The Polypill (Acetyl Salicylic Acid, Atorvastatin, and Ramipril) Paradigm Shift in Secondary Prevention: Global Expert Delphi Consensus

Abstract

Background: The SECURE trial demonstrated that the cardiovascular (CV)-polypill (acetylsalicylic acid [ASA] + atorvastatin + ramipril) reduces CV mortality by 33% in patients with acute myocardial infarction compared to standard care. The 2023 ACS ESC Guidelines recommend the polypill to improve outcomes and adherence. Objective: This study aims to establish a global consensus on the optimal use of the CV-polypill in secondary prevention. Methods: A two-round, modified Delphi method was used, featuring a 30-statement evidence-based questionnaire validated by eight renowned cardiologists. Fifty clinicians from 19 countries in Europe, Latin America, and Asia were invited to join the Delphi panel. Panelists ranked responses using a three-point Likert scale for agreement and importance. Consensus was defined as ≥80% agreement or rating statements ‘very important’ or ‘important’. Statements without consensus after the first round were refined with evidence and feedback in the second round. Remaining disagreements were resolved in a face-to-face meeting. Descriptive statistics were applied. Results: Response rate was 76% (round 1) and 74% (round 2); 82% were cardiologists, with 74% frequently recommending the CV-polypill. Consensus was achieved on 93.3% of statements. Research showing a 24% relative risk reduction in major adverse CV events over a median of 3 years with the CV-polypill post-acute myocardial infarction, compared to usual care, reached 97.4% agreement for clinical implementation, and a 100% consensus supported polypill use at hospital discharge or first follow-up visits; 81.1% agreed on a prompt initiation after patient stabilization. There was agreement on algorithms for initiating (97.3%), considering patient preferences (97.4%) to the polypill and its cost savings over usual care (89.5%). Conclusion: The Delphi consensus on real-world use of a CV polypill (ASA, atorvastatin, and ramipril) for secondary prevention post-acute coronary syndrome supports early initiation (within 8 days or at discharge). The findings provide a foundation to inform practice and policy, identifying priorities for further research.