Ko Dennis T, Chiu Maria, Guo Helen, Austin Peter C, Marquis Jean-François, Tu Jack V
Division of Cardiology, Schulich Heart Centre, Sunnybrook Health Sciences Centre, University of Toronto, Ontario, Canada.
Am Heart J. 2009 Oct;158(4):592-598.e1. doi: 10.1016/j.ahj.2009.06.030. Epub 2009 Aug 22.
Twelve months of uninterrupted thienopyridine therapy after drug-eluting stents (DES) implantation was recently recommended, but limited data are available regarding long-term use in clinical practice. The objective of the study was to determine the adherence to thienopyridine therapy after stent implantation, factors associated with suboptimal adherence, and association of suboptimal adherence with mortality.
We evaluated 5,263 older patients (>65 years) who received DES and 6,081 older patients who received bare-metal stents (BMS) from December 1, 2003, to March 31, 2006, in Ontario, Canada, who were eligible to receive 12 months of thienopyridine at minimal cost.
Primary nonadherence was observed among 6.9% in the DES group and 7.1% in the BMS group that did not fill a single prescription of thienopyridine within 1 year of stent implantation. Premature discontinuation occurred in a progressive manner, with 28% in the DES group and 34% in the BMS group discontinuing therapy by 6 months. Low-income patients eligible for a waiver of deductible and dispensing fee were almost 70% more likely to fill their first prescription. For DES patients, primary nonadherence (hazard ratio [HR] 2.68, 95% CI 1.77-4.07), 12-months proportional days covered <80% (HR 2.39, 95% CI 1.67-3.43), and prematurely discontinuing therapy within 6 months (HR 2.64, 95% 1.60-4.35) were associated with an increased risk of death.
We found suboptimal patterns of adherence to thienopyridine therapy after DES implantation that was strongly associated with an increased mortality risk. Eliminating any costs for thienopyridine therapy may be an effective strategy to increase medication adherence.
近期推荐在药物洗脱支架（DES）植入后进行12个月不间断的噻吩并吡啶治疗，但关于其在临床实践中长期使用的数据有限。本研究的目的是确定支架植入后噻吩并吡啶治疗的依从性、与依从性欠佳相关的因素，以及依从性欠佳与死亡率的关联。
我们评估了2003年12月1日至2006年3月31日在加拿大安大略省接受DES的5263例老年患者（>65岁）和接受裸金属支架（BMS）的6081例老年患者，这些患者有资格以最低成本接受12个月的噻吩并吡啶治疗。
在DES组中，6.9%的患者和BMS组中7.1%的患者在支架植入后1年内未开具过一次噻吩并吡啶处方，观察到原发性不依从。过早停药呈渐进性，DES组28%的患者和BMS组34%的患者在6个月时停止治疗。有资格豁免免赔额和配药费的低收入患者开具首张处方的可能性几乎高出70%。对于DES患者，原发性不依从（风险比[HR]2.68，95%置信区间1.77 - 4.07）、12个月的比例覆盖天数<80%（HR 2.39，95%置信区间1.67 - 3.43）以及在6个月内过早停药（HR 2.64，95% 1.60 - 4.35）与死亡风险增加相关。
我们发现DES植入后噻吩并吡啶治疗的依从性欠佳模式与死亡风险增加密切相关。消除噻吩并吡啶治疗的任何费用可能是提高药物依从性的有效策略。
