Clopidogrel-taking behavior by drug-eluting stent patients: Discontinuers versus continuers

Patient and Physician Perspectives on the Benefits and Risks of Antiplatelet Therapy for Acute Coronary Syndrome

This article is co-authored by a patient with acute coronary syndrome (ACS) who is receiving long-term antiplatelet therapy in the USA and a cardiologist who routinely treats patients with ACS. The patient describes his experience from diagnosis to the present day and discusses his concerns regarding treatment and management of the condition, including the balance between the benefits and risks of antiplatelet therapy. The patient also describes his work as an advocate for cardiac health. The physician perspective on treating and managing patients with ACS is provided by a cardiologist based in the USA who is and was not involved in this patient's care. The physician reviews the benefits and risks of antiplatelet therapies for the treatment of patients with ACS and discusses his own clinical experience of managing these patients, including how issues such as treatment adherence, as well as the potential inertia to prescribing certain medications that may be seen among physicians, could be overcome.

Bleeding risk in patients prescribed dual antiplatelet therapy and triple therapy after coronary interventions: the ADAPTT retrospective population-based cohort studies

Background

Bleeding among populations undergoing percutaneous coronary intervention or coronary artery bypass grafting and among conservatively managed patients with acute coronary syndrome exposed to different dual antiplatelet therapy and triple therapy (i.e. dual antiplatelet therapy plus an anticoagulant) has not been previously quantified.

Objectives

The objectives were to estimate hazard ratios for bleeding for different antiplatelet and triple therapy regimens, estimate resources and the associated costs of treating bleeding events, and to extend existing economic models of the cost-effectiveness of dual antiplatelet therapy.

Design

The study was designed as three retrospective population-based cohort studies emulating target randomised controlled trials.

Setting

The study was set in primary and secondary care in England from 2010 to 2017.

Participants

Participants were patients aged ≥ 18 years undergoing coronary artery bypass grafting or emergency percutaneous coronary intervention (for acute coronary syndrome), or conservatively managed patients with acute coronary syndrome.

Data sources

Data were sourced from linked Clinical Practice Research Datalink and Hospital Episode Statistics.

Interventions

Coronary artery bypass grafting and conservatively managed acute coronary syndrome: aspirin (reference) compared with aspirin and clopidogrel. Percutaneous coronary intervention: aspirin and clopidogrel (reference) compared with aspirin and prasugrel (ST elevation myocardial infarction only) or aspirin and ticagrelor.

Main outcome measures

Primary outcome: any bleeding events up to 12 months after the index event. Secondary outcomes: major or minor bleeding, all-cause and cardiovascular mortality, mortality from bleeding, myocardial infarction, stroke, additional coronary intervention and major adverse cardiovascular events.

Results

The incidence of any bleeding was 5% among coronary artery bypass graft patients, 10% among conservatively managed acute coronary syndrome patients and 9% among emergency percutaneous coronary intervention patients, compared with 18% among patients prescribed triple therapy. Among coronary artery bypass grafting and conservatively managed acute coronary syndrome patients, dual antiplatelet therapy, compared with aspirin, increased the hazards of any bleeding (coronary artery bypass grafting: hazard ratio 1.43, 95% confidence interval 1.21 to 1.69; conservatively-managed acute coronary syndrome: hazard ratio 1.72, 95% confidence interval 1.15 to 2.57) and major adverse cardiovascular events (coronary artery bypass grafting: hazard ratio 2.06, 95% confidence interval 1.23 to 3.46; conservatively-managed acute coronary syndrome: hazard ratio 1.57, 95% confidence interval 1.38 to 1.78). Among emergency percutaneous coronary intervention patients, dual antiplatelet therapy with ticagrelor, compared with dual antiplatelet therapy with clopidogrel, increased the hazard of any bleeding (hazard ratio 1.47, 95% confidence interval 1.19 to 1.82), but did not reduce the incidence of major adverse cardiovascular events (hazard ratio 1.06, 95% confidence interval 0.89 to 1.27). Among ST elevation myocardial infarction percutaneous coronary intervention patients, dual antiplatelet therapy with prasugrel, compared with dual antiplatelet therapy with clopidogrel, increased the hazard of any bleeding (hazard ratio 1.48, 95% confidence interval 1.02 to 2.12), but did not reduce the incidence of major adverse cardiovascular events (hazard ratio 1.10, 95% confidence interval 0.80 to 1.51). Health-care costs in the first year did not differ between dual antiplatelet therapy with clopidogrel and aspirin monotherapy among either coronary artery bypass grafting patients (mean difference £94, 95% confidence interval -£155 to £763) or conservatively managed acute coronary syndrome patients (mean difference £610, 95% confidence interval -£626 to £1516), but among emergency percutaneous coronary intervention patients were higher for those receiving dual antiplatelet therapy with ticagrelor than for those receiving dual antiplatelet therapy with clopidogrel, although for only patients on concurrent proton pump inhibitors (mean difference £1145, 95% confidence interval £269 to £2195).

