Skip to main content

Advertisement

Log in

Impediments to Adherence to Post Myocardial Infarction Medications

  • New Therapies for Cardiovascular Disease (K Mahaffey, Section Editor)
  • Published:
Current Cardiology Reports Aims and scope Submit manuscript

Abstract

Non-adherence to evidence-based medications is a major public health problem. Less than 50 % of patients with coronary artery disease adhere to their prescribed therapies and this has important implications for morbidity, mortality, and health care spending. Like most complex behaviors, medication non-adherence is not solely the result of poor patient choices. Rather, there are myriad potential contributors attributable to patients, health care providers, and, more broadly, the health care system. Interventions including patient education and behavioral modification, improving patient-physician communication, and eliminating copayments for preventive pharmacotherapy have all been studied. Clinicians play a critical role in helping improve adherence and assessment of adherence must become a standard component of each clinical encounter. Ultimately, given the various etiologies that contribute to non-adherence, achieving meaningful gains will undoubtedly require payors, providers, and policymakers to develop, rigorously evaluate, and systematically deploy strategies that address key patient, clinician, and health system factors.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Fig. 1

Similar content being viewed by others

References

Papers of particular interest, published recently, have been highlighted as: • Of importance •• Of major importance

  1. DiMatteo MR. Variations in patients' adherence to medical recommendations: a quantitative review of 50 years of research. Medical Care. 2004;42:200–9.

    Article  PubMed  Google Scholar 

  2. Osterberg L, Blaschke T. Adherence to medication. N Engl J Med. 2005;353:487–97.

    Article  PubMed  CAS  Google Scholar 

  3. Yusuf S, Reddy S, Ounpuu S, Anand S. Global burden of cardiovascular diseases: Part I: general considerations, the epidemiologic transition, risk factors, and impact of urbanization. Circulation. 2001;104:2746–53.

    Article  PubMed  CAS  Google Scholar 

  4. Lloyd-Jones D, Adams RJ, Brown TM, Carnethon M, Dai S, De Simone G, et al. Heart disease and stroke statistics–2010 update: a report from the American Heart Association. Circulation. 2010;121:e46–e215. This report from the American Heart Association offers important statistics about the burden of CAD and acute myocardial infarction in the United States.

    Article  PubMed  Google Scholar 

  5. Antman EM, Hand M, Armstrong PW, Bates ER, Green LA, Halasyamani LK, et al. 2007 focused update of the acc/aha 2004 guidelines for the management of patients with st-elevation myocardial infarction: a report of the American College of Cardiology/American Heart Association task force on practice guidelines: Developed in collaboration with the Canadian Cardiovascular Society endorsed by the American Academy of Family Physicians: 2007 writing group to review new evidence and update the ACC/AHA 2004 guidelines for the management of patients with st-elevation myocardial infarction, writing on behalf of the 2004 writing committee. Circulation. 2008;117:296–329.

    Article  PubMed  Google Scholar 

  6. Ford ES, Ajani UA, Croft JB, Critchley JA, Labarthe DR, Kottke TE, et al. Explaining the decrease in U.S. Deaths from coronary disease, 1980–2000. N Engl J Med. 2007;356:2388–98.

    Article  PubMed  CAS  Google Scholar 

  7. Anderson JL, Adams CD, Antman EM, Bridges CR, Califf RM, Casey Jr DE, et al. ACC/AHA 2007 guidelines for the management of patients with unstable angina/non-st-elevation myocardial infarction: a report of the American College of Cardiology/American Heart Association task force on practice guidelines (writing committee to revise the 2002 guidelines for the management of patients with unstable angina/non-st-elevation myocardial infarction) developed in collaboration with the American College of Emergency Physicians, the Society for Cardiovascular Angiography and Interventions, and the Society of Thoracic Surgeons endorsed by the American Association of Cardiovascular and Pulmonary Rehabilitation and the Society for Academic Emergency Medicine. J Am Coll Cardiol. 2007;50:e1–e157.

