The CV polypill strategy (acetyl salicylic acid + atorvastatin + ramipril) as baseline treatment after a cardiovascular event supported by recent compelling evidence: a global expert consensus
Authors: Abreu A , Juanatey J R G , Vazquez J M C , Araujo F , Weisser B , Parkhomenko A , Alvarez E G , Ponte-Negretti C I , Sosa-Liprandi A , Pineiro D , Fuster V 
Published: June 2024

Abstract

Background
Recurrence of cardiovascular (CV) events (CVe) and mortality are high after the index event. In the SECURE trial, CV Polypill Strategy (acetyl salicylic acid [ASA]+atorvastatin+ramipril) reduced CV mortality by 33% in post-acute myocardial infarction (AMI) patients over 3 years (median) compared to usual pharmacologic treatment. The 2023 ESC Guidelines recommend the CV Polypill to improve outcomes and adherence in secondary prevention after acute coronary syndrome, emphasizing early initiation for better patient prognosis post-discharge.

Purpose
To reach consensus among medical experts worldwide on the optimal utilisation of the CV Polypill Strategy (ASA+atorvastatin+ramipril) as baseline treatment to prevent recurrent CVe in routine clinical practice.

Methods
A two-round, modified Delphi method was used. A questionnaire with 30 evidence-based statements was created and validated by 8 renowned cardiologists. 50 clinicians from 19 countries in Europe, Latin America and Asia formed the Delphi panel. Panellists ranked their responses using a three-point Likert scale for agreement and importance. Consensus was reached when ≥80% agreed or deemed questions 'very important' or 'important' (Graph 1). Statements without consensus in the first round were refined based on evidence and participant feedback in the second round. Any remaining disagreements were resolved in a face-to-face meeting with the experts. Descriptive statistics were applied.

Results
Response rates were 76% and 74% in round 1 (March-April 2023) and round 2 (May-June 2023), respectively. Panellists were 82% cardiologists; 13% internists; 74% frequently advised the CV Polypill Strategy (ASA+atorvastatin+ramipril). 93.3% statements achieved consensus. 97.4% agreement on research findings indicating 24% relative risk reduction of CV death, AMI, stroke, or urgent revascularization over 3 years (median) with the CV Polypill Strategy, compared to usual care after a coronary heart disease event, expected to replicate in clinical practice. 100% accord on the CV Polypill Strategy implemented on hospital discharge or first follow-up visits as baseline therapy. 81.1% coincidence on its initiation as soon as symptoms stabilize. Agreement on following algorithms to start (97.3%) or switch (97.4%) to the CV Polypill Strategy from separate cardioprotective drugs. Agreement on CV Polypill Strategy in discharge plan for therapeutic goals (81.6%) and improved adherence (94.7%), and on hospital team’s awareness of CV Polypill Strategy’s CV benefits (100%). 97.4% accord on considering patients' preferences in the discharge plan. Agreement (89.5%) on the polypill strategy delivering cost savings over the patient's lifetime (Table 1).

Conclusions
Experienced clinicians strongly advocate early adoption of the CV Polypill Strategy (acetyl salicylic acid+atorvastatin+ramipril) to reduce recurrence, enhance prognosis, lower CV mortality, and potentially reduce lifetime costs after a CV event. Graph 1. Table 1