International Journal of Clinical Pharmacy

, Volume 35, Issue 2, pp 275–280 | Cite as

Patients’ adherence to secondary prevention pharmacotherapy after acute coronary syndromes

  • Yaman KassabEmail author
  • Yahaya Hassan
  • Noorizan Abd Aziz
  • Omar Ismail
  • Hadeer AbdulRazzaq
Research Article


Background Secondary prevention pharmacotherapy improves outcomes after acute coronary syndrome (ACS). However, poor medication adherence is common, and various factors play a role in adherence. Objectives The purpose of this study was to evaluate patients’ level of adherence to evidence-based therapies at an average of 6 months after discharge for ACS and to identify factors associated with self-reported non-adherence. Setting This prospective study was conducted in the outpatient cardiac clinics of Hospital Pulau Pinang, located in Penang Island, a northern state in Malaysia. Method A random sample of ACS patients (n = 190) who had been discharged on a regimen of secondary preventive medications were included in this study. Six months after discharge and during their scheduled follow-up appointments to cardiac clinics, patients were interviewed using the translated eight-item Morisky Medication Adherence Scale. Main outcome measure self-reported patients’ adherence to medication. Results Six months following their hospital discharge, only 35 patients (18.4 %) reported high adherence. Medium adherence was reported in majority of patients (51.1 %). Low adherence was reported in 58 patients (30.5 %). Forgetfulness was the most frequently reported reason for patients’ non-adherence to their medications (23.2 %). Furthermore, this study identified 5 factors—namely age, employment status, ACS subtypes, number of comorbidities, and number of prescription medications per day—that may influence Patients’ level of adherence to the prescribed regimens. Conclusions Our findings revealed a problem of non-adherence to secondary prevention medications among patients with ACS in Malaysia. Furthermore, this study demonstrates that older patients, unemployed patients, patients with more comorbid conditions, and those receiving multiple medications are less likely to adhere to their prescribed medications 6 months after hospital discharge.


Adherence Acute coronary syndrome Morisky scale Malaysia Secondary prevention medications 



Special thanks to the staff of Hospital Pulau Pinang cardiology and pharmacy department for their support. This work formed part of a research project submitted as a thesis for the degree of Doctor of Philosophy in clinical pharmacy, Universiti Sains Malaysia, School of Pharmaceutical Sciences.


Funding for this project was provided by the Universiti Sains Malaysia Postgraduate research grant number (1001/PFARMASI/844055).

Conflicts of interest

None of the authors have any conflicts of interest.