    Article  PubMed  Google Scholar 

  8. Choudhry NK, Winkelmayer WC. Medication adherence after myocardial infarction: A long way left to go. J Gen Intern Med. 2008;23:216–8.

    Article  PubMed  Google Scholar 

  9. Lloyd-Jones DM, Hong Y, Labarthe D, Mozaffarian D, Appel LJ, Van Horn L, et al. Defining and setting national goals for cardiovascular health promotion and disease reduction: The American Heart Association's strategic impact goal through 2020 and beyond. Circulation. 2010;121:586–613. This report outlines the American Heart Association's 2020 Goal.

    Article  PubMed  Google Scholar 

  10. Haynes RB, McDonald H, Garg AX, Montague P. Interventions for helping patients to follow prescriptions for medications. Cochrane Database Syst Rev. 2002;2:CD000011.

    Google Scholar 

  11. Morisky DE, Green LW, Levine DM. Concurrent and predictive validity of a self-reported measure of medication adherence. Medical Care. 1986;24:67–74.

    Article  PubMed  CAS  Google Scholar 

  12. Chisholm-Burns MA, Spivey CA, Garrett C, McGinty H, Mulloy LL. Impact of clinical pharmacy services on renal transplant recipients' adherence and outcomes. Patient Preference Adherence. 2008;2:287–92.

    Article  Google Scholar 

  13. Choudhry NK, Shrank WH, Levin RL, Lee JL, Jan SA, Brookhart MA, et al. Measuring concurrent adherence to multiple related medications. Am J Manag Care. 2009;15:457–64.

    PubMed  Google Scholar 

  14. Peterson ED, Shah BR, Parsons L, Pollack Jr CV, French WJ, Canto JG, et al. Trends in quality of care for patients with acute myocardial infarction in the national registry of myocardial infarction from 1990 to 2006. Am Heart J. 2008;156:1045–55.

    Article  PubMed  Google Scholar 

  15. Jackevicius CA, Li P, Tu JV. Prevalence, predictors, and outcomes of primary nonadherence after acute myocardial infarction. Circulation. 2008;117:1028–36.

    Article  PubMed  Google Scholar 

  16. Fischer MA, Choudhry NK, Brill G, Avorn J, Schneeweiss S, Hutchins D, et al. Trouble getting started: Predictors of primary medication nonadherence. Am J Med. 2011;124:1081–e1089–22. This study examines the prevalence, predictors, and outcomes of primary nonadherence.

    Article  PubMed  Google Scholar 

  17. Tricoci P, Roe MT, Mulgund J, Newby LK, Smith Jr SC, Pollack Jr CV, et al. Clopidogrel to treat patients with non-st-segment elevation acute coronary syndromes after hospital discharge. Archives of Internal Medicine. 2006;166:806–11.

    Article  PubMed  CAS  Google Scholar 

  18. Ganz DA, Kuntz KM, Benner JS, Avorn J. Correction: cost-effectiveness of statins in older patients with myocardial infarction. Ann Intern Med. 2002;136:635.

    PubMed  Google Scholar 

  19. Akincigil A, Bowblis JR, Levin C, Jan S, Patel M, Crystal S. Long-term adherence to evidence based secondary prevention therapies after acute myocardial infarction. J Gen Intern Med. 2008;23:115–21.

    Article  PubMed  Google Scholar 

  20. Jackevicius CA, Mamdani M, Tu JV. Adherence with statin therapy in elderly patients with and without acute coronary syndromes. JAMA. 2002;288:462–7.

    Article  PubMed  Google Scholar 

  21. Kramer JM, Hammill B, Anstrom KJ, Fetterolf D, Snyder R, Charde JP, et al. National evaluation of adherence to beta-blocker therapy for 1 year after acute myocardial infarction in patients with commercial health insurance. Am Heart J. 2006;152:454–e451–8.

    Article  PubMed  CAS  Google Scholar 

  22. Benner JS, Glynn RJ, Mogun H, Neumann PJ, Weinstein MC, Avorn J. Long-term persistence in use of statin therapy in elderly patients. JAMA. 2002;288:455–61.

