Drug Therapy and Adherence in Patients With Coronary Heart Disease: Results of the Russian Part of the EUROASPIRE V International Multicenter Study

Progress Analysis of Personalized Antiplatelet Therapy in Patients with Coronary Heart Disease Undergoing Interventional Therapy

Coronary atherosclerosis (or coronary heart disease [CHD]) is a common cardiovascular disease that seriously damages human health. Percutaneous coronary stent implantation represents the primary treatment option for severe CHD in clinical practice; meanwhile, dual antiplatelet therapy (DAPT) is widely used to reduce the risk of postoperative thrombosis. Although the mechanisms of action of the two most commonly used antiplatelet drugs, aspirin and clopidogrel, remain unclear, clinical studies have shown that some patients are susceptible to stent thrombosis-antiplatelet resistance (high on-treatment platelet reactivity [HTPR])-despite using these drugs. Therefore, screening for HTPR and formulating personalized antiplatelet therapies is necessary. Ticagrelor, indobufen, and rivaroxaban are the most common and safe antiplatelet drugs used in clinical practice, with broad application prospects. This review summarizes the mechanisms of action of existing antiplatelet drugs, reasons for personalized treatment, screening of antiplatelet reactions, and development of novel antiplatelet drugs.

Constructing a prognostic tool for predicting the risk of non-adherence to antiplatelet therapy in discharged patients with coronary heart disease: a retrospective cohort study

Objective

To investigate the incidence and influencing factors affecting the non-adherence behavior of patients with coronary heart disease (CHD) to antiplatelet therapy after discharge and to construct a personalized predictive tool.

Methods

In this retrospective cohort study, 289 patients with CHD who were admitted to the Department of Cardiology of The First Affiliated Hospital of the University of Science and Technology of China between June 2021 and September 2021 were enrolled. The clinical data of all patients were retrospectively collected from the hospital information system, and patients were followed up for 1 year after discharge to evaluate their adherence level to antiplatelet therapy, analyze their present situation and influencing factors for post-discharge adherence to antiplatelet therapy, and construct a nomogram model to predict the risk of non-adherence.

Results

Based on the adherence level to antiplatelet therapy within 1 year after discharge, the patients were divided into the adherence (n = 216) and non-adherence (n = 73) groups. Univariate analysis revealed statistically significant differences between the two groups in terms of variable distribution, including age, education level, medical payment method, number of combined risk factors, percutaneous coronary intervention, duration of antiplatelet medication, types of drugs taken at discharge, and CHD type (P < 0.05). Furthermore, multivariate logistic regression analysis revealed that, except for the medical payment method, all the seven abovementioned variables were independent risk factors for non-adherence to antiplatelet therapy (P < 0.05). The areas under the receiver operating characteristic curve before and after the internal validation of the predictive tool based on the seven independent risk factors and the nomogram were 0.899 (95% confidence interval [CI]: 0.858-0.941) and 0.89 (95% CI: 0.847-0.933), respectively; this indicates that the tool has good discrimination ability. The calibration curve and Hosmer-Lemeshow goodness of fit test revealed that the tool exhibited good calibration and prediction consistency (χ2 = 5.17, P = 0.739).

Conclusion

In this retrospective cohort study, we investigated the incidence and influencing factors affecting the non-adherence behavior of patients with CHD after discharge to antiplatelet therapy. For this, we constructed a personalized predictive tool based on seven independent risk factors affecting non-adherence behavior. The predictive tool exhibited good discrimination ability, calibration, and clinical applicability. Overall, our constructed tool is useful for predicting the risk of non-adherence behavior to antiplatelet therapy in discharged patients with CHD and can be used in personalized intervention strategies to improve patient outcomes.

Adherence to Visits to Medical Institutions and Quality of Therapy after Acute Coronary Syndrome (according to the LIS Registry 3)

Aim. The aim of the research is to evaluate the relationship between patients' adherence to visiting polyclinics after acute coronary syndrome (ACS) and the quality of the therapy they receive.

