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Cardio Metabolic

Medication adherence in cardiovascular disease

  • Cardiovascular disease (CVD) is one of the major causes of death globally 1 and poor adherence to medication is a general problem in CVD patients 2.
  • Adherence has been characterized as the “active, voluntary, and collaborative involvement of the patient in a therapeutic manner to create a restorative outcome 3.
  • Patients who don’t stick to recommended courses of prescription are at more risk for poor health outcomes 1.

Importance of medication adherence in managing CVD 

Medication adherence plays a critical role in effectively managing CVD. CVD refers to a group of conditions that affect the heart and blood vessels, including coronary artery disease, heart failure, stroke, and hypertension. Medication adherence is important for several reasons:

  1. Disease progression management: Many prescribed medicines for CVD are designed to control risk factors and prevent disease progression. Hypertensive patients are more likely to adhere to the drug regimen as they believe that their treatment would have a beneficial effect and have better blood pressure control if they adhere to the drug regimen. These trends are not unique to hypertensive patients. Hyperlipidemia is another disease in which an asymptomatic state has been found to influence medication adherence, particularly in patients without coronary artery disease. Elderly patients using statins for primary prevention had the lowest adherence rates 4. Also, it is crucial to recognize the significant role of long-term persistence in anticoagulants, as non-adherence has been linked to considerably higher risks of thromboembolism and mortality, without affecting the risk of major bleeding. For example, there is a possibility of ischemic stroke after anticoagulant discontinuation due to a prothrombotic rebound phenomenon 5,6. 
  1. Prevention of complications: Complications of CVD can be serious and life-threatening. The objective of treating hypertension is to prevent cardiovascular complications from uncontrolled blood pressure. If poor adherence leads to poor blood pressure control, it logically follows that poor adherence also affects long-term outcomes in hypertensive patients. It has been observed that non-adherence to anti-platelet therapy increases the risk of late site thrombosis in patients undergoing coronary stenting 4.
  1. Blood pressure management: Hypertension is a major risk factor for cardiovascular disease. Antihypertensive drugs are prescribed to regulate blood pressure and reduce the burden on the heart and blood vessels. For example, beta blockers, like propranolol and metoprolol, are known to be effective in treating high blood pressure. Beta-blocker sudden withdrawal can cause unfavorable effects like angina pectoris, tachycardia, arterial hypertension, and an increase in heart failure symptoms. The “beta-blocker rebound phenomenon,” also known as beta-blocker withdrawal syndrome, refers to these signs and symptoms that occur when beta-blockers are abruptly stopped 7. Treatment of hypertension usually requires daily lifelong therapy and strict follow-up to maintain adequate blood pressure control and prevent hypertensive complications 4.
  1. Long-term risk reduction: CVD is often a chronic disease that requires long-term treatment. Medication adherence and lifestyle changes can significantly reduce the risk of future cardiovascular events, including heart attacks and strokes. Continuously taking medications as directed helps maintain a stable disease and reduces the likelihood of the disease worsening 4.
  1. Quality of life improvement: Medicines used to treat symptoms of cardiovascular disease can improve patients’ quality of life by relieving symptoms and reducing the frequency and severity of exacerbations. Medication adherence ensures that medications have a consistently beneficial effect that improves symptom control and overall well-being 4.

However, medication adherence can be difficult for a variety of reasons, including forgetfulness, medication side effects, complex regimens, and cost concerns. Healthcare providers have a key role to play in educating patients about the importance of adherence, solving problems, simplifying treatment regimens where possible, and exploring strategies to support patient adherence.

Factors influencing medication adherence in CVD 

Adherence to medication is defined as how many patients are taking their prescribed medicines according to the instructions given by their healthcare professionals. Adherence to treatment regimens is crucial for the management of heart disease and prevents further complications. In the case of CVD, several factors may influence the adherence to treatment, including:

