The impact of readiness to discharge from hospital on adherence to treatment in patients after myocardial infarction.

BACKGROUND: The healthcare professionals involved in in-hospital treatment of myocardial infarction (MI) are also responsible to patients for their education before leaving the hospital. This education aims to modify patient behaviour in order to reduce relevant risk factors and improve self-control and adherence to medications. The aim of the study was to analyse the relationship between readiness for discharge from hospital and adherence to treatment at follow-up in MI patients. METHODS: An observational, single-center, MI cohort study with 6-month follow-up was conducted between May 2015 and July 2016. The Readiness for Hospital Discharge after Myocardial Infarction Scale (RHD-MIS) and the Adherence in Chronic Diseases Scale (ACDS) were applied. RESULTS: Two hundred and thirteen patients aged 30-91 years (62.91 ± 11.26) were enrolled in the study. The RHD-MIS general score ranged from 29 to 69 points (51.16 ± 9.87). A high level of readiness was found in 66 patients (31%), intermediate in 92 (43.2%), and low in 55 (25.8%) of patients. Adherence level assessed with the ACDS 6-months after discharge from hospital ranged from 7 to 28 points (23.34 ± 4.06). An increase in objective assessment of patient knowledge according to RHD-MIS subscale resulted in significantly higher level of adherence at the follow-up visit (p = 0.0154); R Spearman = 0.16671, p = 0.015; p for trend = 0.005. During the 6-month follow-up 3 (1.41%) patients died and 17 (7.98%) were hospitalized for a subsequent acute coronary syndrome. CONCLUSIONS: This study provided preliminary evidence of a long-term association between the results of assessment of readiness for discharge from hospital and adherence to treatment in patients after MI.

The influence of patient expectations on adherence to treatment regimen after myocardial infarction.

OBJECTIVE: In-hospital patient education is one of the elements affecting patient adherence to treatment regimen after myocardial infarction (MI). Its effectiveness is determined by educator and patient-dependent factors. Previous studies did not identify patient expectations as an independent determinant of successful education. The aim of this study was to assess whether patient knowledge and expectations affect adherence to treatment regimen in a 1-year follow-up. METHODS: This was a single-center, cohort study with a 1-year follow-up. Patient knowledge and expectations were evaluated using the Readiness for Hospital Discharge after Myocardial Infarction Scale (RHD-MIS scale). Medication adherence (including angiotensin converting enzyme inhibitors (ACEI), P2Y12 receptor inhibitors and statins) was verified based on prescription refill data extracted from The National Health Fund database. RESULTS: The study included 225 patients aged 30-91 years (mean age 62.9 ± 11.9 years). In the 4th quarter of follow-up, patients with the highest expectations had lower adherence regarding ACEI (p = 0.01), P2Y12 receptor inhibitors (p = 0.03) and the combination of all three analysed medications (p = 0.003). CONCLUSIONS: The initial results suggest presence of a relationship between patient expectations and long-term adherence to treatment. PRACTICE IMPLICATIONS: Post-MI patient education directed at fulfilling or modification of patient expectations could possibly improve execution of treatment regimen.

ANalgesic Efficacy and safety of MOrphiNe versus methoxyflurane in patients with acute myocardial infarction: the rationale and design of the ANEMON-SIRIO 3 study: a multicentre, open-label, phase II, randomised clinical trial.

INTRODUCTION: The unfavourable influence of morphine on the pharmacokinetics of ticagrelor resulting in weaker and retarded antiplatelet effect in patients with acute coronary syndrome (ACS) has been previously shown. Replacing morphine with methoxyflurane, a potent, non-opioid analgesic agent, that does not weaken or delay the effect of antiplatelet agents may improve the clinical efficacy of treatment of patients with ACS. METHODS: The ANEMON-SIRIO 3 study was designed as a multicentre, open-label, phase II, randomised clinical trial aimed to test the analgesic efficacy and safety of methoxyflurane in patients with ACS. The study population will comprise patients with ST-elevation myocardial infarction or non-ST-elevation ACS admitted to the study centres with typical chest pain requiring analgesic treatment. Before percutaneous coronary intervention (PCI) for the patients with index ACS will be randomly assigned in 1:1 ratio to receive methoxyflurane administered by inhalation, or to obtain morphine administered intravenously. Analgesic treatment will be followed by 300 mg loading dose of aspirin and 180 mg loading dose of ticagrelor. Patients will be assessed with regard to pain intensity according to the Numeric Pain Rating Scale at baseline, 3 min after study drug administration and immediately after PCI. Moreover, patients will be actively monitored with regard to the occurrence of side effects of evaluated therapies, as well as adverse events that may be related to insufficient platelet inhibition (no-reflow phenomenon assessed immediately after PCI, administration of GPIIb/IIIa inhibitors during PCI, acute stent thrombosis). ETHICS AND DISSEMINATION: The study will be conducted in six Polish clinical centres from the beginning of in accordance with the ethical standards of the institutional research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards. TRIAL REGISTRATION DETAILS: ClinicalTrials.gov, NCT04476173.

