Association of Diabetes Mellitus Status and Glycemic Control With Secondary Prevention Medication Adherence After Acute Myocardial Infarction

Patient Adherence to Secondary Prevention Therapies After an Acute Coronary Syndrome: A Scoping Review

PURPOSE

Adherence to guideline-recommended, long-term secondary preventative therapies among patients with acute coronary syndrome (ACS) is fundamental to improving long-term outcomes. The purpose of this scoping review was to provide a broad synopsis of pertinent studies in a structured and comprehensive way regarding factors that influence patient adherence to medical therapy after ACS.

METHODS

Relevant articles focusing on adherence to medical therapy after ACS were retrieved from the EMBASE and MEDLINE databases (search date, September 7, 2021). Studies were independently screened, and relevant information was extracted.

FINDINGS

A total of 58 studies were identified by using the EMBASE and MEDLINE databases. Adherence to secondary prevention was moderate to low and steadily decreased over time. Nearly 30% of patients discontinued one or more medications within 90 days of their primary ACS, and adherence decreased to 50% to 60% at 1 year postdischarge. There were no major differences in adherence between drug classes. Factors influencing patient adherence can be broadly divided into 3 categories: patient related, health care system related, and disease related. Patients managed with percutaneous coronary interventions were more adherent to follow-up treatment than medically managed patients. Depression was reported as a major psychological factor that negatively affected adherence. Improved adherence was observed when higher levels of patient education and provider engagement were delivered during postdischarge follow-up, particularly when scheduled early. Notably, the incidence of major adverse cardiovascular events was lower in hospitals with high 90-day medication adherence than those with moderate or low adherence.

IMPLICATIONS

Patient nonadherence to guideline-recommended long-term pharmacologic secondary preventative therapies after ACS is multifactorial. A comprehensive multifaceted approach should be implemented to improve adherence and clinical outcomes. This approach should include key interventions such as early follow-up visits, high medication adherence at 90 days, patient engagement and education, and development of novel interventions that support the 3 broad categories influencing patient adherence as discussed in this review.

Association of Glycemic Control Trajectory with Short-Term Mortality in Diabetes Patients with High Cardiovascular Risk: a Joint Latent Class Modeling Study

BACKGROUND

The relationship between risk factor or biomarker trajectories and contemporaneous short-term clinical outcomes is poorly understood. In diabetes patients, it is unknown whether hemoglobin A1c (HbA1c) trajectories are associated with clinical outcomes and can inform care in scenarios in which a single HbA1c is uninformative, for example, after a diagnosis of coronary artery disease (CAD).

OBJECTIVE

To compare associations of HbA1c trajectories and single HbA1c values with short-term mortality in diabetes patients evaluated for CAD DESIGN: Retrospective observational cohort study PARTICIPANTS: Diabetes patients (n = 7780) with and without angiographically defined CAD MAIN MEASURES: We used joint latent class mixed models to simultaneously fit HbA1c trajectories and estimate association with 2-year mortality after cardiac catheterization, adjusting for clinical and demographic covariates.

KEY RESULTS

Three HBA1c trajectory classes were identified: individuals with stable glycemia (class A; n = 6934 [89%]; mean baseline HbA1c 6.9%), with declining HbA1c (class B; n = 364 [4.7%]; mean baseline HbA1c 11.6%), and with increasing HbA1c (class C; n = 482 [6.2%]; mean baseline HbA1c 8.5%). HbA1c trajectory class was associated with adjusted 2-year mortality (3.0% [95% CI 2.8, 3.2] for class A, 3.1% [2.1, 4.2] for class B, and 4.2% [3.4, 4.9] for class C; global P = 0.047, P = 0.03 comparing classes A and C, P > 0.05 for other pairwise comparisons). Baseline HbA1c was not associated with 2-year mortality (P = 0.85; hazard ratios 1.01 [0.96, 1.06] and 1.02 [0.95, 1.10] for HbA1c 7-9% and ≥ 9%, respectively, relative to HbA1c < 7%). The association between HbA1c trajectories and mortality did not differ between those with and without CAD (interaction P = 0.1).

CONCLUSIONS

In clinical settings where single HbA1c measurements provide limited information, HbA1c trajectories may help stratify risk of complications in diabetes patients. Joint latent class modeling provides a generalizable approach to examining relationships between biomarker trajectories and clinical outcomes in the era of near-universal adoption of electronic health records.

Association of Diabetes Mellitus Status and Glycemic Control With Secondary Prevention Medication Adherence After Acute Myocardial Infarction

Background

Cardioprotective medication adherence can mitigate the risk of recurrent cardiovascular events and mortality after acute myocardial infarction (AMI). We examined the associations of diabetes mellitus status and glycemic control with cardioprotective medication adherence after AMI.

Methods and Results

We performed a retrospective observational cohort study of 14 517 US veterans who were hospitalized for their first AMI between 2011 and 2014 and prescribed a beta‐blocker, 3‐hydroxy‐3‐methyl‐glutaryl‐CoA‐reductase inhibitor, and angiotensin‐converting enzyme inhibitor or angiotensin receptor blocker. The primary exposure was a diagnosis of type 2 diabetes mellitus; in diabetes mellitus patients, hemoglobin A1c (HbA1c) was a secondary exposure. The primary outcome was 1‐year adherence to all 3 medication classes, defined as proportion of days covered ≥0.8, assessed using adjusted risk differences and multivariable Poisson regression. Of 14 517 patients (mean age, 66.3 years; 98% male), 52% had diabetes mellitus; 9%, 31%, 24%, 15%, and 21% had HbA1c <6%, 6% to 6.9%, 7% to 7.9%, 8% to 8.9%, and ≥9%, respectively. Diabetes mellitus patients were more likely to be adherent to all 3 drug classes than those without diabetes mellitus (adjusted difference in adherence, 2.1% [0.5, 3.7]). Relative to those with HbA1c 6% to 6.9%, medication adherence declined with increasing HbA1c (risk ratio of achieving proportion of days covered ≥0.8, 0.99 [0.94, 1.04], 0.93 [0.87, 0.99], 0.82 [0.77, 0.88] for HbA1c 7–7.9%, 8–8.9%, and ≥9%, respectively).

Conclusions

Although diabetes mellitus status had a minor positive impact on cardioprotective medication adherence after AMI, glycemic control at the time of AMI may help identify diabetes mellitus patients at risk of medication nonadherence who may benefit from adherence interventions after AMI.