Division of Cardiology, University of Texas Southwestern Medical Center, Dallas, TX, USA.
Am J Med. 2013 Aug;126(8):693-700.e1. doi: 10.1016/j.amjmed.2013.01.033. Epub 2013 Jun 22.
Although nonadherence with evidence-based secondary prevention medications is common in patients with established atherothrombotic disease, long-term outcomes studies are scant. We assessed the prevalence and long-term outcomes of nonadherence to secondary prevention (antiplatelet agents, statins, and antihypertensive agents) medications in stable outpatients with established atherothrombosis (coronary, cerebrovascular, or peripheral artery disease) enrolled in the international REduction of Atherothrombosis for Continued Health registry.
Adherence with these medications in eligible patients at baseline and 1-year follow-up was assessed. The primary outcome was a composite of cardiovascular death, myocardial infarction, or stroke at 4 years.
A total of 37,154 patients with established atherothrombotic disease were included. Adherence rates with all evidence-based medications at baseline and 1 year were 46.7% and 48.2%, respectively. Nonadherence with any medication at baseline (hazard ratio, 1.18; 95% confidence interval, 1.11-1.25) and at 1 year (hazard ratio, 1.19; 95% confidence interval, 1.11-1.28) were both significantly associated with an increased risk of the primary end point. The risk of all-cause mortality was similarly elevated. Corresponding numbers needed to treat were 31 and 25 patients for the composite end point and total mortality, respectively. This also was true for each disease-specific subgroup. Patients who were fully adherent at both time points had the lowest incidence of adverse outcomes, whereas patients who were nonadherent at both time points had the worst outcomes (P < .01).
Our analysis of a large international registry demonstrates that nonadherence with evidence-based secondary prevention therapies in patients with established atherothrombosis is associated with a significant increase in long-term adverse events, including mortality.
尽管在已确诊动脉粥样硬化疾病的患者中，不遵医嘱服用基于证据的二级预防药物较为常见，但长期结局研究却很少。我们评估了在国际动脉粥样硬化血栓形成的持续健康（REduction of Atherothrombosis for Continued Health，REACH）注册研究中入组的稳定门诊动脉粥样硬化患者（冠状动脉、脑血管或外周动脉疾病）中，不遵医嘱服用二级预防药物（抗血小板药物、他汀类药物和抗高血压药物）的流行率及其长期结局。
在基线和 1 年随访时，评估这些药物在符合条件的患者中的依从性。主要结局是 4 年时心血管死亡、心肌梗死或卒中的复合终点。
共纳入 37154 例确诊动脉粥样硬化疾病的患者。基线和 1 年时，所有基于证据的药物的依从率分别为 46.7%和 48.2%。基线时（危险比，1.18；95%置信区间，1.11-1.25）和 1 年时（危险比，1.19；95%置信区间，1.11-1.28）不服用任何药物均与主要终点风险增加显著相关。全因死亡率的风险也同样升高。对于复合终点和总死亡率，相应的需要治疗人数分别为 31 人和 25 人。这对每个特定疾病亚组也是如此。在两个时间点均完全依从的患者不良结局发生率最低，而在两个时间点均不依从的患者结局最差（P＜0.01）。
我们对大型国际注册研究的分析表明，在已确诊动脉粥样硬化的患者中，不遵医嘱服用基于证据的二级预防治疗药物与长期不良事件（包括死亡）的显著增加相关。
