Future of polypill use for the prevention of cardiovascular disease and strokes

Cardiovascular disease (CVD) remains still the leading cause of death in the United States, and it is estimated to be the leading cause of death in the developing countries by 2020. In addition, the modifiable cardiovascular risk factors (CVRFs), hypertension, hypercholesterolemia, diabetes, and obesity, have increased significantly and by 2020 will account for 80% of all CVD deaths worldwide. Because the CVD and stroke risk increases significantly for subjects aged >50 years, it has been proposed to treat these subjects with a polypill containing 4 to 5 drugs, which is known to reduce the CVRFs for all subjects aged ≥55 years with an estimated reduction of CVD and stroke by 80%. However, this proposal is neither practical nor cost-effective, because it will involve a large number of subjects. Some investigators suggest to incorporate the coronary artery calcium score (CACS) with the Framingham Risk Score (FRS) to reduce the number of subjects who will benefit from the polypill. They have shown that patients with a CACS = 0 at age 50 years will derive no benefit from the polypill regardless of existing CVRFs, whereas those with a CACS of >100 will derive the best benefit. This strategy will reduce the number of qualified subjects for treatment with the polypill by 60%. Greater benefits will be derived with the combination of CACS and FRS. Additionally, other issues will have to be considered before approval of a polypill, and these issues will be discussed in this concise review. In conclusion, a polypill treatment strategy may be effective in the prevention of CVD and stroke, but, to be cost-effective, it may be reasonable to target patients with a high CACS and FRS.