Conclusions

This study suggests that more potent dual antiplatelet therapy may increase the risk of bleeding without reducing the incidence of major adverse cardiovascular events. These results should be carefully considered by clinicians and decision-makers alongside randomised controlled trial evidence when making recommendations about dual antiplatelet therapy.

Limitations

The estimates for bleeding and major adverse cardiovascular events may be biased from unmeasured confounding and the exclusion of an eligible subgroup of patients who could not be assigned an intervention. Because of these limitations, a formal cost-effectiveness analysis could not be conducted.

Future work

Future work should explore the feasibility of using other UK data sets of routinely collected data, less susceptible to bias, to estimate the benefit and harm of antiplatelet interventions.

Trial registration

This trial is registered as ISRCTN76607611.

Funding

This project was funded by the National Institute for Health and Care Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 27, No. 8. See the NIHR Journals Library website for further project information.

Medication-taking for secondary prevention of acute myocardial infarction: a thematic meta-synthesis of patient experiences

Objective

To collate existing qualitative research examining patients’ medication-taking experiences in secondary prevention of acute myocardial infarction (AMI) and produce new knowledge, a systematic review and meta-synthesis of patient qualitative studies was conducted.

Method

A systematic review found nine reports suitable for inclusion. Themes found by the report authors and report characteristic data were extracted. Reports were assessed for quality. A meta-synthesis using thematic coding and constant comparison method produced higher order themes, and these were used to construct a statement organised by theme using specific examples from the included studies.

Results

All patients discussed their medication-taking in thematic categories of beliefs about medication and illness, personal ability and interpersonal factors. Themes differed between classes of medication and between patients, suggesting tailored interventions to medications and individual patients would be appropriate. Some themes overlapped with those discussed by the broader group of cardiovascular patients, but some themes were unique to this myocardial infarction patient group, again indicating that a tailored approach is appropriate for this patient group.

Conclusion

The themes of beliefs about medication and illness, personal ability and interpersonal support provide tangible starting points for addressing adherence issues. The concept of medication-taking had unique elements within the post-AMI group of patients, and between classes of medication. While these themes were grouped into more generalised higher-order constructs, there were differences between patients within the themed group, indicating that themes are useful as a guide, but individual-level patient support is appropriate.

A counseling program on nuisance bleeding improves quality of life in patients on dual antiplatelet therapy: A randomized controlled trial

BACKGROUND

Nuisance bleeding is a major determinant of quality of life and drug discontinuation in patients on dual antiplatelet therapy (DAPT). However, no randomized trial has been focused on the impact of nuisance bleeding on quality of life.

METHODS

BATMAN is an investigator-driven, randomized, controlled, single-center, open trial (NCT02554006). Four hundred and forty-eight consecutive patients with indication to at least 6 months of DAPT were randomized to: i) multimodal counseling program focused on nuisance bleedings (interventional arm); ii) usual discharge process (control arm). The primary endpoint was the one-month health-related quality of life assessed by the EuroQol-5 Dimension (EQ-5D) visual analog scale (VAS) score. Secondary endpoints were EQ-5D at 1 and 6 months, EQ-5D VAS at 6 months, DAPT withdrawal, need of information regarding DAPT and/or nuisance bleedings, 6-month ischemic and bleeding adverse events.

RESULTS

The EQ5D-VAS was significantly higher in the interventional arm compared to the control arm at 1 and 6 months (81[74-88] vs. 73[64-80], p < 0.001 at 1 month; 82[76-88] vs. 74[65-81], p < 0.001 at 6 months). Patients in the interventional arm had also significantly lower pain/discomfort and anxiety/depression at the EQ-5D both at 1 and 6 months. Patients in the control arm withdrew DAPT significantly more (7 (3%) vs. 1 (0.4%), p = 0.03) and looked for information regarding DAPT and/or about nuisance bleeding more frequently than those in the interventional arm (178 (79%) vs.19 (8%), p < 0.001).

CONCLUSIONS

The systematic utilization of a multimodal counseling program improved quality of life and reduced the DAPT withdrawal rate in patients on DAPT.

