; 4:55-71. [PMID: 22162939 PMCID: PMC3234127 DOI: 10.2147/ibpc.s12215] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Clinical guidelines now recognize the importance of a multifactorial approach to managing cardiovascular (CV) risk. This idea was taken a step further with the concept of the Polypill™. There are, however, considerable patent, pharmacokinetic, pharmacodynamic, registration, and cost implications that will need to be overcome before the Polypill™ or other single-pill combinations of CV medications become widely available. However, a medication targeting blood pressure (BP) and lipids provides much of the proposed benefits of the Polypill™. A single-pill combination of the antihypertensive amlodipine besylate and the lipid-lowering medication atorvastatin calcium (SPAA) is currently available in many parts of the world. This review describes the rationale for this combination therapy and the clinical trials that have demonstrated that these two agents can be combined without the loss of efficacy for either agent or an increase in the incidence of adverse events. The recently completed Cluster Randomized Usual Care vs Caduet Investigation Assessing Long-term-risk (CRUCIAL trial) is discussed in detail. CRUCIAL was a 12-month, international, multicenter, prospective, open-label, parallel design, cluster-randomized trial, which demonstrated that a proactive intervention strategy based on SPAA in addition to usual care (UC) had substantial benefits on estimated CV risk, BP, and lipids over continued UC alone. Adherence with antihypertensive and lipid-lowering therapies outside of the controlled environment of clinical trials is very low (~30%–40% at 12 months). Observational studies have demonstrated that improving adherence to lipid-lowering and antihypertensive medications may reduce CV events. One means of improving adherence is the use of single-pill combinations. Real-world observational studies have demonstrated that patients are more adherent to SPAA than co-administered antihypertensive and lipid-lowering therapy, and this improved adherence translated to reduced CV events. Taken together, these findings suggest that SPAA can play an important role in helping physicians improve the management of CV risk in their patients.
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