  1. Lack of understanding: The importance and possible consequences of failure to adhere to a treatment regimen may not be completely understood by the patient. Poor adherence to treatment may be due to insufficient knowledge of the purpose, benefits, and potential side effects of this medicinal product 8,9.
  1. Complexity of medication regimen: A significant reduction of adverse drug reactions was achieved within 30 days after hospital discharge by pharmacist intervention aimed at clarifying the patient’s medication regimens, dosage instructions, review of side effects and consultation with patients. In elderly people or those who have a cognitive impairment, complicated regimens may lead to lack of understanding and forgetfulness 8,9.
  1. Side effects: The difference in adherence rates between classes of medicines could be explained by side effects. Thiazides were more probable to induce a side effect than beta blockers, calcium channel blockers or angiotensin converting enzyme inhibitors when administered in the usual dose 10.
  1. Cost of medications: High medications cost can have a significant impact on adherence. Among younger patients and women, the impact of cost on compliance was highest. Similarly, the cost of medicines was expected to lead to poorer adherence in those who said that they were less trusted by their provider. However, the relationship of cost and adherence was not significant amongst patients who expressed higher confidence in their healthcare provider 8.
  1. Beliefs and attitudes: Sometimes conflicting results have emerged from a search for the characteristics of patients who are non-adherent. Demographic factors such as younger age are associated with reduced compliance, but there are few psychosocial factors showing a clear link between adherence and this. There is a moderate but uneven relationship between personality traits and adherence. Similarly, a mixed relationship exists between patients’ beliefs or attitudes as well as their adherence to treatment 8. 
  1. Forgetfulness: Approximately 30% of all cases of non-adherence, forgetfulness is a common cause of non-adherence. In patients taking several medicinal products to treat their comorbidities, adherence has been reduced, which has contributed to the forgetfulness of the use of medicinal products. There has also been a negative effect on adherence to the regimens due to frequent changes 10.
  1. Social support: An important part of the reinforcement of adherence is social support. The emotional support of the people allows them to speak about their fears and ask for information when necessary. Supporting the patients with encouragement, prayer and financial assistance has been an important tool in making them more driven to continue their treatment and exercise well 10.
  1. Mental health: Patient with impaired level of cognitive capabilities, stress, and anxiety may have difficulty adhering to medication 10.
  1. Healthcare system factors: Adherence to treatment may be influenced by the relationship of patients and healthcare professionals or health systems. This has involved communication issues and the requirements of the healthcare system, which have made it difficult for patients to understand the treatment 10.

Identifying these factors and working with patients to overcome barriers to medication adherence is important for healthcare professionals, so that CVD management and patient outcomes can be improved. Adherence to treatment in CVD can be enhanced by strategies such as patient education, simplification of treatment regimens, addressing cost concerns, providing reminders, and involving caregivers or support networks.

Strategies to improve CVD medication adherence 

Improving medication adherence in cardiovascular disease (CVD) is crucial for the effective management and prevention of complications. Here are some strategies to promote medication adherence in CVD:

  1. Health literacy: Health literacy requires patients to be able to read and comprehend, as well as a healthcare provider’s ability to provide important health information in an appropriate manner. The comprehensibility of current warnings in package inserts could be improved through a patient focused approach towards the design of consumer information on medicinal products 9.
  1. Simplify medication regimen: A significant decrease in the number of adverse reactions has been achieved by pharmacist interventions, which focus on clearer drug regimens, directions for use, reviews of side effects and patient counselling 9.
  1. Tailored treatment plans: After non-adherence is identified, there is a need to identify the underlying cause, and intervention could be tailored accordingly 10.
  1. Communication and follow-up: The support of healthcare professionals in helping patients to comply with treatment is a key factor for improved patient compliance, especially at follow up. Lack of communication with patients led to inadequate information from health care providers, which results in non-adherence 10.
  1. Supportive tools and technologies: The potential to improve medication adherence and clinical outcomes can be achieved using mobile healthcare technologies such as mobile apps. It has been demonstrated that phone calls to patients and providing educational services have improved adherence 9 11.
  1. Collaborative care: The state-of-the-art paradigm for enhancing medication adherence is complex and involves multiple hierarchies. Studies have shown that team-based care, in which physician, pharmacists, and nursing team members are engaged in collaborative care for patient 9.
  1. Address barriers: By identifying and solving the barriers to patient compliance with their medicines, the healthcare team plays a vital role in helping patients stick to them. Regular monitoring with the medical team has been one of the common features of successful interventions 10.
  1. Engage family and friends: To improve the CVD clinical outcomes and adherence to drug regimen, it is necessary to seek the assistance of family, friends, and social services 10.