Adherence to antiplatelet treatment with P2Y12 receptor inhibitors. Is there anything we can do to improve it? A systematic review of randomized trials

Antiplatelet therapy is the cornerstone of treatment for patients with acute coronary syndromes (ACS) and/or undergoing percutaneous coronary interventions. Non-adherence to medication after ACS may lead to increased morbidity, mortality, and costs to the healthcare system due to elevated risk of stent thrombosis, myocardial infarction or death. Medication adherence is an issue of growing concern regarding the improvement of health system performance. Promoting medication adherence offers a rare opportunity to simultaneously improve health outcomes while reducing costs of treatment in patients with coronary artery disease (CAD). The aim of this systematic review was to critically discuss adherence to antiplatelet treatment with P2Y12 receptor inhibitors in CAD patients. After a systematic investigation of the literature in databases including PubMed, CENTRAL and Google Scholar, using appropriate keywords, and considering clinical randomized, prospective observational and retrospective studies, reporting on adherence to treatment with inhibitors of P2Y12 platelet receptors or educational interventions aimed to improve medication adherence in patients with CAD, seven articles were considered eligible for inclusion in this systematic review. Reported adherence to clopidogrel, despite catastrophic consequences of its premature discontinuation, is low. We identified several determinants of low adherence and early discontinuation of clopidogrel. We also present data on the usefulness, utilization and credibility of different methods of medication adherence assessment, and suggest and critically discuss available interventions aimed at improvement of adherence to clopidogrel, still showing the need for innovative approaches to achieve enhanced medication adherence and improve health outcomes after acute myocardial infarction.

Adherence to dual antiplatelet therapy after coronary stenting: a systematic review

BACKGROUND

Adherence to dual antiplatelet therapy (DAPT) is critical after coronary stenting. Although adherence rates are frequently assessed in clinical trials, adherence rates in the unselected population recommended for treatment but beyond clinical trials are largely unknown. Therefore, we performed a systematic review of published observational studies to describe rates of DAPT adherence, trends in DAPT use over time, and patient-level factors associated with nonadherence.

HYPOTHESIS

DAPT adherence declines with increasing time after drug-eluting stent implantation.

METHODS

PubMed, Cumulative Index to Nursing and Allied Health Literature, Embase, and Web of Knowledge were searched through November 20, 2012 for studies including patients receiving 1 or more drug-eluting stents and reporting the use of aspirin and/or thienopyridines, or assessing factors associated with nonadherence to DAPT after bare metal or drug-eluting stent placement.

RESULTS

We included 34 studies in the description of DAPT adherence and 11 studies in the description of factors associated with nonadherence. Adherence to DAPT and thienopyridines was high at 1 month but declined by 12 months. Aspirin adherence was at least 90% throughout. Factors associated with nonadherence included bleeding, lower education level, immigrant status, and lack of education regarding DAPT.

CONCLUSIONS

DAPT adherence is suboptimal at 12 months, and interventions to increase adherence should focus on reducing bleeding risk and improving communication between patients and physicians.

Medication taking in coronary artery disease: a systematic review and qualitative synthesis

PURPOSE

Despite the compelling evidence supporting cardiovascular medications in the secondary prevention of coronary artery disease, many patients discontinue treatment. In this synthesis, we sought to understand from a patient perspective the factors that promote medication persistence.

METHODS

We systematically searched 7 databases (MEDLINE, Embase, PsycINFO, SCOPUS, CINAHL, ASSIA, and SSCI) for published qualitative research about the medication-taking experiences of patients with coronary artery disease and their partners. Articles were assessed for quality using a modified CASP (Critical Appraisal Skills Programme) checklist. Synthesis was undertaken using well-established meta-ethnographic approaches.

RESULTS

We included 17 articles in the final synthesis from the United Kingdom (6), Europe (5), United States (4), China (1), and Australia (1), with a total sample size of 391 patients. Analyses suggested that some patients hold fatalistic beliefs about their disease, whereas others believe they have been cured by interventions; both can lead to failure to take medication. Patients who adapt to being a "heart patient" are positive about medication taking. Some individuals dislike taking tablets generally and are wary of long-term effects. Relationships with prescribing clinicians are of critical importance for patients, with inaccessibility and insensitive terminology negatively affecting patients' perceptions about treatments.

CONCLUSIONS

Strategies to promote higher persistence of secondary prevention medications in patients with coronary artery disease need to recognize the key role of the prescribing clinician. Providing medication-specific information at the time of initiating therapy, improving the transition between secondary and primary care, and explaining the risk of disease recurrence may all help to modify patient attitudes toward drugs to prevent further cardiovascular disease.

Nuisance bleeding with prolonged dual antiplatelet therapy after acute myocardial infarction and its impact on health status

OBJECTIVES

The purpose of this study was to examine the incidence of nuisance bleeding after AMI and its impact on QOL.

BACKGROUND

Prolonged dual antiplatelet therapy (DAPT) is recommended after acute myocardial infarction (AMI) to reduce ischemic events, but it is associated with increased rates of major and minor bleeding. The incidence of even lesser degrees of post-discharge "nuisance" bleeding with DAPT and its impact on quality of life (QOL) are unknown.

