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The Polypill Approach – an Innovative Strategy to Improve Cardiovascular

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The Polypill Approach – an Innovative Strategy to Improve Cardiovascular Fuster et al. BMC Pharmacology and Toxicology (2017) 18:10 DOI 10.1186/s40360-016-0102-9 DEBATE Open Access The polypill approach – An innovative strategy to improve cardiovascular health in Europe Valentín Fuster1,2, Francesc Gambús3, Aldo Patriciello4* , Margaretha Hamrin5 and Diederick E. Grobbee6 Abstract Background: Cardiovascular disease (CVD) is a major cause of disability and premature death. Despite European guidelines advocating the use of medical therapies in CVD, many patients still do not achieve the guideline- recommended treatment, which highlights the need for change and innovations in this field. This requirement has been widely recognised by the national ministries of health, several European cardiology societies, and the European Parliament, who support the initiation of strategies to improve and promote cardiovascular health. Discussion: One of the key risk factors to recurrent cardiovascular events is the lack of adherence to medication and this has been added to the agenda of the European Commission. With the intention to improve treatment adherence in CVD, polypills have been investigated and numerous studies demonstrate that they significantly improve medication adherence, which contributes to the improvement of health outcomes. In Europe, the first cardiovascular polypill, developed by a public-private partnership (CNIC-Ferrer), recently became available for general prescription as a therapy for CVD prevention. This polypill significantly improves adherence, preventing fatal and non-fatal cardiovascular events, and appears to be a cost-effective strategy to improve sustainability of the health care systems in CVD. Conclusions: Given the importance of urgent and simple solutions to restraining the pandemic nature of CVD, the polypill approach should therefore be considered by physicians and public health systems as an available and innovative option to improve cardiovascular health. Background One of the key risk factors to recurrent CV events is Cardiovascular disease (CVD) is a major cause of the lack of adherence to medication and this has been disability and premature death worldwide. Despite added to the agenda of the European Commission. With European and American guidelines advocating the the intention to improve treatment adherence and use of medical therapies in CVD, many patients still strengthen comprehensive CVD prevention plans, sev- do not achieve the guideline-recommended treat- eral approaches and interventions have been analysed, ment, due to several reasons including poor or non- such as the use of Dual Antiplatelet Therapy (DAPT), as adherence to the prescribed therapy or high medication well as different tactics to modify behavioural risk fac- burden. As such, there is a clear need for change and tors. There have, however, only been few advances in the innovation in this field. field of drug treatment aimed at enhancing treatment ef- This need has been widely recognised in political, sci- fectiveness. In particular, polypills have been investigated entific and patient communities in their support of the in the CVD field and numerous studies demonstrate that initiation of strategies to improve and promote cardio- they significantly improve medication adherence, which vascular (CV) health. contributes to the improvement of health outcomes. This article analyses the issue of poor and non- * Correspondence: [email protected] adherence to medication as a risk factor for CVD pre- 4Group of the European People’s Party (Christian Democrats), European vention and focuses on the polypill therapy as an Parliament, Rue Wiertz, Altiero Spinelli 10E209, 1047 Brussels, Belgium Full list of author information is available at the end of the article © The Author(s). 2017 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated. Fuster et al. BMC Pharmacology and Toxicology (2017) 18:10 Page 2 of 8 effective approach to help reduce the number of recur- factors as critical for the progression of CVD in patients, ring CV events in Europe. such as smoking, unbalanced diet, lack of physical activ- ity and harmful use of alcohol [12]. In addition, medical Discussion risk factors, such as no revascularization procedures, the Epidemiology and burden of CVD in Europe presence of comorbidities, as well as the lack of adher- It has been widely demonstrated that CVD is a major ence to prescribed medication, have also been shown to cause of disability and premature death worldwide [1]. be associated with recurrent CV events [13]. An estimated 17.5 million people died in 2012 as a con- Although modifying patients’ lifestyle and behaviours sequence of CVD [2], and it is expected that this figure could partly reduce the