Medication nonadherence remains a significant factor in cardiovascular disease (CVD) management.¹ Specifically, older adults with polypharmacy, frailty, or cognitive impairment are more likely to experience adverse medication events because of physiologic changes but are less likely to adhere to complex medication regimens because of reduced executive and memory function.²

The SECURE (Secondary Prevention of Cardiovascular disease in the Elderly) trial was a randomized, multicenter trial focused on secondary CVD prevention in older adults (age ≥75 years or ≥65 years with at least one CVD risk factor) that compared outcomes for patients taking a single polypill containing three guideline-recommended medications for CVD—aspirin 100 mg, atorvastatin 40 mg, and ramipril 2.5-10 mg—with those for patients taking the same medications as three separate pills.³ The trial demonstrated a significant reduction in the composite outcome of cardiovascular death, nonfatal myocardial infarction (MI), nonfatal ischemic stroke, or urgent revascularization in the polypill group compared with that of the usual-care group (9.5% vs. 12.7%; hazard ratio, 0.76; 95% confidence interval, 0.6-0.96; p = 0.02). Medication adherence improved in the polypill group whereas adverse events (bleeding, refractory cough, acute kidney injury leading to medication discontinuation, medication allergy) were similar, although the reasons for medication nonadherence were not discussed.

The trial had a limitation from a geriatric cardiology perspective—the lack of data on special populations that may result in different clinical outcomes (cognitive impairment, physical function, frailty, or nursing residence). Medication adherence may be different in community-dwelling older adults than in nursing residents because of the availability of assistance. A more specific in-depth analysis of these special populations would be needed.

The polypill strategy has been mainly studied in CVDs such as hypertension and MI, including primary and secondary prevention in a broad population.⁴ The SECURE trial again provides specific insight into how clinicians may be able to address the issue of polypharmacy and nonadherence and to improve secondary CVD prevention among older adults.

References

1. Leslie KH, McCowan C, Pell JP. Adherence to cardiovascular medication: a review of systematic reviews. J Public Health (Oxf) 2019;41:e84-e94.
2. Woodford HJ, Fisher J. New horizons in deprescribing for older people. Age Ageing 2019;48:768-75.
3. Castellano JM, Pocock SJ, Bhatt DL, et al.; SECURE Investigators. Polypill strategy in secondary cardiovascular prevention. N Engl J Med 2022;387:967-77.
4. Cimmaruta D, Lombardi N, Borghi C, Rosano G, Rossi F, Mugelli A. Polypill, hypertension and medication adherence: the solution strategy? Int J Cardiol 2018;252:181-6.

Clinical Topics: Cardiovascular Care Team, Dyslipidemia, Vascular Medicine, Lipid Metabolism, Statins, Geriatric Cardiology, Prevention

Keywords: ESC Congress, ESC22, Ramipril, Cardiovascular Diseases, Atorvastatin, Confidence Intervals, Frailty, Ischemic Stroke, Polypharmacy, Risk Factors, Infarction, Hypersensitivity

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