Early Medication Nonadherence After Acute Myocardial Infarction: Insights into Actionable Opportunities From the TReatment with ADP receptor iNhibitorS: Longitudinal Assessment of Treatment Patterns and Events after Acute Coronary Syndrome (TRANSLATE-ACS) Study

Abstract

Background: Nonadherence to prescribed evidence-based medications after acute myocardial infarction (MI) can contribute to worse outcomes and higher costs. We sought to better understand the modifiable factors contributing to early nonadherence of evidence-based medications after acute MI.

Methods and results: We assessed 7425 acute MI patients treated with percutaneous coronary intervention at 216 US hospitals participating in TReatment with ADP receptor iNhibitorS: Longitudinal Assessment of Treatment Patterns and Events after Acute Coronary Syndrome (TRANSLATE-ACS) between April 2010 and May 2012. Using the validated Morisky instrument to assess cardiovascular medication adherence at 6 weeks post MI, we stratified patients into self-reported high (score, 8), moderate (score, 6-7), and low (score, <6) adherence groups. Moderate and low adherence was reported in 25% and 4% of patients, respectively. One third of low adherence patients described missing doses of antiplatelet therapy at least twice a week after percutaneous coronary intervention. Signs of depression and patient-reported financial hardship because of medication expenses were independently associated with a higher likelihood of medication nonadherence. Patients were more likely to be adherent at 6 weeks if they had follow-up appointments made before discharge and had a provider explain potential side effects of their medications. Lower medication adherence may be associated with a higher risk of 3-month death/readmission (adjusted hazard ratio, 1.35; 95% confidence interval, 0.98-1.87) although this did not reach statistical significance.

Conclusions: Even early after MI, a substantial proportion of patients report suboptimal adherence to prescribed medications. Tailored patient education and pre discharge planning may represent actionable opportunities to optimize patient adherence and clinical outcomes.

Clinical trial registration: URL: http://www.clinicaltrials.gov. Unique identifier: NCT01088503.

Keywords: acute myocardial infarction; medication nonadherence; percutaneous coronary intervention.

Conflict of interest statement

Conflict of Interest Disclosures

R Mathews: Dr. Mathews has no relevant disclosures to report.

ED Peterson: Dr. Peterson reports research funding for the American College of Cardiology, American Heart Association, Eli Lilly & Company, Janssen Pharmaceuticals, and Society of Thoracic Surgeons (all significant); consulting (including CME) for Merck & Co. (modest), Boehringer Ingelheim, Genentech, Janssen Pharmaceuticals, and Sanofi-Aventis (all significant).

E Honeycutt: Ms. Honeycutt has no relevant disclosures to report.

CT Chin: Dr. Chin has no relevant disclosures to report.

MB Effron: Dr. Effron reports being an employee of Eli Lilly & Company; shareholder of Lilly, USA.

M Zettler: Dr. Zettler reports being an employee of Eli Lilly & Company.

GC Fonarow: Dr. Fonarow reports being a consultant to Novartis (significant) and Janssen (modest).

TD Henry: Dr. Henry has no relevant disclosures to report.

TY Wang: Dr. Wang reports research funding from AstraZeneca, Gilead, Lilly, The Medicines Company, and Canyon Pharmaceuticals (all significant); educational activities or lectures (generates money for Duke) for AstraZeneca (modest); consulting (including CME) for Medco (modest) and American College of Cardiology (significant).

© 2015 American Heart Association, Inc.

Figures

Figure 1. Forest Plot

This figure displays significant factors associated with medication nonadherence. Other variables included in the model: gender, non-Hispanic, black race, smoker, cardiac rehab referral, EuroQol-5 Dimensions score, married, ≥high school graduation, employed, written discharge medication list/instructions, insurance coverage, assistance program to pay for medications, cardiac rehab participation. Moderate exercise= at least 1 day a week of ≥20 minutes of exercise. OR listed with 95% confidence intervals. OR, odds ratio

Figure 2. Rates of Death/Readmission

Kaplan Meier curves for rates of death/readmission within 120 days according to Morisky score. Variables included in the model: age, gender, race, ethnicity, insurance status, marital status, educational level, prior MI, prior PCI, prior CABG surgery, prior stroke or transient ischemic attack, peripheral arterial disease, prior heart failure, prior atrial fibrillation or flutter, diabetes, hypertension, dyslipidemia, dialysis, smoking status, chronic lung disease, recent gastrointestinal or genitourinary bleeding in the 6 months prior to index MI admission, STEMI presentation, cardiac arrest within 24 hours of admission, cardiogenic shock within 24 hours of admission, heart failure signs or symptoms within two weeks before admission, body mass index, admission heart rate, admission systolic blood pressure, pre-procedure hemoglobin, pre-procedure creatinine clearance, multivessel disease on angiography, multivessel PCI, bifurcating culprit lesion, culprit lesion involving a CABG graft, drug-eluting stent implantation, culprit lesion successfully dilated, left ventricular ejection fraction, transfer-in status, number of hospitalizations between index hospital discharge and the 6-week interview, and hospital referral region. CABG, coronary artery bypass grafting; MI, myocardial infarction; PCI, percutaneous coronary intervention; STEMI, ST-segment elevation myocardial infarction