Medication Adherence in Cardiovascular Disease

Serious adverse events following immunization with COVID-19 vaccines in Lebanon: a retrospective analysis of the National Pharmacovigilance Database

Continuous surveillance and risk assessment of inactivated Coronavirus Disease 2019 (COVID-19)) vaccines provide an understanding of their safety profiles, guide vaccination strategy and public health policy. This study aims to analyze the characteristics and prevalence of officially reported serious adverse events following immunization (AEFIs) with inactivated COVID-19 vaccines by System Organ Class (SOC), age, and sex.To achieve this aim, a retrospective observational study was conducted between February 14th, 2021, and June 30th, 2022. Reported AEFIs were evaluated for data completeness. Causality assessment adhered to the World Health Organization guidelines.Findings revealed that the AEFIs occurrence did not significantly differ between vaccines used (ChAdOx1 vs. BNT162b2), sex, or SOC. The most prevalent AEFIs were vascular disorders (37%), followed by cardiac (25%) and nervous system disorders (14%). The adverse events were predominantly reported post-vaccination with the BNT162b2 vaccine, mainly after the first dose. The mean age was highest for miscellaneous disorders (70 ± 21.7 years) and the lowest for nervous system (46 ± 22 years) and immune system disorders (45 ± 19 years). Age differences were statistically different for vascular disorders (p = 0.003) and immune system disorders (p = 0.012).In conclusion, ongoing surveillance and risk assessment of the vaccine's safety profile is crucial for detecting potential safety signals. Active surveillance of the reported serious AEFIs is highly needed to support evidence-based vaccination strategies and maintain public confidence in immunization programs.

The Impact of a Medication Therapy Management Service on the Outcomes of Hypertension Treatment Follow-Up Care in an Ethiopian Tertiary Hospital: A Pre-Post Interventional Study

Background

According to a report from the WHO, an estimated 1.13 billion people worldwide have hypertension. Medication therapy management (MTM) service is a clinical service based on the theoretical and methodological framework of pharmaceutical care practice, which aims to ensure the best therapeutic outcomes for the patient by identifying, preventing, and resolving drug therapy problems (DTPs).

Purpose

The goal of this study was to determine the impact of MTM on hypertension management in Ethiopia.

Methods

A pre-post interventional study design was used. Descriptive statistics, linear regression, and logistic regressions were employed to present and analyze data.

Results

The final analysis included 279 patients out of 304, with a 7.8% attrition rate. The prevalence of drug therapy problems (DTPs) reduced from 63.4% at baseline to 31.5% during the post-intervention phase. Polypharmacy (AOR = 2.46; 95% CI: 1.27-4.77) and complications (AOR = 0.52; 95% CI: 0.27-0.99) were substantially associated with DTPs at the start of the study. The MTM resulted in a significant reduction in mean systolic blood pressure (SBP) (AOR = 5.31, 95% CI (3.50-7.11), P < .001), as well as a significant increase (P < .001) in the number of study patients who reached a target BP. At the end of the MTM intervention, non-adherence was linked with DTP (AOR = 2.40; 95% CI: 1.33-4.334) and living outside Addis Ababa (AOR = 1.73; 95% CI: 1.38-1.88). On average, treatment satisfaction was 86.55% (+SD) 10.34.

Conclusion

To resolve DTPs and improve clinical outcomes, the MTM service was critical. The majority of patients were found to be compliant with a high treatment satisfaction score.

The impact of non-pharmacological interventions on adherence to medication and persistence in dyslipidaemia and hypertension: a systematic review

INTRODUCTION

Suboptimal medication adherence is common among patients with cardiovascular diseases. We sought evidence on non-pharmacological interventions used to support adherence for patients with hypertension and/or dyslipidemia.

METHODS

We searched MEDLINE, EMBASE, MEDLINE In-Process, ClinicalTrials.gov, EUCTR, and conference proceedings from July 2011 to July 2021 to identify trials evaluating effects of health education, phone reminders, or digital interventions on medication adherence or persistence of adult patients with hypertension and/or dyslipidemia. Risk of bias was assessed using the Cochrane Risk of Bias Assessment Tool v2.

RESULTS

Of 64 studies, 62 used health education approaches (e.g. educational interviews, motivational meetings, advice from physicians, and mobile health content), 16 phone reminders (e.g. text reminders, electronic pill-box linked reminders, bi-directional text messaging), and 10 digital applications as interventions (e.g., various self-management applications). All studies assessed medication adherence; only two persistence. Overall, 30 studies (83%) assessing health education approaches alone and 25 (78%) combined with other strategies, 12 (75%) phone reminders and eight studies (80%) digital applications combined with other strategies reported improved medication adherence. Two studies assessing health education approaches reported improved persistence.

CONCLUSIONS

Our findings indicate non-pharmacological interventions may positively impact adherence. Therefore, 'beyond the pill' approaches could play a role in preventing cardiovascular diseases.

Social participation is associated with a habituated blood pressure response to recurrent stress

Lower cardiovascular reactivity is a proposed marker of motivational dysregulation and is related to a range of adverse behavioural and health outcomes. Social participation is a form of motivated behaviour and represents the frequency in which an individual engages in social activities. Low social participation has recently been linked to lower cardiovascular responses to acute psychological stress. With recent work emphasizing the importance of assessing adaptation of the cardiovascular response to recurrent stress, the aim of the current study is to build on previous work by examining the relationship between social participation and cardiovascular stress response adaptation. This study utilised data from the Pittsburgh Cold Study 3 (PCS 3). Two hundred and thirteen participants (M = 30.13; SD = 10.85) completed a social participation measure and had their systolic blood pressure (SBP), diastolic blood pressure (DBP) and heart rate (HR) monitored across two separate standardized stress testing sessions. The testing sessions consisted of a 20-minute baseline and a 15-minute stress task. Results indicated that higher levels of social participation were associated with greater blood pressure habituation to recurrent stress, extending previous work identifying that social participation was associated with higher cardiovascular responses to stress. The present study identifies that those reporting greater levels of social participation may show enhanced stress tolerance when exposed to recurrent stress.

Association Between Immigration Status and Ambulatory Secondary Stroke Preventive Care in Ontario, Canada

BACKGROUND AND OBJECTIVES

Secondary stroke preventive care includes evaluation and control of vascular risk factors to prevent stroke recurrence. Our objective was to evaluate the quality of ambulatory stroke preventive care and its variation by immigration status in adult stroke survivors in Ontario, Canada.

METHODS

We conducted a population-based administrative database-derived retrospective cohort study in Ontario, Canada. Using immigration records, we defined immigrants as those immigrating after 1985 and long-term residents as those arriving before 1985 or those born in Canada. We included community-dwelling stroke survivors 40 years and older with a first-ever stroke between 2011 and 2017. In the year following their stroke, we evaluated the following metrics of stroke prevention: testing for hyperlipidemia and diabetes; among those with the condition, control of diabetes (hemoglobin A1c ≤7%) and hyperlipidemia (low-density lipoprotein <2 mmol/L); medication use to control hypertension, diabetes, and atrial fibrillation; and visit to a family physician and a specialist (neurologist, cardiologist, or geriatrician). We determined age and sex-adjusted absolute prevalence difference (APD) between immigrants and long-term residents for each metric using generalized linear models with binomial distribution and an identity link function.

RESULTS

We included 34,947 stroke survivors (median age 70 years, 46.9% women) of whom 12.4% were immigrants. The receipt of each metric ranged from 68% to 90%. Compared with long-term residents, after adjusting for age and sex, immigrants were slightly more likely to receive screening for hyperlipidemia (APD 5.58%; 95% CI 4.18-6.96) and diabetes (5.49%; 3.76-7.23), have visits to family physicians (1.19%; 0.49-1.90), receive a prescription for antihypertensive (3.12%; 1.76-4.49) and antihyperglycemic medications (9.51%; 6.46-12.57), and achieve control of hyperlipidemia (3.82%; 1.01-6.63). By contrast, they were less likely to achieve diabetes control (-4.79%; -7.86 to -1.72) or have visits to a specialist (-1.68%; -3.12 to -0.24). There was minimal variation by region of origin or time since immigration in immigrants.

DISCUSSION

Compared with long-term residents, many metrics of secondary stroke preventive care were better in immigrants, albeit with small absolute differences. However, future work is needed to identify and mitigate the factors associated with the suboptimal quality of stroke preventive care for all stroke survivors.

Improving medication adherence among persons with cardiovascular disease through m-health and community health worker-led interventions in Kerala; protocol for a type II effectiveness-implementation research-(SHRADDHA-ENDIRA)

BACKGROUND

Cardiovascular disease (CVD) is the leading cause of mortality worldwide, and at present, India has the highest burden of acute coronary syndrome and ST-elevation myocardial infarction (MI). A key reason for poor outcomes is non-adherence to medication.

METHODS

The intervention is a 2 × 2 factorial design trial applying two interventions individually and in combination with 1:1 allocation ratio: (i) ASHA-led medication adherence initiative comprising of home visits and (ii) m-health intervention using reminders and self-reporting of medication use. This design will lead to four potential experimental conditions: (i) ASHA-led intervention, (ii) m-health intervention, (iii) ASHA and m-health intervention combination, (iv) standard of care. The cluster randomized trial has been chosen as it randomizes communities instead of individuals, avoiding contamination between participants. Subcenters are a natural subset of the health system, and they will be considered as the cluster/unit. The factorial cluster randomized controlled trial (cRCT) will also incorporate a nested health economic evaluation to assess the cost-effectiveness and return on investment (ROI) of the interventions on medication adherence among patients with CVDs. The sample size has been calculated to be 393 individuals per arm with 4-5 subcenters in each arm. A process evaluation to understand the effect of the intervention in terms of acceptability, adoption (uptake), appropriateness, costs, feasibility, fidelity, penetration (integration of a practice within a specific setting), and sustainability will be done.

DISCUSSION

The effect of different types of intervention alone and in combination will be assessed using a cluster randomized design involving 18 subcenter areas. The trial will explore local knowledge and perceptions and empower people by shifting the onus onto themselves for their medication adherence. The proposal is aligned to the WHO-NCD aims of improving the availability of the affordable basic technologies and essential medicines, training the health workforce and strengthening the capacity of at the primary care level, to address the control of NCDs. The proposal also helps expand the use of digital technologies to increase health service access and efficacy for NCD treatment and may help reduce cost of treatment.

