Polypill Programs to Prevent Stroke and Cut Costs in Low Income Countries: Moving From Clinical Efficacy to Pragmatic Implementation

Abstract

Current projections are that the already overwhelming burden of strokes and atherosclerotic cardiovascular diseases in low- and middle-income countries (LMICs) will continue to rise over the coming decades as the prevalence of traditional vascular risk factors burgeon in these countries. Cardiovascular polypills containing combinations of antihypertensive(s), a statin, with or without aspirin or folic acid in the form of a single pill, represent a viable strategy for both primary and secondary prevention of atherosclerotic cardiovascular diseases in LMICs. Large multicenter trials in LMIC and high-income country (HIC) settings have now clearly demonstrated the beneficial effects of the cardiovascular polypill versus placebo (or usual care) in reducing primary stroke risk by 50%. For survivors of a recent myocardial infarction residing in HICs, the polypill reduced risk of major cardiovascular events by 25% due to improved treatment adherence. Data on the clinical efficacy of the polypill for secondary stroke prevention are scanty both in HICs and LMICs. Cost-effectiveness analyses data from LMICs suggest cost savings with the polypill for primary and secondary prevention of stroke and atherosclerotic cardiovascular diseases. However, major contextual barriers in LMICs need to be surmounted through mixed methods research and hybrid clinical trials to assess its real-world effectiveness, before the adoption of the polypill for primary and secondary atherosclerotic cardiovascular disease prevention in routine clinical practice.

A comprehensive review of stroke-related signaling pathways and treatment in western medicine and traditional Chinese medicine

“…TCM has shown to have fewer side effects and can be widely promoted in developing countries, especially in Asia and Africa, for the prevention and treatment of stroke. Moreover, TCM can also be used to assist the diagnosis, treatment, and recovery of stroke in developed countries ( Sarfo et al, 2023 ). It is crucial to develop TCM suitable for stroke treatment, as it can be used as a means to extend the time window of stroke, retard the advancement of the ailment, and improve the prognosis and rehabilitation ( Liu et al, 2018 ; Zhu et al, 2022 ).…”

Health Equity and Actionable Disparities in Stroke: 2022 Update

“…The focused review by Sarfo et al 8 provides an overview of the use of fixed-dose combination pills, polypills , in prevention of atherosclerotic cardiovascular disease in low- and middle-income countries (LMIC). LMICs bear the greatest burden of stroke worldwide 9 ; sub-Saharan Africa is disproportionately affected.…”

“…Based on meta-analyses of studies, it appears that polypills are a cost-effective option for reducing death and disability. 8 Despite the evidence for both efficacy and cost-effectiveness, polypill interventions have not been implemented for primary and secondary cardiovascular disease prevention. Sarfo et al 8 suggest using an implementation science framework such as the Consolidated Framework for Implementation Research to systematically evaluate the barriers for implementation at patient, provider, health system, and policy levels.…”