Material and methods. The study was conducted on the basis of the LIS registers (LIS and LIS-3) (Lyubertsy study of mortality) in the Lyubertsy district of the Moscow region. To clarify the vital status of all patients discharged in the first 9 months of 2014 and 2018. from Lyubertsy district hospital 2, contact was established no earlier than 1 year after discharge, and in case of death, its cause was clarified. In the course of a telephone survey, information was obtained on the therapy taken, adherence to visits to medical institutions, a record of cases of cardiovascular events and invasive treatment, hospitalizations due to worsening of the course of the underlying disease for the period after discharge from the hospital was carried out. The search for patients who did not answer the phone call was carried out by studying the archives of polyclinics, using the Megaclinic statistical database, and the data of the individual rehabilitation program for the disabled. In the course of a telephone survey, the response was 60.5%, the search for the remaining patients through statistical databases, the archive of polyclinics made it possible to increase the total response to 87.2%.

Results. In the LIS-3 registry, out of 104 patients discharged in 2014, the status was determined in 90 (86.5%) patients, out of 223 patients in 2018 – in 195 (87.4%) patients. During the survey, it was found that 172 patients are observed after discharge from the hospital, 53 patients are not observed at all in the medical facility after discharge. 11 (4.9%) people did not take any groups of medications at the time of the survey. In the group of patients who are highly committed to attending a health facility, the best quality of taking essential medications after discharge from the hospital was noted according to the survey: statins (88.2%, p<0.001), beta-blockers (86.4%, p<0.001) and antiplatelets (90.9%, p=0.001). In both groups, committed and not committed to attending a medical facility, there is a negative dynamics in the quality of taking medications after discharge from the hospital, however, in the group of patients committed to attending a medical facility, it was noted that the odds of taking antiplatelet agents after discharge was 3.4 times higher (OR 3.449, p=0.002), beta-blockers – 4 times (OR 4.103, p<0.001), statins – 4.5 times (OR 4.450, p<0.001), in relation to the group of patients who are not observed in the medical facility after discharge from the hospital.

Conclusion. 1-6 years after discharge from the hospital after the reference event, the quality of therapy deteriorated significantly in both groups, mostly in non-adherent patients. Significant differences in the quality of medication intake (antiplatelet agents, statins, β-blockers) were noted in the group of adherents to visiting health care facilities in comparison with those who were not committed to visiting health facilities. It is obvious that high adherence to visits to healthcare facilities after discharge from the hospital is associated with better quality of medication intake. Despite improvements in the quality of adherence to clinical recommendations, the percentage of patients who independently refuse to take drug therapy (4.9%), regardless of visits to healthcare facilities after discharge from the hospital, remains. 

The prevalence of hyperlipidemia and features of lipid-lowering therapy in patients with myocardial infarction according to the Russian register of acute myocardial infarction REGION-MI

Aim      To study the prevalence of hyperlipidemia in patients with myocardial infarction (MI) in the Russian Federation; to assess the compliance with clinical practice guidelines of the lipid-lowering therapy prescribed upon discharge from the hospital; and to determine the number of patients who are indicated for the combination lipid-lowering therapy to achieve the low-density lipoprotein cholesterol (LDL-C) goal.Material and methods  REGION-MI is Russian rEGIstry Of acute myocardial iNfarction, a multicenter, retrospective and prospective observational study. The observation period was divided into 3 stages: observation during the stay in the hospital and at 6 and 12 months after the inclusion in the registry. Plasma total cholesterol (TC) and LDL-C were measured in all patients on admission. Evaluation of the prescribed lipid-lowering therapy included the intensity of the treatment.Results The study included 3 620 patients; 62.4 of them had hyperlipidemia on admission. Mean TC on admission was 5.29 mmol/l and LDl-C level was 3.35 mmol/l. Upon discharge, 95.4% of patients after myocardial infarction continued on or were prescribed statin therapy; ezetimibe was prescribed to 1.22% of patients. Patients with an extremely high level of LDL-C &gt;5 mmol/l accounted for 10.7% of patients with hyperlipidemia. The target level of LDL-C ≤1.4 mmol/l cannot be achieved with the statin and ezetimibe combination therapy in these patients; drugs from the group of PCSK9 inhibitors are indicated for them.Conclusion      According to the data of the Russian registry of acute myocardial infarction, REGION-MI, a high incidence of hyperlipidemia is observed in patients with acute MI. Despite multiple studies that have proven the importance of achieving a low LDL-C level and good tolerance and safety of ezetimibe and PCSK9 inhibitors, the prescription frequency of combination therapy remains unreasonably low. Results of a simulation study that was conducted in Sweden and the data of the REGION-MI registry showed that PCSK9 inhibitors as a part of the combination therapy are indicated for many patients. The combination therapy is presently the most powerful type of lipid-lowering treatment that allows, in most cases, achievement of the LDL-C goal.