TRIAL REGISTRATION

The trial has been registered with the Clinical Trial Registry of India (CTRI), reference number CTRI/2023/10/059095.

Rationale and design for the randomized placebo-controlled double-blind trial studying the effect of single antiplatelet therapy (clopidogrel) versus dual antiplatelet therapy (clopidogrel/acetylsalicylic acid) on the occurrence of atherothrombotic events following lower extremity peripheral transluminal angioplasty (CLEAR-PATH)

RATIONALE

Antiplatelet therapy (APT) is the standard of care after endovascular revascularization (EVR) in patients with peripheral artery disease (PAD). APT aims to prevent both major adverse cardiovascular events (MACE) and major adverse limb events (MALE). Nonetheless, the rates of MACE and MALE after EVR remain high. In coronary artery and cerebrovascular disease, dual APT (DAPT)compared to acetylsalicylic acid alone has been proven to reduce MACE without increasing the risk of major bleeding when applied for a restricted number of weeks. However, within the PAD population, insufficient data are available to understand the potential attributable effect of DAPT over single APT (SAPT). Therefore, prospective randomized studies in targeted study populations are warranted.

TRIAL DESIGN

CLEAR-PATH is a Dutch multicenter, double-blind, placebo-controlled, randomized trial comparing SAPT (clopidogrel 75 mg plus placebo) with DAPT (clopidogrel 75 mg plus acetylsalicylic acid 80 mg) in patients with PAD undergoing EVR. CLEAR-PATH includes a time-to-event analysis with a follow-up of one year. The primary composite efficacy endpoint consists of all-cause mortality, nonfatal stroke, nonfatal myocardial infarction, severe limb ischemia, (indication for) re-intervention due to any symptomatic restenosis, re-occlusion, or due to acute limb ischemia, and major amputation. The primary safety endpoint contains major bleeding following the Thrombolysis in Myocardial Infarction classification. The enrolment started in August 2022. In total 450 primary efficacy outcome events are required which expectedly amounts to 1696 subjects. Recruitment will take approximately 36 months.

CONCLUSION

CLEAR-PATH will assess the efficacy and safety of DAPT compared to SAPT following EVR in PAD patients.

TRIAL REGISTRATION NUMBER

NL80009.041.21.

Spiritual Well-Being, Disease Perception, and Disease Adaptation in Diabetic Patients in Southern Turkey: A Cross-Sectional Study

Introduction This cross-sectional descriptive study investigated the relationship between spiritual well-being, disease perception, and disease adaptation in individuals with diabetes mellitus (DM). Methods The sample consisted of 340 patients admitted to the internal medicine outpatient clinics of a city hospital in southern Turkey between January 2022 and January 2023. Data were collected using patient information, the Spiritual Well-Being Scale (SWBS), the Illness Perception Questionnaire (IPQ), and the Adaptation to Chronic Illness Scale (ACIS). The data were analyzed at a significance level of 0.05. Results Most participants were familiar with integrative interventions (84.1%). Less than half of the participants learned about integrative interventions from friends (46%). Less than a quarter of the participants had turned to integrative interventions (23.5%), such as cupping therapy (7.6%) and cinnamon therapy (7.1%). Participants had mean SWBS and ACIS scores of 118.40±11.46 and 84.46±9.18, respectively. There was a positive correlation between the ACIS and SWBS scores. There was also a positive correlation between total SWBS scores and scores on the IPQ "perceptions about the illness" subscale "timeline (acute/chronic)". Additionally, there was a positive correlation between the total ACIS score and the scores on the IPQ subscales "perceptions about the illness", "personal control", "treatment control", and "illness identification". Conclusion DM patients with greater spiritual well-being tend to adhere more to their treatment and management regimens. Moreover, DM patients with more positive perceptions of their illness tend to have greater levels of spiritual well-being, which correlates with improved adaptation to their disease management and treatment protocols.

Efficacy and safety of cangrelor as compared to ticagrelor in patients with ST-elevated myocardial infarction (STEMI): a systematic review and meta-analysis

BACKGROUND

This systematic review and meta-analysis aimed to compare the efficacy and safety of cangrelor as compared to ticagrelor in patients with ST-elevated myocardial infarction (STEMI) who underwent percutaneous intervention.

METHODS

PubMed, Embase, Scopus, Web of Science, Cochrane CENTRAL, and ClinicalTrials.gov databases were searched for relevant head-on-comparison or swapping studies. The primary outcome was the rate of high platelet reactivity (HPR) at specific time intervals after stopping cangrelor infusion during the first 24 h. Secondary outcomes were the risks of thrombosis, all-cause mortality and bleeding. Pooled odds ratios (ORs) were calculated using random-effects models.

RESULTS

A total of 1018 studies were screened and eight were included in the analysis. There were four head-on-comparison studies and four swapping studies. There was no significant difference in the proportion of patients achieving a high platelet reactivity in swapping studies [OR, 0.71 (95% CI 0.04, 13.87), p = 0.82, i2 = 88%]. In head-on-comparison studies, PRU from Fig. 2B shows there was no significant reduction in high platelet reactivity [mean difference - 77.83 (95% CI - 238.84, 83.18), p < 0.001, i2 = 100%]. PRU results from (Fig. 2C) show a mean difference of 7.38 (95% CI - 29.74, 44.51), p < 0.001, i2 = 97%. There was no significant difference in the risks of thrombosis [OR, 0.91 (95% CI 0.20, 4.13), p = 0.81, i2 = 0%], all-cause mortality [OR, 3.52 (95% CI 0.44, 27.91), p = 0.24, i2 = 26%] and bleeding [OR, 0.89 (95% CI 0.37, 2.17), p = 0.93, i2 = 0%] between the two groups as revealed in the head-on-comparison studies.

CONCLUSION

The efficacy and safety profiles of cangrelor and ticagrelor were similar in patients with STEMI.

Relationship Between Social Support and Clinical Outcomes: An Evaluation of Participant-Nominated Treatment Supporters in the HOPE 4 Intervention

BACKGROUND

The HOPE 4 trial (Heart Outcomes Prevention and Evaluation 4) investigated the effectiveness of a comprehensive, collaborative model of care, implemented in Colombia and Malaysia, which aimed to reduce cardiovascular disease risk in individuals with hypertension. One component of this intervention was the nomination of a treatment supporter, where participants could select a family member or friend to assist them with their care. The purpose of this study was to investigate the impact of these individuals on participant outcomes, as well as the relationship dynamics between participants and their treatment supporter.

METHODS

Participants in the HOPE 4 intervention group with baseline and 12 months of follow-up were included for analysis. They were divided into Every Visit (n=339) and

RESULTS

Groups were majority female (53% versus 62%) with a mean age of 63 and 66 years. Country of origin differed between groups (22% versus 86%; Colombia). A 15.5% ([95% CI, 6.2%-24.8%] P=0.004) greater increase in statin medication use was reported in the Every Visit group at 12 months compared with the

CONCLUSIONS

Long-term support from a nominated treatment supporter was associated with improved adherence, risk factor management, and medication use among individuals with hypertension.

REGISTRATION

URL: https://www.clinicaltrials.gov; Unique identifier: NCT01826019.

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Key Words

• cardiovascular diseases
• hypertension
• medical adherence
• risk factors
• social support

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MESH Headings

• Humans
• Female
• Middle Aged
• Aged
• Hypertension/diagnosis
• Hypertension/drug therapy
• Hypertension/epidemiology
• Blood Pressure
• Medication Adherence
• Risk Factors
• Social Support

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Affiliation(s)

Anastasia Drakos Faculty of Medicine, University of Ottawa, ON, Canada (A.D.) Population Health Research Institute, McMaster University and Hamilton Health Sciences, Hamilton, ON, Canada (A.D., T.M., S.I., S.Y., J.D.S.)
Tara McCready Population Health Research Institute, McMaster University and Hamilton Health Sciences, Hamilton, ON, Canada (A.D., T.M., S.I., S.Y., J.D.S.)
Patricio Lopez-Jaramillo Research Institute, Fundación Oftalmológica de Santander, Floridablanca, Colombia (P.L.-J.) Masira Institute, Medical School, Universidad de Santander, Bucaramanga, Colombia (P.L.-J.)
Shofiqul Islam Population Health Research Institute, McMaster University and Hamilton Health Sciences, Hamilton, ON, Canada (A.D., T.M., S.I., S.Y., J.D.S.)
Martin McKee Department of Health Services Research and Policy, London School of Hygiene and Tropical Medicine, London, United Kingdom (M.M.)
Salim Yusuf Population Health Research Institute, McMaster University and Hamilton Health Sciences, Hamilton, ON, Canada (A.D., T.M., S.I., S.Y., J.D.S.) Department of Health Research Methods, Evidence and Impact, McMaster University Faculty of Health Sciences, Hamilton, ON, Canada (S.Y.)
J D Schwalm Population Health Research Institute, McMaster University and Hamilton Health Sciences, Hamilton, ON, Canada (A.D., T.M., S.I., S.Y., J.D.S.)

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Impact of myocardial perfusion and coronary calcium on medical management for coronary artery disease

AIMS

Single-photon emission computed tomography (SPECT) myocardial perfusion imaging (MPI) remains one of the most widely used imaging modalities for the diagnosis and prognostication of coronary artery disease (CAD). Despite the extensive prognostic information provided by MPI, little is known about how this influences the prescription of medical therapy for CAD. We evaluated the relationship between MPI with computed tomography (CT) attenuation correction and prescription of acetylsalicylic acid (ASA) and statins.

METHODS AND RESULTS

We performed a retrospective analysis of consecutive patients who underwent SPECT MPI at a single centre between 2015 and 2021. Myocardial perfusion abnormalities and coronary calcium burden were assessed, with attenuation correction imaging 77.8% of patients. Medication prescriptions before and within 180 days after the test were compared. Associations between abnormal perfusion and calcium burden with ASA and statin prescription were assessed using multivariable logistic regression. In total, 9908 patients were included, with a mean age 66.8 ± 11.7 years and 5337 (53.9%) males. The prescription of statins increased more in patients with abnormal perfusion (increase of 19.2 vs. 12.0%, P < 0.001). Similarly, the presence of extensive CAC led to a greater increase in statin prescription compared with no calcium (increase 12.1 vs. 7.8%, P < 0.001). In multivariable analyses, ischaemia and coronary artery calcium were independently associated with ASA and statin prescription.

