Association of genetic variants related to combined lipid-lowering and antihypertensive therapies with risk of cardiovascular disease: 2 × 2 factorial Mendelian randomization analyses

BACKGROUND

Lipid-lowering drugs and antihypertensive drugs are commonly combined for cardiovascular disease (CVD). However, the relationship of combined medications with CVD remains controversial. We aimed to explore the associations of genetically proxied medications of lipid-lowering and antihypertensive drugs, either alone or both, with risk of CVD, other clinical and safety outcomes.

METHODS

We divided 423,821 individuals in the UK Biobank into 4 groups via median genetic scores for targets of lipid-lowering drugs and antihypertensive drugs: lower low-density lipoprotein cholesterol (LDL-C) mediated by targets of statins or proprotein convertase subtilisin/kexin type 9 (PCSK9) inhibitors, lower systolic blood pressure (SBP) mediated by targets of β-blockers (BBs) or calcium channel blockers (CCBs), combined genetically lower LDL-C and SBP, and reference (genetically both higher LDL-C and SBP). Associations with risk of CVD and other clinical outcomes were explored among each group in factorial Mendelian randomization.

RESULTS

Independent and additive effects were observed between genetically proxied medications of lipid-lowering and antihypertensive drugs with CVD (including coronary artery disease, stroke, and peripheral artery diseases) and other clinical outcomes (ischemic stroke, hemorrhagic stroke, heart failure, diabetes mellitus, chronic kidney disease, and dementia) (P > 0.05 for interaction in all outcomes). Take the effect of PCSK9 inhibitors and BBs on CVD for instance: compared with the reference, PCSK9 group had a 4% lower risk of CVD (odds ratio [OR], 0.96; 95%CI, 0.94-0.99), and a 3% lower risk was observed in BBs group (OR, 0.97; 95%CI, 0.94-0.99), while combined both were associated with a 6% additively lower risk (OR, 0.94; 95%CI, 0.92-0.97; P = 0.87 for interaction).

CONCLUSIONS

Genetically proxied medications of combined lipid-lowering and antihypertensive drugs have an independent and additive effects on CVD, other clinical and safety outcomes, with implications for CVD clinical practice, subsequent trials as well as drug development of polypills.

Adherence to antihypertensives in the United States: A comparative meta-analysis of 23 million patients

Adherence to antihypertensives is crucial for control of blood pressure. This study analyzed factors and interventions that could affect adherence to antihypertensives in the US. PubMed, Scopus, Web of Science, and Embase were searched on January 21, 2022 and December 25, 2023 for studies on the adherence to antihypertensives in the US. Nineteen studies and 23 545 747 patients were included in the analysis, which showed that adherence to antihypertensives was the highest among Whites (OR: 1.47, 95% CI 1.34-1.61 compared to African Americans). Employment status and sex were associated with insignificant differences in adherence rates. In contrast, marital status yielded a significant difference where unmarried patients demonstrated low adherence rates compared to married ones (OR: 0.8, 95% CI 0.67-0.95). On analysis of comorbidities, diabetic patients reported lower adherence to antihypertensives (OR: 0.95, 95% CI 0.92-0.97); furthermore, patients who did not have Alzheimer showed higher adherence rates. Different BMIs did not significantly affect the adherence rates. Patients without insurance reported significantly lower adherence rates than insured patients (OR: 3.93, 95% CI 3.43-4.51). Polypill users had higher adherence rates compared with the free-dose combination (OR: 1.21, 95% CI 1.2-1.21), while telepharmacy did not prove to be as effective. Lower adherence rates were seen among African Americans, uninsured, or younger patients. Accordingly, interventions such as fixed-dose combinations should be targeted at susceptible groups. Obesity and overweight did not affect the adherence to antihypertensives.

LDL-C target attainment in secondary prevention of ASCVD in the United States: barriers, consequences of nonachievement, and strategies to reach goals

Atherosclerotic cardiovascular disease (ASCVD) is the leading cause of death in the United States. Elevated low-density lipoprotein cholesterol (LDL-C) is a major causal risk factor for ASCVD. Current evidence overwhelmingly demonstrates that lowering LDL-C reduces the risk of secondary cardiovascular events in patients with previous myocardial infarction or stroke. There is no lower limit for LDL-C: large, randomized studies and meta-analyses have found continuous benefit and no safety concerns in patients achieving LDL-C levels <25 mg/dL. As 'Time is plaque' in patients with ASCVD, early, sustained reductions in LDL-C are critical to slow or halt disease progression. However, despite use of lipid-lowering medications, <30% of patients with ASCVD achieve guideline-recommended reductions in LDL-C, resulting in a substantial societal burden of preventable cardiovascular events and early mortality. LDL-C goals are not met due to several factors: lipid-lowering therapy is not initiated and intensified as directed by clinical guidelines (clinical inertia); most patients do not adhere to prescribed medications; and high-risk patients are frequently denied access to add-on therapies by their insurance providers. Promoting patient and clinician education, multidisciplinary collaboration, and other interventions may help to overcome these barriers. Ultimately, achieving population-level guideline-recommended reductions in LDL-C will require a collaborative effort from patients, clinicians, relevant professional societies, drug manufacturers, and payers.