  1. 1.
    Kernis SJ, Harjai KJ, Stone GW, Grines LL, Boura JA, et al. Does beta-blocker therapy improve clinical outcomes of acute myocardial infarction after successful primary angioplasty? J Am Coll Cardiol. 2004;43:1773–9.PubMedCrossRefGoogle Scholar
  2. 2.
    Bhatt DL, Fox KA, Hacke W, Berger PB, Black HR, et al. Clopidogrel and aspirin versus aspirin alone for the prevention of atherothrombotic events. N Eng J Med. 2006;354:1706–17.CrossRefGoogle Scholar
  3. 3.
    Serruys PC, de Feyter P, Macaya C, Kokott N, Puel J, et al. Fluvastatin for prevention of cardiac events following successful first percutaneous coronary intervention: a randomized controlled trial. J Am Med Assoc. 2002;287:3215–22.CrossRefGoogle Scholar
  4. 4.
    Tea KK, Yusuf S, Pfeffer M, Kober L, Hall A, et al. Effects of long-term treatment with angiotensin-converting-enzyme inhibitors in the presence or absence of aspirin: a systematic review. Lancet. 2002;360:1037–43.CrossRefGoogle Scholar
  5. 5.
    Ars F, Loma-Osorio Á, Vila J, Lpez-Bescs L, Cuat J, et al. Effect of combined beta-blocker and angiotensin-converting enzyme inhibitor treatment on 1-year survival after acute myocardial infarction: findings of the PRIAMHO-II registry. Rev Esp Cardiol. 2006;59:313–20.CrossRefGoogle Scholar
  6. 6.
    Spencer FA, Lessard D, Yarzebski J, Gore JM, Goldberg RJ. Decade-long changes in the use of combination evidence-based medical therapy at discharge for patients surviving acute myocardial infarction. Am Heart J. 2005;150:838–44.PubMedCrossRefGoogle Scholar
  7. 7.
    Sud A, Kline-Rogers EM, Eagle KA, Fang J, Armstrong DF, et al. Adherence to medications by patients after acute coronary syndromes. Ann Pharmacother. 2005;39:1792–7.PubMedCrossRefGoogle Scholar
  8. 8.
    Kassab YW, Hassan Y, Abd Aziz N, Akram H, Ismail O. Use of evidence-based therapy for the secondary prevention of acute coronary syndromes in Malaysian practice. J Eval Clin Pract. 2012. doi: 10.1111/j.1365-2753.2012.01894.x.
  9. 9.
    Al-Qasem A, Smith F, Clifford S. Adherence to medication among chronic patients in Middle Eastern countries: review of studies. East Mediterr Health J. 2011;17:356–63.PubMedGoogle Scholar
  10. 10.
    Gallagher E, Viscoli CM, Horwitz RI. The relationship of treatment adherence to the risk of death after myocardial infarction in women. J Am Med Assoc. 1993;270:742–4.CrossRefGoogle Scholar
  11. 11.
    Ockene I, Hayman L, Pasternak R, Schron E, Dunbar-Jacob J. Task force #4-adherence issues and behavior changes: achieving a long-term solution. J Am Coll Cardiol. 2002;40:630–40.PubMedCrossRefGoogle Scholar
  12. 12.
    Berg JS, Dischler J, Wagner DJ, Raia JJ, Palmer-Shevlin N. Medication compliance: a healthcare problem. Ann Pharmacother. 1993;27(9 suppl):S1–24.PubMedGoogle Scholar
  13. 13.
    Al-Qazaz HK, Hassali MA, Shafie AA, Sulaiman SA, Sundram S, Morisky DE. The eight-item Morisky Medication Adherence Scale MMAS: translation and validation of the Malaysian version. Diabetes Res Clin Pract. 2010;90:216–21.PubMedCrossRefGoogle Scholar
  14. 14.
    Morisky DE, Ang A, Krousel-Wood M, Ward HJ. Predictive validity of a medication adherence measure in an outpatient setting. J Clin Hypertens. 2008;10:348–54.CrossRefGoogle Scholar
  15. 15.
    Quek KF, Low WY, Razack AH, Loh CS. Reliability and validity of the International Prostate Symptom Score in a Malaysian population. Brit J Urol. 2001;88:21–5.CrossRefGoogle Scholar
  16. 16.
    Hinton PR, Brownlow C, McMurray I, Cozens B. SPSS Explained. 1st ed. London: Routledge; 2004.Google Scholar
  17. 17.
    Eagle K, Kline-Rogers E, Goodman S, Gurfinkel E, Avezum A, et al. Adherence to evidence-based therapies after discharge for acute coronary syndromes: an ongoing prospective, observational study. Am J Med. 2004;117:73–81.PubMedCrossRefGoogle Scholar
  18. 18.
    Wang PS, Bohn RL, Knight E, Glynn RJ, Mogun H, Avorn J. Non-compliance with antihypertensive medications: the impact of depressive symptoms and psychosocial factors. J Gen Intern Med. 2002;17:504–11.PubMedCrossRefGoogle Scholar
  19. 19.
    Eagle KA, Goodman SG, Avezum Á, Budaj A, Sullivan CM, López-Sendón J. Practice variation and missed opportunities for reperfusion in ST-segment elevation myocardial infarction—findings from the global registry of acute coronary events (GRACE). Lancet. 2002;359:373–7.PubMedCrossRefGoogle Scholar
  20. 20.
    Jackevicius CA, Mamdani M, Tu JV. Adherence with statin therapy in elderly patients with and without acute coronary syndromes. J Am Med Assoc. 2002;288:462–7.CrossRefGoogle Scholar
  21. 21.
    Benner JS, Glynn RJ, Mogun H, Neumann PJ, Weinstein MC, Avorn J. Long-term persistence in use of statin therapy in elderly patients. J Am Med Assoc. 2002;288:455–61.CrossRefGoogle Scholar
  22. 22.
    Cheng JWM, Kalis MM, Feifer S. Patient-reported adherence to guidelines of the sixth joint national committee on prevention, detection, evaluation, and treatment of high blood pressure. Pharmacotherapy. 2001;21:828–41.PubMedCrossRefGoogle Scholar
  23. 23.
    Khanderia U, Townsend KA, Erickson SR, Vlasnik J, Prager RL, Eagle KA. Medication adherence following coronary artery bypass graft surgery: assessment of beliefs and attitudes. Ann Pharmacother. 2008;42:192–9.PubMedCrossRefGoogle Scholar
  24. 24.
    Roe CM, Motheral BR, Teitelbaum F, Rich MW. Compliance with and dosing of angiotensin-converting-enzyme inhibitors before and after hospitalization. Am J Health Syst Pharm. 2000;57:139–45.PubMedGoogle Scholar
  25. 25.
    McLane CG, Zyzanski SJ, Flocke SA. Factors associated with medication noncompliance in rural elderly hypertensive patients. Am J Hypertens. 1995;8:206–9.PubMedCrossRefGoogle Scholar

Copyright information

© Springer Science+Business Media Dordrecht 2012

Authors and Affiliations

  • Yaman Kassab
    • 1
    Email author
  • Yahaya Hassan
    • 2
  • Noorizan Abd Aziz
    • 2
  • Omar Ismail
    • 3
  • Hadeer AbdulRazzaq
    • 1
  1. 1.Department of Clinical Pharmacy, School of Pharmaceutical SciencesUniversiti Sains MalaysiaPulau PinangMalaysia
  2. 2.Department of Clinical Pharmacy, Faculty of PharmacyUniversity Teknologi MARASelangorMalaysia
  3. 3.Department of CardiologyHospital Pulau PinangPinangMalaysia

Personalised recommendations