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Fixed-dose combination therapy and secondary cardiovascular prevention: rationale, selection of drugs and target population

Nature Clinical Practice Cardiovascular Medicine volume 6, pages 101–110 (2009)Cite this article

Abstract

Ischemic heart disease and stroke are the leading causes of death worldwide. A large proportion of individuals at high 10-year risk of a cardiovascular event live in low-income and middle-income countries, and the large majority of all cardiovascular events occur in developing countries. A large amount of evidence supports the use of pharmacological treatment for the prevention of cardiovascular death in this population, including antiplatelet drugs, beta blockers, lipid-lowering agents and angiotensin-converting-enzyme inhibitors. However, the efficacy of cardiovascular prevention is hampered by several problems, including inadequate prescription of medication, poor adherence to treatment, limited availability of medications and unaffordable cost of treatment. Here we examine the use of fixed-dose combination therapy (a 'polypill'), and how this therapy could improve adherence to treatment, reduce the cost and improve treatment affordability in low-income countries.

Key Points

  • In 2005, cardiovascular diseases caused 3.3 times more deaths worldwide than AIDS, tuberculosis and malaria combined

  • Of all cardiovascular events that occur worldwide, four-fifths occur in low-income and middle-income countries

  • Although the efficacy of medication for secondary prevention of cardiovascular disease has been clearly demonstrated, a large proportion of potential candidates for therapy do not receive adequate treatment

  • Poor adherence to treatment and cost of medication are largely responsible for the discrepancy between evidence-based recommendations and actual treatment

  • Complexity of treatment is the main cause of patients' lack of adherence

  • Fixed-dose combination therapy (a 'polypill') might improve secondary prevention owing to a reduction in treatment complexity, and could provide medication at an affordable cost in developing countries

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Figure 1: Distribution of cardiovascular events according to the number of risk factors in the INTERHEART study.9
Figure 2: Affordability measured as the number of days' wages required for the lowest-paid government worker to purchase a 1-month supply of standard preventive medication for coronary heart disease in selected low-income and middle-income countries.
Figure 3: Effect of fixed-dose combinations on treatment adherence in patients with hypertension.
Figure 4: Incidence of cardiovascular events according to antiplatelet treatment status.
Figure 5: Reduction in the risk of ischemic heart disease events according to LDL cholesterol level and years in treatment.
Figure 6: Effect of angiotensin-converting-enzyme inhibitors on mortality in different subgroups of high-risk patients.

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Acknowledgements

Ariana Del Negro, Medscape Cardiology, New York, NY and Désirée Lie, University of California, Irvine, CA, are the authors of and are solely responsible for the content of the learning objectives, questions and answers of the Medscape-accredited continuing medical education activity associated with this article.

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Authors and Affiliations

  1. G Sanz is Chair of the Department of Translational Research, CNIC, Madrid, Spain.,

    Ginés Sanz

  2. V Fuster is Editor-in-Chief of Nature Clinical Practice Cardiovascular Medicine, Director of the Zena and Michael A Wiener Cardiovascular Institute and the Marie-Josée and Henry R Kravis Center for Cardiovascular Health, and the Richard Gorlin, MD/Heart Research Foundation Professor of Cardiology, Mount Sinai School of Medicine, New York, NY, USA.,

    Valentin Fuster

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Correspondence to Ginés Sanz.

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Sanz, G., Fuster, V. Fixed-dose combination therapy and secondary cardiovascular prevention: rationale, selection of drugs and target population. Nat Rev Cardiol 6, 101–110 (2009). https://doi.org/10.1038/ncpcardio1419

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