May be appropriate for secondary, but perhaps not for primary prevention

The prevention of cardiovascular disease with drug therapy is well known. Randomised controlled trials and meta-analyses of trials of lipid and blood pressure lowering and antiplatelet therapy have established their efficacy in the prevention of cardiovascular diseases. Wald and Law have proposed that these three treatments, along with folic acid, be combined into a “polypill.”1 They propose a combined strategy for primary and secondary prevention—targeting all people with pre-existing cardiovascular disease (secondary prevention) but more controversially, targeting all adults aged over 55 (primary prevention) as well. The underlying assumption concerning the efficacy of this strategy is that the six individual ingredients of the polypill (thiazide diuretic, angiotensin converting enzyme inhibitor, β blocker, statin, aspirin, and folic acid) when combined together have synergistic treatment effects—calculated by multiplying the relative risk reductions on each class of treatment. Their polypill strategy has generated worldwide interest, with some critics questioning this underlying multiplicative assumption as being too optimistic.

For these reasons, the …