Therapy Discontinuation after Myocardial Infarction.

The discontinuation of recommended therapy after myocardial infarction predisposes patients to serious thrombotic complications. The aim of this study was a comprehensive analysis of permanent as well as short- and long-term discontinuation of pharmacotherapy, taking into consideration the basic groups of medications and nonadherence determinants in a one-year follow-up in post-myocardial infarction (MI) patients. MATERIAL AND METHODS: The study was a single center cohort clinical trial with a one-year follow-up including 225 patients (73.3% men, 26.7% women) aged 62.9 ± 11.9 years. In eight cases (3.6%), the follow-up duration was less than one year due to premature death. The following factors were analyzed: lack of post-discharge therapy initiation; short-term therapy discontinuation (<30 days); long-term therapy discontinuation (≥30 days); and permanent cessation of therapy. The analysis of therapy discontinuation was performed based on prescription filling data. RESULTS: Occupational activity (Odds Ratio (OR) 5.15; 95% Confidence interval (CI) 1.42-18.65; p = 0.013) and prior MI (OR 5.02; 95% CI 1.45-16.89; p = 0.009) were found to be independent predictors of a lack of post-discharge therapy initiation with P2Y12 receptor inhibitors. We found no independent predictors of lack of post-discharge therapy initiation with other medications, whether analyzed separately or together. Age above 65 years (Hazard Ratio (HR)-1.59; 95% CI 1.15-2.19; p = 0.0049) and prior revascularization (HR-1.44; 95% CI 1.04-2.19; p = 0.0273) were identified as independent predictors of therapy discontinuation. Multilogistic regression analysis showed no independent predictors of the cessation of any of the medications as well as the permanent or temporary simultaneous discontinuation of all medications. CONCLUSIONS: The vast majority of post-MI patients discontinue, either temporarily or permanently, one of the essential medications within one year following myocardial infarction. The most likely medication class to be discontinued are statins. Older age and prior cardiac revascularization are independent determinants of therapy discontinuation.

Medication adherence and its determinants in patients after myocardial infarction.

Non-adherence to prescribed medication is a serious limitation of long-term treatment in patients after myocardial infarction (MI), which can be associated with medical, social and economical consequences. Improvement of medication adherence has been shown to be a challenge for healthcare providers. The aim of this study was to evaluate changes in medication adherence and variability of adherence determinants during follow-up in patients after MI. A single-center, cohort observational study was conducted in 225 post-MI patients treated with primary coronary intervention (PCI) (27% women and 73% men) aged 30-91 years. Adherence was defined as availability of evaluated drugs within 1-year after discharge from hospital, based on completed prescriptions data obtained from the National Health Fund. The analysis of therapeutic plan realization (adherence to medication prescribed at discharge from hospital) embraced only reimbursed drugs: ACEIs (ramipril, perindopril), P2Y12 receptor inhibitors (clopidogrel) and statins (atorvastatin, simvastatin, rosuvastatin). Sufficient adherence was defined as ≥ 80%. During 1-year follow-up, adherence for all three drug classes was 64 ± 25%, with 67 ± 32% for ACEIs, 62 ± 34% for P2Y12 receptor inhibitor and 64 ± 32% for statins. A gradual decline in adherence was observed from 65% ± 26% in the first quarter of follow-up to 51% ± 34% in the last quarter of follow-up (p < 0.00001). Sufficient adherence for all drugs classes was found only in 29% of patients throughout the whole follow-up period (44% for ACEI, 36% for P2Y12 receptor inhibitor and 41% for statins). According to a multivariate analysis, age, prior CABG, level of education, place of residence, economic status and marital status were independent predictors of drug adherence. Whereas patients > 65 years and having a history of prior CABG more often had an insufficient adherence to drugs, married and hypertensive patients, city inhabitants and patients with higher education tended to have a sufficient drug adherence. Adherence to pharmacotherapy after myocardial infarction decreases over time in a similar manner for all pivotal groups of drugs prescribed after MI. A number of socioeconomic and clinical factors have been identified to affect medication adherence over time.

