Fixed-Dose Combination Therapy and Secondary Cardiovascular Prevention

Table 1.

Cost-effectiveness Analysis of Cardiovascular Disease Prevention With a Multidrug Regimen

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Summary and Introduction

Summary

Ischemic heart disease and stroke are the leading causes of death worldwide. A large proportion of individuals at high 10-year risk of a cardiovascular event live in low-income and middle-income countries, and the large majority of all cardiovascular events occur in developing countries. A large amount of evidence supports the use of pharmacological treatment for the prevention of cardiovascular death in this population, including antiplatelet drugs, beta blockers, lipid-lowering agents and angiotensin-converting-enzyme inhibitors. However, the efficacy of cardiovascular prevention is hampered by several problems, including inadequate prescription of medication, poor adherence to treatment, limited availability of medications and unaffordable cost of treatment. Here we examine the use of fixed-dose combination therapy (a 'polypill'), and how this therapy could improve adherence to treatment, reducethe cost and improve treatment affordability in low-income countries.

Introduction

In 2005, cardiovascular diseases caused 17.5 million deaths worldwide, which is 3.3 times more than AIDS, tuberculosis and malaria combined. In Europe, cardiovascular disease is the major cause of premature death in adults,^[1,2] and data from the US show that in 2004, 869,700 people died as a result of cardiovascular and cerebrovascular diseases.^[3]

The problem is even worse in low-income and middle-income countries; four-fifths of all cardiovascular-related events occur in these parts of the world.^[4] In addition, the global burden of cardiovascular disease is increasing steadily. Although cardiovascular-related mortality in high-income countries is projected to increase from 5 million in 2000 to 6 million in 2020, the corresponding figures for low-income and middle-income countries are set to rise from 10 million to a staggering 19 million.^[4,5] Furthermore, a large proportion of deaths occur in the working-age population, particularly in developing countries.^[6,7] However, even in countries in which cardiovascular mortality is declining, such as the US, the economic burden is increasing as the number of individuals living with these diseases increases, as reflected by the number of annual hospital discharges.^[8]

Coronary heart disease accounts for a large proportion of cardiovascular deaths worldwide. As this condition is multifactorial, successful reduction of the huge effect it has on global health and the global economy requires effective control of risk factors and the appropriate use of medication. To date, unfortunately, most secondary prevention programs have shown only modest results. Research in this field and the development of new approaches to cope with the cardiovascular epidemic is, therefore, mandatory. The purpose of this Review is to discuss the problems faced by prevention of adverse cardiovascular events in clinical practice, and provide evidence for the need for fixed-dose combination drugs or 'polypills' in this setting. We feel that fixed-dose combination drugs will improve adherence, reduce costs and improve treatment affordability in low-income countries. Here we focus in particular on secondary prevention in the context of ischemic heart disease.