Adherence Tradeoff to Multiple Preventive Therapies and All-Cause Mortality After Acute Myocardial Infarction
Maarit J Korhonen1, Jennifer G Robinson2, Izabela E Annis3
1Division of Pharmaceutical Outcomes and Policy, UNC Eshelman School of Pharmacy, University of North Carolina, Chapel Hill, North Carolina; National Health and Medical Research Council Centre for Research Excellence in Frailty and Healthy Ageing, Adelaide, South Australia, Australia; Centre for Medicine Use and Safety, Faculty of Pharmacy and Pharmaceutical Sciences, Monash University, Parkville, Victoria, Australia.
Insights
Adherence to ACE inhibitors/ARBs and statins after heart attack is linked to similar survival as taking all three recommended medications. Skipping statins or ACE inhibitors/ARBs significantly increases mortality risk in older adults.
Area of Science:
- Cardiology
- Geriatric Medicine
- Pharmacology
Background:
- Standard post-acute myocardial infarction (AMI) care recommends Angiotensin-converting enzyme (ACE) inhibitors/angiotensin II receptor blockers (ARB), beta-blockers, and statins.
- Patient adherence to these multiple therapies can vary, impacting treatment effectiveness.
Purpose of the Study:
- To investigate how adherence tradeoffs among ACE inhibitors/ARBs, beta-blockers, and statins affect survival in older adults post-AMI.
- To quantify the mortality risks associated with partial or non-adherence to these key post-AMI medications.
Main Methods:
- A cohort of 90,869 Medicare beneficiaries aged 65+ surviving 180 days post-AMI hospitalization (2008-2010) was analyzed.
- Medication adherence was measured by Proportion of Days Covered (PDC) over 180 days post-discharge.
- Cox proportional hazards models were used to assess mortality risk up to 18 months post-adherence measurement.
Main Results:
- Only 49% of patients achieved ≥80% adherence to all three prescribed medication classes.
- Compared to adherence to all three, adherence to only ACE inhibitors/ARBs and statins showed similar mortality (HR: 0.98).
- Non-adherence to all three therapies significantly increased mortality risk (HR: 1.65).
Conclusions:
- Adherence to ACE inhibitors/ARBs and statins provides similar survival benefits as adherence to all three therapies, indicating potentially limited added value of beta-blockers in this specific adherent subgroup.
- Non-adherence to ACE inhibitors/ARBs and/or statins is strongly associated with increased mortality risk in older AMI survivors.
Background:
Angiotensin-converting enzyme (ACE) inhibitors/angiotensin II receptor blockers (ARB), beta-blockers and statins are recommended after acute myocardial infarction (AMI). Patients may adhere to some, but not all, therapies.
Objectives:
The authors investigated the effect of tradeoffs in adherence to ACE inhibitors/ARBs, beta-blockers, and statins on survival among older people after AMI.
Methods:
The authors identified 90,869 Medicare beneficiaries ≥65 years of age who had prescriptions for ACE inhibitors/ARBs, beta-blockers, and statins, and survived ≥180 days after AMI hospitalization in 2008 to 2010. Adherence was measured by proportion of days covered (PDC) during 180 days following hospital discharge. Mortality follow-up extended up to 18 months after this period. The authors used Cox proportional hazards models to estimate hazard ratios of mortality for groups adherent to 2, 1, or none of the therapies versus group adherent to all 3 therapies.
Results:
Only 49% of the patients adhered (PDC ≥80%) to all 3 therapies. Compared with being adherent to all 3 therapies, multivariable-adjusted hazard ratios (95% confidence intervals [CIs]) for mortality were 1.12 (95% CI: 1.04 to 1.21) for being adherent to ACE inhibitors/ARBs and beta-blockers only, 0.98 (95% CI: 0.91 to 1.07) for ACEI/ARBs and statins only, 1.17 (95% CI: 1.10 to 1.25) beta-blockers and statins only, 1.19 (95% CI: 1.07 to 1.32) for ACE inhibitors/ARBs only, 1.32 (95% CI: 1.21 to 1.44) for beta-blockers only, 1.26 (95% CI: 1.15 to 1.38) statins only, and 1.65 (95% CI: 1.54 to 1.76) for being nonadherent (PDC <80%) to all 3 therapies.
Conclusions:
Patients adherent to ACE inhibitors/ARBs and statins only had similar mortality rates as those adherent to all 3 therapies, suggesting limited additional benefit for beta-blockers in patients who were adherent to statins and ACE inhibitors/ARBs. Nonadherence to ACE inhibitors/ARBs and/or statins was associated with higher mortality.
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