Two months ago, a 63-year old Hispanic male had a myocardial infarction (MI) followed by an angioplasty and coated stent. He was discharged on 80 mg atorvastatin, low-dose aspirin, clopidogrel, a long-acting beta blocker, and lisinopril 5 mg. One year ago his LDL–C was 140 mg/dL. He was prescribed a low dose of pravastatin 10 mg/day at that time but never returned for a follow-up lipid panel. He reported stopping the pravastatin about 6 months before his MI. He returns now for a follow-up visit. He reports adhering to a heart healthy diet and taking atorvastatin 80 mg/day for the first month after discharge. He had no musculoskeletal or other symptoms during this period but did not refill the prescription. He thought he was already taking too many pills and did not understand why he was taking a pill for cholesterol. His fasting lipid panel returns with an LDL-C of 125 mg/dL.
Which of the following statements is the most correct answer?
The correct answer is: D. Nonadherence to statin therapy is associated with an increased risk of stroke, MI and death.
A large prospective registry with complete adherence data showed 47% were adherent to guideline-recommended recommendations after 1 year, and 48% after 4 years. Nonadherence at 1 year was associated with a 19% increased risk of stroke, MI, cardiovascular death, and total mortality over the next 3 years.
In 2 registries of 31 U.S. hospitals, nearly all patients were discharged on appropriate evidence-based secondary prevention medications. This patient was discharged as recommended by the guidelines on atorvastatin 80 mg. Statin dose at discharge is an important predictor of subsequent dose. Uptitration to higher statin doses occurs infrequently. However, this patient had numerous other characteristics predicting statin nonadherence over the long term.
Characteristics of those who are adherent include being younger, white, less polyvascular disease, and having insurance. This patient is Hispanic, putting him in a category with East Asians, as being less adherent as compared to white patients. Adverse effects are not the main cause for medication nonadherence.
There are at least 6 nonadherence phenotypes, representing different behaviors and barriers that exist for patients:
The patient lacks an understanding of the relationship between medication adherence to continued health and well-being;
The patient has concluded that the costs of taking a medication outweigh the benefits;
The complexity of the medication regimen is beyond the capacity of the patient to understand
The patient is not sufficiently vigilant;
The patient's belief regarding medications are inaccurate, irrational, or conflicting; and
The patient does not believe the medication will help them.
Educational interventions with behavioral support through continued patient contact over several weeks or months has been shown to be effective. The guideline recommends follow-up every 4-12 weeks until the patient has achieved an acceptable level of lifestyle and mediation adherence as evidenced by the LDL–C response.
Clinical strategies to improve adherence are discussed in the paper by Bosworth et al (2011). ICD-9 code (V15.81) can be used for medication nonadherence counselling billing purposes. In addition, significant variation in the use of evidence-based secondary medication has been observed across outpatient medical practices, suggesting that quality improvement efforts are needed.
The new cholesterol guidelines strongly emphasize adherence to evidence-based cholesterol-lowering therapies rather than targeting a fixed LDL–C cutoff. Thus, assessment of adherence to lifestyle and his statin therapy by checking a fasting lipid panel is needed at future visits. The guideline does note, however, that in participants in randomized trials who were taking a high-intensity statin, almost all had an LDL–C <100 mg/dL. This is not a target or performance measure but designed to give the clinician an idea of the anticipated LDL–C response to treatment. In this patient with an untreated LDL–C 125-140 mg/dL, atorvastatin 80 mg would be expected to decrease LDL–C by about 50% on average, to a level of 65-70 mg/dL.
Arnold SV, Spertus JA, Masoudi FA, et al. Beyond Medication Prescription as Performance Measures: Optimal Secondary Prevention Medication Dosing After Acute Myocardial Infarction. Journal of the American College of Cardiology. 2013;62(19):1791-1801.
Kumbhani DJ, Steg PG, Cannon CP, et al. Adherence to Secondary Prevention Medications and Four-year Outcomes in Outpatients with Atherosclerosis. The American Journal of Medicine. 2013;126(8):693-700.e691.
Rodriguez F, Cannon CP, Steg PG, Kumbhani DJ, Goto S, Smith SC, Eagle KA,Ohman EM, Umez-Eronini AA, Hoffman E, Bhatt DL; on Behalf of the REACH RegistryInvestigators. Predictors of Long-term Adherence to Evidence-based CardiovascularDisease Medications in Outpatients With Stable Atherothrombotic Disease: Findings From the REACH Registry. Clin Cardiol. 2013 Oct 25.
Maddox TM, Chan PS, Spertus JA, et al. Variation in CAD Secondary Prevention Prescription among Outpatient Cardiology Practices: Insights from the NCDR®. Journal of the American College of Cardiology. 2013(0).
Smolderen KG, Spertus JA, Tang F, et al. Treatment Differences by Health Insurance Among Outpatients With Coronary Artery Disease: Insights From the National Cardiovascular Data Registry. Journal of the American College of Cardiology. 2013(0).
Marcum Za SMHSM. Medication nonadherence: A diagnosable and treatable medical condition. JAMA. 2013;309(20):2105-2106.
Naderi SH, Bestwick JP, Wald DS. Adherence to Drugs That Prevent Cardiovascular Disease: Meta-analysis on 376,162 Patients. The American Journal of Medicine. 2012;125(9):882-887.e881.
Bosworth HB, Granger BB, Mendys P, et al. Medication adherence: A call for action. American Heart Journal. 2011;162(3):412-424.