Remember, the improvement of adherence to medicines is a multidisciplinary process requiring collaboration among healthcare professionals, patients, and their support network. You can increase medication adherence and improve clinical outcome of patients with cardiovascular disease when you implement these strategies.

To read more about “Understanding adherence from a cardiovascular-disease perspective” click here

Conclusion

Adherence to the use of medicines is vital for effective management of heart disease. It has a key role to play in the improvement of outcomes for patients, reduction of complications and reduced health care costs. However, patients, healthcare providers and the healthcare system continue to face significant challenges due to the lack of adherence to medicines.

A comprehensive and patient-centric approach is needed to improve adherence to medicinal products in cardiovascular disease. Healthcare providers can greatly improve outcomes for patients, reduce the incidence of cardiovascular problems and help people to live a normal life if they address barriers to compliance and implement efficient interventions.

“Better medication management and better adherence will result in better health system performance on quality and cost metrics” – Jonathan Niloff, M.D.

References

1. Leslie KH, McCowan C, Pell JP. Adherence to cardiovascular medication: a review of systematic reviews. J Public Health (Oxf). Mar 1 2019;41(1):e84-e94. doi:10.1093/pubmed/fdy088

2. Ruppar TM, Cooper PS, Mehr DR, Delgado JM, Dunbar-Jacob JM. Medication Adherence Interventions Improve Heart Failure Mortality and Readmission Rates: Systematic Review and Meta-Analysis of Controlled Trials. J Am Heart Assoc. Jun 17 2016;5(6)doi:10.1161/JAHA.115.002606

3. Ho PM, Bryson CL, Rumsfeld JS. Medication adherence: its importance in cardiovascular outcomes. Circulation. Jun 16 2009;119(23):3028-35. doi:10.1161/CIRCULATIONAHA.108.768986

4. Frishman WH. Importance of medication adherence in cardiovascular disease and the value of once-daily treatment regimens. Cardiol Rev. Sep-Oct 2007;15(5):257-63. doi:10.1097/CRD.0b013e3180cabbe7

5. Grymonprez M, Capiau A, Steurbaut S, et al. Adherence and persistence to oral anticoagulants in patients with atrial fibrillation: A Belgian nationwide cohort study. Front Cardiovasc Med. 2022;9:994085. doi:10.3389/fcvm.2022.994085

6. Park JH, Han SW, Lee KY, et al. Impact of Non-vitamin K Antagonist Oral Anticoagulant Withdrawal on Stroke Outcomes. Front Neurol. 2018;9:1095. doi:10.3389/fneur.2018.01095

7. Garbus SB, Weber MA, Priest RT, Brewer DD, Hubbell FA. The abrupt discontinuation of antihypertensive treatment. J Clin Pharmacol. Aug-Sep 1979;19(8-9 Pt 1):476-86. doi:10.1002/j.1552-4604.1979.tb02510.x

8. Pina IL, Di Palo KE, Brown MT, et al. Medication adherence: Importance, issues and policy: A policy statement from the American Heart Association. Prog Cardiovasc Dis. Jan-Feb 2021;64:111-120. doi:10.1016/j.pcad.2020.08.003

9. Ferdinand KC, Senatore FF, Clayton-Jeter H, et al. Improving Medication Adherence in Cardiometabolic Disease: Practical and Regulatory Implications. J Am Coll Cardiol. Jan 31 2017;69(4):437-451. doi:10.1016/j.jacc.2016.11.034

10. Suol Thanh Pham TAN, Nghia Minh Tran, Hoang Thi Kim Cao, Khanh Kim Le, Chu Xuan Duong, Thao Huong Nguyen, Katja Taxis, Khanh Duy Dang and Thang Nguyen. Medication Adherence in Cardiovascular Diseases. IntechOpen. 2022.

11. Al-Arkee S, Mason J, Lane DA, et al. Mobile Apps to Improve Medication Adherence in Cardiovascular Disease: Systematic Review and Meta-analysis. J Med Internet Res. May 25 2021;23(5):e24190. doi:10.2196/24190