    Article  PubMed  Google Scholar 

  23. Choudhry NK, Setoguchi S, Levin R, Winkelmayer WC, Shrank WH. Trends in adherence to secondary prevention medications in elderly post-myocardial infarction patients. Pharmacoepidemiol Drug Saf. 2008;17:1189–96.

    Article  PubMed  Google Scholar 

  24. Newby LK, LaPointe NM, Chen AY, Kramer JM, Hammill BG, DeLong ER, et al. Long-term adherence to evidence-based secondary prevention therapies in coronary artery disease. Circulation. 2006;113:203–12.

    Article  PubMed  CAS  Google Scholar 

  25. Bowry AD, Shrank WH, Lee JL, Stedman M, Choudhry NK. A systematic review of adherence to cardiovascular medications in resource-limited settings. J Gen Intern Med. 2011;26:1479–91. This review discusses adherence to cardiovascular medications in resource-limited settings.

    Article  PubMed  Google Scholar 

  26. Rasmussen JN, Chong A, Alter DA. Relationship between adherence to evidence-based pharmacotherapy and long-term mortality after acute myocardial infarction. JAMA. 2007;297:177–86.

    Article  PubMed  CAS  Google Scholar 

  27. Ho PM, Magid DJ, Masoudi FA, McClure DL, Rumsfeld JS. Adherence to cardioprotective medications and mortality among patients with diabetes and ischemic heart disease. BMC Cardiovasc Disord. 2006;6:48.

    Article  PubMed  Google Scholar 

  28. Ho PM, Magid DJ, Shetterly SM, Olson KL, Maddox TM, Peterson PN, et al. Medication nonadherence is associated with a broad range of adverse outcomes in patients with coronary artery disease. Am Heart J. 2008;155:772–9.

    Article  PubMed  Google Scholar 

  29. Enhancing prescription medicine adherence: a national action plan. National Council on Patient Information and Education. August 2007. Available at http://www.talkaboutrx.org/documents/enhancing_prescription_medicine_adherence.pdf. Accessed August 19, 2012.

  30. Sabate E. Adherence to long term therapies: evidence for action. Geneva. Switzerland: World Health Organization; 2003. Accessed August 19, 2012.

  31. Chapman RH, Benner JS, Petrilla AA, Tierce JC, Collins SR, Battleman DS, et al. Predictors of adherence with antihypertensive and lipid-lowering therapy. Arch Intern Med. 2005;165:1147–52.

    Article  PubMed  Google Scholar 

  32. Shrank WH, Liberman JN, Fischer MA, Kilabuk E, Girdish C, Cutrona S, et al. Are caregivers adherent to their own medications? J Am Pharm Assoc (2003). 2011;51:492–8. This study examines adherence patterns among caregivers.

  33. Chan DC, Shrank WH, Cutler D, Jan S, Fischer MA, Liu J, et al. Patient, physician, and payment predictors of statin adherence. Med Care. 2010;48:196–202. This study examines patient, physician, and payment predictors of statin adherence.

    Article  PubMed  Google Scholar 

  34. Fischer MA, Choudhry NK, Brill G, Avorn J, Schneeweiss S, Hutchins D, et al. Trouble getting started: predictors of primary medication nonadherence. Am J Med. 2011;124:1081.e1089–1081.e1022. This study examines the prevalence, predictors, and outcomes of primary nonadherence.

  35. Marshall IJ, Wolfe CD, McKevitt C. Lay perspectives on hypertension and drug adherence: Systematic review of qualitative research. BMJ. 2012;345:e3953.

    Google Scholar 

  36. Aikens JE, Piette JD. Diabetic patients' medication underuse, illness outcomes, and beliefs about antihyperglycemic and antihypertensive treatments. Diabetes Care. 2009;32:19–24.

    Article  PubMed  CAS  Google Scholar 

  37. Kulik A, Shrank WH, Levin R, Choudhry NK. Adherence to statin therapy in elderly patients after hospitalization for coronary revascularization. Am J Cardiol. 2011;107:1409–14. This study examines the impact of coronary revascularizatin on adherence to statin therapy.