The Era of Polypills in the Management of Cardiovascular Diseases: Are We There Yet?

Cardiovascular Diseases (CVD) are the leading cause of mortality globally. Wald and Law proposed the idea of a 'polypill'; a fixed dose combination therapy (FDC) in the form of a single pill to curb the CVD epidemic. Such a drug would include the combination of a broad spectrum of drugs including cholesterol lowering drugs, antihypertensive drugs, anti-platelet drugs, anti-coagulation drugs, anti-arrhythmic drugs, which are frequently integrated to combat specific CVDs. This 'polypill' holds the potential to pose several advantages like increased compliance, improved quality of life, risk factor control, psychological relief, and cost effectiveness along with minimal side effects. Several trials (like TIPS, UMPIRE, PolyIran etc.) have tested different treatment strategies to test the hypothesis of Wald and Law. Unlike the past physicians are now highly aware of this new strategy.The future of polypill in the management of CVD lies in a strategy where polypills are treated supplementary to the already existing preventive care, which includes lifestyle modifications and efforts to reduce tobacco use.

Preformulation Studies of Ezetimibe-Simvastatin Solid Dispersions in the Development of Fixed-Dose Combinations

Two active pharmaceutical ingredients (APIs) with limited solubility, simvastatin and ezetimibe, prepared as a drug-drug solid dispersion (SD) was evaluated for physicochemical, microstructural, and aqueous dissolution properties. The simvastatin-ezetimibe SD was prepared using the co-grinding method in a wide range of weight fractions and differential scanning calorimetry (DSC) and X-ray powder diffraction (XRPD) were used to perform the phase composition analysis. DSC studies confirmed that simvastatin and ezetimibe form a simple eutectic phase equilibrium diagram. Analysis of Fourier transform infrared spectroscopy (FTIR) studies excluded strong interactions between the APIs. Our investigations have revealed that all studied dispersions are characterized by substantially improved ezetimibe dissolution regardless of simvastatin content, and are best when the composition oscillates near the eutectic point. Data obtained in our studies provide an opportunity for the development of well-formulated, ezetimibe-simvastatin fixed-dose combinations (for hypercholesterolemia treatment) with reduced ezetimibe dosages based on its dissolution improvement.

Effectiveness of Fixed-Dose Combination Therapy (Polypill) Versus Exercise to Improve the Blood-Lipid Profile: A Network Meta-analysis

BACKGROUND

Both exercise and polypills are recommended treatments to improve the blood-lipid profile.

OBJECTIVE

The aim of this study was to compare head-to-head the effectiveness of polypill and exercise strategies in improving the blood-lipid profile in high-risk cardiovascular patients.

METHODS

We performed an electronic search in Web of Science, EMBASE, Cochrane Database of Systematic Reviews, MEDLINE and SPORTDiscus, from inception to August 2021. Randomized controlled trials (RCTs) testing the effectiveness of exercise interventions or treatment with fixed-dose combination therapy (polypill) in improving the blood-lipid profile in adults with atherosclerotic cardiovascular disease or presenting at least one well recognized cardiovascular risk factor were included.

RESULTS

A total of 131 RCTs were included: 15 and 116 studies analyzing the effects of polypills and exercise, respectively, on blood-lipid levels. Both exercise and polypill strategies were effective in reducing low-density lipoprotein cholesterol (LDL-c) and total cholesterol (TC), but only exercise interventions improved high-density lipoprotein cholesterol (HDL-c) and triglyceride levels compared with the control group. The results of the network meta-analyses showed that the polypill without antiplatelet therapy was the most effective pharmacological treatment for improving the lipid profile, while aerobic interval exercise was the most effective exercise intervention.

CONCLUSIONS

Considering that both polypills and exercise are effective in reducing LDL-c and TC but only exercise improves HDL-c and triglycerides, and that exercise provides further health benefits (e.g., increases in physical fitness and decreases in adiposity), it seems reasonable to recommend exercise as the first treatment option in dyslipidemia when the patient's general condition and symptoms allow it.

