LLast week, the Washington Post reported that former CDC Director Tom Frieden’s “This is the world’s biggest killer. Make it the focus of your next progress.” “It is the deadliest, yet most neglected and widespread pandemic of modern times, killing more than 10 million people a year worldwide.”
Although I strongly support Mr. Frieden’s call to action, I am perplexed by his policy prescriptions. To reduce the global burden of high blood pressure, he is calling on the world to invest heavily in a complex mix of prevention and treatment strategies, which have repeatedly failed. If you keep doing the same thing over and over again, you’re unlikely to get different results.
Ironically, the “next breakthrough” Frieden seeks already exists and has been proven to work. It is available as a private service in the UK, and the World Health Organization approved the concept in July. But it’s not available in the United States, where heart disease kills 695,000 people a year and costs $240 billion. Stroke claims an additional 150,000 lives and costs $56 billion.
in the 20’sth In the century, preventive measures accounted for nearly half of the reduction in cardiovascular mortality in the United States. Unfortunately, modern medicine is not built on this success. “Blood pressure control, which can save more lives than any other clinical intervention, is successful in only about half of Americans,” Frieden wrote in a 2015 essay. Globally, the problem is even worse. According to the WHO, “nearly half of people with high blood pressure worldwide are currently unaware of their hypertension status.” If countries do a better job of reducing high blood pressure, “76 million people will die between 2023 and 2050.” WHO estimates that 1,000 deaths could be avoided.
Rather than leading the world in blood pressure management, the United States is lagging behind. The Cardiovascular Health of Middle-Aged Adults in the United States study found that high-income adults and older adults did not improve their high blood pressure rates between 1999 and 2020. It got worse Among low-income adults. According to the Centers for Disease Control and Prevention, from 2000 to 2019, blood pressure-related deaths increased overall among Americans age 35 and older, and particularly among Americans ages 35 to 64.
Either we’re not trying hard enough or we’re trying the wrong way. The first explanation seems unlikely. After all, we’ve been promoting blood pressure screening for decades, and testing stations and low-cost monitors are widely available. Patients identified as having “hypertension” during screening are immediately referred for treatment. If lack of effort isn’t the problem, you might want to change your approach.
Twenty years ago, two British preventive medicine experts, Nicholas Wald and Malcolm Roe, proposed a dramatically different strategy. They are calling on doctors to “lower blood pressure across the board,” rather than “measuring everyone’s blood pressure and lowering some.” [over age 50] And take some measurements of it. ”
Their idea is based on the fact that age is the biggest risk factor for a heart attack or stroke, other than having already had one. At age 20, your risk of heart attack or stroke approximately doubles every seven years. In a recent commentary, Wald said, “If you divide age at 50 years, more than 90% of people who would experience their first heart attack or stroke would be detected in the absence of preventive drugs.”
Treating so many people is a daunting task, so Wald and Roe tried to make it as easy as possible. Rather than individualize treatment, they give everyone over the age of 50 or 55 three types of cheap, low-dose generic blood pressure drugs, a generic statin (which lowers cholesterol), folic acid, and in some cases suggested taking a daily “polypill” consisting of low-dose aspirin. . (Later versions omit folic acid and leave aspirin optional.)
This sounds unconventional, but it actually works. Numerous studies have shown that polypills, taken daily, safely and reliably lower blood pressure and serum cholesterol, regardless of a patient’s starting level. Its impact on results is dramatic. A 2021 meta-analysis of three large international studies involving more than 18,000 participants found that compared to usual care, taking a once-daily polypill was associated with 38 fewer heart attacks, strokes, and cardiovascular deaths. It was found that % decreased. When low-dose aspirin was added, the reduction approached 50%.
In 2022, a large US-based study found that taking a daily polypill could help people who had already had a heart attack or stroke (and were therefore at very high risk of having another heart attack or stroke). It was investigated whether there was Of the 2,500 patients followed for a median of three years, those randomized to receive the daily polypill had significantly fewer events than those in the usual care group. Based on the strength of the evidence, the World Health Organization recently added the cardiovascular polypill to its list of essential medicines.
Despite these advances, leading physicians, our nation’s pharmaceutical industry, and key decision makers in federal regulatory and research agencies remain unconvinced. For them, the idea of putting four or more drugs in one pill and treating millions of people without first doing diagnostic tests is too radical from the way medicine has been practiced for years. It seems that there is a deviation.
But this is exactly why researchers conduct randomized controlled trials. It is important to note that the dramatic reductions in heart attacks, strokes, and other serious outcomes achieved with the polypill were achieved compared to the polypill. Daily care, not a placebo. Perhaps the simplicity, low cost, and ease of compliance of this approach explain the effectiveness of this pill.
Economic factors may also play a role in the reluctance to adopt the polypill. If America adopts that strategy, there will be winners and losers. Award recipients include seniors and patients with limited access to care, their families, employers and taxpayers. Losers (in an economic sense) include interventional cardiologists and radiologists, acute care hospitals, pharmaceutical companies, healthcare investors, and countless intermediaries. Research by RAND (in which I participated) and other groups shows that the surest way to achieve significant returns on investment in the U.S. health care system is to increase health care spending, not reduce it. It’s about developing a product.
Another large US-based clinical trial of the polypill and conventional treatment is needed to resolve this impasse. Primary prevention heart attack, stroke, sudden cardiac death, etc. Ideally, a diverse range of women and men between the ages of 50 and 59 years should be enrolled and followed for 3 to 5 years. No pharmaceutical company will take over the polypill because it contains cheap generic drugs. A federal research agency or charitable organization must sponsor the trial.
If the findings so far bear out, the polypill should be accepted by American doctors. With U.S. health care costs reaching $4.5 trillion annually and adult life expectancy lagging behind 56 other countries, we must find better ways to prevent cardiovascular disease. If our country adopts the polypill approach, the rest of the world may follow suit. Millions of lives could be saved.
Art Kellerman is a health policy researcher, former medical director, and former CEO of an academic health system. His views are his own. He has no conflicts of interest to disclose.
