Adherence to evidence-based therapies after discharge for acute coronary syndromes: An ongoing prospective, observational study
To determine the rates of patient adherence to key evidence-based therapies at 6 months after hospital discharge for an acute coronary syndrome.
In this nonrandomized, prospective, multinational, multicenter study, adherence to aspirin, beta-blockers, statins, or angiotensin-converting enzyme (ACE) inhibitors 6 months after discharge for myocardial infarction or unstable angina was assessed in 21,408 patients aged 18 years or older. Patients were enrolled at 104 tertiary and community hospitals representing a broad range of care facilities and practice settings (e.g., teaching vs. nonteaching).
Of 13,830 patients, discontinuation of therapy was observed at 6-month follow-up in 8% of those taking aspirin on discharge, 12% of those taking beta-blockers, 20% of those taking ACE inhibitors, and 13% of those taking statins. In a multivariate analysis, adherence to beta-blocker therapy was higher in patients with a myocardial infarction (odds ratio [OR] = 1.25; 95% confidence interval [CI]: 1.06 to 1.47), hypertension (OR = 1.33; 95% CI: 1.15 to 1.54), ST-segment elevation myocardial infarction (OR = 1.33; 95% CI: 1.11 to 1.61), or non-ST-segment elevation myocardial infarction (OR = 1.25; 95% CI: 1.08 to 1.45). Aspirin adherence was higher among patients cared for by cardiologists (OR = 1.45; 95% CI: 1.19 to 1.75; P <0.001) than among those cared for by nonspecialists. Male sex and prior heart failure were associated with improved adherence to ACE inhibitor therapy. Hypertension was associated with poorer adherence to statin therapy (OR = 0.85; 95% CI: 0.74 to 0.99; P = 0.04).
Among patients prescribed key evidence-based medications at discharge, 8% to 20% were no longer taking their medication after 6 months. The reasons for noncompliance are complex, and may be elucidated by future studies of medical and social determinants.
Available from: PubMed Central
- "Despite the general consensus on the efficacy of these drugs for secondary prevention of CAD, adherence to these guidelines is highly variable among physicians (Eagle et al.
2004; Margulis et al.
2011; Lee et al.
2010; Spencer et al.
2001). Previous studies showed that these therapies are neither consistently prescribed when appropriate nor adhered to by patients in the long term (Setoguchi et al.
2008; Eagle et al.
2004; Lappe et al.
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ABSTRACT: Coronary artery disease (CAD) is the major leading cause of death worldwide. The national practice guidelines from the American College of Cardiology (ACC) and American Heart Association (AHA) promote the use of several medical therapies for secondary prevention for patients with CAD. The purpose of this study was to evaluate whether ACS patients, admitted into two tertiary referral medical centers in Beirut, Lebanon, are discharged on optimal medical therapy based on the current AHA/ACC guidelines.
We reviewed the medical records of all patients with ACS who were admitted to the coronary care units (CCU) of two hospitals in Beirut, Lebanon between May and August 2012. Discharge prescriptions were reviewed and rating for the appropriateness of discharge cardiac medications was based on the AHA/ACC guidelines. We assessed whether patients were discharged on antiplatelet therapy, β-blockers, angiotensin converting enzymes inhibitors (ACEIs) or angiotensin receptor blockers (ARBs), statins, and nitrates, unless contraindicated or not tolerated. In addition, we assessed whether patients and/or their caregivers were counseled about their disease(s) and discharge medications.
186 patients with a mean age of 63 ± 11.78 years, 70.4% of which were males, were admitted with ACS and were included in the study. Fifty three (28.5%) patients had ST elevation MI (STEMI), 64 (34.4%) had non-ST-elevation myocardial infarction (NSTEMI) and 69 (37.1%) had unstable angina (USA). Sixty two patients (33.3%) were treated with medical therapy and 124 patients (66.7%) underwent percutaneous coronary intervention (PCI). Among eligible patients, 98.9% were discharged on aspirin, 89.1% on dual antiplatelet therapy (aspirin + thienopyridine or ticagrelor), 90.5% on a β-blocker, 81.9% on an ACEI or ARB, 89.8% on a statin, and 19.4% on nitroglycerin. Overall, 62.9% of the patients received the optimal cardiovascular drug therapy (the combination of dual antiplatelet therapy, a β-blocker, an ACEIs or an ARB, and a statin), 55.1% were counseled on their disease state(s) and drug therapy, and 92.2% and 55.9% were counseled on smoking cessation and life style changes, respectively.
In patients admitted with ACS, discharge cardiac medications are prescribed at suboptimal rates. Education of healthcare providers and implementation of ACS discharge protocols may help improve compliance with ACC/AHA guidelines. In addition, clinicians should be encouraged to provide adequate patient counseling.
Available from: ncbi.nlm.nih.gov
- "Drug holidays of 3 or more consecutive days of omitted medication were common (Vrijens et al., 2008). 2. Studies of a variety of chronic cardiovascular medications gave discontinuing rates of 8 to 22% (Eagle et al., 2004). 3. A study of charts of 124 elderly outpatients for drug discontinuations during a 1-year period was to identify adverse events. "
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ABSTRACT: Most reviews of drug withdrawal effects focus on drugs of potential abuse such as opioids, benzodiazepines, etc. Abrupt discontinuation of many other drugs used in medicine cause withdrawal syndromes, some of which can be fatal. Discontinuation of a number of cardiovascular drugs can increase risk of cardiovascular events above that of people not taking these drugs. These include β-adrenergic receptor antagonists, aspirin, HMG-CoA reductase inhibitors (statins), and heparin. Rebound hypertension occurs after abrupt cessation of many antihypertensive drugs. The possibility of discontinuation syndromes has usually been neglected until adverse clinical events force them to be noticed. Attention to the possibility of drug discontinuation effects is an important part of drug safety evaluation.
Available from: Christine Struthers
- "noncompliance has been linked to poor health outcomes and increased adverse events (Chapman et al., 2005; Eagle et al., 2004). "
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ABSTRACT: Interactive voice response (IVR) technology was used to increase medication compliance and reduce adverse events (hospitalization and emergency visits) in post-cardiac surgery patients.
Patients randomized to intervention received 11 automated IVR calls in the six months after discharge. A total of 331 patients (164 IVR, 167 usual care) participated.
Findings showed significant differences in the IVR group for the primary composite outcome of compliance and adverse events (relative risk (RR] and 95% confidence interval [CI]: 0.60 [0.37, 0.96), p = 0.041) and the secondary outcome of medication compliance (RR: 0.34 (0.20, 0.56), p < 0.0001). There was no significant impact on emergency room visits (RR: 1.04 (0.63, 1.73J) and hospitalization (RR: 0.77 [0.41, 1.45]). Most patients (93%) preferred IVR follow-up to no follow-up.
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