Telephone Contact to Improve Adherence to Dual Antiplatelet Therapy After Drug-Eluting Stent Implantation by the EASY-IMPACT Investigators

Study Questions:

Dual antiplatelet therapy (DAT) is frequently discontinued after DES implantation, increasing the risk of stent thrombosis and death. Can simple telephone contact made by nurses improve adherence to and persistence of DAT after drug-eluting stent (DES) implantation?

Methods:

EASY-IMPACT was a randomized, controlled trial of 300 patients (mean ± standard deviation 64 ± 10 years, 73% male) recruited in the hospital after DES implantation was performed, between June 2009 and June 2010. Patients were randomized to receive either four telephone follow-ups plus usual care versus usual care (which included counseling by a pharmacist and physician prior to discharge). In the telephone follow-up group, calls were made within 7 days of the DES implantation and at 1, 6, and 9 months to support drug adherence. Pharmacy data were collected to assess drug prescription filling and refill with the primary endpoint of the proportion of days covered with aspirin and clopidogrel over the year after discharge, as assessed by pharmacy refill data (i.e., adherence). Secondary outcome measures included measures of persistence (i.e., still on a drug at 12 months) and self-reported measures of both adherence and persistence.

Results:

Most patients (73%) underwent DES implantation in the context of an acute coronary syndrome, and all had insurance coverage for medications. Complete pharmacy follow-up data were available for 96% of the cohort. At 12 months, median scores (25th–75th centile) for adherence to aspirin and clopidogrel were 99.2% (97.5–100%) and 99.3% (97.5–100%), respectively, in the telephone follow-up group compared with 90.2% (84.2–95.4%) and 91.5% (85.1–96.0%), respectively, in the usual care group (p < 0.0001 for aspirin and clopidogrel). Patients in the telephone follow-up group also were significantly more persistent in the aspirin and clopidogrel treatment than those in the usual care group at 12 months: for clopidogrel, 87.2% compared with only 43.1% (p < 0.0001).

Conclusions:

The authors concluded: “A simple approach of four telephone calls to patients after DES implantation significantly improved 1-year drug adherence to near-perfect scores. Persistence of DAT was also significantly improved…”.

Perspective:

This elegantly performed study from Quebec found that a simple, low resource-intense strategy of telephone follow-up significantly improved adherence to and persistence of DAT after DES implantation. This is an important area of investigation, given the strong relationship between premature discontinuation of DAT and stent thrombosis and mortality in observational studies. The results were particularly impressive, given the high baseline rates of adherence in the usual care group. Although it would have been ideal to have evaluated ‘hard’ outcomes (i.e., stent thrombosis) and to have examined these approaches at multiple centers, this study strongly suggests that care management programs for patients after DES implantation should consider implementing telephone follow-up at regularly scheduled times after discharge.

Clinical Topics: Acute Coronary Syndromes, Invasive Cardiovascular Angiography and Intervention, Interventions and ACS

Keywords: Pharmacists, Acute Coronary Syndrome, Follow-Up Studies, Platelet Aggregation Inhibitors, Drug-Eluting Stents, Quebec, Telephone, Counseling


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