Impact of health education on adherence to clopidogrel and clinical effectiveness of antiplatelet treatment in patients after myocardial infarction (original) (raw)
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Predictors of Low Clopidogrel Adherence Following Percutaneous Coronary Intervention
The American Journal of Cardiology, 2011
Few data are available on factors associated with low adherence or early clopidogrel discontinuation following percutaneous coronary intervention (PCI). Patients (n=284) were evaluated prior to hospital discharge following PCI to identify factors associated with low adherence to clopidogrel 30 days later. Pre-PCI adherence to daily medications was assessed using the 8-item Morisky Medication Adherence Scale (MMAS-8) and categorized as low, medium, or high (scores <6, 6 to <8 and 8, respectively). Low adherence to clopidogrel was defined as a MMAS-8 score < 6 (n=21) or having discontinued clopidogrel (n=11), both ascertained during a 30-day post-PCI interview. At 30 days post-PCI, 11% of patients had low adherence to clopidogrel. The odds ratios (95% confidence interval) for low adherence to clopidogrel was 3.78 (1.09-13.1), 3.06 (1.36-6.87), 2.46 (0.97-6.27) and 3.36 (0.99-11.4) for patients who reported, prior to PCI, taking smaller doses of medication due to cost, had difficulty filling prescriptions, had difficulty reaching their primary physician and were not comfortable asking their doctor for instructions, respectively. The odds ratios (95% CI) for low clopidogrel adherence following PCI among patients with medium and low, versus high adherence, to daily medications prior to PCI was 6.13 (1.34-28.2) and 10.9 (2.46-48.7), respectively. The c-statistic associated with pre-PCI MMAS-8 scores for discriminating low clopidogrel adherence at 30 days post-PCI
Journal of the American College of Cardiology, 2012
Background: Data regarding patient understanding of the required continuation of clopidogrel dosing after percutaneous coronary intervention (PCI) are sparse. We attempted to identify the level of understanding/information patients have regarding usage of this drug after PCI. Our objective was to learn patient understanding about continuation of clopidogrel after elective PCI for treatment of coronary heart disease (CHD) in a contemporary clinical setting. Methods: A cross-sectional survey of consecutive patients undergoing elective PCI for CHD at a tertiary care referral center was performed over 4 months. The standardized questionnaire included sections on demographic information, reason for PCI and information provided by hospital staff, including physicians, regarding clopidogrel usage post-PCI. Results: The study cohort comprised 208 consecutive patients (median age 61 years, interquartile range 54-70 years; males 57%) undergoing PCI (with bare or drug-eluting stents) for CHD. Of 208 patients, 80% were non-Hispanic whites and 87% had some high school education. Awareness regarding the required continuation of clopidogrel usage post-PCI is depicted (figure). Conclusions: Of patients who undergo PCI (stenting) for coronary heart disease in contemporary clinical practice, almost half are not fully aware of the time line for continuation of clopidogrel after implantation of either a bare-metal or a drug-eluting stent.
Prediction of high risk of non-adherence to antiplatelet treatment
Kardiologia Polska, 2016
Background: Dual antiplatelet therapy with acetylsalicylic acid (ASA) and clopidogrel is the standard of care for secondary prevention. Premature discontinuation of clopidogrel is associated with an increased risk of myocardial infarction (MI) or death, and greater health care expenditure. Aim: To develop an objective method for identification of patients with high risk of non-adherence to clopidogrel after MI. Methods: A total of 189 patients were enrolled into a prospective, observational, single-centre study with a nine-month follow-up. Patients received a 600-mg loading dose and 75-mg maintenance dose of clopidogrel in combination with ASA doses of 300 mg and 75 mg, respectively. Adenosine diposphate-induced platelet aggregation (ADP-PA) was assessed during baseline hospitalisation and at three, six, and nine months after discharge. Adherence to medication with clopidogrel was defined as the proportion of drug availability based on data from the National Health Fund regarding prescribed drug purchases. Adherence was arbitrarily judged adequate when the proportion exceeded 80%. Results: According to our hypothesis, ADP-PA in non-adherent patients should be higher at follow-up visits (at least once) as compared with measurement at hospitalisation. Based on the ROC curve analysis, the optimal cutoff point equal to 4 U was defined (p < 0.0001, 95% CI 0.562-0.654; sensitivity: 60.6%, specificity: 57.1%, positive predictive value: 63.3%, negative predictive value: 54.2%). The prevalence of true adherence to medication in groups of high and low probability of adherence defined according to developed criteria amounted 60 (50.8%) and 23 (32.4%) cases, respectively (p = 0.01). Conclusions: The newly developed method of objective identification of patients with high risk of non-adherence to clopidogrel after MI is easily applicable and cheap, and, despite relatively low sensitivity and specificity, it efficiently differentiates patients with regard to clinical end-points during follow-up.
