scholarly journals De-escalation of antiplatelet therapy after acute coronary syndrome — a way to improve medication adherence?

Author(s):  
Andrzej Kleinrok ◽  
Jolita Badarienė
BMJ Open ◽  
2018 ◽  
Vol 8 (1) ◽  
pp. e019463 ◽  
Author(s):  
Clara K Chow ◽  
Aravinda Thiagalingam ◽  
Karla Santo ◽  
Cindy Kok ◽  
Jay Thakkar ◽  
...  

BackgroundIdentifying simple, low-cost and scalable means of supporting lifestyle change and medication adherence for patients following a cardiovascular (CV) event is important.ObjectiveThe TEXTMEDS (TEXT messages to improve MEDication adherence and Secondary prevention) study aims to investigate whether a cardiac education and support programme sent via mobile phone text message improves medication adherence and risk factor levels in patients following an acute coronary syndrome (ACS).Study designA single-blind, multicentre, randomised clinical trial of 1400 patients after an ACS with 12 months follow-up. The intervention group will receive multiple weekly text messages that provide information, motivation, support to adhere to medications, quit smoking (if relevant) and recommendations for healthy diet and exercise. The primary endpoint is the percentage of patients who are adherent to cardioprotective medications and the key secondary outcomes are mean systolic blood pressure (BP) and low-density lipoprotein cholesterol. Secondary outcomes will also include total cholesterol, mean diastolic BP, the percentage of participants who are adherent to each cardioprotective medication class, the percentage of participants who achieve target levels of CV risk factors, major vascular events, hospital readmissions and all-cause mortality. The study will be augmented by formal economic and process evaluations to assess acceptability, utility and cost-effectiveness.SummaryThe study will provide multicentre randomised trial evidence of the effects of a text message-based programme on cardioprotective medication adherence and levels of CV risk factors.Ethics and disseminationPrimary ethics approval was received from Western Sydney Local Health District Human Research Ethics Committee (HREC2012/12/4.1 (3648) AU RED HREC/13/WMEAD/15). Results will be disseminated via peer-reviewed publications and presentations at international conferences.Trial registration numberACTRN12613000793718; Pre-results.


Author(s):  
Katherine M Fagan ◽  
Anne Lambert-Kerzner ◽  
Evan P Carey ◽  
Eric J Del Giacco ◽  
Renee Mihalko-Corbitt ◽  
...  

Background: Prior studies have shown that depression may be associated with longitudinal medication non-adherence for patients with chronic cardiovascular disease. However, little is known about depression and medication adherence following acute coronary syndrome (ACS) hospitalization. Our objective was to assess whether depression was associated with longitudinal medication adherence following ACS among Veterans enrolled in a clinical trial designed to improve medication adherence. Methods: Patients included in the current analysis were enrolled in the MEDICATION study, which tested a multifaceted intervention versus usual care to improve medication adherence in the year following ACS hospitalization at 4 VA Medical Centers. Depression was assessed using the Patient Health Questionnaire (PHQ-9) prior to hospital discharge based on a score of ≥10. Medication adherence was assessed for 4 classes of cardioprotective medications (Statins, ACEI/ARBs, Clopidogrel, and Beta Blockers) in the 12-months following hospital discharge using pharmacy refill data. A proportion of days covered (PDC) was calculated based on the 4 classes of medications, and adherent patients were categorized based on a PDC ≥0.80. Then, we assessed the association between depression and medication adherence in the year after ACS hospitalization. Results: Of the 241 patients, the average age was 63.9 years, mean BMI was 30.9 kg/m 2 , and they had a number of comorbidities: 45.2% had diabetes and 65.6% had a history of coronary artery disease. The mean PHQ-9 score was 8.2 and 35.4% had depression (PHQ≥10) prior to discharge, with no difference in the prevalence of depression between treatment groups. In the year after ACS hospitalization, the mean PDC was 0.90 for all patients and there was no difference between depressed (PDC=0.91) and non-depressed patients (PDC=0.90). Among patients in the usual care group, there was also no difference in adherence between depressed (PDC=0.88) and non-depressed (PDC=0.86) patients. Conclusions: In this cohort of patients enrolled in a clinical trial, depression was present in 1 out of 3 patients during ACS hospitalization but not associated with medication adherence in the year after hospital discharge. A potential explanation for the lack of association between depression and adherence may be related to the overall high adherence rates found in the MEDICATION study. It will be important to assess whether depression is a marker of medication non-adherence in other ACS cohorts.


