Ma, Tian-Tian; (2021) Cardiovascular polypharmacy in patients with coronary heart disease and stroke. Doctoral thesis (Ph.D), UCL (University College London).

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Abstract

Abstract Background: There was limited evidence on the utilisation and effectiveness of cardiovascular (CV) polypharmacy (≥5 CV medications) in the secondary prevention of cardiovascular disease (CVD). Aim: To investigate the patterns of CV polypharmacy and the impact of multiple CV medications on long-term survival in patients following the incident of myocardial infarction (MI) or stroke or CVD patients with diabetes and chronic obstructive pulmonary disease (COPD). Methods: Firstly, a systematic review and meta-analysis was conducted to assess the effect of evidence-based combination pharmacotherapy on mortality and CV events in patients with CVD. Secondly, a cross-sectional study was conducted to investigate the patterns of CV medications initially prescribed after the incident CVD event. Thirdly, six retrospective cohort studies were conducted to assess the impact of multiple CV medications on long-term survival among patients with incident ischemic stroke or MI, and among those with comorbidity of type 2 diabetes or COPD. Results: There were 40.6% of patients with CV polypharmacy. Male, younger age, current smoking, high BMI, hypertension, hyperlipidaemia, higher deprivation score and multiple comorbidities were associated with an increased likelihood of CV polypharmacy. Among patients with ischemic stroke, combination therapy with four or five CV medications was associated with around 40% reduction of all-cause mortality compared to monotherapy. Combinations containing antiplatelet agents (APAs), lipid-regulating medications (LRMs), angiotensin-converting enzyme inhibitors (ACEIs)/ angiotensin receptor blockers (ARBs) and calcium channel blockers (CCBs) were associated with a significant 61% lower risk of mortality (95% CI: 53%-68%) compared with APAs alone. Among patients with MI, combination therapy with four CV medications was associated with the lowest risk of mortality compared to monotherapy (HR: 0.38, 0.32-0.45). The combination of APAs, LRMs, ACEIs/ARBs and BBs decreased the risk of mortality by 79% (70%-85%) compared with APAs alone. Conclusions: This project suggested that combination therapy (more than two CV medications) is potentially beneficial and necessary to improve long-term survival among all individuals who have had an ischemic stroke or MI regardless of the further risk of CVD.

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