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Many patients report suboptimal adherence to medications after acute MI
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As early as 6 weeks after acute MI, nearly 30% of patients report moderate or low adherence to medications, which is potentially linked to increased risk for death or readmission, according to new findings.
“Tailored patient education and pre-discharge planning, as well as the availability of continued patient interactions with the health system early after hospital discharge, may represent key actionable opportunities to optimize patient adherence and improve outcomes,” Robin Mathews, MD, and colleagues wrote in Circulation: Cardiovascular Quality and Outcomes.
The researchers assessed 7,425 patients with acute MI who underwent PCI between April 2010 and May 2012 at 216 U.S. hospitals participating in the TRANSLATE-ACS study of treatment with adenosine diphosphate receptor inhibitors after ACS.
Patients were stratified by self-reported high, moderate or low medication adherence at 6 weeks using the Morisky instrument. Seventy-one percent of patients had a high score (8), 25% had a moderate score (6 or 7) and 4% had a low adherence score (5 or lower), Mathews, from Duke Clinical Research Institute, and colleagues reported.
Of those with a low adherence score, approximately one-third reported missing doses of antiplatelet therapy at least twice a week after PCI, according to the researchers.
Independent predictors of medication nonadherence were financial hardship (OR = 1.4; 95% CI, 1.1-1.8) and signs of depression as indicated by patient responses to a health questionnaire (OR = 1.49; 95% CI, 1.02-2.17). Independent predictors of medication adherence were age per 5-year increase (OR = 0.85; 95% CI, 0.8-0.91), moderate exercise (OR = 0.72; 95% CI, 0.56-0.94), follow-up scheduled before discharge (OR = 0.76; 95% CI, 0.58-0.98) and receiving an explanation of medication adverse effects from a care provider (OR = 0.78; 95% CI, 0.61-0.99).
Mathews and colleagues also observed a trend toward lower medication adherence being associated with higher risk for death or readmission at 3 months (adjusted HR = 1.35; 95% CI, 0.98-1.87). However, at 6 months, event rates were similar between all three groups (adjusted HR = 1.02; 95% CI, 0.8-1.3). This could be due to the small number of patients in the low-adherence group or because adherence in some members of the other groups got worse over time, the researchers wrote.
“Nonadherent patient behavior may be associated with early mortality and readmission risks,” Mathews and colleagues wrote. “Although some nonmodifiable socioeconomic and clinical factors are associated with nonadherence, our results suggest several opportunities for provider intervention.” – by Erik Swain
Disclosure: The TRANSLATE-ACS study was sponsored by Daiichi Sankyo and Lilly USA. Mathews reports receiving an NIH grant. Please see the full study for a list of all other authors’ relevant financial disclosures.
Perspective
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Joseph S. Alpert, MD, MACP
The findings were no surprise. We know, for example, that the best drug to give someone after acute MI is a statin, but 50% of patients in the United States with STEMI have stopped taking their statin 12 months after MI, thus markedly increasing their risk for mortality or recurrent MI. And this is a generic, inexpensive drug with minimal side effects. We know that we can benefit the patients, but for whatever reason, probably a communication gap, some patients decide they don’t want to take their medication. Some of them say they’d rather take something natural, and there is a natural product called red yeast rice, which contains small amounts of lovastatin, but the problem is that the amount varies from batch to batch. If they’ll at least take that, it’s better than nothing, but I try to convince them that if they take a statin, they’re getting something that is a lot cleaner and more controlled than the natural product, and is based on the same chemistry. Otherwise, it’s hard to know what to do. You can’t prop open a patient’s mouth and throw the pill in. I do the best I can to convince patients that this is in their interest, in addition to stopping cigarettes, exercising and undergoing cardiac rehabilitation; those in cardiac rehab are more likely to be adherent. We have had patients who had an MI 15 years ago that are taking their medications and are doing just beautifully.
A number of steps have been tried, including paying patients. That seems to work a little bit, but the most important tool is education. The U.S. has a woefully inadequate level of health knowledge. There are a lot of fantasies and superstitions that exist. Where education will have the most impact is with children. We need to teach about health and education very early. The American Journal of Medicine published a couple of very nice studies showing that when educating young children on heart health and other health information using tools such as Sesame Street characters, a year later, they remembered the information much better than if they had been told in a straightforward, didactic way. In addition, the teachers and parents also remembered. We should keep trying to educate the 60-year-olds, but clearly we need to educate children at a younger age about health. If we have a much more health-literate population, then hopefully more people will understand why it’s a good idea to take their drugs.
Adherence remains one of our biggest problems. We know that if patients don’t follow medication guidelines, their chances of recurrent MI are markedly increased. It is a major public health issue, and the only solution is to educate people so they understand it is in their best interest to take their medications.
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