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Polypill for Stroke Secondary Prevention in China | Journal Scan
Study Questions:
How many Chinese stroke patients would be candidates for a polypill, what types of medication should be included in such a pill, and how well are vascular risk factors controlled in Chinese stroke patients?
Methods:
The authors used data from the China National Stroke Prevention Project (CSPP). The CSPP is a cross-sectional survey that invites all residents >40 years old in a community to be screened. This study consists of CSPP data from six provinces selected because of “medium” stroke rates. In the CSPP, stroke patients are identified by self-report, followed by a physician interview, physical examination, and laboratory testing to capture additional information including: information about the diagnosis, risk factors, and current treatments. Risk factors analyzed included: elevated low-density lipoprotein (LDL) cholesterol, hypertension, overweight or obese, smoking, frequent alcohol use, diabetes, and atrial fibrillation. Eligibility for secondary prevention treatments was based on guidelines or if the relevant medication was taken within the prior 2 weeks. The authors assumed all stroke patients would be candidates for antiplatelet treatment. The five potential components of a polypill included antihypertensive medications, antidiabetes medications, statins, antiplatelet agents, and anticoagulants. Standardized proportions were calculated to determine how many patients were candidates for secondary prevention treatments and received secondary prevention treatments. Extrapolation to determine implications for the entire Chinese population was done using data from the 2010 Chinese census.
Results:
There were 717,620 subjects screened by the CSPP in the providences identified (84.4% response rate). The standardized prevalence rate of stroke was 1.9% (95% confidence interval, 1.913-1.918%), suggesting that there are 10,883,045 patients >40 years old with a history of stroke in China. The most common stroke risk factors were elevated LDL cholesterol (75.3%), hypertension (70.6%), overweight or obese (56.9%), and smoking (28.3%), frequent alcohol use (17.5%), diabetes (16.3%), and atrial fibrillation (5.5%). A polypill that included at least two classes of medications would be indicated for 93.1% of stroke patients, and a polypill that included at least three classes of medication would be indicated for 53.9%. The most common components of a polypill were a statin, antiplatelet agent, and antihypertensive medication. Of the patients with two risk factors that could be treated with a polypill, only 6.9% were receiving these medications in separate pills. Among the patients taking antihypertensive medications and statins for secondary prevention, there was poor control of these risk factors, despite using the medication (blood pressure control rate 33.3%, LDL control rate 14.3%).
Conclusions:
In China, patients who are eligible for stroke secondary prevention therapies are often not receiving them, and in the patients who are being treated, control of risk factors is often not optimized. There are more than 10 million Chinese stroke patients who could be eligible for a polypill that addressed components of stroke secondary prevention.
Perspective:
Since stroke is a leading cause of disability, prevention is of the upmost importance. Effective secondary prevention can dramatically reduce the risk of future stroke. Polypills can improve adherence; and since most stroke patients have multiple risk factors, a polypill has the promise to address these risk factors with a single pill. This study shows that a large number of stroke patients in China would be eligible for a polypill that included two or three types of medications (antihypertensive medication, statin, and/or antiplatelet agent). Limitations of this work include nonrandom sampling and assumptions about eligibility for particular treatments, which could bias the results. The enthusiasm for a polypill should be tempered by the fact that many patients on appropriate secondary prevention medications did not have good risk factor control, and a polypill could potentially worsen this control due to difficulties with medication titration. Additionally, lifestyle factors, such as smoking and heavy alcohol use, that increase the risk of stroke, are not addressed by a polypill.
Keywords: Stroke, Anticoagulants, Antihypertensive Agents, Atrial Fibrillation, Blood Pressure, Cholesterol, LDL, Diabetes Mellitus, Hypertension, Life Style, Overweight, Platelet Aggregation Inhibitors, Prevalence, Risk Factors, Secondary Prevention, Smoking, Cross-Sectional Studies, China, Vascular Diseases
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