PROSPERO REGISTRATION NUMBER

CRD42019122794.

Real-life effect on the control of risk factors associated with initiation of the cardiovascular polypill created from equipotent drugs

OBJECTIVE

This work aims to analyze the impact of Spain's National Center for Cardiovascular Research (CNIC-Ferrer)'s cardiovascular (CV)-polypill on blood pressure (BP) and low-density lipoprotein cholesterol (cLDL) levels in patients in our healthcare area who previously took equipotent doses of statins and antihypertensives.

MATERIAL AND METHODS

All patients in our healthcare area (Santiago de Compostela, Spain) who, as of December 31, 2019, had an active prescription for the CV-polypill (CNIC-Ferrer) since January 16, 2015 were registered. The index date was the start date of the CV-polypill prescription. The drugs the patient had previously received for dyslipidemia and hypertension were analyzed, classifying them by their equivalent potency to atorvastatin and ramipril. Changes in cLDL and BP were analyzed by means of Student's t-test for paired samples.

RESULTS

We analyzed 547 patients with a mean age of 71.5 ± 11.5 years. The majority were men (60.6%). We observed a decrease in cLDL (-10.6 [95% CI: -7.0, -14.3], p < 0.001) in patients who started taking the CV-polypill who had previously taken equally potent doses of atorvastatin (n = 471). We documented a reduction in systolic BP (-3.7 [95% CI: -0.4, -6.9], p = 0.029) in patients who had previously taken equally potent doses of ramipril (n = 360). In 88 patients, the CV-polypill was started via equally potent doses of atorvastatin and ramipril, with a decrease in cLDL (-8.7 [95% CI: -3.8, -13.6], p = 0.001) and systolic BP (-3.6 [95% CI: -7.8, 0.5], p = 0.085).

CONCLUSIONS

The initiation of treatment with the CV-polypill in patients who previously received equally potent treatment with atorvastatin and ramipril was associated with a greater reduction in cLDL and systolic BP.

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

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

Effectiveness of polypill for primary and secondary prevention of cardiovascular diseases (PolyIran): a pragmatic, cluster-randomised trial

BACKGROUND

A fixed-dose combination therapy (polypill strategy) has been proposed as an approach to reduce the burden of cardiovascular disease, especially in low-income and middle-income countries (LMICs). The PolyIran study aimed to assess the effectiveness and safety of a four-component polypill including aspirin, atorvastatin, hydrochlorothiazide, and either enalapril or valsartan for primary and secondary prevention of cardiovascular disease.

METHODS

The PolyIran study was a two-group, pragmatic, cluster-randomised trial nested within the Golestan Cohort Study (GCS), a cohort study with 50 045 participants aged 40-75 years from the Golestan province in Iran. Clusters (villages) were randomly allocated (1:1) to either a package of non-pharmacological preventive interventions alone (minimal care group) or together with a once-daily polypill tablet (polypill group). Randomisation was stratified by three districts (Gonbad, Aq-Qala, and Kalaleh), with the village as the unit of randomisation. We used a balanced randomisation algorithm, considering block sizes of 20 and balancing for cluster size or natural log of the cluster size (depending on the skewness within strata). Randomisation was done at a fixed point in time (Jan 18, 2011) by statisticians at the University of Birmingham (Birmingham, UK), independent of the local study team. The non-pharmacological preventive interventions (including educational training about healthy lifestyle-eg, healthy diet with low salt, sugar, and fat content, exercise, weight control, and abstinence from smoking and opium) were delivered by the PolyIran field visit team at months 3 and 6, and then every 6 months thereafter. Two formulations of polypill tablet were used in this study. Participants were first prescribed polypill one (hydrochlorothiazide 12·5 mg, aspirin 81 mg, atorvastatin 20 mg, and enalapril 5 mg). Participants who developed cough during follow-up were switched by a trained study physician to polypill two, which included valsartan 40 mg instead of enalapril 5 mg. Participants were followed up for 60 months. The primary outcome-occurrence of major cardiovascular events (including hospitalisation for acute coronary syndrome, fatal myocardial infarction, sudden death, heart failure, coronary artery revascularisation procedures, and non-fatal and fatal stroke)-was centrally assessed by the GCS follow-up team, who were masked to allocation status. We did intention-to-treat analyses by including all participants who met eligibility criteria in the two study groups. The trial was registered with ClinicalTrials.gov, number NCT01271985.

