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The polypill concept
  1. Nicholas J Wald,
  2. David S Wald
  1. Correspondence to Professor N J Wald, Wolfson Institute of Preventive Medicine, Barts and the London School of Medicine and Dentistry, Charterhouse Square, London, UK; n.j.wald{at}qmul.ac.uk

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“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.

Effect on cardiovascular risk of reducing serum cholesterol and blood pressure

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 …

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