CONCLUSION

Abnormal MPI testing was associated with significant changes in medical therapy. Both calcium burden and perfusion abnormalities were associated with increased prescriptions of medical therapy for CAD.

Evidence for clinician underprescription of and patient non-adherence to guideline-recommended cardiovascular medications among adults with peripheral artery disease: protocol for a systematic review and meta-analysis

INTRODUCTION

International guidelines recommend that adults with peripheral artery disease (PAD) be prescribed antiplatelet, statin and antihypertensive medications. However, it is unclear how often people with PAD are underprescribed these drugs, which characteristics predict clinician underprescription of and patient non-adherence to guideline-recommended cardiovascular medications, and whether underprescription and non-adherence are associated with adverse health and health system outcomes.

METHODS AND ANALYSIS

We will search MEDLINE, EMBASE and Evidence-Based Medicine Reviews from 2006 onwards. Two investigators will independently review abstracts and full-text studies. We will include studies that enrolled adults and reported the incidence and/or prevalence of clinician underprescription of or patient non-adherence to guideline-recommended cardiovascular medications among people with PAD; adjusted risk factors for underprescription of/non-adherence to these medications; and adjusted associations between underprescription/non-adherence to these medications and outcomes. Outcomes will include mortality, major adverse cardiac and limb events (including revascularisation procedures and amputations), other reported morbidities, healthcare resource use and costs. Two investigators will independently extract data and evaluate study risk of bias. We will calculate summary estimates of the incidence and prevalence of clinician underprescription/patient non-adherence across studies. We will also conduct subgroup meta-analyses and meta-regression to determine if estimates vary by country, characteristics of the patients and treating clinicians, population-based versus non-population-based design, and study risks of bias. Finally, we will calculate pooled adjusted risk factors for underprescription/non-adherence and adjusted associations between underprescription/non-adherence and outcomes. We will use Grading of Recommendations, Assessment, Development and Evaluation to determine estimate certainty.

ETHICS AND DISSEMINATION

Ethics approval is not required as we are studying published data. This systematic review will synthesise existing evidence regarding clinician underprescription of and patient non-adherence to guideline-recommended cardiovascular medications in adults with PAD. Results will be used to identify evidence-care gaps and inform where interventions may be required to improve clinician prescribing and patient adherence to prescribed medications.

PROSPERO REGISTRATION NUMBER

CRD42022362801.

Adherence to Medications in Patients with Ischaemic Heart Disease in Oman

Objectives

This study aimed to evaluate the level of adherence to medication among patients with ischaemic heart disease (IHD) in Oman and assess the related factors.

Methods

This cross-sectional questionnaire-based study among patients with IHD attending the outpatient clinic at Sultan Qaboos University Hospital, Muscat, Oman, was performed between January and December 2021.

Results

A total of 105 patients (mean age = 49.9 ± 11.1 years, 78.1% male) were recruited. Most of the patients (80%) reported taking the medications by themselves; 77 (73.3%) patients said that over the preceding 2 weeks, they had missed at least 3 doses of their medication. The reasons for missing the medications included forgetting (100%), having to take too many tablets (57%), feeling that the tablets are not effective (48%) and having to take the tablets too often each day (23%). The factors responsible for patients failing to take medications could not be identified.

Conclusion

Medication adherence was low among patients with IHD in Oman, with high pill burden being the most common reason for non-adherence. Physicians must bear this in mind when reviewing patients.

Assessing a Pharmacist-Enabled Intervention to Improve Adherence to Medication for Hypertension, Dyslipidemia, and Chronic Venous Circulation Disorders in Greece

Background

Adherence to medication in chronic conditions may be influenced by interventions from pharmacists. This study aimed to assess the impact of guidance and reminders from pharmacists on adherence to medication for hypertension, dyslipidemia, and chronic venous circulation disorders (CVCD) in Greece.

Methods

The prospective CONCORD study aimed to record and report on change in self-reported adherence to medication following pharmacist reminders amongst a cohort of adult patients, diagnosed with at least one or a combination of these health conditions. All study participants were regular patients of a network of pharmacies in Attica and southern Greece. Pharmacists were trained to provide adherence reminders over 4 months. Impact on self-reported adherence of the intervention was reported at baseline and again in month 4.

Results

Of the 1146 participants, 48% were men and 60% were aged 55-74 years. Among them, 23.7% were diagnosed with hypertension, 16.5% with dyslipidemia, 3% with CVCD, 42.5% with hypertension and dyslipidemia, 3.1% with hypertension and CVCD, 2.6% with dyslipidemia and CVCD, and 8.6% with dyslipidemia, hypertension, and CVCD. In month 4 vs month 0, patients were less likely to forget to take their prescribed medications (p<0.001), to be careless about their medications during the last 30 days (p<0.001), and to temporarily discontinue their medications without prior doctor's advice (p<0.001). Patients with CVCD were more prone to lower self-reported adherence compared to patients who were not diagnosed with CVCD or a combination of conditions that included CVCD.

Discussion

Reminders and advice from pharmacists resulted in higher adherence to medication amongst participants in month 4 versus month 0.

Conclusion

Pharmacist-enabled interventions, including reminders and advice, following targeted training, may positively impact on patient medication adherence in chronic health conditions.

Polypill-based strategy vs. usual care for secondary prevention of cardiovascular disease: a meta-analysis of randomized controlled trials

AIMS

We aimed to perform a systematic review and meta-analysis of randomized controlled trials (RCTs) to determine the impact of a polypill-based strategy (PBS) on therapeutic adherence and cardiovascular outcomes compared with usual care for secondary prevention of cardiovascular diseases (CVDs).

METHODS AND RESULTS

We systematically searched PubMed, Cochrane, and Scopus databases from inception to January 2023, including RCTs comparing PBS with usual care in patients with prior CVD. We assessed efficacy outcomes of therapeutic adherence, systolic blood pressure (SBP), and LDL-cholesterol (LDL-C) and safety outcomes of all-cause and cardiovascular mortality. Statistical analysis was performed with Review Manager 5.4.1 and R Version 4.2.1. A total of 8 RCTs with a population of 6541 individuals were included, of whom 3318 (50.7%) were treated with the PBS. Follow-up ranged from 6 to 60 months. The polypill-based strategy was associated with a significantly increased therapeutic adherence [risk ratio (RR) 1.22; 95% confidence interval (CI) 1.10-1.34; P < 0.001]. Cardiovascular mortality (RR 0.61; 95% CI 0.44-0.85; P = 0.004), SBP [mean difference (MD) -1.47 mmHg; 95% CI -2.86 to -0.09; P = 0.04], and LDL-C (MD -3.83 mg/dL; 95% CI -6.99 to -0.67; P = 0.02) were significantly lower in the PBS group. The incidence of all-cause mortality was similar between groups (RR 0.83; 95% CI 0.54-1.29; P = 0.41).

CONCLUSION

In patients with pre-existing CVD, a PBS is associated with lower cardiovascular mortality and improved therapeutic adherence, along with a modest decrease in SBP and LDL-C compared with usual care. Thus, a PBS may be considered a preferred option for this patient population.

Two-Year Follow-Up of Chronic Ischemic Heart Disease Patients in a Specialized Center in Brazil

The incidence of cardiovascular events in patients with chronic ischemic heart disease (CIHD) may vary significantly among countries. Although populous, Brazil is often underrepresented in international records. This study aimed to describe the quality of care and the two-year incidence of cardiovascular events and associated prognostic factors in CIHD patients in a tertiary public health care center in Brazil. Patients with CIHD who reported for clinical evaluation at Instituto do Coração (São Paulo, Brazil) were registered and followed for two years. The primary endpoint was a composite of myocardial infarction (MI), stroke, or death. A significance level of 0.05 was adopted. From January 2016 to December 2018, 625 participants were included in the study. Baseline characteristics show that 33.1% were women, median age 66.1 [59.6 - 71.9], 48.6% had diabetes, 83.1% had hypertension, 62.6% had previous MI, and 70.4% went through some revascularization procedure. At a median follow-up (FU) of 881 days, we noted 37 (7.05%) primary endpoints. After adjustments, age, previous stroke, and LDL-cholesterol were independently associated with the primary endpoint. Comparing baseline versus FU, participants experienced relief of angina based on the Canadian Cardiovascular Society (CCS) scale according to the following percentages: 65.7% vs. 81.7% were asymptomatic and 4.2% vs. 2.9% CCS 3 or 4 (p < 0.001). They also experienced better quality of medication prescription: 65.8% vs. 73.6% (p < 0.001). However, there was no improvement in LDL-cholesterol or blood pressure control. This study shows that CIHD patients had a two-year incidence of the primary composite endpoint of 7.05%, and the reduction of LDL-cholesterol was the only modifiable risk factor associated with prognosis.

Disparities in cardiovascular disease and treatment in the Nordic countries

The Nordic countries, including Denmark, Finland, Iceland, Norway, and Sweden have seen a steep decline in cardiovascular mortality in recent decades. They are among the most egalitarian countries by several measures, and all have universal, publicly funded welfare systems providing healthcare for all citizens. However, despite these seemingly ideal conditions, disparities in access to cardiovascular care and outcomes persist. To address this challenge, The Lancet Region Health-Europe convened experts from a broad range of countries to summarize the current state of knowledge on cardiovascular disease disparities across Europe. This Series Paper presents the main challenges in Nordic countries based on evidence from high-quality nationwide registries. Focusing on major cardiovascular health determinants, areas in need of improvement were identified. There is a need for addressing structural causes underlying these disparities, such as poverty and discrimination, but also to improve access to healthcare in deprived neighborhoods and to address underlying social determinants of health that may mitigate disparities in cardiovascular outcomes. Overall, while the Nordic countries have made great strides in promoting egalitarianism and providing universal healthcare, there is still much work to be done to ensure equitable access to care and improved cardiovascular outcomes for all members of society.

The effect of a multi-component behavior change technique intervention on medication adherence among individuals on primary prevention statin therapy: a dose-finding protocol

BACKGROUND

In the USA, the primary cause of death and morbidity continues to be cardiovascular disease (CVD). Numerous trials have shown that statin medication reduces the likelihood of CVD events; it is a cornerstone of CVD prevention. However, studies have also indicated that up to 60% of the estimated 26.8 million Americans prescribed primary prevention statin treatment are nonadherent during the first year. Multi-component behavioral change technique (BCT) therapies have shown moderate promise in improving medication adherence as well as other positive health behaviors (such as physical activity). However, no research has looked at the duration of multi-component BCT intervention needed to result in a clinically significant improvement in statin adherence behaviors. This study aims to determine the necessary dose of a multi-component BCT intervention (defined as duration in weeks) to promote adherence to statin medication among those on primary prevention statin treatment by utilizing the modified time-to-event continuous reassessment method (TiTE-CRM).

