Polypill: chimera or reality?

The idea of including several drugs in a fixed-dose combination for cardiovascular prevention was born at the beginning of this century. Although the suggestion initially received scant attention, the seminal work of Wald and Law in 2003, which introduced the term polypill, attracted the interest of researchers and the media, sparking a controversy that continues today. For some health professionals, the idea of a polypill for cardiovascular prevention is merely an interesting concept that is of limited usefulness and applicability, a chimera, which is defined by the official Spanish dictionary of the Real Academia Española de la Lengua as ‘‘aquello que se propone a la imaginación como posible o verdadero, no siéndolo’’ (‘‘something entertained by the imagination as possible or real, but which is not’’). For others, however, the polypill could save thousands of lives if used in the proper context and with the correct indication. Regardless of the debate, the polypill is now a reality; in fact, various polypills are already available (Table 1). One such polypill has been developed in collaboration between the Spanish National Center for Cardiovascular Research (Centro Nacional de Investigaciones Cardiovasculares [CNIC]) and the pharmaceutical company, Ferrer. This polypill contains acetylsalicylic acid, simvastatin, and ramipril, already forms part of the therapeutic arsenal of various Latin American countries: Mexico, Guatemala, Nicaragua, the Dominican Republic, Honduras, El Salvador, and Argentina. Registration of a second polypill that replaces simvastatin with atorvastatin has been approved in Spain and Sweden, among other European countries, and will be available for prescription during the present year. Why, then, does the polypill controversy continue? Reservations about this cardiovascular prevention strategy can be explained by various factors (Table 2), but a decisive part has clearly been played by the different interpretations of the role of the polypill and its possible indications, which have appeared in the literature since the article by Wald and Law. The initial proposal of Wald and Law involved administration of a polypill with 6 active components to all individuals older than 55 years, regardless of their risk factors and with no need to know their cholesterol levels or blood pressure values. The proposal— defined by the authors as a ‘‘preventive strategy’’—has found strong opposition among health care professionals because of the