Current Cardiology Reports

, 15:322 | Cite as

Impediments to Adherence to Post Myocardial Infarction Medications

  • Nihar R. Desai
  • Niteesh K. ChoudhryEmail author
New Therapies for Cardiovascular Disease (K Mahaffey, Section Editor)
Part of the following topical collections:
  1. Topical Collection on New Therapies for Cardiovascular Disease


Non-adherence to evidence-based medications is a major public health problem. Less than 50 % of patients with coronary artery disease adhere to their prescribed therapies and this has important implications for morbidity, mortality, and health care spending. Like most complex behaviors, medication non-adherence is not solely the result of poor patient choices. Rather, there are myriad potential contributors attributable to patients, health care providers, and, more broadly, the health care system. Interventions including patient education and behavioral modification, improving patient-physician communication, and eliminating copayments for preventive pharmacotherapy have all been studied. Clinicians play a critical role in helping improve adherence and assessment of adherence must become a standard component of each clinical encounter. Ultimately, given the various etiologies that contribute to non-adherence, achieving meaningful gains will undoubtedly require payors, providers, and policymakers to develop, rigorously evaluate, and systematically deploy strategies that address key patient, clinician, and health system factors.


Post myocardial infarction Medication adherence Review 



Conflicts of interest: N.R. Desai: none; N.K. Choudhry: has been a consultant for Mercer Health and Benefits; has received unrestricted grants from CVS Caremark, Aetna, Robert Wood Johnson Foundation, and Commonwealth Fund that were paid to Brigham and Women's Hospital to study medication adherence.


Papers of particular interest, published recently, have been highlighted as: • Of importance •• Of major importance