Cardiovascular Outcomes after a Change in Prescription Policy for Clopidogrel
New England Journal of Medicine, 2008
Background Drug-reimbursement policies may have an adverse effect on patient outcomes if they interfere with timely access to efficacious medications for acute medical conditions. Clopidogrel in combination with aspirin is the recommended standard of care for patients receiving coronary stents to prevent thrombosis. We examined the population-level effect of a change by a Canadian provincial government in a pharmacy-benefits program from a prior-authorization policy to a less restrictive, limiteduse policy on access to clopidogrel among patients undergoing percutaneous coronary intervention (PCI) with stenting after acute myocardial infarction. Methods We conducted a population-based, retrospective, time-series analysis from April 1, 2000, to March 31, 2005, of all patients 65 years of age or older with acute myocardial infarction who underwent PCI with stenting in Ontario, Canada. The primary outcome was the composite rate of death, recurrent acute myocardial infarction, PCI, and coronary-artery bypass grafting at 1 year, with adjustment for sex and age. The secondary outcome was major bleeding. Results The rate of clopidogrel use within 30 days after hospital discharge following myocardial infarction increased from 35% in the prior-authorization period to 88% in the limited-use period. The median time to the first dispensing of a clopidogrel prescription decreased from 9 days in the first period to 0 days in the second period. The 1-year composite cardiovascular outcome significantly decreased from 15% in the prior-authorization group to 11% in the limited-use group (P = 0.02). Rates of bleeding in the two groups did not change. Conclusions The removal of a prior-authorization program led to improvement in timely access to clopidogrel for coronary stenting and improved cardiovascular outcomes.
European Heart Journal, 2011
Adherence to evidence-based treatments and its consequences after acute myocardial infarction (MI) are poorly defined. We examined the extent to which clopidogrel treatment initiated in hospital is continued in primary care; the factors predictive of clopidogrel discontinuation and the hazard of death or recurrent MI. Methods and results We linked the Myocardial Ischaemia National Audit Project registry and the General Practice Research Database to examine adherence to clopidogrel in primary care among patients discharged from hospital after MI (2003-2009). Hospital Episode Statistics and national mortality data were linked, documenting all-cause mortality and non-fatal MI. Of the 7543 linked patients, 4650 were prescribed clopidogrel in primary care within 3 months of discharge. The adjusted odds of still being prescribed clopidogrel at 12 months were similar following non-ST-elevation myocardial infarction (NSTEMI) 53% (95% CI, 51-55) and ST-elevation myocardial infarction (STEMI) 54% (95% CI, 52-56), but contrast with statins: NSTEMI 84% (95% CI, 82-85) and STEMI 89% (95% CI, 87-90). Discontinuation within 12 months was more frequent in older patients [.80 vs. 40-49 years, adjusted hazard ratio (HR) 1.50 (95% CI, 1.15-1.94)] and with bleeding events [HR 1.34 (95% CI, 1.03-1.73)]. 18.15 patients per 100 person-years (95% CI, 16.83-19.58) died or experienced non-fatal MI in the first year following discharge. In patients who discontinued clopidogrel within 12 months, the adjusted HR for death or non-fatal MI was 1.45 (95% CI, 1.22-1.73) compared with untreated patients, and 2.62 (95% CI, 2.17-3.17) compared with patients persisting with clopidogrel treatment. Conclusion This is the first study to use linked registries to determine persistence of clopidogrel treatment after MI in primary care. It demonstrates that discontinuation is common and associated with adverse outcomes.
British journal of clinical pharmacology, 2016
The biological response to clopidogrel is highly variable and a poor responsiveness is associated with major adverse cardiac events. Adherence to therapy is a major cause of poor responsiveness, but its impact on long-term platelet inhibition is unknown. The objective of this study was to evaluate the effect of different adherence monitoring programs to clopidogrel on platelet reactivity. Monocentric, parallel group, randomized controlled trial. Adults treated with clopidogrel 75 mg after elective coronary stenting were randomized in 3 groups: 1) Standard Of Care group, 2) Standard of Care + Adherence Electronic Monitoring group in which drug intake was recorded but kept blinded until study end, 3) Integrated-Care group, with regular feedback on recorded adherence. Clopidogrel response was assessed with the vasodilator-stimulated phosphoprotein platelet reactivity index (VASP-PRI) at randomization, 3 and 6 months. 123 adults were enrolled and randomized. Baseline VASP-PRI was highly...
Adherence to antiplatelet therapy after percutaneous coronary intervention
Journal of Cardiovascular Medicine, 2015
Aims We evaluated adherence to dual antiplatelet therapy (DAPT) after percutaneous coronary intervention (PCI) for patients in the Lazio region of Italy and the impact of discharge ward type on therapy discontinuation. Methods From the Hospital Information System, we selected patients who underwent PCI from 2006 to 2007 and obtained Regional Drug Dispense Registry data for antiplatelet drugs prescribed for 12 months after discharge. Appropriate therapy was defined as DAPT with prescribed daily doses for each drug covering at least 75% of each individual follow-up period. The association between discharge ward type and antiplatelet therapy adherence at 12 months post discharge was estimated using multilevel logistic regression analysis. Results A total of 11 186 patients with PCI were included, and fewer than half (4984; 44.56%) were on adequate DAPT. Only 2930 of 5390 patients (54.36%) with DAPT in the first 6 months post discharge continued DAPT in the second 6 months. Patients discharged from cardiology units or intensive coronary care units were more likely (odds ratio U 1.26; P U 0.003) to receive appropriate antiplatelet therapy, and elderly patients were less likely (odds ratio U 0.65; P < 0.001) to do so. Conclusion The proportion of PCI patients receiving appropriate DAPT after discharge is suboptimal in this region, and elderly patients are less likely to receive appropriate therapy. These findings could be important for improving patient management and ensuring adherence to clinical guidelines and indicate the need for a systematic evaluation of the appropriateness of postdischarge therapy.