A Reflection on Prevention: Can a Holistic Approach to Prevention Include a Polypill?
Does a polypill obviate the need for behavioral changes? Absolutely not. As a physician training in Cardiology, I spend a sizeable part of my time discussing achievable weekly nutritional goals with patients in addition to stressing the importance of medication adherence. I ask myself after watching the “Bending the Curve for CV Disease- Precision or Polypill,” would I recommend a pill that can treat both hypertension and hypercholesterolemia and decrease the risk for CV disease? Certainly, this would make medication adherence for our patients much simpler, especially with the combination of atenolol, ramipril, hydrochlorothiazide, and simvastatin into one pill.
The International Polycap Study (TIPS-3) presented by Drs. Prem Peis and Salim Yusuf was a double-blinded, randomized trial of more than 5,700 adult men and women at increased CV risk with an intervention of the once-daily polypill, aspirin, combination of both or placebo (see figure). Endpoints of CVD events included CV death, non-fatal stroke, non-fatal MI, heart failure, resuscitated cardiac arrest, or arterial revascularization.
To summarize the results, 5-year outcomes found that the polypill was superior to placebo in decreasing systolic blood pressure, LDL-C, and non-fatal CV events in mostly Southeast Asian participants. Low-dose aspirin resulted in lower stroke risk and the additive effect of aspirin to the polypill had a higher reduction in nonfatal CV events when compared to the double placebo arm. The side effects of the intervention group included dizziness and hypotension.
As I return back to clinical responsibilities, I reflect on the AHA Scientific Sessions with particular attention to this polypill. Would you recommend a pill that was cost-effective that decreased pill-burden in your patient? I think I would but not at the cost of leaving behind crucial behavior changes that are integral for health and well-being.
More importantly, the following slide resonated with me the most and I believe conceptualizes a comprehensive framework for prevention and precision medicine:
The takeaways here are that there is a continuum of care across a spectrum of healthy, at risk, and diseased patients we see on a daily basis. Each group in this spectrum requires an individualized, community, and health system approach to intervention and implementation of decreasing cardiovascular risk. The domains needing to be addressed are part of a long list but each important in their own right:
Human Resource Training
Media and Communication
Monitoring and Evaluation
With this framework in mind, I challenge myself and you all to think more deeply about how we might integrate universal standards along with individually-tailored preventative interventions when managing our patients. Our day-to-day clinic experience can at times lull us into the feeling of an unchanging routine, however this presentation was a great reminder of future opportunities to probe further to apply novel universal approaches while also seeking to understand individual patients’ health behavior needs and pushing individualized medicine further in the domain of CV prevention. This will be accomplished through quality care projects, educational work, health equity advocacy, and investigative research.
Take care and be well.
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