Clinical Investigation
Acute Ischemic Heart Disease
Persistence with secondary prevention medications after acute myocardial infarction: Insights from the TRANSLATE-ACS study

https://doi.org/10.1016/j.ahj.2015.03.019Get rights and content

Background

Persistent use of secondary prevention therapies after acute myocardial infarction (MI) is critical to optimizing long-term outcomes.

Methods

Medication persistence was assessed among 7,955 MI patients in 216 hospitals participating in the Treatment with Adenosine Diphosphate Receptor Inhibitors: Longitudinal Assessment of Treatment Patterns and Events after Acute Coronary Syndrome study from 2010 to 2012. Persistence was defined as continuation of aspirin, adenosine diphosphate receptor inhibitors, β-blockers, angiotensin-converting enzyme inhibitors/angiotensin receptor blockers, and statins from discharge to 6 months post-MI. Multivariable logistic regression modeling was used to determine factors associated with nonpersistence, defined as <80% persistence with all medication classes.

Results

Overall, 31% of MI patients stopped taking a least 1 medication by 6 months. The most common reasons cited for medications discontinuation were side effects and physician instruction (57%), whereas financial concerns were cited in 8% overall. After multivariable modeling, black race (odds ratio 1.36, 95% CI 1.15-1.62), older age (odds ratio 1.07, 95% CI 1.02-1.12), atrial fibrillation (odds ratio 1.67, 95% CI 1.33-2.09), dialysis (odds ratio 1.79, 95% CI 1.15-2.78), and depression (odds ratio 1.22, 95% CI 1.02-1.45) were associated with lower likelihood of persistence. Private insurance (odds ratio 0.85, 95% 0.76-0.95), prescription cost assistance (odds ratio 0.63, 95% CI 0.54-0.75), and outpatient follow-up arranged before discharge (odds ratio 0.89, 95% CI 0.80-0.99) were associated with higher persistence.

Conclusions

Nearly one-third of MI patients are no longer persistent with their prescribed medications by 6 months. Patients at high risk for nonpersistence may be identified by clinical and sociodemographic features. These observations underscore key opportunities to optimize longitudinal use of secondary prevention therapies.

Section snippets

Study design and population

TRANSLATE-ACS is an observational study of acute ST-segment elevation MI or non–ST-segment elevation MI patients treated with percutaneous coronary intervention (PCI) (clinical trial no. NCT01088503). Inclusion and exclusion criteria, collected variables, and the details of data collection have been previously described.11 Briefly, the study was broadly inclusive and excluded only patients who were not able or willing to provide written informed consent for longitudinal follow-up and those who

Patterns of medication persistence by 6 months

Our final study population included 7,955 MI patients treated with PCI. Nearly all patients were discharged on aspirin (98%), an ADPRi (99.5%), statins (95%), β-blockers (93%), and ACEIs/ARBs (74%). At 6 months post-MI, 5,509 patients (69%) were persistent with all evidence-based cardiovascular medications prescribed at discharge. Of those who discontinued at least 1 medication (31% of total), 2,265 patients were moderately persistent (continued use of 40%-80% of all medications prescribed at

Discussion

Although the use of guideline-based therapies in the management of coronary artery disease is strongly recommended to improve morbidity and mortality, we found that up to one-third of contemporary patients are no longer persistent with therapies prescribed at discharge by 6 months post-MI. Reasons cited for discontinuation of medications vary according to medication class and include side effects, physician decision, and financial burden. Private insurance, prescription coverage insurance, and

Disclosures

Dr Mathews, Ms Honeycutt, Dr Henry, and Dr Chang have no relevant disclosures to report. 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); and consulting (including CME) for Medco (modest) and American College of Cardiology (significant). Dr Zettler reports being an employee of Eli Lilly & Company. Dr Fonarow reports being a

Acknowledgements

We would like to thank Erin Hanley, MS, for her editorial contributions to this manuscript. Ms Hanley did not receive compensation for her contributions, apart from her employment at the institution where this study was conducted.

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  • Cited by (0)

    Sources of funding: TRANSLATE-ACS was funded by Daiichi Sankyo Ltd and Eli Lilly USA (clinicaltrials.gov no. NCT01088503). The Duke Clinical Research Institute is the coordinating center for this study, which represents a collaborative effort with the American College of Cardiology. Robin Mathews is supported by grant number KM1CA156687 from the National Institute of Health/National Cancer Institute.

    William S. Weintraub, MD served as guest editor for this article.

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