Influence of factors on medication adherence among patients after percutaneous coronary intervention: a commentary

Le résumé fourni par la source

This invited commentary refers to ‘An attempt to explore the relative importance of factors influencing medication adherence after percutaneous coronary intervention’ by H. Xu et al., https://doi.org/10.1093/eurjcn/zvaf223. The World Health Organization defined adherence as ‘the extent to which a person’s behavior—taking medication, following a diet, and/or implementing lifestyle changes—corresponds to recommendations agreed upon with a healthcare professional’.1 In the context of coronary artery disease, advances in cardiovascular pharmacology and interventional cardiology have contributed to improved survival after myocardial infarction (MI); however, medication adherence is a key element in the primary and secondary prevention of the disease.2 Despite the proven effectiveness of a range of well-tolerated and effective medications for secondary prevention after a MI, evidence suggests that therapeutic targets for risk factors are not being met in many patients.3,4,5 It is estimated that less than half of all patients with a history of MI benefit from cardiac prevention and rehabilitation.3 A possible explanation for this is low patient adherence to drug treatment.6,7 The literature emphatically points out that discontinuation of drug treatment after an ischaemic event occurs early after hospital discharge.8,9,10 Previous studies have shown that one in five patients discontinues the use of at least one medication in the first month after MI and that one in eight patients discontinues the use of the remaining medications in the first month after the acute manifestation.11,12 After 1 year of follow-up, a significant increase in mortality was found among patients who did not adhere to drug therapy.10,12 The high prevalence of drug non-adherence following an ischaemic event is not surprising, considering that drug treatment plans tend to be complex and lifelong.13,14 Especially in the context of percutaneous coronary intervention (PCI), medication adherence is one of the main determinants of prognosis in patients after MI and is directly associated with a reduction in ischaemic events, stent thrombosis, readmissions, and mortality.3 Given the complexity of the problem, much effort has been expended to understand the factors that influence medication adherence; however, the results are inconsistent and have shown large discrepancies in adherence levels.15–17 In this context, Xu et al.18 through a cross-sectional approach explored not only the factors associated with non-adherence to medication after PCI, but above all the relative importance of these determinants on behaviour. The study involved 901 patients who underwent PCI with drug-eluting stents, and adherence was analysed in the fourth and seventh years after the procedure based on the ABC taxonomy19 (Ascertaining Barriers for Compliance), a theoretical framework designed to consistently define and measure behaviour through three consecutive phases (Initiation—when the patient takes the first dose of medication; Implementation—the degree to which the dosage the patient takes corresponds to the prescribed dosage regimen, from the beginning to the last dose; Discontinuation—interruption of medication intake). The results corroborate other findings in the literature3,20,21 by noting that medication adherence among patients with a history of MI is low even several years after PCI, with 39.3% of study participants showing incorrect implementation, 16.6% reporting a dose-taking rate of less than 90% of the prescribed dose, and 8.9% discontinuing at least part of the therapy without guidance from the healthcare team. The authors also conducted a comparative analysis of factors influencing adherence using multivariate models and identified three determinants that they classified as ‘common’ because they exerted a strong influence on different dimensions of behaviour: residence in a rural area, perception that the medication was not necessary, and occurrence of side effects. Other factors were classified as ‘uncommon’ because they showed limited association with one or two indicators of non-adherence, such as complex prescriptions, interference of the therapeutic regimen in daily routine, economic difficulties, memory decline, inconvenience in obtaining or using medications, being excessively busy, frequent travel, age, and number of stents implanted. The findings indicated that the uncommon factors acted in an individualized way, predominantly influencing the implementation phase, without necessarily impacting long-term persistence. This study made a significant contribution by proposing a hierarchy of factors that influenced medication adherence. The evidence available in the literature to date has treated these factors as equally relevant; however, the authors suggest that the number of adherence indicators directly impacts the structural weight of the determinant. Thus, Xu et al.18 recommend an integrated intervention model organized as routine and personalized. It was proposed that routine interventions be delivered to all patients focusing on common factors using health education to reinforce therapeutic needs, active monitoring and early management of side effects, as well as promoting continuous follow-up of patients from rural areas through remote strategies or integration with primary care. In contrast, personalized interventions are delivered according to the identification of individual barriers, considering simplified medication prescriptions, financial assistance for medication access, organization of daily routines, memorization strategies, and adaptation to the patient’s occupational or mobility conditions. The findings contribute to clinical practice by providing support for the construction of multifaceted and precise interventions, capable of optimizing resources and increasing clinical effectiveness. Another strength of the study is the availability of a theoretical basis that can contribute to the structuring of post-PCI follow-up programmes in a hierarchical manner, prioritizing determinants of greater impact without neglecting specific needs. In summary, the study broadens the understanding of the complexity of medication adherence after PCI by proposing that not all factors exert an equivalent influence on patient behaviour. The distinction between common and uncommon factors provides a promising conceptual framework for the development of more strategic, sustainable, and patient-centred care models, with the potential to improve long-term cardiovascular care. Rafaela Batista Dos Santos Pedrosa (Conceptualization, Project administration, Validation, Visualization, Writing—original draft, Writing—review & editing [lead]). No funding is supporting this work. This commentary does not contain new data.

Ce résumé expose les affirmations des auteurs. BNTIC ne l’interprète pas comme une validation indépendante des résultats.