recurrence of CV events, [12], a will increase by 2030, reaching 23.3 million deaths dir- large body of evidence supports the use of medical ther- ectly related to CV events [1]. apies as the most effective approach to secondary pre- Looking at a regional level, CVD is the leading con- vention of CVD [14, 15]. The combined use of aspirin, tributor to mortality in the 53 countries of the World angiotensin-converting-enzyme (ACE) inhibitors and Health Organization (WHO) Europe Region, causing al- lipid-lowering therapies has been proven [16, 17] to be most 4.1 million deaths each year, which means 46 % of highly effective in lowering the risk of secondary CV all deaths in Europe. In the European Union (EU) alone, events. Indeed, it has been estimated that about two- CVD causes more than 1.9 million deaths annually thirds to three-quarters of future vascular events could and the geographical distribution of this figure across be prevented when using these drugs together [15], and Europe reflects particularly higher rates of deaths in it also leads to a large reduction of CVD-related deaths the northern countries over the southern nations. In [14]. Given this evidence, decreasing the recurrence of all countries, death rates for coronary heart disease CV events has become a global priority [18], and, ac- (CHD) are higher in males than females [3]. cordingly, European guidelines have openly and strongly The global burden of CVD is led by CHD and stroke, advocated for the use of medical therapies in the preven- which have been identified as the first and third lead dis- tion of secondary CV events and in particular for the eases for disability-adjusted life-years, as a sum of years use of polypills to increase adherence [19]. of life lost due to premature death and years of life lived However, while guidance from experts is clear, recent with disability, worldwide [4]. For Europeans, in addition studies have demonstrated a suboptimal use of medi- to being the lead cause of mortality, CVD also makes a cines targeted for the prevention of recurrent CV events, substantial contribution to morbidity rates. Overall, showing that only 43 % of patients with acute coronary CVD is estimated to cost the European economy almost syndrome (ACS) are actually prescribed with optimal EUR 196 billion a year. Of the total spending, around treatment for secondary prevention [20, 21]. As a conse- 54 % is directly associated to health care costs, 24 % to quence, experts have made a call to action, which high- productivity losses and 22 % is a consequence of the in- lights the need to improve clinical prevention particularly formal care of people with CVD [5]. in primary care, where it may be beneficial to enhance the quality of the relationship between healthcare providers The importance of secondary prevention in CVD and patients to ensure that they benefit from fully avail- Some studies showed that the progresses made in secur- able knowledge [10]. ing the stabilisation of patients after a CV event, such as In addition, the latest EUROASPIRE study [22], a myocardial infarction (MI), have largely contributed to cross-sectional study undertaken across 78 centres in 24 the prevalence of CHD as a chronic disease. Conse- European countries, demonstrated that a large majority quently, recurrent CVD events are common among of coronary patients does not follow the recommenda- people who have previously been diagnosed with an tions set by guidelines on modifying their behavioural MI, with rates found as close to 50 % for any CVD patterns towards a balanced and healthy lifestyle. There- event [6, 7] or subsequent revascularisation [8] during fore, risk factor control and therapeutic targets are not the first year after suffering an MI. It has also been achieved as required to manage the prevention of recur- demonstrated that up to 75 % of patients have a recur- rent CV events properly. rent event within 3 years after suffering a MI [7, 9]. In Adherence to medication has been widely identified as addition, patients with a history of acute myocardial in- a risk factor to the recurrence of CVD. Good adherence farction (AMI) are at least five to six times more likely is associated with positive health outcomes and poor ad- to die of CV causes within a year [10]. herence to treatment actually increases the likelihood of It is therefore essential to understand and to consider suffering a recurrent CV event [23, 24]. A recent study the implications for the long-term prognosis of the con- further showed that low-risk, intermediate risk and dition, both for survival and the risk of recurrence [11]. high-risk patients with AMI in the year following dis- In this regard, guidelines have suggested behavioural risk charge, present poor adherence rates to prescribed Fuster et al. BMC Pharmacology and Toxicology (2017) 18:10 Page 3 of 8 therapies: 61.5, 57.9 and 45.9 % respectively [25].
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