    Article  PubMed  Google Scholar 

  38. Jiang W, Glassman A, Krishnan R, O'Connor CM, Califf RM. Depression and ischemic heart disease: what have we learned so far and what must we do in the future? Am Heart J. 2005;150:54–78.

    Article  PubMed  Google Scholar 

  39. Gehi A, Haas D, Pipkin S, Whooley MA. Depression and medication adherence in outpatients with coronary heart disease: findings from the heart and soul study. Arch Intern Med. 2005;165:2508–13.

    Article  PubMed  Google Scholar 

  40. Rieckmann N, Gerin W, Kronish IM, Burg MM, Chaplin WF, Kong G, et al. Course of depressive symptoms and medication adherence after acute coronary syndromes: An electronic medication monitoring study. J Am Coll Cardiol. 2006;48:2218–22.

    Article  PubMed  Google Scholar 

  41. Saini SD, Schoenfeld P, Kaulback K, Dubinsky MC. Effect of medication dosing frequency on adherence in chronic diseases. Am J Manag Care. 2009;15:e22–33.

    PubMed  Google Scholar 

  42. Ingersoll KS, Cohen J. The impact of medication regimen factors on adherence to chronic treatment: a review of literature. J Behav Med. 2008;31:213–24.

    Article  PubMed  Google Scholar 

  43. Chapman RH, Petrilla AA, Benner JS, Schwartz JS, Tang SS. Predictors of adherence to concomitant antihypertensive and lipid-lowering medications in older adults: a retrospective, cohort study. Drugs Aging. 2008;25:885–92.

    Article  PubMed  Google Scholar 

  44. Bangalore S, Kamalakkannan G, Parkar S, Messerli FH. Fixed-dose combinations improve medication compliance: a meta-analysis. Am J Med. 2007;120:713–9.

    Article  PubMed  Google Scholar 

  45. Yusuf S. Two decades of progress in preventing vascular disease. Lancet. 2002;360:2–3.

    Article  PubMed  Google Scholar 

  46. Wald NJ, Law MR. A strategy to reduce cardiovascular disease by more than 80 %. BMJ. 2003;326:1419.

    Article  PubMed  CAS  Google Scholar 

  47. Brookhart MA, Patrick AR, Schneeweiss S, Avorn J, Dormuth C, Shrank W, et al. Physician follow-up and provider continuity are associated with long-term medication adherence: a study of the dynamics of statin use. Arch Intern Med. 2007;167:847–52.

    Article  PubMed  Google Scholar 

  48. Bosworth HB, Granger BB, Mendys P, Brindis R, Burkholder R, Czajkowski SM, et al. Medication adherence: a call for action. Am Heart J. 2011;162:412–24. This comprehensive review examines the prevalence, predictors, and interventions to address non-adherence.

    Article  PubMed  Google Scholar 

  49. Choudhry NK, Brennan T, Toscano M, Spettell C, Glynn RJ, Rubino M, et al. Rationale and design of the post-mi freee trial: a randomized evaluation of first-dollar drug coverage for post–myocardial infarction secondary preventive therapies. Am Heart J. 2008;156:31–6.

    Article  PubMed  CAS  Google Scholar 

  50. Rector TS, Venus PJ. Do drug benefits help medicare beneficiaries afford prescribed drugs? Health Aff (Millwood). 2004;23:213–22.

    Article  Google Scholar 

  51. Felland LE, Reschovsky JD. More nonelderly Americans face problems affording prescription drugs. Tracking Rep/Center for Studying Health System Change. 2009:1–4.

  52. Adams AS, Soumerai SB, Ross-Degnan D. Use of antihypertensive drugs by medicare enrollees: does type of drug coverage matter? Health Aff (Millwood). 2001;20:276–86.

    Article  CAS  Google Scholar 

  53. Polinski JM, Shrank WH, Glynn RJ, Huskamp HA, Roebuck MC, Schneeweiss S. Beneficiaries with cardiovascular disease and thepart d coverage gap. Circ Cardiovasc Qual Outcomes. 2012;5:387–95. This study explores the relationship between medication cost and adherence among patients with cardiovascular disease.

