Reasons for discontinuation of recommended therapies according to the patients after acute coronary syndromes

Highlights

• Discontinuation of medication therapies is common after acute coronary syndromes.

• Discontinuation of aspirin is lower compared to other recommended therapies.

• Asking patients for the reasons of medication discontinuation is a novel approach.

• According to patients, most stopped their cardiovascular medication based on their physician's decision.

• Data are needed to understand the appropriateness of medication discontinuation.

Abstract

Background

The prescription of recommended medical therapies is a key factor to improve prognosis after acute coronary syndromes (ACS). However, reasons for cardiovascular therapies discontinuation after hospital discharge are poorly reported in previous studies.

Methods

We enrolled 3055 consecutive patients hospitalized with a main diagnosis of ACS in four Swiss university hospitals with a prospective one-year follow-up. We assessed the self-reported use of recommended therapies and the reasons for medication discontinuation according to the patient interview performed at one-year follow-up.

Results

3014 (99.3%) patients were discharged with aspirin, 2983 (98.4%) with statin, 2464 (81.2%) with beta-blocker, 2738 (90.3%) with ACE inhibitors/ARB and 2597 (100%) with P2Y12 inhibitors if treated with coronary stent. At the one-year follow-up, the discontinuation percentages were 2.9% for aspirin, 6.6% for statin, 11.6% for beta-blocker, 15.1% for ACE inhibitor/ARB and 17.8% for P2Y12 inhibitors. Most patients reported having discontinued their medication based on their physicians' decision: 64 (2.1%) for aspirin, 82 (2.7%) for statin, 212 (8.6%) for beta-blocker, 251 (9.1% for ACE inhibitor/ARB) and 293 (11.4%) for P2Y12 inhibitors, while side effect, perception that medication was unnecessary and medication costs were uncommon reported reasons (< 2%) according to the patients.

Conclusions

Discontinuation of recommended therapies after ACS differs according the class of medication with the lowest percentages for aspirin. According to patients, most stopped their cardiovascular medication based on their physician's decision, while spontaneous discontinuation was infrequent.

Introduction

The prescription and continuation of recommended drug preventive therapies after hospitalization for acute coronary syndromes (ACS) are associated with an improvement of clinical outcome [1], [2], [3]. Current European and American guidelines recommend the long-term use of 5 classes of medications in secondary prevention after ACS: aspirin, statin, beta-blocker, angiotensin-converting enzyme inhibitor or angiotensin receptor blocker (ACEI or ARB) and in addition P2Y12 inhibitors for 1 year [4], [5], [6], [7], [8]. However, discontinuation to prescribed therapies after hospital discharge is common with adverse clinical outcomes in patients with ACS [9], [10], [11], [12].

A recent meta-analysis on 376,162 patients reported that adherence to recommended therapies varied between 60 and 75% in secondary prevention [13]. In those studies, adherence was defined as the proportion of patients who had at least 75% of days covered by the drug over a defined time period using pharmacy prescription refill data. Patients who forgot to take medications on some days were considered to be non-adherent, although physicians could have stopped the treatment for a medical reason. Measuring non-adherence based on prescription claims databases might be flawed, because the appropriateness of medication discontinuation is not provided and discontinuation of recommended mediation is traditionally referred to as medication non-adherence [14], [15], [16], [17], [18]. Therefore, assessment of medication adherence and reasons for non-adherence by physicians are strongly recommended (Class I, Level A) by the 2012 European Society of Cardiology (ESC) guidelines on cardiovascular disease prevention [19].

Limited data exist about the reasons for medication discontinuation in the real practice after ACS according to patients' point of view [20]. Attributing medication discontinuation to patient non-adherence might be stigmatizing and asking patients the reasons for therapies discontinuation could provide a patient-centered care approach of the potential barriers regarding the long-term use of preventive therapies after ACS [21]. In this Swiss prospective multicenter cohort of patients with an ACS, we aimed at determining (1) the discontinuation percentage of recommended cardiovascular therapies one year after the index ACS event and (2) the reasons for cardiovascular medication discontinuation reported by the patients.