Coronary angioplasty aka PCI is a common procedure with excellent success rates. The in-hospital mortality following PCI is 1-2% and in the setting of acute coronary syndrome is 3%. Additionally,1-2% of patients die after discharge within 30 days. Two recent retrospective database analyses from the states of New York and Michigan Blue shield studied mortality after PCI1,2. The New York database included 135,000 patients studying in-hospital and 30-day mortality while the Michigan database had 92,000 patients analysing in-hospital mortality. I present these papers with the learning points so that we can improve patient outcomes. The findings Both databases showed a 1.5% - 30-day mortality after PCI. 30% of these deaths are preventable. Most in-hospital deaths were non preventable (70%). They were attributed to pre-existing cardiac conditions such as cardiogenic shock, left ventricular failure, co-morbidities etc. Most of them are emergency and high-risk patients. 30% of in-hospital
On a rainy afternoon, Narayana visited Dr
Venkatesh his personal Cardiologist who has been treating him for high
blood pressure, elevated cholesterol and diabetes. Vigilantly he observed his
prescription and asked “Can you cut off some medicines? It is bothersome
to track the multiple medicines and timings”. Doctor replied “we have a new
drug for diabetes that reduces heart attack which I added”.
It is not uncommon for patients to wish that the
medication list be pruned at every visit. But they are bewildered to see
additional medicines in the new prescription. Every few months new medicines
with additional benefits are introduced into medical science leading to
prescription elongation.
Polypill is one of the solutions for long prescriptions
where multiple fixed-dose medicines for various diseases are combined in a
single pill. This combination is to prevent future heart attacks. This concept
is not new; Wald and Law coined the term Polypill in 2003 to denote a
fixed-dose medication combination for preventing cardiovascular disease.
They suggested administering a polypill to all adults above age 55years would
reduce cardiovascular events by more than 80%. This concept was not accepted by
the Cardiologists despite the World Health Organisation
recommendations.
The concept of polypill is useful for treatment of life
style diseases, heart attack, brain stroke, where synergistic effect of
multiple medicines is required. Polypill contains smaller doses of multiple
medicines reducing the side effects than when given at a higher doses.
Apart from reducing pill burden and improving drug compliance, it
translates into cost benefit. This led to rapid acceptance of a fixed-dose polypill
concept in the lower socio-economic countries.
In the West, medicines are dispensed individually, and
the concept of polypill was not encouraged as the fixed dose combination is
rigid not accommodating dose adjustment. In addition, individual
medicines are manufactured by different companies and there was no
possibility of a polypill incorporating medicines from two manufacturers.
But in India it is a common practice to see combination pills as
most medicines are “branded generics”. Manufacturers combine different
medicines within a single pill mainly to reduce the pill burden and
improve medication compliance. The West was late to embrace the concept of
polypill where as Indian doctors practised for the past two decades.
The concept of disease prevention can be broadly
categorised as – Primary prevention – measures taken to prevent the onset
of disease in vulnerable people. For example people with diabetes or
hypertension have a high probability for developing their first heart
attack. Measures taken to prevent first heart attack are termed primary
prevention. Secondary prevention indicates the steps taken to prevent
recurrence of heart attack in those with previous heart problem.
For the primary prevention of heart disease, standard polypill usually has
a fixed-dose of Atorvastatin, Ramipril and Aspirin. But the role of these
medicines is still under intense research. Recent trials showed that aspirin is
not useful for primary prevention of heart attacks even in high risk
population discouraging aspirin as a component of polypill for primary
prevention. However, the PolyIran study showed a 30% reduction of events
with polypill compared to individual medicines for primary prevention which contained
aspirin. It is also not uncommon for patients to develop side-effects
to individual medicines leading to stopping of polypill.
A combination of Aspirin, Ramipril, Beta blocker and
statin is a standard secondary prevention polypill. Everyone with established
cardiovascular disease requires life-long medical treatment and
polypill would be an ideal solution here. The only limitation would be a
risk of undermedication, owing to the inability to adjust dosage of the
individual components of polypill. However, in the latest SECURE study
published by Castellano and others in the New England Journal of Medicine, a
fixed-dose polypill reduced repeat heart attacks in comparison with the
same medicines given separately at similar doses.
So what has evolved over the past 20 years - polypill remains an attractive concept for both primary and secondary prevention of heart attacks. There is no single ideal polypill, instead the composition and dosage of individual components needs to be flexible with the availability of polypill in multiple strengths. Fortunately India has a wide choice of polypill for various life-style diseases. Polypill are being widely used in low socio economic countries as they were economical. Two recent Polypill trials - PolyIran and SECURE studied polypill in primary and secondary prevention respectively demonstrated superior outcomes.
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