    Article  PubMed  Google Scholar 

  54. Doshi JA, Zhu J, Lee BY, Kimmel SE, Volpp KG. Impact of a prescription copayment increase on lipid-lowering medication adherence in veterans. Circulation. 2009;119:390–7.

    Article  PubMed  Google Scholar 

  55. Goldman DP, Joyce GF, Escarce JJ, Pace JE, Solomon MD, Laouri M, et al. Pharmacy benefits and the use of drugs by the chronically ill. JAMA. 2004;291:2344–50.

    Article  PubMed  CAS  Google Scholar 

  56. Goldman DP, Joyce GF, Zheng Y. Prescription drug cost sharing: associations with medication and medical utilization and spending and health. JAMA. 2007;298:61–9.

    Article  PubMed  CAS  Google Scholar 

  57. Choudhry NK, Fischer MA, Avorn J, Liberman JN, Schneeweiss S, Pakes J, et al. The implications of therapeutic complexity on adherence to cardiovascular medications. Arch Intern Med. 2011;171:814–22. This study highlights the impact of therapeutic complexity on adherence, demonstrating that beyond number of medications, refill consolidation and number of different prescribers have important effects on adherence.

    Article  PubMed  Google Scholar 

  58. Smith DH, Kramer JM, Perrin N, Platt R, Roblin DW, Lane K, et al. A randomized trial of direct-to-patient communication to enhance adherence to beta-blocker therapy following myocardial infarction. Arch Intern Med. 2008;168:477–83.

    Article  PubMed  Google Scholar 

  59. Ito K, Shrank WH, Avorn J, Patrick AR, Brennan TA, Antman EM, et al. Comparative cost-effectiveness of interventions to improve medication adherence after myocardial infarction. Health Serv Res. (in press). This study demonstrates that interventions that improve adherence post myocardial infarction are cost-saving.

  60. Choudhry NK, Avorn J, Antman EM, Schneeweiss S, Shrank WH. Should patients receive secondary prevention medications for free after a myocardial infarction? An economic analysis. Health Aff (Millwood). 2007;26:186–94.

    Article  Google Scholar 

  61. Choudhry NK, Patrick AR, Antman EM, Avorn J, Shrank WH. Cost-effectiveness of providing full drug coverage to increase medication adherence in post–myocardial infarction medicare beneficiaries. Circulation. 2008;117:1261–8.

    Article  PubMed  Google Scholar 

  62. Chernew ME, Shah MR, Wegh A, Rosenberg SN, Juster IA, Rosen AB, et al. Impact of decreasing copayments on medication adherence within a disease management environment. Health Aff (Millwood). 2008;27:103–12.

    Article  Google Scholar 

  63. Choudhry NK, Avorn J, Glynn RJ, Antman EM, Schneeweiss S, Toscano M, et al. Full coverage for preventive medications after myocardial infarction. N Engl J Med. 2011;365:2088–97. This randomized trial of full coverage vs standard coverage for preventive medications after myocardial infarction demonstrates that the former was associated with improvements in adherence and major vascular events without increasing costs.

    Article  PubMed  CAS  Google Scholar 

  64. Shah ND, Dunlay SM, Ting HH, Montori VM, Thomas RJ, Wagie AE, et al. Long-term medication adherence after myocardial infarction: experience of a community. Am J Med. 2009;122:961 e967–913.

    Google Scholar 

  65. Kwan G, Balady GJ. Cardiac rehabilitation 2012: advancing the field through emerging science. Circulation. 2012;125:e369–73. This is a review of the benefits of cardiac rehabilitation.

    Article  PubMed  Google Scholar 

  66. Kripalani S, Yao X, Haynes RB. Interventions to enhance medication adherence in chronic medical conditions: a systematic review. Arch Intern Med. 2007;167:540–50.

    Article  PubMed  Google Scholar 

  67. Cutrona SL, Choudhry NK, Fischer MA, Servi AD, Stedman M, Liberman JN, et al. Targeting cardiovascular medication adherence interventions. J Am Pharmts Assoc. 2012;52:381–97. This study examines various approaches to improving adherence, finding that targetted interventions are more effective than broad interventions.