METHODS AND DESIGN

The study will utilize the modified TiTE-CRM in 42 participants, recruited in 14 cohorts of 3 participants each. The goal of this analysis is to identify the minimum effective dose (MED) of a multi-behavior change technique (BCT) intervention required to increase adherence to statins by 20% between baseline and follow-up periods. Using the TiTE-CRM method, the dose of the behavior intervention in weeks will be assigned to each cohort based on the performance of the prior cohort. At the end of the study, the intervention dose that has been found to be associated with a 20% increase in statin adherence among 80% of participants assigned to that dose will be identified as the MED.

DISCUSSION

If successful, the current trial will provide additional guidance to researchers and clinicians seeking to increase statin medication adherence using a BCT intervention by identifying the dose (i.e., the duration) of an intervention required to meaningfully increase adherence.

TRIAL REGISTRATION

ClinicalTrials.gov NCT05273736. Registered on March 10, 2022. https://www.

CLINICALTRIALS

gov/ct2/show/NCT05273736.

Determination of the Potential Clinical Benefits of Small Molecule Factor XIa Inhibitors in Arterial Thrombosis

Anticoagulants are the mainstay for the prevention and treatment of thrombosis. However, bleeding complications remain a primary concern. Recent advances in understanding the contribution of activated factor XI (FXIa) in arterial thrombosis with a limited impact on hemostasis have led to the development of several FXIa-targeting modalities. Injectable agents including monoclonal antibodies and antisense oligonucleotides against FXIa have been primarily studied in venous thrombosis. The orally active small molecules that specifically inhibit the active site of FXIa are currently being investigated for their antithrombotic activity in both arteries and veins. This review focuses on a discussion of the potential clinical benefits of small molecule FXIa inhibitors, mainly asundexian and milvexian, in arterial thrombosis based on their pharmacological profiles and the compelling results of phase 2 clinical studies. The preclinical and epidemiological basis for the impact of FXIa in hemostasis and arterial thrombosis is also addressed. In recent clinical study results, asundexian appears to reduce ischemic events in patients with myocardial infarction and minor-to-moderate stroke, whereas milvexian possibly provides benefits in patients with minor stroke or high-risk transient ischemic attack (TIA). In addition, asundexian and milvexian had a minor impact on hemostasis even in combination with dual-antiplatelet therapy. Other orally active FXIa inhibitors also produce antithrombotic activity in vivo with low bleeding risk. Therefore, FXIa inhibitors might represent a new class of direct-acting oral anticoagulants (DOACs) for the treatment of thrombosis, although the explicit clinical positions of asundexian and milvexian in patients with ischemic stroke, high-risk TIA, and coronary artery disease require confirmation from the outcomes of ongoing phase 3 trials.

Aromatic Plant-Based Functional Foods: A Natural Approach to Manage Cardiovascular Diseases

Aromatic plants and their essential oils have shown beneficial effects on the cardiovascular system and, therefore, are potential raw materials in the development of functional foods. However, despite their undeniable potential, essential oils present several limitations that need to be addressed, such as stability, poor solubility, undesirable sensory effects, and low bioavailability. The present review provides a current state-of-the-art on the effects of volatile extracts obtained from aromatic plants on the cardiovascular system and focuses on major challenges that need to be addressed to increase their use in food products. Moreover, strategies underway to overcome these limitations are pointed out, thus anticipating a great appreciation of these extracts in the functional food industry.

Overcoming barriers to patient adherence: the case for developing innovative drug delivery systems

Poor medication adherence is a pervasive issue with considerable health and socioeconomic consequences. Although the underlying reasons are generally understood, traditional intervention strategies rooted in patient-centric education and empowerment have proved to be prohibitively complex and/or ineffective. Formulating a pharmaceutical in a drug delivery system (DDS) is a promising alternative that can directly mitigate many common impediments to adherence, including frequent dosing, adverse effects and a delayed onset of action. Existing DDSs have already positively influenced patient acceptability and improved rates of adherence across various disease and intervention types. The next generation of systems have the potential to instate an even more radical paradigm shift by, for example, permitting oral delivery of biomacromolecules, allowing for autonomous dose regulation and enabling several doses to be mimicked with a single administration. Their success, however, is contingent on their ability to address the problems that have made DDSs unsuccessful in the past.

Comparing Medication Non-adherence in Cardiovascular Disease Patients at Public and Private Hospitals in Peshawar: A Cross-Sectional Study of Prevalence and Contributing Factors

Introduction The incidence of cardiovascular diseases continues to increase, becoming one of the leading causes of mortality globally. The proper use of medication can greatly reduce the death rate by slowing the progression of the disease. Yet, many patients struggle with following their medication regimen due to various reasons. Effective treatment management relies on patients' self-care and understanding of their illness and medications, which can impact their adherence to taking their prescribed drugs. The objective of the study was to determine the prevalence of medication non-compliance among patients in two public and private tertiary care hospitals in Peshawar and to identify the factors that contribute to this behavior. Material and methods A comparative cross-sectional study design was employed for the research. The study was conducted at Hayatabad Medical Complex and Rehman Medical Institute in Peshawar, as these two hospitals provide care for a significant proportion of cardiovascular disease patients in the area. To assess adherence, a quantitative scale was devised with scores of 8 considered high adherence, scores between 6 and 7 considered medium adherence, and scores below 6 considered low adherence. The factors impacting medication non-adherence were analyzed using a self-administered questionnaire, which was developed following a preliminary study conducted at both hospitals. Results In total, 168 eligible patients from the two hospitals were given the questionnaire. Out of these patients, 107 (63.7%) were male, and 61 (36.3%) were female, with ages ranging from 19 to 84 and a mean age of 55.33. The level of medication adherence was calculated among the participants, with 20.2% reporting high adherence, 22.6% reporting medium adherence, and 57.1% reporting low adherence. The results showed that monthly income (p = 0.006), the presence of co-morbidities (p = 0.002), and the fear of addiction to medication (p = 0.048) were the main factors influencing medication adherence. In regression analysis with high adherence as the reference category and a 95% confidence interval, hospital affiliation was found to be significantly associated with adherence levels. Conclusions The study found that medication adherence among cardiovascular disease patients in private tertiary care hospitals is generally high. However, the level of adherence was seen to be impacted by the patient's monthly income. In light of this, the government should implement programs to reduce the cost of healthcare provision and increase affordability for patients.

Psychosocial factors correlate with adherence to medications among cardiovascular outpatient clinics in Jordan

BACKGROUND

Adherence to medications is a significant element of self-care behaviors for patients with cardiovascular diseases (CVDs). Non-adherence to cardiovascular medications is the major risk for poor outcomes following any cardiac event. However, there is a lack of studies that addressed medication adherence among patients with CVDs attending outpatient clinics in Arabic countries, including Jordan. Thus, this study purposed to assess the psychosocial factors (e.g. depression, anxiety, stress, social support and self-esteem) and their correlation with adherence to medications among patients with CVDs attending outpatient clinics in Jordan.

METHODS

A total of 395 Jordanian patients attending CVDs outpatient clinics at government, military and private healthcare facilities were recruited.

RESULTS

Our study findings showed that 31.4% of the patients reported complete adherence to their medications. The proportion of psychological reactions reported by the participants was 72.1% for depressive symptoms, 62.6% for anxiety and 50.1% for stress; 79.7% had moderate and normal social support, and 44% had low self-esteem. Depression, anxiety and stress had a significant negative correlation with adherence to medications; however, self-esteem had a significant positive relationship with adherence to medications. In addition, depression, anxiety and stress were the main predictors of adherence to medications.

CONCLUSION

Our findings might aid in paving the road for designing and developing strategies and interventions to increase adherence to medications and minimize these psychosocial problems among CVD patients in outpatient clinics.

Utilizing quantitative dried blood spot analysis to objectively assess adherence to cardiovascular pharmacotherapy among patients at Kenyatta National Hospital, Nairobi, Kenya

The burden of cardiovascular disease (CVD) is rising in Kenya and non-adherence to cardiovascular pharmacotherapy is a growing global public health issue that leads to treatment failure, an increased risk of cardiac events and poor clinical outcomes. This study assessed adherence to selected cardiovascular therapy medications among CVD patients attending outpatient clinics at Kenyatta National Hospital, Kenya by determining drug concentration(s) in patient dried blood spot (DBS) samples. Patients who had been taking one or more of the five commonly prescribed CVD medications (amlodipine, atenolol, atorvastatin, losartan, and valsartan) for at least six months were enrolled. Each patient completed a short questionnaire about their medication history and then provided a finger-prick blood spot sample from which drug concentrations were determined by liquid chromatography-high resolution mass spectrometry analysis. Two hundred and thirty-nine patients (62.3% female) participated in the study. The median number of medications used by patients was 2 (IQR 75%-25% is 3-1). Less than half (117; 49.0%) of patients were adherent to their prescribed CVD pharmacotherapy. Binary regression analysis revealed a significant correlation between non-adherence and the number of medications in the treatment regimen (Odds Ratio (OR) 1.583; 95%CI: 0.949-2.639; P-value = 0.039) and that gender was not an independent predictor of medication adherence (OR 1.233; 95%CI: 0.730-2.083; P-value = 0.216). Valuable information about adherence to each medication in the patient's treatment regimen was obtained using quantitative DBS analysis showing that adherence to CVD medications was not uniform. DBS sampling, due its minimally invasive nature, convenience and ease of transport is a useful alternative matrix to monitor adherence to pharmacotherapies objectively, when combined with hyphenated mass spectrometry analytical techniques. This information can provide physicians with an evidence-based novel approach towards personalization and optimization of CVD pharmacotherapy and implementing interventions in the Kenyan population, thereby improving clinical outcomes.

Associations between socioeconomic status and adherence to hypertension treatment among older adults in urban and rural areas in Myanmar: a cross-sectional study using baseline data from the JAGES in Myanmar prospective cohort study

OBJECTIVES

This study aims to investigate whether there is a differential association between socioeconomic status (SES) and adherence to hypertension medication among older adults in rural and urban areas in Myanmar and assess what type of SES is associated with a difference.

