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This ‘4-in-1’ pill cut heart disease risk by a third — should we all take it?

The reduced risk of cardiovascular problems held true even in people who had no history of heart disease.
The reduced risk of cardiovascular problems held true even in people who had no history of heart disease. Caiaimage/Sam Edwards

Would you take a pill, even though you’re healthy, if it promised to cut your risk of future health problems?

That’s a question raised by some new research on heart disease, published last week in the Lancet.

In a study, researchers took nearly 7,000 people in Iran, between the ages of 40 and 75. Half of them were given advice on healthy eating, smoking cessation and physical activity. The other half got that same advice, plus an experimental daily pill called a “polypill” that contained aspirin, two common blood-pressure medications, and a statin to lower cholesterol.

After five years, 5.9 per cent of the people taking the pill had a major cardiovascular event, like heart failure, heart attack or a stroke, compared to 8.8 per cent of people who weren’t taking the pill — a 34 per cent difference.

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“I think this is a really important study,” said Dr. Mansoor Husain, a professor of medicine at the University of Toronto and executive director of the Ted Rogers Centre for Heart Research. “The profession perks up and listens” with results like these, he said.

The reduced risk of cardiovascular problems held true even in people who had no history of heart disease.

“What’s really important there is that that applied to men and women equally, older and younger subjects equally, and there seemed to be almost greater benefit in those individuals who did not have a history of cardiovascular disease,” said Dr. Ruth McPherson, a professor of medicine at the University of Ottawa and director of the Lipid Clinic at the Ottawa Heart Institute.

“So you know that kind of opens it up to, we should maybe be considering treatment in a much broader range of individuals even if they don’t seem to be high risk: they don’t have cardiovascular disease, their LDL (cholesterol levels) are kind of so-so.”

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Heart disease is the second leading cause of death for Canadians, according to the Public Health Agency of Canada, and about one in 12 Canadian adults is living with diagnosed heart disease.

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“I think there is a broad implication for public health, not that different from something like vaccination,” Husain said.

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He said the field is slowly warming to the idea of tools like polypills for primary prevention of cardiovascular events, as it’s easier to take a single pill than several, the pill’s components are generic and affordable, and the benefits at a population level could be significant.

Polypills have been proposed and studied before. A 2017 Cochrane review of studies on the subject found that the pills’ effectiveness was uncertain, and people who took them experienced some adverse effects — though most studies included in that review were of moderate to poor quality, the authors noted.

This is a single study, but there are other ongoing studies on polypills to prevent cardiac problems that should start reporting results soon, Husain said. He expects they will provide even more evidence to guide public health policy decisions on the medication.

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The authors of this Lancet study suggest that giving this kind of medication out to the general population could be an effective public health measure in low- or medium-income countries like Iran.

But it might not work everywhere, some caution.

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“I think that for people who don’t have access to primary prevention, which is to say family physicians, nurse practitioners, family health teams, this approach works very well,” said Dr. Mike Sharma, who holds the Michael G. DeGroote chair in stroke prevention at McMaster University and is a spokesperson for Heart & Stroke.

“If you have access to those sorts of teams, then a better approach is to target each of these risk factors in detail and adjust medication to meet the target.”

In other words, in a place like Canada where there is better access to primary care, Sharma thinks that it’s better to identify problems like high blood pressure in a doctor’s office, then treat those problems specifically and tailor medications to the individual rather than giving everyone a one-size-fits-all pill.

One of the components of this polypill, Aspirin, has also been associated with gastrointestinal bleeding in some individuals. The American College of Cardiology recommends against the routine use of Aspirin for primary prevention of cardiovascular problems in people with no history of issues.

READ MORE: Daily aspirin reduces the risk of heart attack, but raises the risk of internal bleeding, study finds

To McPherson, this suggests that people at risk of bleeding should be identified and their treatment considered accordingly, rather than just dismissing the polypill altogether.

“You have to remember about one in two men die of cardiovascular disease, about one in three women. And the older you live, the greater the risk. So anything you can do to attenuate the progression of atherosclerosis is undoubtedly going to be a benefit,” she said.

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