Brieger David, Chow Clara, Gullick Janice, Hyun Karice, D'Souza Mario, Briffa Tom
Department of Cardiology, Concord Repatriation General Hospital and The University of Sydney, Sydney, New South Wales, Australia.
Department of Cardiology, Westmead Hospital, The University of Sydney, Sydney, New South Wales, Australia.
Intern Med J. 2018 May;48(5):541-549. doi: 10.1111/imj.13736.
Most patients are recommended secondary prevention pharmacotherapies following an acute coronary syndromes (ACS).
To identify predictors of adherence at 6 months and strategies to improve adherence to these therapies.
Patients in the CONCORDANCE registry who were discharged on evidence-based medications were stratified into those receiving ≥75% ('adherent') or <75% ('non-adherent') of indicated medications at 6 months. Baseline characteristics, hospital and post-discharge care were compared between groups. Multivariable logistic analysis identified independent predictors of adherence. The relative contribution of each clinical or treatment factor to 'adherence' was determined using an adequacy measure method.
Follow-up data were available for 6595 patients, 4492 (68.1%) of whom were 'adherent'. Clinical factors predictive of adherence included previous stroke, percutaneous coronary intervention (PCI) and hypertension (odds ratios (OR) 1.36-1.56); factors predictive of non-adherence included discharge diagnosis of non-ST-segment elevation myocardial infarction (vs unstable angina) (OR 0.51) and atrial fibrillation (OR 0.59). Discharge on ≥75% of indicated medications was a strong predictor of adherence at 6 months (OR 10.23, 95% confidence interval 7.89-13.27); in-hospital management factors predicting non-adherence were medical management alone (OR 0.34) and coronary artery bypass graft (OR 0.50) (both vs PCI). Post-discharge predictors of adherence included cardiac rehabilitation (OR 1.36) and general practitioner attendance (OR 1.40).
Failure to discharge patients on indicated therapies is the most important modifiable predictor of adherence failure 6 months after an ACS. Implementing protocols to automate prescription of indicated discharge therapies, has the potential to reduce non-adherence dramatically in the 6 months following discharge.
大多数急性冠状动脉综合征（ACS）患者在出院后会接受二级预防药物治疗。
确定6个月时依从性的预测因素以及提高这些治疗依从性的策略。
将CONCORDANCE注册研究中出院时接受循证药物治疗的患者分为6个月时接受≥75%（“依从”）或<75%（“不依从”）规定药物治疗的两组。比较两组的基线特征、住院情况和出院后护理情况。多变量逻辑分析确定了依从性的独立预测因素。使用充分性测量方法确定每个临床或治疗因素对“依从性”的相对贡献。
6595例患者有随访数据，其中4492例（68.1%）为“依从”。预测依从性的临床因素包括既往中风、经皮冠状动脉介入治疗（PCI）和高血压（比值比（OR）为1.36 - 1.56）；预测不依从的因素包括非ST段抬高型心肌梗死（与不稳定型心绞痛相比）的出院诊断（OR 0.51）和心房颤动（OR 0.59）。出院时接受≥75%规定药物治疗是6个月时依从性的有力预测因素（OR 10.23，95%置信区间7.89 - 13.27）；预测不依从的住院管理因素是单纯药物治疗（OR 0.34）和冠状动脉旁路移植术（OR 0.50）（均与PCI相比）。出院后依从性的预测因素包括心脏康复（OR 1.36）和全科医生就诊（OR 1.40）。
出院时未给予患者规定治疗是ACS后6个月依从性失败的最重要可改变预测因素。实施规定出院治疗自动处方方案有可能在出院后的6个月内显著降低不依从性。