DESIGN

Cross-sectional study using baseline data from the Japan Gerontological Evaluation Study in Myanmar prospective cohort study. A multistage random sampling method was applied in each region.

SETTING

An urban and a rural area in Myanmar.

PARTICIPANTS

A total of 1200 older adults over 60 years old in Myanmar were randomly selected in 2018 (600 each from rural and urban areas). Of them, 573 had hypertension and were eligible for the analysis (urban: 317, rural: 256).

OUTCOME

Adherence to hypertension medication (yes/no) is the outcome of interest. Three types of SES (wealth, education and current employment status) were the independent variables.

RESULTS

We found that 21.5% of urban residents and 48.4% of rural residents were non-adherent in the study population. Poisson regression modelling stratified by area was performed to estimate the prevalence ratios (PRs) of not following treatment instructions. Demographic information and complications of hypertension were adjusted for in all models as possible confounders. In terms of SES, middle level of wealth compared with low level was significantly associated with poor adherence (PR 2.68, 95% CI 1.28 to 5.59) in the urban area, but education and employment status did not show similar associations. Lower education compared with middle/high school or higher was significantly associated with poor adherence in the rural area (no school: PR 3.22, 1.37-7.58; monastic: 3.42, 1.16-5.07; primary school: 2.41, 1.18-4.95), but wealth and income did not show similar associations.

CONCLUSIONS

SES and adherence to hypertension medication were differently associated among older adults in rural and urban areas in Myanmar. To ensure healthcare access to hypertension treatment for every citizen, the differential association between SES and adherence in urban/rural areas needs to be recognised.

Adherence to hypertension and dyslipidemia treatment and its implication on control of cardiovascular disease in Vietnam: A semi-systematic review

BACKGROUND

To understand the prevalent issues and challenges in the provision of care for dyslipidemia and hypertension in Vietnamese adults, quantification of patient journey stages (awareness, screening, diagnosis, treatment, adherence, and control) was performed in this semi-systematic review.

METHODS

The EMBASE and MEDLINE databases were searched for English articles published between 2010 and 2019. Thesis abstracts, letters to the editor, editorials, case studies, and studies on patient subgroups or nationally unrepresentative studies, were excluded. Articles from Google, the Incidence and Prevalence Database, the World Health Organization, Vietnam's Ministry of Health, and those suggested by the authors were also included. The last search was run on December 10, 2019 for dyslipidemia and hypertension.

RESULTS

A reviewer independently screened 586 retrievals for dyslipidemia and 177 retrievals for hypertension, and extracted data from 2 articles on dyslipidemia and 6 articles on hypertension that were included in the final synthesis.

CONCLUSION

The data generated in this review will help overcome these issues and barriers to patient care in populations with these 2 conditions.

β-blocker adherence among patients with congenital long QT syndrome: a nationwide study

AIM

β-blockers are the first line of treatment in patients with congenital long QT syndrome (cLQTS) (class I or II recommendation) in order to prevent malignant arrhythmias. Hence, we examined long-term β-blocker adherence and associated risk factors among patients with cLQTS.

METHODS AND RESULTS

Danish patients with cLQTS claiming a prescription for any β-blocker after their cLQTS diagnosis were identified using data from nationwide registries and specialized inherited cardiac disease clinics (1995-2017). Patients were followed for up to 5 years. Treatment breaks >60 days were assessed (i.e. proxy for reduced adherence). Multivariable Cox regression was used to identify risk factors associated with breaks of >60 days in β-blocker treatment. Overall, 500 out of 633 (79%) patients with cLQTS claimed at least one prescription for any β-blocker after cLQTS diagnosis. During follow-up, 38.4% had a treatment break. Risk factors significantly associated with treatment breaks were implantable cardioverter defibrillator (ICD) [hazard ratio (HR) = 1.65, 95% confidence interval (CI): 1.08-2.53], β-blocker side effects (HR = 2.69, 95% CI: 1.75-4.13), and psychiatric disease (HR = 1.63, 95% CI: 1.04-2.57). In contrast, patients presenting with ventricular tachycardia/syncope as cLQTS disease manifestation were less likely to have a treatment break compared with asymptomatic patients (HR = 0.55, 95% CI: 0.33-0.92).

CONCLUSION

Reduced β-blocker adherence was common with more than a third of patients having a treatment break >60 days after cLQTS diagnosis. Patients with psychiatric disease, self-reported β-blocker side effects, and an ICD were more likely to display reduced adherence, whereas a severe cLQTS disease manifestation was associated with optimal β-blocker adherence.

Left atrial appendage exclusion with less invasive left ventricular assist device implantation

OBJECTIVES

The objective of this single-center, pilot, prospective, and historical control study is to evaluate safety and feasibility outcomes associated with left atrial appendage exclusion (LAAE) concomitant with left ventricular assist device (LVAD) implantation via less invasive surgery (LIS) as a stroke prevention strategy.

METHODS

A predefined number of 30 eligible subjects scheduled for LIS LVAD with LAAE were enrolled in the prospective arm between January 2020 and February 2021. Eligible retrospective LIS LVAD patients without LAAE were propensity-matched in a 1:1 ratio with the prospective arm subjects. The primary study objectives were to evaluate the safety, feasibility, and efficacy of the LAAE concomitant with LIS LVAD.

RESULTS

Preoperative characteristics of patients in the Non-LAAE and LAAE groups were similar. LAAE was successfully excluded in all prospective patients (100%). Primary safety endpoints of chest tube output within the first 24 postoperative hours, Reoperation for bleeding within 48 h, and index hospitalization mortality demonstrated comparable safety of LAAE versus Non-LAAE with LIS LVAD. Cox proportional hazard regression demonstrated that LAAE with LIS LVAD was associated with 37% and 49% reduction in the risk of stroke and disabling stroke, respectively (p > .05).

CONCLUSION

Results from our pilot study demonstrated the safety and feasibility of LAAE concomitant with LIS LVAD as a stroke prevention strategy. This is the first prospective study describing LAAE performed concomitantly to less invasive LVAD implantation. The efficacy of LAAE in long-term stroke prevention needs to be confirmed in future prospective randomized clinical trials.

Defining preventive cardiology: A clinical practice statement from the American Society for Preventive Cardiology

Remarkable transformations in science and healthcare have resulted in declines in mortality from cardiovascular disease over the past several decades, largely driven by progress in prevention and treatment of persons at risk. However, these trends are now beginning to stall, as our county faces increases in cardiovascular risk factors including overweight and obesity, type 2 diabetes mellitus, and metabolic syndrome. Furthermore, poor long-term adherence to a healthy lifestyle and lifesaving pharmacotherapy have exacerbated these trends, with recent data suggesting unprecedented increases in cardiovascular morbidity and mortality. A paradigm shift is needed to improve the cardiovascular health of our nation. Preventive cardiology, a growing subspecialty of cardiovascular medicine, is the practice of primordial, primary, and secondary prevention of all cardiovascular diseases. Preventive cardiologists and preventive cardiology specialists are well equipped with the knowledge and skill-set necessary to reduce deaths related to the growing burden of heart disease and its risk factors. Despite dedicated efforts, cardiovascular disease remains the leading killer of men and women in the United States. Although there is little debate regarding the importance of prevention, many healthcare professionals question the need for preventive cardiology as a distinct subspecialty. Additionally, the field's growth has been hampered by a lack of organization and standardization, and variability of training within programs across the country. The purpose of this document is to delineate the key attributes that define the field of preventive cardiology according to the American Society for Preventive Cardiology.

Monitoring Risk Factors and Improving Adherence to Therapy in Patients With Chronic Kidney Disease (Smit-CKD Project): Pilot Observational Study

BACKGROUND

Chronic kidney disease is a major public health issue, with about 13% of the general adult population and 30% of the elderly affected. Patients in the last stage of this disease have an almost uniquely high risk of death and cardiovascular events, with reduced adherence to therapy representing an additional risk factor for cardiovascular morbidity and mortality. Considering the increased penetration of mobile phones, a mobile app could educate patients to autonomously monitor cardiorenal risk factors.

OBJECTIVE

With this background in mind, we developed an integrated system of a server and app with the aim of improving self-monitoring of cardiovascular and renal risk factors and adherence to therapy.

METHODS

The software infrastructure for both the Smit-CKD server and Smit-CKD app was developed using standard web-oriented development methodologies preferring open source tools when available. To make the Smit-CKD app suitable for Android and iOS, platforms that allow the development of a multiplatform app starting from a single source code were used. The integrated system was field tested with the help of 22 participants. User satisfaction and adherence to therapy were measured by questionnaires specifically designed for this study; regular use of the app was measured using the daily reports available on the platform.

RESULTS

The Smit-CKD app allows the monitoring of cardiorenal risk factors, such as blood pressure, weight, and blood glucose. Collected data are transmitted in real time to the referring general practitioner. In addition, special reminders improve adherence to the medication regimen. Via the Smit-CKD server, general practitioners can monitor the clinical status of their patients and their adherence to therapy. During the test phase, 73% (16/22) of subjects entered all the required data regularly and sent feedback on drug intake. After 6 months of use, the percentage of regular intake of medications rose from 64% (14/22) to 82% (18/22). Analysis of the evaluation questionnaires showed that both the app and server components were well accepted by the users.

CONCLUSIONS

Our study demonstrated that a simple mobile app, created to self-monitor modifiable cardiorenal risk factors and adherence to therapy, is well tolerated by patients affected by chronic kidney disease. Further studies are required to clarify if the use of this integrated system will have long-term effects on therapy adherence and if self-monitoring of risk factors will improve clinical outcomes in this population.

National Adherence to Medical Management of Aortic Aneurysms

OBJECTIVES

The purpose of this study was to describe levels of adherence to guideline-based medical management in patients with aortic aneurysms, using an analogous population with coronary artery disease as a comparator. Adherence among those with aortic aneurysms has never been studied.

METHODS

Adult patients with an aortic aneurysm or coronary artery disease diagnosed between 2004 and 2018 in the Optum Clinformatics deidentified Datamart were queried. Aneurysms were subclassified as thoracic, abdominal, or both. Receipt of an antihypertensive or antihyperlipidemic was determined through pharmacy claims. Adherence was determined as receipt of the indicated pharmacologic(s) after a diagnosis of aneurysm or coronary artery disease. Adherence was compared between those with aneurysms and coronary disease using univariable logistic regression.

