Polypills Approach for Multiple Cardiovascular Risk Factors

The overall objective of the PACIF Trial is to test a fixed-dose combination strategy for the integrated management of hypertension, dyslipidemia, and diabetes. This multicenter randomized controlled trial will evaluate whether a polypill-based approach, compared with usual care, improves cardiovascular risk factor control and reduces cardiovascular disease events among adults with multiple cardiovascular risk factors. The trial will recruit an estimated 8,252 participants aged 50 to 75 years who have hypertension, dyslipidemia, and diabetes. Participants will be randomly assigned to receive either a fixed-dose combination strategy or usual care. In the intervention group, the study medication regimen will consist of six fixed-dose formulations, including three antihypertensive formulations, two lipid-lowering formulations, and one glucose-lowering formulation. The antihypertensive component will be titrated using prespecified dose combinations, including olmesartan medoxomil/amlodipine and indapamide, until the blood pressure target is achieved. Lipid-lowering therapy will be initiated with rosuvastatin plus ezetimibe, with dose reduction of the rosuvastatin component in participants who are intolerant to the initial statin dose. Glucose-lowering therapy will include dapagliflozin as the prespecified study medication. Treatment targets are defined as systolic blood pressure <130 mmHg and diastolic blood pressure <80 mmHg, LDL cholesterol <1.8 mmol/L, and HbA1c <7.0%. The primary outcome at phase 1 is the ACC/AHA 10-year cardiovascular disease risk estimated by the PREVENT equations. In addition, the proportions of participants achieving the prespecified blood pressure, lipid, and glycemic targets will also be evaluated. The primary outcome at phase 2 is composite cardiovascular disease events, including myocardial infarction, stroke, heart failure requiring hospitalization or treatment, or cardiovascular death. Cognitive function will also be assessed, with incident dementia prespecified as a major secondary endpoint.

Inclusion criteria

• Men or women
• Age ≥50 years and <75 years
• Hypertension, defined as systolic blood pressure ≥140 mmHg or diastolic blood pressure ≥90 mmHg among participants not currently taking antihypertensive medication, or systolic blood pressure ≥130 mmHg or diastolic blood pressure ≥80 mmHg among participants currently taking any antihypertensive medication
• Dyslipidemia, defined as LDL-C ≥1.8 mmol/L (70 mg/dL)
• Type 2 diabetes with HbA1c ≥6.5% and <12%
• Willing to participate and able to sign informed consent

Exclusion criteria

• Known secondary cause of hypertension
• Type 1 diabetes
• Pancreatic insufficiency or diabetes secondary to pancreatitis
• Triglycerides ≥5.65 mmol/L (500 mg/dL)
• History of coronary, carotid, or cerebrovascular revascularization within the previous 12 months
• History of myocardial infarction or stroke within the previous 6 months
• NYHA class III-IV heart failure at entry or hospitalization for exacerbation of chronic heart failure within the previous 6 months
• Abnormal kidney function, defined as estimated glomerular filtration rate <30 mL/min/1.73 m² or dialysis
• Abnormal liver function, defined as alanine aminotransferase or aspartate aminotransferase >3 times the upper limit of normal
• Abnormal serum potassium, defined as serum potassium >5.5 mmol/L or <3.5 mmol/L
• Contraindication to any of the components of the polypill
• Currently living with another PACIF participant
• Pregnancy, currently trying to become pregnant, or of child-bearing potential and not using birth control
• Clinical diagnosis of dementia or treatment with medications for dementia
• History of malignancy
• Life expectancy <3 years
• Currently participating in another intervention study
• Any factors judged by the clinic team to be likely to limit adherence to interventions