  1. 1.
    DiMatteo MR. Variations in patients' adherence to medical recommendations: a quantitative review of 50 years of research. Medical Care. 2004;42:200–9.PubMedCrossRefGoogle Scholar
  2. 2.
    Osterberg L, Blaschke T. Adherence to medication. N Engl J Med. 2005;353:487–97.PubMedCrossRefGoogle Scholar
  3. 3.
    Yusuf S, Reddy S, Ounpuu S, Anand S. Global burden of cardiovascular diseases: Part I: general considerations, the epidemiologic transition, risk factors, and impact of urbanization. Circulation. 2001;104:2746–53.PubMedCrossRefGoogle Scholar
  4. 4.••
    Lloyd-Jones D, Adams RJ, Brown TM, Carnethon M, Dai S, De Simone G, et al. Heart disease and stroke statistics–2010 update: a report from the American Heart Association. Circulation. 2010;121:e46–e215. This report from the American Heart Association offers important statistics about the burden of CAD and acute myocardial infarction in the United States.PubMedCrossRefGoogle Scholar
  5. 5.
    Antman EM, Hand M, Armstrong PW, Bates ER, Green LA, Halasyamani LK, et al. 2007 focused update of the acc/aha 2004 guidelines for the management of patients with st-elevation myocardial infarction: a report of the American College of Cardiology/American Heart Association task force on practice guidelines: Developed in collaboration with the Canadian Cardiovascular Society endorsed by the American Academy of Family Physicians: 2007 writing group to review new evidence and update the ACC/AHA 2004 guidelines for the management of patients with st-elevation myocardial infarction, writing on behalf of the 2004 writing committee. Circulation. 2008;117:296–329.PubMedCrossRefGoogle Scholar
  6. 6.
    Ford ES, Ajani UA, Croft JB, Critchley JA, Labarthe DR, Kottke TE, et al. Explaining the decrease in U.S. Deaths from coronary disease, 1980–2000. N Engl J Med. 2007;356:2388–98.PubMedCrossRefGoogle Scholar
  7. 7.
    Anderson JL, Adams CD, Antman EM, Bridges CR, Califf RM, Casey Jr DE, et al. ACC/AHA 2007 guidelines for the management of patients with unstable angina/non-st-elevation myocardial infarction: a report of the American College of Cardiology/American Heart Association task force on practice guidelines (writing committee to revise the 2002 guidelines for the management of patients with unstable angina/non-st-elevation myocardial infarction) developed in collaboration with the American College of Emergency Physicians, the Society for Cardiovascular Angiography and Interventions, and the Society of Thoracic Surgeons endorsed by the American Association of Cardiovascular and Pulmonary Rehabilitation and the Society for Academic Emergency Medicine. J Am Coll Cardiol. 2007;50:e1–e157.PubMedCrossRefGoogle Scholar
  8. 8.
    Choudhry NK, Winkelmayer WC. Medication adherence after myocardial infarction: A long way left to go. J Gen Intern Med. 2008;23:216–8.PubMedCrossRefGoogle Scholar
  9. 9.•
    Lloyd-Jones DM, Hong Y, Labarthe D, Mozaffarian D, Appel LJ, Van Horn L, et al. Defining and setting national goals for cardiovascular health promotion and disease reduction: The American Heart Association's strategic impact goal through 2020 and beyond. Circulation. 2010;121:586–613. This report outlines the American Heart Association's 2020 Goal.PubMedCrossRefGoogle Scholar
  10. 10.
    Haynes RB, McDonald H, Garg AX, Montague P. Interventions for helping patients to follow prescriptions for medications. Cochrane Database Syst Rev. 2002;2:CD000011.Google Scholar
  11. 11.
    Morisky DE, Green LW, Levine DM. Concurrent and predictive validity of a self-reported measure of medication adherence. Medical Care. 1986;24:67–74.PubMedCrossRefGoogle Scholar
  12. 12.
    Chisholm-Burns MA, Spivey CA, Garrett C, McGinty H, Mulloy LL. Impact of clinical pharmacy services on renal transplant recipients' adherence and outcomes. Patient Preference Adherence. 2008;2:287–92.CrossRefGoogle Scholar
  13. 13.
    Choudhry NK, Shrank WH, Levin RL, Lee JL, Jan SA, Brookhart MA, et al. Measuring concurrent adherence to multiple related medications. Am J Manag Care. 2009;15:457–64.PubMedGoogle Scholar
  14. 14.
    Peterson ED, Shah BR, Parsons L, Pollack Jr CV, French WJ, Canto JG, et al. Trends in quality of care for patients with acute myocardial infarction in the national registry of myocardial infarction from 1990 to 2006. Am Heart J. 2008;156:1045–55.PubMedCrossRefGoogle Scholar
  15. 15.
    Jackevicius CA, Li P, Tu JV. Prevalence, predictors, and outcomes of primary nonadherence after acute myocardial infarction. Circulation. 2008;117:1028–36.PubMedCrossRefGoogle Scholar
  16. 16.•
