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The Polypill (Acetyl Salicylic Acid, Atorvastatin, and Ramipril) Paradigm Shift in Secondary Prevention: Global
Daniel Piñeiro1, José Ramón González-Juanatey2,3,4, Ana Abreu5,6
1School of Medicine, University of Buenos Aires, Argentina.
Insights
The cardiovascular polypill (acetylsalicylic acid, atorvastatin, ramipril) is recommended for secondary prevention after acute myocardial infarction. Global experts reached consensus on its optimal use, supporting early initiation for improved patient outcomes.
Area of Science:
- Cardiology
- Preventive Medicine
- Clinical Pharmacology
Background:
- The cardiovascular (CV) polypill, combining acetylsalicylic acid (ASA), atorvastatin, and ramipril, significantly reduces CV mortality in post-acute myocardial infarction patients.
- The 2023 ACS ESC Guidelines endorse the CV polypill for enhancing patient outcomes and treatment adherence.
Purpose of the Study:
- To establish a global consensus on the optimal utilization of the CV polypill in secondary cardiovascular prevention.
- To inform clinical practice and policy regarding polypill implementation.
Main Methods:
- A modified Delphi method involving two rounds and a 30-statement questionnaire was employed.
- Fifty international clinicians participated, ranking statements on a Likert scale to achieve consensus (≥80% agreement).
Main Results:
- Consensus was reached on 93.3% of statements regarding the CV polypill's use.
- Strong agreement (97.4%) was found for clinical implementation post-myocardial infarction, with 100% supporting use at discharge or first follow-up.
- High consensus (≥81.1%) was achieved on algorithms for initiation, patient preferences, and cost-effectiveness.
Conclusions:
- Global expert consensus supports the early initiation of the CV polypill (ASA, atorvastatin, ramipril) for secondary prevention post-acute coronary syndrome.
- These findings provide a framework for practice and policy, guiding future research priorities in polypill therapy.
Background:
The SECURE trial demonstrated that the cardiovascular (CV)-polypill (acetylsalicylic acid [ASA] + atorvastatin + ramipril) reduces CV mortality by 33% in patients with acute myocardial infarction compared to standard care. The 2023 ACS ESC Guidelines recommend the polypill to improve outcomes and adherence.
Objective:
This study aims to establish a global consensus on the optimal use of the CV-polypill in secondary prevention.
Methods:
A two-round, modified Delphi method was used, featuring a 30-statement evidence-based questionnaire validated by eight renowned cardiologists. Fifty clinicians from 19 countries in Europe, Latin America, and Asia were invited to join the Delphi panel. Panelists ranked responses using a three-point Likert scale for agreement and importance. Consensus was defined as ≥80% agreement or rating statements 'very important' or 'important'. Statements without consensus after the first round were refined with evidence and feedback in the second round. Remaining disagreements were resolved in a face-to-face meeting. Descriptive statistics were applied.
Results:
Response rate was 76% (round 1) and 74% (round 2); 82% were cardiologists, with 74% frequently recommending the CV-polypill. Consensus was achieved on 93.3% of statements. Research showing a 24% relative risk reduction in major adverse CV events over a median of 3 years with the CV-polypill post-acute myocardial infarction, compared to usual care, reached 97.4% agreement for clinical implementation, and a 100% consensus supported polypill use at hospital discharge or first follow-up visits; 81.1% agreed on a prompt initiation after patient stabilization. There was agreement on algorithms for initiating (97.3%), considering patient preferences (97.4%) to the polypill and its cost savings over usual care (89.5%).
Conclusion:
The Delphi consensus on real-world use of a CV polypill (ASA, atorvastatin, and ramipril) for secondary prevention post-acute coronary syndrome supports early initiation (within 8 days or at discharge). The findings provide a foundation to inform practice and policy, identifying priorities for further research.
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