    Article  Google Scholar 

  68. Cutrona SL, Choudhry NK, Fischer MA, Servi A, Liberman JN, Brennan TA, et al. Modes of delivery for interventions to improve cardiovascular medication adherence. Am J Manage Care. 2010;16:929–42. This study examines the impact of different modes and locations of adherence interventions.

    Google Scholar 

  69. Lambert-Kerzner A, Del Giacco EJ, Fahdi IE, Bryson CL, Melnyk SD, Bosworth HB, et al. Patient-centered adherence intervention after acute coronary syndrome hospitalization. Circ Cardiovasc Qual Outcomes. 2012;5:571–6. This paper describes an ongoing trial of a multifaceted intervention to improve adherence after myocardial infarction.

    Article  PubMed  Google Scholar 

  70. Choudhry NK. Promoting persistence: improving adherence through choice of drug class. Circulation. 2011;123:1584–6. This paper highlights the impact of provider prescribing choice on medication adherence.

    Article  PubMed  Google Scholar 

  71. Peters E, Dieckmann N, Dixon A, Hibbard JH, Mertz CK. Less is more in presenting quality information to consumers. Med Care ResRev MCRR. 2007;64:169–90.

    Article  Google Scholar 

  72. Shrank WH, Parker R, Davis T, Pandit AU, Knox JP, Moraras P, et al. Rationale and design of a randomized trial to evaluate an evidence-based prescription drug label on actual medication use. Contemp Clin Trials. 2010;31:564–71. This study examines patient beliefs about effective communications about their medical regimens.

    Article  PubMed  Google Scholar 

  73. Misono AS, Cutrona SL, Choudhry NK, Fischer MA, Stedman MR, et al. Healthcare information technology interventions to improve cardiovascular and diabetes medication adherence. Am J Manag Care. 2010;16:SP82–92. This study explores the impact of health information technology based interventions on medication adherence.

    PubMed  Google Scholar 

  74. Anderson JL, Adams CD, Antman EM, Bridges CR, Califf RM, Casey Jr DE, et al. 2011 ACCF/AHA focused update incorporated into the ACC/AHA 2007 guidelines for the management of patients with unstable angina/non-st-elevation myocardial infarction: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. Circulation. 2011;123:e426–579. These are the 2011 guidelines for patients with non-ST segment elevation acute coronary syndromes.

    Article  PubMed  Google Scholar 

  75. Roe MT, Messenger JC, Weintraub WS, Cannon CP, Fonarow GC, Dai D, et al. Treatments, trends, and outcomes of acute myocardial infarction and percutaneous coronary intervention. J Am Coll Cardio. 2010;56:254–63. This is a contemporary examination of patterns of care for patients with acute myocardial infarction.

    Article  Google Scholar 

  76. Gellad WF, Grenard J, McGlynn EA. A review of barriers to medication adherence: a framework for driving policy options. RAND Corporation. 2009. Available at http://www.rand.org/pubs/technical_reports/TR765.html. Accessed August 19, 2012.

Download references

Disclosure

Conflicts of interest: N.R. Desai: none; N.K. Choudhry: has been a consultant for Mercer Health and Benefits; has received unrestricted grants from CVS Caremark, Aetna, Robert Wood Johnson Foundation, and Commonwealth Fund that were paid to Brigham and Women's Hospital to study medication adherence.

Author information

Authors and Affiliations

Authors

Corresponding author

Correspondence to Niteesh K. Choudhry.

Additional information

This article is part of the Topical Collection on New Therapies for Cardiovascular Disease

Rights and permissions

Reprints and permissions

About this article

Cite this article

Desai, N.R., Choudhry, N.K. Impediments to Adherence to Post Myocardial Infarction Medications. Curr Cardiol Rep 15, 322 (2013). https://doi.org/10.1007/s11886-012-0322-6

Download citation

  • Published:

  • DOI: https://doi.org/10.1007/s11886-012-0322-6

Keywords

Navigation