by Robert Fay

Patients who don't fill their prescriptions following an acute myocardial infarction (AMI) have a higher 1-year mortality rate than those who do, according to a study published in the February 26, 2008 issue of Circulation. The authors of the current study say that theirs is the first to report adverse outcomes associated with primary nonadherence.

Medication is the main method of achieving secondary prevention after AMI, but patients must take their medications to benefit. Most medication research has focused on secondary adherence rather than primary adherence (continuation of medications rather than not filling the first prescription written), although nonadherence can occur at different points in a patient's decision-making process. With the current study, the authors sought to investigate primary medication nonadherence after AMI to help characterize it, determine its factors, and measure outcomes. The primary outcome was 1-year mortality.

For this population-based cohort study, the researchers analyzed the outcomes of 4,591 people older than age 65 who had experienced AMI by looking at an AMI registry linked to administrative data in Ontario, Canada. The patients received 12,832 prescriptions. The authors found that 73 percent of the prescriptions were filled within 7 days of discharge from the hospital, and 79 percent were filled by 120 days. Heart drug prescriptions were more likely than other drug prescriptions to be filled by 120 days (82 percent versus 35 percent), but only 74 percent of patients filled all of their prescriptions after 120 days. The death rate 1 year after discharge was 44 percent higher among patients who filled some but not all of their heart medication prescriptions. That number jumped to 80 percent in patients who filled none of their prescriptions compared to patients who filled all of their prescriptions. Factors associated with filling all prescriptions at discharge rather than no prescriptions at discharge included younger age, low income, discharge medication counseling, in-hospital attending cardiologist, and few medications before AMI.

Although the research regarding the impact of medication counseling on adherence and outcomes has been inconsistent, the authors found that patients who received discharge medication counseling had a "significantly lower risk of 1-year mortality." The authors observe that clinicians often assume that patients fill their prescriptions once written, but the current study shows this may be incorrect. "Recognition of factors associated with filling discharge prescriptions in the post-AMI population may aid in targeting interventions such as discharge medication counseling and postdischarge follow-up to improve primary nonadherence and mortality," they conclude.

James S. Forrester, MD, FACC, director of Cardiovascular Research and Burns and Allen Professor of Cardiology Research at Cedars-Sinai Medical Center, commented, "The 44 percent annual mortality difference is pretty shocking even though it was entirely predictable, since it's similar to a drug versus placebo trial. The disturbing irony is that we hear hundreds of lectures on drug efficacy for each one on compliance. It's hard to avoid the conclusion that it's time to give equal time to compliance."

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Source: Jackevicius A, Li P, Tu JV. 2008. Prevalence, predictors, and outcomes of primary nonadherence after acute myocardial infarction. Circulation 117:1028-1036.

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