Assessment of adherence to medication in patients after myocardial infarction treated with percutaneous coronary intervention. Is there a place for newself-reported questionnaires?

INTRODUCTION: Non-adherence to medication regimen after myocardial infarction (MI) leads to increased morbidity and mortality and generates additional cost to the healthcare system. OBJECTIVES: The aim of this systematic review was to critically discuss assessment methods of adherence to medication in patients after myocardial infarction treated with percutaneous coronary intervention and the possible application of a new self-reported questionnaire. METHODS: A systematic investigation of all published literature was conducted to minimize the risk of bias. A database search (PubMed, CENTRAL and Google Scholar databases) from January 1998 through December 2017. RESULTS: Adequate assessment of patient adherence to treatment is necessary to understand the potential for adverse outcomes. Methods developed for adherence evaluation are classified as subjective and objective or as direct and indirect. Direct, objective measures reflect pharmacokinetics and include measurement of the drug or its metabolite concentration, evaluation of the presence of biological markers given with the drug and direct observation of patients' medication-taking behavior. Several indirect, objective methods are based on evaluation of the availability of prescribed medications assuming that medication is taken exactly as prescribed. Assessment of the effectiveness of treatment, both at the pharmacodynamic and clinical level, indirectly but objectively reflects adherence to treatment. Subjective methods, including patient-kept diaries, patient interviews and self-reported questionnaires, due to their simplicity, real-time feedback and low cost, are often used for adherence evaluation in clinical practice. CONCLUSIONS: In spite of the availability, convenience and variety of methods, measuring adherence still remains a real challenge. Using a well designed questionnaire provides an opportunity to identify patients at increased risk of non-adherence and the obstacles impeding implementation of the treatment plan, allowing implementation of tailored interventions in order to improve patient medication-taking behavior.

Adherence to treatment assessed with the Adherence in Chronic Diseases Scale in patients after myocardial infarction.

INTRODUCTION: A substantial subset of patients after myocardial infarction (MI) discontinue pivotal medication early after discharge. In particular, cessation of antiplatelet treatment may lead to catastrophic ischemic events. Thus, adherence to prescribed medication in patients after MI is an issue of medical and social concern. PURPOSE: The aim of the study was to evaluate the level of adherence to treatment using a newly developed scale in patients after MI treated with percutaneous coronary intervention. PATIENTS AND METHODS: A single-center, prospective, observational cohort clinical study with a 6-month follow-up was performed. Patients with physical or cognitive impairment, prisoners, soldiers, and family members and coworkers of the researchers were excluded from the study. The impact of selected sociodemographic and clinical factors on adherence was evaluated in 221 patients (63 women and 158 men) aged 30 to 91 years. RESULTS: The results obtained with the Adherence in Chronic Diseases Scale (ACDS) ranged from 7 to 28 points; with the average and median scored being 23.35 and 24, respectively. The ACDS score reflects the level of adherence to prescribed medication. The high ACDS scores (>26 points) were obtained in 59 (26.7%) patients, intermediate scores (21-26 points) in 110 (49.8%) and low scores (<21 points) in 52 subjects (23.5%). Acute coronary syndrome (re-ACS) occurred in 18 (8.1%) patients during the follow-up period. The high-level adherence (ACDS score >26 points) was found in 11.1% of patients with re-ACS vs 28.4% of the remaining ones (P=0.1). Lower scores (mean ± standard deviation) in re-ACS patients were found for items 2 and 3 of the ACDS: 3.11±0.68 vs 3.45±0.73 (P=0.02) and 3.28±0.89 vs 3.64±0.64 (P=0.04), respectively. CONCLUSION: Age and previous MI were found to be independent factors influencing adherence assessed with the ACDS.