METHODS

Data from the 24-center TRIUMPH (Translational Research Investigating Underlying Disparities in Acute Myocardial Infarction Patients' Health Status) study of 3,560 patients, who were interviewed at 1, 6, and 12 months after AMI, were used to investigate the incidence of nuisance bleeding (defined as Bleeding Academic Research Consortium type 1). Baseline characteristics associated with "nuisance" bleeding and its association with QOL, as measured by the EuroQol 5 Dimension visual analog scale, and subsequent re-hospitalization were examined.

RESULTS

Nuisance (Bleeding Academic Research Consortium type 1) bleeding occurred in 1,335 patients (37.5%) over the 12 months after AMI. After adjusting for baseline bleeding and mortality risk, ongoing DAPT was the strongest predictor of nuisance bleeding (rate ratio [RR]: 1.44, 95% confidence interval [CI]: 1.17 to 1.76 at 1 month; RR: 1.89, 95% CI: 1.35 to 2.65 at 6 months; and RR: 1.39, 95% CI: 1.08 to 1.79 at 12 months; p < 0.01 for all comparisons). Nuisance bleeding at 1 month was independently associated with a decrement in QOL at 1 month (-2.81 points on EuroQol 5 Dimension visual analog scale; 95% CI: 1.09 to 5.64) and nonsignificantly toward higher re-hospitalization (hazard ratio: 1.20; 95% CI: 0.95 to 1.52).

CONCLUSIONS

Nuisance bleeding is common in the year after AMI, associated with ongoing use of DAPT, and independently associated with worse QOL. Improved selection of patients for prolonged DAPT may help minimize the incidence and adverse consequences of nuisance bleeding.

[Compliance enhancement in drug therapy : opportunities and limitations]

In the execution of their pharmacotherapy, many patients deviate from the prescribed treatment regimen. Reasons for noncompliance can be diverse and range from forgetfulness of the patient to attributes of the health care system. Besides increased health care costs, poor compliance causes both an endangerment to the patient and poor health outcomes. Therefore, it is crucial that compliance enhancement receives high priority. In the beginning of this process, noncompliance must be detected in daily practice. Moreover, various methods can provide valuable information about medication-taking behavior, time patterns, and reasons for noncompliance. Based on this assessment, appropriate measures to enhance compliance can be taken. In this article, the opportunities and limitations of compliance enhancement are discussed.

Medication Discussion Questions (MedDQ): developing a guide to facilitate patient-clinician communication about heart medications

BACKGROUND AND RESEARCH OBJECTIVE

Adherence to evidence-based therapies has emerged as one of the great challenges of translating discoveries to clinical care to optimize patient outcomes. In particular, nonadherence to lifesaving medications continues to trouble health care systems. We conducted a series of studies to investigate why cardiac patients stop life-sustaining medications and to develop a tool to proactively address medication adherence issues. We could find no available preventive tools for communicating with patients about their medications in the clinical setting. In this article, we summarize the process of developing such a tool.

SUBJECTS AND METHODS

We used a mixed-methods approach in a series of studies that included examining quantitative data from a large patient registry, conducting in-depth qualitative patient interviews, creating items representative of the qualitative findings, pilot testing items with heart patients, surveying an expert panel to establish content validity, and conducting in-depth interviews with health care providers to assess implementation opportunities.

RESULTS AND CONCLUSIONS

Patient interviews revealed that patients' values and beliefs, barriers to treatment, and prior medication-taking behavior were of primary importance in understanding medication discontinuance. Pilot testing, expert panel review, and an implementation feasibility evaluation resulted in an 11-item communication guide to be used in a variety of health care settings. Clinicians need an efficient way of systematically communicating with patients about heart medications to identify barriers and to initiate preventive interventions when patients report barriers or challenges to medication adherence.

Clinician-patient discord: exploring differences in perspectives for discontinuing clopidogrel

BACKGROUND

Premature stopping of anti-platelet therapy has potentially fatal consequences for myocardial infarction (MI) patients who have received a drug-eluting stent (DES). Exploring multiple perspectives to identify contributing factors to the problem is essential.

AIM

We gained patient and clinician perspectives as to why MI patients prematurely stop anti-platelet therapy (clopidogrel) after DES implantation.

METHODS

This qualitative, descriptive study of DES-treated MI patients (n=22) and of clinicians (physicians and nurse practitioners; n=17) from multiple U.S. cities used content analysis of interview data. Findings across patients and clinicians were then compared to examine congruent and contrasting reasons for premature clopidogrel discontinuance.

FINDINGS

Patients frequently identified communication and education (e.g. unaware they should be taking clopidogrel, unaware of intended duration of therapy) as the primary reasons for having stopped. Patients rarely cited cost, while clinicians most commonly cited cost as a reason for premature stopping.

CONCLUSIONS

The discrepancy in perceptions of patients and clinicians as to the primary reason for early discontinuance suggests an important opportunity for improving persistence. Rather than focusing on the high costs of medications, something outside of their control, physicians should consider communicating more effectively the importance and intended duration of clopidogrel to their patients.