    Fischer MA, Choudhry NK, Brill G, Avorn J, Schneeweiss S, Hutchins D, et al. Trouble getting started: Predictors of primary medication nonadherence. Am J Med. 2011;124:1081–e1089–22. This study examines the prevalence, predictors, and outcomes of primary nonadherence.PubMedCrossRefGoogle Scholar
  17. 17.
    Tricoci P, Roe MT, Mulgund J, Newby LK, Smith Jr SC, Pollack Jr CV, et al. Clopidogrel to treat patients with non-st-segment elevation acute coronary syndromes after hospital discharge. Archives of Internal Medicine. 2006;166:806–11.PubMedCrossRefGoogle Scholar
  18. 18.
    Ganz DA, Kuntz KM, Benner JS, Avorn J. Correction: cost-effectiveness of statins in older patients with myocardial infarction. Ann Intern Med. 2002;136:635.PubMedGoogle Scholar
  19. 19.
    Akincigil A, Bowblis JR, Levin C, Jan S, Patel M, Crystal S. Long-term adherence to evidence based secondary prevention therapies after acute myocardial infarction. J Gen Intern Med. 2008;23:115–21.PubMedCrossRefGoogle Scholar
  20. 20.
    Jackevicius CA, Mamdani M, Tu JV. Adherence with statin therapy in elderly patients with and without acute coronary syndromes. JAMA. 2002;288:462–7.PubMedCrossRefGoogle Scholar
  21. 21.
    Kramer JM, Hammill B, Anstrom KJ, Fetterolf D, Snyder R, Charde JP, et al. National evaluation of adherence to beta-blocker therapy for 1 year after acute myocardial infarction in patients with commercial health insurance. Am Heart J. 2006;152:454–e451–8.PubMedCrossRefGoogle Scholar
  22. 22.
    Benner JS, Glynn RJ, Mogun H, Neumann PJ, Weinstein MC, Avorn J. Long-term persistence in use of statin therapy in elderly patients. JAMA. 2002;288:455–61.PubMedCrossRefGoogle Scholar
  23. 23.
    Choudhry NK, Setoguchi S, Levin R, Winkelmayer WC, Shrank WH. Trends in adherence to secondary prevention medications in elderly post-myocardial infarction patients. Pharmacoepidemiol Drug Saf. 2008;17:1189–96.PubMedCrossRefGoogle Scholar
  24. 24.
    Newby LK, LaPointe NM, Chen AY, Kramer JM, Hammill BG, DeLong ER, et al. Long-term adherence to evidence-based secondary prevention therapies in coronary artery disease. Circulation. 2006;113:203–12.PubMedCrossRefGoogle Scholar
  25. 25.•
    Bowry AD, Shrank WH, Lee JL, Stedman M, Choudhry NK. A systematic review of adherence to cardiovascular medications in resource-limited settings. J Gen Intern Med. 2011;26:1479–91. This review discusses adherence to cardiovascular medications in resource-limited settings.PubMedCrossRefGoogle Scholar
  26. 26.
    Rasmussen JN, Chong A, Alter DA. Relationship between adherence to evidence-based pharmacotherapy and long-term mortality after acute myocardial infarction. JAMA. 2007;297:177–86.PubMedCrossRefGoogle Scholar
  27. 27.
    Ho PM, Magid DJ, Masoudi FA, McClure DL, Rumsfeld JS. Adherence to cardioprotective medications and mortality among patients with diabetes and ischemic heart disease. BMC Cardiovasc Disord. 2006;6:48.PubMedCrossRefGoogle Scholar
  28. 28.
    Ho PM, Magid DJ, Shetterly SM, Olson KL, Maddox TM, Peterson PN, et al. Medication nonadherence is associated with a broad range of adverse outcomes in patients with coronary artery disease. Am Heart J. 2008;155:772–9.PubMedCrossRefGoogle Scholar
  29. 29.
    Enhancing prescription medicine adherence: a national action plan. National Council on Patient Information and Education. August 2007. Available at Accessed August 19, 2012.
  30. 30.
    Sabate E. Adherence to long term therapies: evidence for action. Geneva. Switzerland: World Health Organization; 2003. Accessed August 19, 2012.Google Scholar
  31. 31.
    Chapman RH, Benner JS, Petrilla AA, Tierce JC, Collins SR, Battleman DS, et al. Predictors of adherence with antihypertensive and lipid-lowering therapy. Arch Intern Med. 2005;165:1147–52.PubMedCrossRefGoogle Scholar
  32. 32.•
    Shrank WH, Liberman JN, Fischer MA, Kilabuk E, Girdish C, Cutrona S, et al. Are caregivers adherent to their own medications? J Am Pharm Assoc (2003). 2011;51:492–8. This study examines adherence patterns among caregivers.Google Scholar
  33. 33.•
    Chan DC, Shrank WH, Cutler D, Jan S, Fischer MA, Liu J, et al. Patient, physician, and payment predictors of statin adherence. Med Care. 2010;48:196–202. This study examines patient, physician, and payment predictors of statin adherence.PubMedCrossRefGoogle Scholar
  34. 34.•
    Fischer MA, Choudhry NK, Brill G, Avorn J, Schneeweiss S, Hutchins D, et al. Trouble getting started: predictors of primary medication nonadherence. Am J Med. 2011;124:1081.e1089–1081.e1022. This study examines the prevalence, predictors, and outcomes of primary nonadherence.Google Scholar
  35. 35.•
    Marshall IJ, Wolfe CD, McKevitt C. Lay perspectives on hypertension and drug adherence: Systematic review of qualitative research. BMJ. 2012;345:e3953.Google Scholar
  36. 36.