2021 ◽  
Vol 74 (4) ◽  
Author(s):  
Heather L Neville ◽  
Kelsey Mann ◽  
Jessica Killen ◽  
Michael Callaghan

Background: Despite ample evidence of benefit, adherence to secondary prevention medication therapy after acute coronary syndrome (ACS) is often suboptimal. Hospital pharmacists are uniquely positioned to improve adherence by providing medication education at discharge. Objective: To determine whether a standardized counselling intervention at hospital discharge significantly improved patients’ adherence to cardiovascular medications following ACS. Methods: This single-centre, prospective, nonrandomized comparative study enrolled patients with a primary diagnosis of ACS (January 2014 to July 2015). Patients who received standardized discharge counselling from a clinical pharmacist were compared with patients who did not receive counselling. At 30 days and 1 year after discharge, follow-up patient surveys were conducted and community pharmacy refill data were obtained. Adherence was assessed using pharmacy refill data and patient self-reporting for 5 targeted medications: acetylsalicylic acid, P2Y purinoceptor 12 (P2Y12) inhibitors, angiotensin-converting enzyme inhibitors or angiotensin II receptor blockers, β-blockers, and statins. Thirty-day and 1-year medication utilization, cardiovascular readmission rates, and all-cause mortality were also assessed. Results: Of the 259 patients enrolled, 88 (34.0%) received discharge counselling. Medication data were obtained for 253 patients (97.7%) at 30 days and 242 patients (93.4%) at 1 year. At 1 year after discharge, there were no statistically significant differences between patients who did and did not receive counselling in terms of rates of nonadherence (11.9% versus 18.4%, p = 0.19), cardiovascular readmission (17.6% versus 22.3%, p = 0.42), and all-cause mortality (3.4% versus 4.2%, p > 0.99). Overall medication nonadherence was 2.8% (7/253) at 30 days and 16.1% (39/242) at 1 year. Conclusions: Discharge medication counselling provided by hospital pharmacists after ACS was not associated with significantly better medication adherence at 1 year. Higher-quality evidence is needed to determine the most effective and practical interventions to ensure that patients adhere to their medication regimens and achieve positive outcomes after ACS. RÉSUMÉ Contexte : Malgré l’abondance de preuves démontrant ses avantages, l’adhésion à la pharmacothérapie de prévention secondaire après les syndromes coronariens aigus (SCA) est souvent « sous-optimale ». Les pharmaciens d’hôpitaux occupent une place unique pour améliorer l’adhésion en expliquant au patient l’usage des médicaments au moment du congé hospitalier. Objectif : Déterminer si une consultation standardisée au moment du congé hospitalier améliore significativement ou non l’adhésion à la pharmacothérapie cardiovasculaire après les SCA. Méthodes : Des patients ayant reçu un diagnostic primaire de SCA (de janvier 2014 à juillet 2015) ont été inscrits pour participer à cette étude comparative unicentrique prospective et non randomisée. Ceux ayant bénéficié d’une consultation standardisée par un pharmacien clinicien au moment du congé ont été comparés aux patients qui n’en n’avaient pas reçu. Trente jours et un an après le congé, des enquêtes de suivi du patient ont été menées et les données de renouvellement d’ordonnance des pharmacies communautaires ont été recueillies. L’adhésion a été évaluée à l’aide des données de renouvellement d’ordonnance et celles rapportées par le patient pour cinq médicaments ciblés : l’acide acétylsalicylique, les inhibiteurs P2Y purinoceptor 12 (P2Y12), les inhibiteurs de l’enzyme de conversion de l’angiotensine ou les antagonistes des récepteurs de l’angiotensine II, les antagonistes β et les statines. L’utilisation des médicaments à 30 jours et à un an, le taux de réadmission en raison d’un trouble cardiovasculaire et le taux de mortalité toutes causes confondues ont également fait l’objet d’une évaluation. Résultats : Sur les 259 patients inscrits, 88 (34 %) ont bénéficié d’une consultation au moment du congé. Des données concernant la médication de 253 patients ont été obtenues (97,7 %) à 30 jours et pour 242 patients (93,4 %) à un an. Un an après le congé, aucune différence statistique significative n’a été observée entre les patients ayant reçu ou non une consultation concernant la non-adhésion (11,9 % contre 18,4 %, p = 0,19), la réadmission en raison d’un trouble cardiovasculaire (17,6 % contre 22,3 %, p = 0,42), et le taux de mortalité toutes causes confondues (3,4 % contre 4,2 %, p > 0,99). La non-adhésion aux médicaments de manière générale se montait à 2,8 % (7/253) à 30 jours et à 16,1 % (39/242) à un an. Conclusions : La consultation concernant la médication donnée par les pharmaciens d’hôpitaux au moment du congé après les SCA n’était pas associée à un meilleur suivi de la médication un an plus tard. Des données probantes de meilleure qualité sont nécessaires pour déterminer les interventions les plus efficaces et pratiques pour que les patients adhèrent à leur régime médicamenteux et qu’ils obtiennent des résultats positifs après les SCA.


