Baylor University Medical Center Proceedings October 2017 - 411

Table 1. Baseline demographic and clinical characteristics
Five-drug therapy
Characteristics

Yes
(n = 77)

No
(n = 78)

P
value

Age (years), mean ± standard deviation

59 ± 12

62 ± 13

0.13

Men

55 (71%)

52 (67%)

0.60

Coronary artery disease

17 (22%)

17 (22%)

1.0

Diabetes mellitus

21 (27%)

24 (31%)

0.72

Dyslipidemia

34 (44%)

32 (41%)

0.75

Hypertension

50 (65%)

43 (55%)

0.25

Smoker

41 (53%)

43 (55%)

0.87

Among the 155 ACS patients, 77 (50%) received all five
guideline-recommended medications at discharge. Overall,
95% of the study patients were prescribed aspirin; 92%, thienopyridine inhibitors; 67%, angiotensin-converting enzyme
inhibitors (ACEIs)/angiotensin receptor blockers (ARBs); 92%,
beta-blockers; and 69%, high-intensity statins. Seventy-eight
patients (50%) did not receive the five-drug combination therapy at discharge. The absence of one of the five agents does not
necessarily imply lack of optimal treatment. A reason behind
the nonadherence was documented for 48 patients (62.0%), as
summarized in Table 2.
Table 2. Reasons for nonadherence to five-drug combination therapy
Drug
ACEI/ARBs

Beta-blockers

Statin

Thienopyridine
inhibitors

Aspirin

Not prescribed
the drug
52 (34%)

12 (8%)

54 (69%)

13 (8%)

4 (3%)

Reason

Number
of patients

Hypotension

16

Kidney disease

13

Not documented

23

Bradycardia

6

Hypotension

2

Heart block

1

Cocaine use

1

Not documented

2

Active liver disease

6

Myalgia

1

Allergies

6

Inappropriate statin
intensity

36

Not documented

5

GI bleeding

2

Allergy

2

Not documented

9

GI bleeding

0

Not documented

4

ACEI indicates angiotensin-converting enzyme inhibitors; ARBs, angiotensin receptor
blockers; GI, gastrointestinal.

October 2017

DISCUSSION
This study demonstrates that the five-drug regimen was
provided to only half of the patients, leaving substantial room
for improvement. However, it is also important to note that
the individual prescription rates of the medications were
encouraging. Observational studies provide valuable insight
into treatment effectiveness and generalizability in routine
practice (1). This study has demonstrated that these lifesaving
medications are being prescribed at suboptimal rates. Other
studies have examined the proportion of hospitalized cardiac
patients discharged on secondary prevention medications. One
study conducted by Yetgin et al showed patients received aspirin,
thienopyridine inhibitors, ACEI/ARBs, beta-blockers, statins,
and combination therapy at rates of 94%, 100%, 80%, 87%,
96%, and 65%, respectively (2). Another study demonstrated
that only 27% of the patients received the combination of all
five agents (3).
Although 50% of the patients were not on all of the five
medications at discharge, this does not necessarily imply that
the patients were treated suboptimally. In the present study,
only 62.0% patients had a reasonable explanation for nonadherence. Documented reasons for nonadherence included
hypotension, kidney disease, bradycardia, heart block, cocaine
use, active liver disease, myalgia, gastrointestinal bleeding, and
drug allergies. Beta-blockers have historically been underprescribed, likely due to adverse effects. One study with a rate of
nonadherence to beta-blocker therapy similar to ours (6.8% vs
8%) documented the following reasons for nonadherence: sinus
node disease/bradycardia (24.2%), hypotension (20.3%), airway disease (14.8%), congestive heart failure (11.7%), unknown
(11.7%), other (7%), illicit drug use (6.2%), atrioventricular
block (5.5%), depressed mood (0.8%), lightheadedness (0.8%),
and fatigue (0.8%) (4). In order to overcome this barrier, patient education and outpatient follow-up to initiate beta-blocker
therapy should be considered in all patients who do not have
absolute contraindications.
Another underlying problem is compliance. Many studies
have shown that patients are nonadherent to the prescribed
regimens (1, 5, 6). Premature discontinuation of therapy and
prescription nonrenewals have been documented at rates of
33.3% and 75%, respectively (7). Although a compliance rate
of 100% would be ideal, certain preclusions exist. Inappropriate prescribing by physicians, adverse effects, contraindications,
cost, and nonadherence in addition to other patient-specific
factors must also be considered. The use of reinforcement programs to help aid in application of the guidelines, such as the
CHAMP program, have been shown to improve prescription
rates at discharge and demonstrated treatment persistence at
1-year follow-up (8). Implementation of such programs may
be beneficial to ensure proper prescribing and help increase
adherence rates.
One interesting finding of our study is the rate of prescribing inappropriate statin intensity. We believe this finding can be
explained by changes in guidelines followed by a lag in physician response to such changes, such that some physicians may
have still been targeting low-density lipoprotein levels based on

Evaluation of medication compliance for secondary prevention of acute coronary syndrome

411



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