The "polypill" for heart disease

From the May 7 BMJ

They propose a combined strategy for primary and secondary prevention— targeting all people with pre-existing cardiovascular disease (secondary prevention) but more controversially, targeting all adults aged over 55 (primary prevention) as well. The underlying assumption concerning the efficacy of this strategy is that the six individual ingredients of the polypill (thiazide diuretic, angiotensin converting enzyme inhibitor, blocker, statin, aspirin, and folic acid) when combined together have synergistic treatment effects—calculated by multiplying the relative risk reductions on each class of treatment.

In plain English, this means advocating that every adult >55 take this multi-ingredient pill for the rest of their life (primary prevention), along with everyone with a history of cardiovascular disease (secondary prevention).

I think the primary prevention idea is nuts. It is hard to show efficacy in primary prevention even in relatively high risk groups, to treat everyone, even those at low risk is crazy. You not only send everyone the message that there is something wrong with them, but you spend a ton of money and guarantee a lot of adverse effects for people who were at low risk anyway. Not to mention how good treatment for CVD, has gotten.

Given how low rates of use of the various components of the polypill are for those with known disesae, however, the idea of combination therapy makes sense. But in secondary prevention you are treating people you already know are sick, which is a whole different story.