2021 ◽  
Vol 10 (Supplement_1) ◽  
Author(s):  
HY Wang ◽  
R Zhang ◽  
ZX Cai ◽  
KF Dou

Abstract Funding Acknowledgements Type of funding sources: None. Background Recent emphasis on reduced duration and/or intensity of antiplatelet therapy following PCI irrespective of indication for PCI may fail to account for the substantial risk of subsequent nontarget lesion events in acute coronary syndrome (ACS) patients. This study sought to investigate the benefits and risks of extended-term (>12-month) DAPT as compared with short-term DAPT in high-risk "TWILIGHT-like" ACS patients undergoing PCI. Methods All consecutive patients fulfilling the "TWILIGHT-like" criteria undergoing PCI from January 2013 to December 2013 were identified from the prospective Fuwai PCI Registry. High-risk "TWILIGHT-like" patients were defined by at least 1 clinical and 1 angiographic feature based on TWILIGHT trial selection criteria. The present analysis evaluated 4,875 high-risk "TWILIGHT-like" patients with ACS who were event-free at 12 months after PCI. The primary outcome was the composite of all-cause death, myocardial infarction (MI), or stroke at 30 months while BARC type 2, 3, or 5 bleeding was key secondary outcome. Results Extended DAPT compared with shorter DAPT reduced the composite outcome of all-cause death, MI, or stroke by 63% (1.5% vs. 3.8%; HRadj: 0.374, 95% CI: 0.256 to 0.548; HRmatched: 0.361, 95% CI: 0.221-0.590). The HR for cardiovascular death was 0.049 (0.007 to 0.362) and that for MI 0.45 (0.153 to 1.320) and definite/probable stent thrombosis 0.296 (0.080-1.095) in propensity-matched analyses. Rates of BARC type 2, 3, or 5 bleeding (0.9% vs. 1.3%; HRadj: 0.668 [0.379 to 1.178]; HRmatched: 0.721 [0.369-1.410]) did not differ significantly in patients treated with DAPT > 12-month or DAPT ≤ 12-month. The effect of long-term DAPT on primary and key secondary outcome across the proportion of ACS patients with 1-3, 4-5, or 6-9 risk factors showed a consistent manner (Pinteraction > 0.05). Conclusion Among high-risk "TWILIGHT-like" patients with ACS after PCI, long-term DAPT reduced ischemic events without increasing clinically meaningful bleeding events as compared with short-term DAPT, suggesting that extended DAPT might be considered in the treatment of ACS patients who present with a particularly higher risk for thrombotic complications. Abstract Figure.


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