The polypill concept

“Polypill” describes a fixed dose combination pill containing several components designed to lower several cardiovascular risk factors simultaneously.1 For people who have had a cardiovascular disease event or related disorders such as angina pectoris, combination treatment has been practised for many years, although apart from the use of aspirin there has been a tendency to treat each risk factor rather than the overall risk of the disease. For example, until recently statins have been prescribed only if serum cholesterol is raised.2 3 4 Blood pressure lowering drugs are given only if a diagnosis of hypertension has been made.2 4 5 6 7 This is inappropriate and leads to many people not receiving preventive treatment who could benefit from receiving such treatment. The basis for preventing clinical cardiovascular disease with a combination of agents that reduce causal risk factors is that, within the range of values of these risk factors in the population, there is no threshold below which a reduction in risk factor ceases to confer a reduction in risk. Indeed, cohort (prospective observational) studies show that blood pressure and cholesterol exhibit a linear relation between the level of the risk factor and the risk of the disease when the risk of the disease is plotted on a proportional (that is, logarithmic) scale.8 9 10 11 12 This relation has great clinical significance, because it shows that for given changes in the risk factor there is a constant proportional change in the risk of disease. So, for example, a reduction of 1 mmol/l in low-density lipoprotein (LDL) cholesterol is associated with an approximate 40% reduction in the risk of having an ischaemic heart disease (IHD) event,13 and a 10 mm Hg decrease in diastolic blood pressure is associated with an approximate 60% decrease in risk of …