FINDINGS

Between Feb 22, 2011, and April 15, 2013, we enrolled 6838 individuals into the study-3417 (in 116 clusters) in the minimal care group and 3421 (in 120 clusters) in the polypill group. 1761 (51·5%) of 3421 participants in the polypill group were women, as were 1679 (49·1%) of 3417 participants in the minimal care group. Median adherence to polypill tablets was 80·5% (IQR 48·5-92·2). During follow-up, 301 (8·8%) of 3417 participants in the minimal care group had major cardiovascular events compared with 202 (5·9%) of 3421 participants in the polypill group (adjusted hazard ratio [HR] 0·66, 95% CI 0·55-0·80). We found no statistically significant interaction with the presence (HR 0·61, 95% CI 0·49-0·75) or absence of pre-existing cardiovascular disease (0·80; 0·51-1·12; pinteraction=0·19). When restricted to participants in the polypill group with high adherence, the reduction in the risk of major cardiovascular events was even greater compared with the minimal care group (adjusted HR 0·43, 95% CI 0·33-0·55). The frequency of adverse events was similar between the two study groups. 21 intracranial haemorrhages were reported during the 5 years of follow-up-ten participants in the polypill group and 11 participants in the minimal care group. There were 13 physician-confirmed diagnoses of upper gastrointestinal bleeding in the polypill group and nine in the minimal care group.

INTERPRETATION

Use of polypill was effective in preventing major cardiovascular events. Medication adherence was high and adverse event numbers were low. The polypill strategy could be considered as an additional effective component in controlling cardiovascular diseases, especially in LMICs.

FUNDING

Tehran University of Medical Sciences, Barakat Foundation, and Alborz Darou.

Can a polypill one single tablet combat different cardiovascular risk factors?

Polypharmacy is defined as the use of two or more drugs simultaneously. Cardiovascular drugs and antihypertensives are commonly prescribed for treatment of cardiovascular disease (CVD), especially in elderly patients. Recent studies in patients with a history of CVD demonstrated that the fixed-dose combination of cardiovascular drugs in a polypill retain their individual efficacy, safety, and tolerability, thus have the potential to improve medication adherence and multiple risk factor control, thereby improving patient outcomes in secondary cardiovascular prevention. Since the initial conception of the fixed-dose polypill, just over a decade ago, only six large randomized trials assessing the efficacy and safety of this innovative concept have been completed (one is still ongoing). The results demonstrate that the polypill therapy significantly improved adherence, lowered systolic blood pressure, and low-density lipoprotein cholesterol, compared with usual care, in patients at high risk for CVD, especially among those who were undertreated at baseline. Correspondingly, further studies showed that the strengths of the polypill include better adherence, equivalent or better risk factor control, and improved quality of life among polypill users, as compared with usual care. However, the long-term outcome of the polypill on CVD events and mortality are unavailable and are currently being studied in clinical trials.

Strengths and Limitations of Using the Polypill in Cardiovascular Prevention

Purpose of Review

Polypill and its role in cardiovascular disease (CVD) prevention has been extensively discussed and debated since the inception of the concept in 2003. This article reviews the subsequent accumulated research in this area.

Recent Findings

Several short and intermediate to long-term studies with different brands of polypills have analysed the impact of polypill in phase II and III trials. The strengths of polypill that have emerged include better adherence, equivalent or better risk factor control and quality of life among polypill users as compared to usual care. The lurking limitations include difficulty with dose adjustment to targets, fear of mass medicalisation and low acceptability among physicians.

Summary

The current literature supports polypill use in reducing blood pressure and cholesterol levels for CVD prevention with improvement in adherence to medication. However, the long-term outcome of polypill on CVD events and mortality are unavailable and are currently being studied in clinical trials.

Polypill, hypertension and medication adherence: The solution strategy?

INTRODUCTION

Hypertension is an important global health challenge and a leading preventable risk factor for premature death and disability worldwide. In current cardiology practice, the main obstacles in the management of patients affected by hypertension are comorbidities and poor adherence to pharmacological treatments. The World Health Organization has recently highlighted increased adherence as a key development need for reducing cardiovascular disease.

METHODS

Principal observational and clinical trial data regarding adherence, reductions in cardiovascular risk and safety of the polypill approach are summarized and reviewed.

CONCLUSIONS

The polypill approach has been conclusively shown to increase adherence relative to usual care in all cardiovascular patients, furthermore, concomitant risk factor reductions have also been suggested. To date, the use of polypill could represent a solution strategy in patients affected by hypertension, comorbidities and non-adherence even though further studies, especially in the real-world settings, are needed in order to better understand its role in clinical practice.