RESULTS

After exclusions, 194,144 patients with an aortic aneurysm and 3,946,782 with coronary artery disease were identified. Overall adherence was low (45.0%) and differed significantly by aneurysm subtype: highest in isolated thoracic (45.9%) and lowest in isolated abdominal aneurysms (42.6%). Adherence levels declined significantly after 1 year by about 15% in each aneurysm subtype. All subtypes of aneurysm had a significantly lower odds of adherence compared to those with coronary disease with odds ranging from 0.61 in those with isolated abdominal aneurysms to 0.80 with isolated thoracic aneurysms.

CONCLUSIONS

Adherence among those with aortic aneurysms is very low, differs by subtype, and declines with time. Levels of adherence in those with aortic aneurysms is significantly lower compared to those with coronary artery disease. This should prove a reasonable target for implementation initiatives.

Natural Products in Cardiovascular Diseases: The Potential of Plants from the Allioideae Subfamily (Ex-Alliaceae Family) and Their Sulphur-Containing Compounds

Cardiovascular diseases (CVDs) are the leading cause of mortality worldwide and, together with associated risk factors such as diabetes, hypertension, and dyslipidaemia, greatly impact patients' quality of life and health care systems. This burden can be alleviated by fomenting lifestyle modifications and/or resorting to pharmacological approaches. However, due to several side effects, current therapies show low patient compliance, thus compromising their efficacy and enforcing the need to develop more amenable preventive/therapeutic strategies. In this scenario, medicinal and aromatic plants are a potential source of new effective agents. Specifically, plants from the Allioideae subfamily (formerly Alliaceae family), particularly those from the genus Allium and Tulbaghia, have been extensively used in traditional medicine for the management of several CVDs and associated risk factors, mainly due to the presence of sulphur-containing compounds. Bearing in mind this potential, the present review aims to gather information on traditional uses ascribed to these genera and provide an updated compilation of in vitro and in vivo studies validating these claims as well as clinical trials carried out in the context of CVDs. Furthermore, the effect of isolated sulphur-containing compounds is presented, and whenever possible, the relation between composition and activity and the mechanisms underlying the beneficial effects are pointed out.

Baseline characteristics and secondary medication adherence among Medicare patients diagnosed with transthyretin amyloid cardiomyopathy and/or receiving tafamidis prescriptions: A retrospective analysis of a Medicare cohort

BACKGROUND: Transthyretin amyloid cardiomyopathy (ATTR-CM) is an underdiagnosed, life-threatening condition that mostly affects older persons. In May 2019, regulatory approval of tafamidis provided the first pharmacologic treatment of ATTR-CM. In the pivotal phase 3 Transthyretin Amyloidosis Cardiomyopathy Clinical Trial (ATTR-ACT), 97.2% of patients were classified as adherent (defined as taking ≥ 80% of scheduled doses). Given its recent approval, there is limited real-world evidence examining patient adherence to tafamidis. OBJECTIVE: To evaluate adherence patterns, demographics, and clinical characteristics of patients in the United States receiving tafamidis prescriptions through Medicare. Secondarily, we aimed to evaluate concomitant medications filled by this patient population. METHODS: We conducted a retrospective cohort study of US Medicare claims data, limited by the Health Insurance Portability and Accountability Act of 1996, in adult patients with an adjudicated pharmacy claim for tafamidis (tafamidis free acid 61-mg capsule once daily or tafamidis meglumine four 20-mg capsules once daily) between May 1, 2019, and June 30, 2021. Gaps in therapy were measured using day gaps between prescription refills and continuous measure of medication gaps. Implementation adherence was assessed through modified medication possession ratio (MPRm), medication refill adherence (MRA), and proportion of days covered (PDC). Patients were grouped based on Medicare coverage. Patients were analyzed by subgroups based on age and at the zip code level, via distressed communities index quartiles and rural-urban tiers. RESULTS: A total of 3,558 patients who received a prescription fill of a tafamidis formulation were identified using Medicare Fee-for-Service (FFS) and Medicare Advantage (MA) claims data from May 1, 2019, to June 30, 2021. The characteristics of this patient population were consistent with published literature, as 98.6% were older than 65 years, 53.4% were between 75 years and 84 years, and 81.5% were male. In the patient population receiving tafamidis refills, adherence was high across all 3 measures, with mean MPRm greater than 90% and mean MRA greater than 80%, across all age groups. Mean PDC adherence rates were 79% or more across all age groups. Concomitant medications were generally indicated for heart failure and thrombosis. Among monotherapy groups with similar demographic makeup, adherence was significantly higher among users of tafamidis free acid vs tafamidis meglumine (P < 0.0001 across all mean adherence measures). CONCLUSIONS: Our results demonstrate that real-world adherence to tafamidis in the Medicare population is high, regardless of age, zip code-level socioeconomic quartile, or geography. Adherence was higher among patients receiving tafamidis free acid, suggesting that the enhanced convenience of a single capsule once daily may positively contribute to adherence among patients with ATTR-CM. DISCLOSURES: Darrin Benjumea is an employee of Genesis Research who has been contracted by Pfizer, Inc., for involvement in this study. Andrew Peterson is an employee of University of the Sciences who has been contracted by Pfizer, Inc., for involvement in this study. Zach Bredl is an employee of Care Journey who has been contracted by Pfizer, Inc., for involvement in this study. Anuja Roy, Nick Marchant, Jose Alvir, Rahul Bhambri, Jason Kemner, and Bhash Parasuraman are employees of Pfizer, Inc., and own stock and/or stock options. This study was supported by Pfizer, Inc.

Predictors of Medication Adherence of Patients With Coronary Heart Disease After Percutaneous Coronary Intervention: A Structural Equation Modeling Based on the Extended Theory of Planned Behavior

BACKGROUND

The theory of planned behavior (TPB), combined with social support, forms the extended TPB, which has shown to predict adherence to health-related behavior effectively, but few studies have applied it to explain medication adherence in patients with coronary heart disease (CHD) after percutaneous coronary intervention (PCI).

OBJECTIVES

The aim of this study was to explore the factors associated with medication adherence and the underlying mechanisms based on the extended TPB among patients with CHD after PCI.

METHODS

A cross-sectional descriptive study was conducted among patients with CHD after PCI in 2 major hospitals in Guangzhou, China. Medication adherence was measured with the Medication Adherence Report Scale. Constructs of the TPB contributing to medication adherence were assessed by the Theory of Planned Behavior Questionnaire for Medication Adherence. Social support was measured by the Multidimensional Scale of Perceived Social Support. Structural equation modeling was used to examine the hypotheses based on the extended TPB.

RESULTS

A total of 300 patients were surveyed and 26.0% of them were nonadherent. The structural equation modeling had good fit indices and estimated 62.6% of the variance in medication adherence. Regarding the relationships between the extended TPB constructs and medication adherence, "intention" was directly associated with medication adherence, and "perceived behavioral control" positively predicted medication adherence directly and indirectly. "Affective attitude" and "subjective norm" were indirectly associated with medication adherence through "intention." Social support exerted an indirect effect on medication adherence through "subjective norm."

CONCLUSIONS

The extended TPB is an appropriate model to predict medication adherence and provides an effective framework for adherence-enhancing interventions.

Effects of pharmacist interventions on cardiovascular risk factors and outcomes: An umbrella review of meta-analysis of randomized controlled trials

AIMS

To grade the evidence from published meta-analyses of randomized controlled trials (RCTs) that assessed effects of pharmacist intervention on cardiovascular risk factors and cardiovascular outcomes.

METHODS

MEDLINE, Embase, and the Cochrane Library were searched from database inception to July 2021. Meta-analyses of RCTs were eligible. Quality of evidence were assessed by GRADE approach.

RESULTS

From 9308 publications, 149 full-text articles were evaluated for eligibility, and 24 studies with 85 unique meta-analyses that assessed effects of pharmacist intervention on cardiovascular risk factors and cardiovascular outcomes were selected. Overall, 71.7% (61/85) of unique meta-analyses showed significant impacts of pharmacist intervention. For the quality of evidence, 63.4% of meta-analyses had large heterogeneity (I2  > 50%) while 1.2, 16.5, 32.9 and 49.4% of meta-analyses were graded as high, moderate, low and very low quality based on GRADE approach, respectively. Among meta-analyses with moderate quality, pharmacist interventions significantly mitigated risk factors (including 6/3 mmHg reduction of blood pressure, increased the rate of lipid control, glucose control and smoking cessation (pooled odds ratio, [95% confidence interval] 1.91 [1.55, 2.35], 3.11 [2.3, 4.3] and 2.3 [1.33, 3.97], respectively) and improved medication adherence (1.67 [1.38, 2.02]). Furthermore, pharmacist interventions significantly reduced all-cause mortality (0.72 [0.58, 0.89]) and improved quality of life in patients suffering from chronic heart failure.

CONCLUSION

This umbrella review found convincing evidence that pharmacist intervention can provide a wide range of benefits in cardiovascular disease management, ranging from risk factor control, improvement in medication adherence and, in some settings, reduction in morbidity and mortality.

Psychometric evaluation of a culturally adapted illness perception questionnaire for African Americans with type 2 diabetes

Background

Diabetes is burdensome to African Americans, who are twice as likely to be diagnosed, more likely to develop complications and are at a greater risk for death and disability than non-Hispanic whites. Medication adherence interventions are sometimes ineffective for African Americans because their unique illness perceptions are not adequately addressed. The Illness Perception Questionnaire-Revised (IPQ-R) that assesses illness perceptions has shown reliability and validity problems when used with African Americans. Thus, the study objective was to adapt the IPQ-R for African Americans and assess the validity and reliability of the culturally adapted questionnaire.

Methods

The parent study used an exploratory sequential mixed methods design, to explore African Americans’ illness perceptions qualitatively, used the results to adapt the IPQ-R, and tested the culturally adapted IPQ-R items quantitatively. In this paper, a preliminary culturally adapted IPQ-R refined based on the qualitative study, was administered to 170 middle-aged United States-based African Americans with type 2 diabetes in a face-to-face survey. Content, construct, convergent, and predictive validity, including reliability was examined. Pearson and item-total correlations, item analysis, exploratory factor analysis, multiple linear regression analysis, and test-retest were conducted.

