Clinical study
Adherence to evidence-based therapies after discharge for acute coronary syndromes: an ongoing prospective, observational study

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Abstract

Purpose

To determine the rates of patient adherence to key evidence-based therapies at 6 months after hospital discharge for an acute coronary syndrome.

Methods

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).

Results

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).

Conclusion

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.

Section snippets

Methods

Full details of the GRACE rationale and methodology have been published 8, 9, 10. The registry is designed to reflect an unbiased sample of patients with acute coronary syndromes, irrespective of geographic region. Currently, 104 hospitals in 14 countries (Argentina, Australia, Austria, Belgium, Brazil, Canada, France, Germany, Italy, New Zealand, Poland, Spain, United Kingdom, United States) are participating in this observational study. A broad range of hospitals was chosen based on the

Results

Of the 21,408 patients with myocardial infarction or unstable angina, 65% (n = 13,830) were alive at 5 to 12 months after discharge and had adherence data for the therapies in question (Table 1). The median age was 65 years, and 32% (n = 4404) were women. A total of 4662 (34%) patients were discharged with ST-segment elevation myocardial infarction, 4137 (30%) with non–ST-segment elevation myocardial infarction, and 5031 (36%) with unstable angina.

Among patients included in the analysis,

Discussion

Nonadherence to key medications often leads to worsening of the condition being treated, at an estimated annual cost (direct and indirect) to society of U.S. $1000 billion 12, 13. Further, adherence to treatment in the months and years following admission for acute coronary syndromes is essential if patients are to derive the long-term benefit demonstrated in clinical trials (14).

The GRACE project represents a unique opportunity to gain further insights into the question of adherence to

Acknowledgements

The authors would like to express their gratitude to the physicians and nurses participating in GRACE. Further information about the project, along with the complete list of participants, can be found at www.outcomes.org/grace. Members of the GRACE Scientific Advisory Committee include Keith A. A. Fox, United Kingdom; Joel M. Gore, United States (GRACE Co-Chairs); Kim A. Eagle, United States; Philippe Gabriel Steg, France (GRACE Publication Committee Co-Chairs); Giancarlo Agnelli, Italy;

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    The Global Registry of Acute Coronary Events is funded by an unrestricted educational grant from Aventis Pharma, Bridgewater, New Jersey.

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