# Stroke minimization through additive anti-atherosclerotic agents in routine treatment (SMAART) II: Rationale for a multi-country polypill phase 3 trial in sub-Saharan Africa

## TL;DR

This study aims to test a low-cost polypill to reduce stroke risk and improve outcomes for patients in sub-Saharan Africa.

## Contribution

The SMAART-II trial introduces a multi-country phase 3 evaluation of a polypill in post-stroke care in sub-Saharan Africa.

## Key findings

- The trial will assess the efficacy of a polypill in reducing vascular risk over 24 months.
- It will evaluate implementation outcomes like adoption and cost in under-resourced healthcare systems.
- Results will inform policy for integrating the polypill into routine post-stroke care in Africa.

## Abstract

Global estimates suggest that sub-Saharan Africa (SSA) now has the highest incidence, prevalence, and worst survival outcomes of stroke. Fixed-dose combination pills, also known as “polypills”, containing generic drugs: Aspirin, a statin, and blood pressure (BP) lowering medications may be a viable low-cost avenue to broadly improve medication adherence and consequently reduce further disability or death on a large scale among stroke survivors in SSA.

The Stroke Minimization through Additive Anti-atherosclerotic agents in Routine Treatment II (SMAART-II) study seeks to deploy a hybrid study design to 1) demonstrate the efficacy of a polypill (Polycap ®) containing fixed doses of antihypertensives, a statin, and antiplatelet therapy taken as two capsules, once daily orally in reducing composite vascular risk over 24 months vs. usual care among 1000 recent ischemic stroke patients encountered at primary and tertiary hospitals in Benin, Nigeria and Tanzania; 2) develop an implementation strategy for routine integration and policy adoption of polypill for post-stroke cardiovascular risk reduction in an under-resourced system burdened by suboptimal care and outcomes.

SMAART II will establish the definitive efficacy and safety of the polypill to improve meaningful post-stroke global risk factor control across several sites, across diverse healthcare settings, beyond tertiary level care, and over a longer period. In addition to assessing clinical outcomes, SMAART II will assess implementation outcomes such as adoption, acceptability, cost, pertinent to uptake of the polypill strategy in the three proposed African countries to inform policy.

NCT05963568