Results

A revised culturally adapted IPQ-R was identified with a 9-factor structure and was distinct from the old factor structure of the original IPQ-R. The ‘consequences’ domain from the IPQ-R occurred as two factors (external and internal consequences) while the ‘emotional representations’ domain in the IPQ-R emerged as separate ‘present’ and ‘future’ emotional representation factors. Illness coherence’ was differently conceptualized as ‘illness interpretations’ to capture additional culturally adapted items within this domain. Most items had factor loadings greater than 0.4, with moderate factor score correlations. Necessity and concern beliefs in medicines significantly correlated with domains of the culturally adapted IPQ-R. Pearson’s correlation values were not greater than 0.7, indicating good convergent validity. The culturally adapted IPQ-R significantly predicted medication adherence. None of the correlation values were higher than 0.7 for the test-retest, indicating moderate reliability. Most domains of the culturally adapted IPQ-R had Cronbach’s alpha values higher than 0.7, indicating good internal consistency.

Conclusions

The results provide preliminary support for the validity of the culturally adapted IPQ-R in African Americans with diabetes, showing good construct, convergent and predictive validity, as well as reliability.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12889-022-13172-2.

A Cross-Sectional Study on Hypertension Medication Adherence in a High-Burden Region in Namibia: Exploring Hypertension Interventions and Validation of the Namibia Hill-Bone Compliance Scale

In Namibia, the prevalence of hypertension among women and men aged 35−64 years is high, ranging from 44% to 57%. In this study, we aimed to determine adherence and predictors to antihypertensive therapy in Khomas region, Namibia. A cross-sectional study was performed to consecutively sample 400 patients from urban and peri-urban settings in Namibia. Results were validated using the Hill-Bone Compliance to High Blood Pressure Therapy Scale. Crude associations between predictors of adherence and compliance were tested using the Pearson chi-square test. A multivariable logistic regression analysis was then performed on adherence variables found to be significant to adjust for confounders, and the results are presented as adjusted odds ratios (aOR) with 95% confidence intervals. A total of 400 patients participated in this study. The participants’ mean age and standard deviation were Mean ± SD = 48.9 ± 12.5. In this study, 351 (87.7%) patients were estimated to have good adherence. Education, employment, and the presence of other chronic diseases were associated with adherence. Following multivariate adjustment, the following factors were significantly associated and are therefore predictors of adherence (95%CI, p < 0.005): receiving enough medication at last check-up until next one (OR = 5.44, CI 1.76−16.85), lack of encouragement from family and friends (OR = 0.11 (0.03−0.42)), and attendance of follow-ups on schedule (OR = 8.49, CI = 3.82−18.85). The success of hypertension therapy is dependent on the healthcare systems and healthcare professionals in supplying enough medication, support of friends/family, and maintaining scheduled follow-ups. A combination of interventions using low-cost mobile technology led by healthcare professionals could be endorsed. To fully practice universal access to medication, public and private hospitals in Namibia should collaborate.

[Adherence to antiplatelet and statin therapy by patients with acute coronary syndrome following discharge]

OBJECTIVE

To assess levels of medication adherence to antiplatelet and statins therapy among acute coronary syndrome (ACS) patients 30 days after hospital discharge and identify the main barriers to medication adherence and the main sociodemographic and clinical variables associated with treatment adherence.

METHOD

This was a quantitative longitudinal study. Patients admitted to hospital with ACS were included. Initially, data collection was conducted using a semi-structured interview during the hospital stay. Thirty days after hospital discharge, the Brief Medication Questionnaire was applied by phone to assess treatment adherence. Descriptive statistics were used and tests were applied to analyze the association between medication adherence and clinical and sociodemographic data.

RESULTS

One hundred and sixty-two patients were assessed. The Brief Medication Questionnaire test showed that 49.3% presented probable low adherence to treatment. Marital status, household income and alcohol intake showed an association with medication adherence.

CONCLUSIONS

The findings of the present study indicate high rates of probable nonadherence to medication among ACS patients 30 days after hospital discharge, this information could help nurses to choose specific nursing interventions that could improve adherence in patients' daily routines.

Behavioral Nudges as Patient Decision Support for Medication Adherence: The ENCOURAGE Randomized Controlled Trial

BACKGROUND

Medication adherence is generally low and challenging to address because patient actions control healthcare delivery outside of medical environments. Behavioral nudging changes clinician behavior, but nudging patient decision-making requires further testing. This trial evaluated whether behavioral nudges can increase statin adherence, measured as the proportion of days covered (PDC).

METHODS

In a 12-month parallel-group, unblinded, randomized controlled trial, adult patients in Intermountain Healthcare cardiology clinics were enrolled. Inclusion required an indication for statins and membership in SelectHealth insurance. Subjects were randomized 1:1 to control or nudges. Nudge content, timing, frequency, and delivery route were personalized by CareCentra using machine learning of subject motivations and abilities from psychographic assessment, demographics, social determinants, and the Intermountain Mortality Risk Score. PDC calculation used SelectHealth claims data.

RESULTS

Among 182 subjects, age averaged 63.2±8.5 years, 25.8% were female, baseline LDL-C was 82.5±32.7 mg/dL, and 93.4% had coronary disease. Characteristics were balanced between nudge (n = 89) and control arms (n = 93). The statin PDC was greater at 12 months in the nudge group (PDC: 0.742±0.318) compared to controls (PDC: 0.639±0.358, P = 0.042). Adherent subjects (PDC ≥80%) were more concentrated in the nudge group (66.3% vs controls: 50.5%, P = 0.036) while a composite of death, myocardial infarction, stroke, and revascularization was non-significant (nudges: 6.7% vs control: 10.8%, P = 0.44).

CONCLUSIONS

Persuasive behavioral nudges driven by artificial intelligence resulted in a clinically important increase in statin adherence in general cardiology patients. This precision patient decision support utilized computerized nudge design and delivery with minimal on-going human input.

Baseline Characteristics and Secondary Medication Adherence Patterns Among Patients Receiving Tafamidis Prescriptions: A Retrospective Analysis Using a National Specialty Pharmacy Dispensing Database

INTRODUCTION

Transthyretin amyloid cardiomyopathy (ATTR-CM) is a serious, underrecognized condition, which leads to heart failure and early mortality if left untreated. Until recently, heart transplantation was the only treatment for ATTR-CM. Regulatory approval of tafamidis transformed treatment for patients. In the phase 3 Transthyretin Amyloidosis Cardiomyopathy Clinical Trial (ATTR-ACT), which established the safety and efficacy of tafamidis, medication adherence was high with 97.2% of patients taking ≥80% of scheduled doses. Evidence of real-world adherence to cardiology drugs demonstrates low adherence and suboptimal outcomes; however, real-world adherence to tafamidis has not been investigated. The main objective of this study was to describe adherence patterns of patients filling tafamidis in the Symphony Health database.

METHODS

This retrospective analysis of the Symphony Health Solutions claims database used secondary adherence measures, including modified medication possession ratio (MPRm), days between fills adherence rate, and compliance rate, to assess adherence patterns of 2020 patients filling tafamidis free acid 61-mg capsules or tafamidis meglumine 4x20-mg capsules from June 1, 2019 to August 31, 2020.

RESULTS

Patients receiving a tafamidis formulation had characteristics consistent with the expected patient population; 71.6% were aged 75-84 years, 83.2% were male, and the highest proportion resided in the Northeast region (30.5%) of the United States. Adherence for tafamidis was high, as 75% to 100% of the patients across subgroups met or exceeded the commonly defined adherence threshold of 80%. Median number of refills ordered and received was six refills per patient. Most patients received refills with no gap (n=1633) or a gap <30 days (n=1267/1317 patients). Adherence was high across follow-up time, sex, and age subgroups. Adherence varied by geographic region, with the Northeast being significantly higher than the Midwest (mean MPRm 94.41% vs 88.21%, p=0.0007).

CONCLUSION

These results provide evidence that real-world adherence to tafamidis in patients with ATTR-CM is high.

A phenomenological analysis of the experience of taking medication to prevent a further heart attack

Following an acute myocardial infarction, patients are prescribed a regime of cardio-protective medication to prevent recurrent cardiovascular events and mortality. Adherence to medication is poor in this patient group, and not fully understood. Current interventions have made limited improvements but are based upon presumed principles. To describe the phenomenon of medicine-taking for an individual taking medication for secondary prevention for an AMI, Interpretative Phenomenological Analysis was used to analyse transcripts of semi-structured interviews with participants. Themes were generated for each participant, then summarized across participants. Five key themes were produced; the participants needed to compare themselves to others, showed that knowledge of their medicines was important to them, discussed how the future was an unknown entity for them, had assimilated their medicines into their lives, and expressed how an upset to their routine reduced their ability to take medication. Participants described complex factors and personal adaptations to taking their medication. This suggests that a patient-centred approach is appropriate for adherence work, and these themes could inform clinical practice to better support patients in their medicine adherence.

Association between adherence to oral therapies in cancer patients and clinical outcome: A systematic review of the literature

AIMS

Adherence to therapy is a key factor in successful treatment. The aim of this systematic review is to assess the extent to which patients with better adherence to oral therapy have better clinical outcomes among cancer patients.

METHODS

All studies published in PubMed up to 20 October 2020, which considered the use of oral anticancer drugs for cancer patients and which correlated treatment adherence with a clinical outcome, were considered.

RESULTS

From the 42 studies considered in the systematic review, 14 were for oncological indications and 28 for haematological indications. There was considerable variance in calculation methods, outcomes considered, and in the definitions of adherence. However, it emerged that most studies reported a significant correlation between adherence to therapy and clinical outcome.

CONCLUSION

As adherence to therapy is a key factor in achieving a better clinical outcome, future studies with large samples, robust endpoints and the use of at least two methods of assessing adherence would be desirable in order to produce more robust evidence.

The impact of pharmacy care and motivational interviewing on improving medication adherence in patients with cardiovascular diseases: A systematic review of randomised controlled trials

BACKGROUND

Cardiovascular disease (CVD) is prevalent worldwide, and for many patients, non-adherence to medication remains a problem. Motivational interviewing is a behavioural, communication strategy used as an intervention aimed to improve health outcomes.

AIMS

This systematic review sought to investigate the effect of motivational interviewing delivered as part of pharmacy care on medication adherence, and the effect this has on clinical outcomes. These included systolic and diastolic blood pressure, haemoglobin A1C, lipid profiles and cardiovascular risk scores.

