Division of Pharmacoepidemiology and Pharmacoeconomics, Brigham and Women's Hospital and Harvard Medical School, Boston, MA.
Division of Pharmacoepidemiology and Pharmacoeconomics, Brigham and Women's Hospital and Harvard Medical School, Boston, MA; Department of Medicine, Division of Preventive Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA.
Am Heart J. 2014 Jan;167(1):51-58.e5. doi: 10.1016/j.ahj.2013.09.014. Epub 2013 Oct 17.
Patients who adhere to medications experience better outcomes than their nonadherent counterparts. However, these observations may be confounded by patient behaviors. The level of adherence necessary for patients to derive benefit and whether adherence to all agents is important for diseases that require multiple drugs remain unclear. This study quantifies the relationship between medication adherence and post-myocardial infarction (MI) adverse coronary events.
This is a secondary analysis of the randomized MI FREEE trial. Patients who received full prescription coverage were classified as adherent (proportion of days covered ≥80%) or not based upon achieved adherence in the 6 months after randomization. First major vascular event or revascularization rates were compared using multivariable Cox models adjusting for comorbidity and health-seeking behavior.
Compared with patients randomized to usual care, full coverage patients adherent to statin, β-blocker, or angiotensin-converting enzyme inhibitor/angiotensin receptor blocker were significantly less likely to experience the study's primary outcome (hazard ratio [HR] range 0.64-0.81). In contrast, nonadherent patients derived no benefit (HR range 0.98-1.04, P ≤ .01 for the difference in HRs between adherent and nonadherent patients). Partially adherent patients had no reduction in clinical outcomes for any of the drugs evaluated, although their achieved adherence was higher than that among controls.
Achieving high levels of adherence to each and all guideline-recommended post-MI secondary prevention medication is associated with improved event-free survival. Lower levels of adherence appear less protective.
与非依从患者相比，依从药物治疗的患者的治疗效果更好。然而，这些观察结果可能受到患者行为的影响。对于需要多种药物治疗的疾病，患者需要达到何种程度的依从性才能获益，以及依从所有药物是否重要，目前仍不清楚。本研究定量评估了药物依从性与心肌梗死后（MI）不良冠状动脉事件之间的关系。
这是一项随机 MI FREEE 试验的二次分析。根据随机分组后 6 个月内的实际依从情况，将接受全处方覆盖的患者分为依从组（服药天数覆盖率≥80%）或非依从组。使用多变量 Cox 模型比较主要血管事件或血运重建率，模型调整了合并症和寻求医疗服务的行为。
与接受常规治疗的患者相比，依从他汀类药物、β受体阻滞剂或血管紧张素转换酶抑制剂/血管紧张素受体阻滞剂的全剂量覆盖患者发生研究主要结局的可能性显著降低（风险比范围 0.64-0.81）。相比之下，不依从的患者未从中获益（风险比范围 0.98-1.04，依从和不依从患者的风险比差异有统计学意义，P ≤.01）。对于评估的所有药物，部分依从患者的临床结局无改善，尽管他们的实际依从性高于对照组。
达到指南推荐的 MI 二级预防药物的高依从性水平与改善无事件生存率相关。较低水平的依从性似乎保护作用较小。