METHOD

A systematic review was conducted in six databases: PubMed Central UK, Cochrane Library, CINAHL (EBSCO), PsycINFO, EMBASE and MEDLINE from the inception of motivational interviewing in 1983 to November 2020. Randomised controlled trials (RCTs) that assessed motivational interviewing as part of pharmacy care interventions were selected. The Cochrane risk of bias tool was used to assess the risk of bias for each included study. This review was registered with PROSPERO (registration number CRD42020222954).

RESULTS

A total of eight RCTs met the inclusion criteria. Five out of eight studies demonstrated medication adherence significantly improved following motivational interviewing interventions. One study showed a significant improvement for systolic blood pressure change by 7.2 mmHg (95% CI 1.6-12.8 mmHg); this reduction was observed in patients whose baseline blood pressure was above their target blood pressure. No statistically significant effect was seen across other clinical outcomes.

CONCLUSION

Motivational interviewing could be an effective behavioural strategy to enhance medication adherence in patients with CVD. Although the evidence is promising thus far, further research is required to explore the impact of motivational interviewing on clinical outcomes as well as the feasibility of implementing motivational interviewing interventions within existing pharmacy care services.

Predictors of adherence to composite therapy after acute coronary syndromes

AIMS

Adherence to medical therapy following acute coronary syndrome (ACS) affects a patient's prognosis. In this cohort study, we sought to assess the factors that could affect a patient's adherence to therapy after ACS.

METHODS

We prospectively collected information from patients (N = 964) hospitalized at the coronary care unit of the Federico II University Hospital, from 1 January 2015 to 30 June 2017, for ACS. Adherence to three classes of drugs including statins, antiplatelets [dual or single antiplatelet agent (SAPT)] and angiotensin-converting enzyme inhibitors/angiotensin receptor blockers (ACE-I/ARB) and their composites were assessed at 1 month, 1 and 2 years after discharge.

RESULTS

At 30 days adherence to prescribed therapy was 94.4% for dual antiplatelet therapy (DAPT), 78.2% for statins, 92.7% for ACE-I/ARB and 70.7% for multitherapy. At 1 year, it was 91.1% for DAPT, 81.2% for ACE-I/ARB, 84.9% for statins and 71.4% for multitherapy. At 2 years, it was 97.1% for SAPT, 78.1% for ACE-I/ARB, 91.8% for statins, 72.8% for multitherapy. Multivariable logistic analysis demonstrated that at each time point, a telephone follow-up assessment predicts nonadherence to multitherapy and that a percutaneous coronary intervention at the index hospitalization is an independent predictor of adherence to composite therapy at 1 month and 1 year.

CONCLUSION

Up to 2 years after ACS, three out of four patients are adherent to multitherapy prescription; percutaneous coronary intervention during the index hospitalization improves a patient's adherence, whereas telephone follow-up is associated with reduced adherence to multitherapy.Campania Salute Network Registry (Clinical Trials.gov Identifier: NCT02211365).

Primary Care of Adult Patients After Stroke: A Scientific Statement From the American Heart Association/American Stroke Association

Primary care teams provide the majority of poststroke care. When optimally configured, these teams provide patient-centered care to prevent recurrent stroke, maximize function, prevent late complications, and optimize quality of life. Patient-centered primary care after stroke begins with establishing the foundation for poststroke management while engaging caregivers and family members in support of the patient. Screening for complications (eg, depression, cognitive impairment, and fall risk) and unmet needs is both a short-term and long-term component of poststroke care. Patients with ongoing functional impairments may benefit from referral to appropriate services. Ongoing care consists of managing risk factors such as high blood pressure, atrial fibrillation, diabetes, carotid stenosis, and dyslipidemia. Recommendations to reduce risk of recurrent stroke also include lifestyle modifications such as healthy diet and exercise. At the system level, primary care practices can use quality improvement strategies and available resources to enhance the delivery of evidence-based care and optimize outcomes.

Effect of self-administration of medication programme on cardiovascular inpatients' medication adherence and nurses' satisfaction: A randomized clinical trial

AIM

To investigate the effect of self-administration of medication programme on medication adherence in cardiovascular inpatients and nurse's satisfaction.

DESIGN

Randomized clinical trial with parallel-group design guided by the CONSORT checklist.

METHODS

In this study, sixty cardiovascular inpatients were selected through convenience sampling and then randomly assigned to control and intervention groups, in 2018, Iran. The intervention group took responsibility for consuming their prescribed medication according to the self-administration of medication programme and the control group took medications routinely. Medication adherence was measured one and two weeks after the discharge via telephonic follow-up by Morisky Medication Adherence Scale MMAS-8-item and nurses' satisfaction by researcher-made questioner.

RESULT

There was a higher medication adherence level in the intervention group rather than the usual care group at the follow-up. Most nurses in the study environment were very satisfied.

CONCLUSION

The self-administration of medication programme can effectively increase patients' medication adherence and nurses' satisfaction.

The Role of Essential Oils and Their Main Compounds in the Management of Cardiovascular Disease Risk Factors

Cardiovascular diseases (CVDs) are a global health burden that greatly impact patient quality of life and account for a huge number of deaths worldwide. Despite current therapies, several side effects have been reported that compromise patient adherence; thus, affecting therapeutic benefits. In this context, plant metabolites, namely volatile extracts and compounds, have emerged as promising therapeutic agents. Indeed, these compounds, in addition to having beneficial bioactivities, are generally more amenable and present less side effects, allowing better patient tolerance. The present review is an updated compilation of the studies carried out in the last 20 years on the beneficial potential of essential oils, and their compounds, against major risk factors of CVDs. Overall, these metabolites show beneficial potential through a direct effect on these risk factors, namely hypertension, dyslipidemia and diabetes, or by acting on related targets, or exerting general cellular protection. In general, monoterpenic compounds are the most studied regarding hypotensive and anti-dyslipidemic/antidiabetic properties, whereas phenylpropanoids are very effective at avoiding platelet aggregation. Despite the number of studies performed, clinical trials are sparse and several aspects related to essential oil’s features, namely volatility and chemical variability, need to be considered in order to guarantee their efficacy in a clinical setting.

The Combined Effect of Psychological and Relational Aspects on Cardiac Patient Activation

The literature assumes that activating patients in the treatment is associated with positive health-related outcomes, such as clinical indicators in the normal range, high medication adherence, and low emergency department utilization. In the cardiac population, patient activation, that is the patient's knowledge, skills, confidence, and behaviors needed for managing one's own health and health care, has been less investigated. In addition, limited attention has been given to the role of the partner as an informal caregiver. However, the patient in the care process is rarely alone, and the partner may play a key role in this process. The goal of this dyadic study (N = 100 heterosexual couples with one partner suffering from an acute cardiac event) is to analyze how individual factors (patients' anxiety, depression, medication adherence, pessimistic perception of illness) and the couple's relationship functioning (e.g., different kinds of partner support and dyadic coping) are associated with patient activation. The results showed that patient activation is not a mere question of age. It is positively related to medication adherence and to the partner's support patient activation. It is negatively correlated with the patient's psychological distress, pessimistic perception of illness, and to the partner's hostility. The need for a dyadic approach to both research and intervention with this population is discussed.

Adherence to cardiovascular pharmacotherapy by patients in Iraq: A mixed methods assessment using quantitative dried blood spot analysis and the 8-item Morisky Medication Adherence Scale

This study evaluated the adherence to prescribed cardiovascular therapy medications among cardiovascular disease patients attending clinics in Misan, Amara, Iraq. Mixed methods were used to assess medication adherence comprising the Arabic version of the eight-item Morisky Medication Adherence Scale (MMAS-8) and determination of drug concentrations in patient dried blood spot (DBS) samples by liquid chromatography-high resolution mass spectrometry. Three hundred and three Iraqi patients (median age 53 years, 50.5% female) who had been taking one or more of the nine commonly prescribed cardiovascular medications (amlodipine, atenolol, atorvastatin, bisoprolol, diltiazem, lisinopril, losartan, simvastatin and valsartan) for at least six months were enrolled. For each patient MMAS-8 scores were determined alongside drug concentrations in their dried blood spot samples. Results from the standardized questionnaire showed that adherence was 81.8% in comparison with 50.8% obtained using the laboratory-based microsample analysis. The agreement between the indirect (MMAS-8) and direct (DBS analysis) assessment approaches to assessing medication adherence showed significantly poor agreement (kappa = 0.28, P = 0.001). The indirect and direct assessment approaches showed no significant correlation between nonadherence to prescribed cardiovascular pharmacotherapy and age and gender, but were significantly associated with the number of medications in the patient's treatment regimen (MMAS-8: Odds Ratio (OR) 1.947, 95% CI, P = 0.001; DBS analysis: OR 2.164, 95% CI, P = 0.001). The MMAS-8 results highlighted reasons for nonadherence to prescribed cardiovascular pharmacotherapy in this patient population whilst the objective DBS analysis approach gave valuable information about nonadherence to each medication in the patient's treatment regimen. DBS sampling, due its minimally invasive nature, convenience and ease of transport is a useful alternative matrix to monitor adherence objectively in Iraq to cardiovascular pharmacotherapy. This information combined with MMAS-8 can provide clinicians with an evidence-based novel approach to implement intervention strategies to optimise and personalise cardiovascular pharmacotherapy in the Iraqi population and thereby improve patient health outcomes.

Cardiac-specific experiential avoidance predicts change in general psychological well-being among patients completing cardiac rehabilitation

Previous studies have shown that experiential avoidance (EA) is associated with physical and psychological well-being in medical and non-medical samples. The aims of the present study were to evaluate the reciprocal association between psychological well-being and EA over time among cardiac rehabilitation (CR) patients with moderately to severely low levels of psychological well-being. Pre-CR data on demographic characteristics, measures of psychological well-being, and cardiac-specific EA were collected from 915 CR patients, as well as post-CR psychological well-being and EA data, from 800 of these patients. A cross-lagged model was estimated to examine the relationship between EA and psychological well-being among patients with moderately to severely low levels of psychological well-being based on questionnaire scores. Both EA and psychological well-being significantly changed during CR and were negatively associated with each other at both pre- and post-CR. Results from cross-lagged structural equation modeling supported a nonreciprocal association between EA and psychological well-being during CR. Pre-CR assessment of EA in patients showing low levels of well-being at the beginning of CR could help to identify patients at risk for worse psychological outcomes. EA could be a promising target of psychological treatments administered during CR.