    Aikens JE, Piette JD. Diabetic patients' medication underuse, illness outcomes, and beliefs about antihyperglycemic and antihypertensive treatments. Diabetes Care. 2009;32:19–24.PubMedCrossRefGoogle Scholar
  37. 37.•
    Kulik A, Shrank WH, Levin R, Choudhry NK. Adherence to statin therapy in elderly patients after hospitalization for coronary revascularization. Am J Cardiol. 2011;107:1409–14. This study examines the impact of coronary revascularizatin on adherence to statin therapy.PubMedCrossRefGoogle Scholar
  38. 38.
    Jiang W, Glassman A, Krishnan R, O'Connor CM, Califf RM. Depression and ischemic heart disease: what have we learned so far and what must we do in the future? Am Heart J. 2005;150:54–78.PubMedCrossRefGoogle Scholar
  39. 39.
    Gehi A, Haas D, Pipkin S, Whooley MA. Depression and medication adherence in outpatients with coronary heart disease: findings from the heart and soul study. Arch Intern Med. 2005;165:2508–13.PubMedCrossRefGoogle Scholar
  40. 40.
    Rieckmann N, Gerin W, Kronish IM, Burg MM, Chaplin WF, Kong G, et al. Course of depressive symptoms and medication adherence after acute coronary syndromes: An electronic medication monitoring study. J Am Coll Cardiol. 2006;48:2218–22.PubMedCrossRefGoogle Scholar
  41. 41.
    Saini SD, Schoenfeld P, Kaulback K, Dubinsky MC. Effect of medication dosing frequency on adherence in chronic diseases. Am J Manag Care. 2009;15:e22–33.PubMedGoogle Scholar
  42. 42.
    Ingersoll KS, Cohen J. The impact of medication regimen factors on adherence to chronic treatment: a review of literature. J Behav Med. 2008;31:213–24.PubMedCrossRefGoogle Scholar
  43. 43.
    Chapman RH, Petrilla AA, Benner JS, Schwartz JS, Tang SS. Predictors of adherence to concomitant antihypertensive and lipid-lowering medications in older adults: a retrospective, cohort study. Drugs Aging. 2008;25:885–92.PubMedCrossRefGoogle Scholar
  44. 44.
    Bangalore S, Kamalakkannan G, Parkar S, Messerli FH. Fixed-dose combinations improve medication compliance: a meta-analysis. Am J Med. 2007;120:713–9.PubMedCrossRefGoogle Scholar
  45. 45.
    Yusuf S. Two decades of progress in preventing vascular disease. Lancet. 2002;360:2–3.PubMedCrossRefGoogle Scholar
  46. 46.
    Wald NJ, Law MR. A strategy to reduce cardiovascular disease by more than 80 %. BMJ. 2003;326:1419.PubMedCrossRefGoogle Scholar
  47. 47.
    Brookhart MA, Patrick AR, Schneeweiss S, Avorn J, Dormuth C, Shrank W, et al. Physician follow-up and provider continuity are associated with long-term medication adherence: a study of the dynamics of statin use. Arch Intern Med. 2007;167:847–52.PubMedCrossRefGoogle Scholar
  48. 48.••
    Bosworth HB, Granger BB, Mendys P, Brindis R, Burkholder R, Czajkowski SM, et al. Medication adherence: a call for action. Am Heart J. 2011;162:412–24. This comprehensive review examines the prevalence, predictors, and interventions to address non-adherence.PubMedCrossRefGoogle Scholar
  49. 49.
    Choudhry NK, Brennan T, Toscano M, Spettell C, Glynn RJ, Rubino M, et al. Rationale and design of the post-mi freee trial: a randomized evaluation of first-dollar drug coverage for post–myocardial infarction secondary preventive therapies. Am Heart J. 2008;156:31–6.PubMedCrossRefGoogle Scholar
  50. 50.
    Rector TS, Venus PJ. Do drug benefits help medicare beneficiaries afford prescribed drugs? Health Aff (Millwood). 2004;23:213–22.CrossRefGoogle Scholar
  51. 51.
    Felland LE, Reschovsky JD. More nonelderly Americans face problems affording prescription drugs. Tracking Rep/Center for Studying Health System Change. 2009:1–4.Google Scholar
  52. 52.
    Adams AS, Soumerai SB, Ross-Degnan D. Use of antihypertensive drugs by medicare enrollees: does type of drug coverage matter? Health Aff (Millwood). 2001;20:276–86.CrossRefGoogle Scholar
  53. 53.•
    Polinski JM, Shrank WH, Glynn RJ, Huskamp HA, Roebuck MC, Schneeweiss S. Beneficiaries with cardiovascular disease and thepart d coverage gap. Circ Cardiovasc Qual Outcomes. 2012;5:387–95. This study explores the relationship between medication cost and adherence among patients with cardiovascular disease.PubMedCrossRefGoogle Scholar
  54. 54.
    Doshi JA, Zhu J, Lee BY, Kimmel SE, Volpp KG. Impact of a prescription copayment increase on lipid-lowering medication adherence in veterans. Circulation. 2009;119:390–7.PubMedCrossRefGoogle Scholar
  55. 55.
    Goldman DP, Joyce GF, Escarce JJ, Pace JE, Solomon MD, Laouri M, et al. Pharmacy benefits and the use of drugs by the chronically ill. JAMA. 2004;291:2344–50.PubMedCrossRefGoogle Scholar
  56. 56.
    Goldman DP, Joyce GF, Zheng Y. Prescription drug cost sharing: associations with medication and medical utilization and spending and health. JAMA. 2007;298:61–9.PubMedCrossRefGoogle Scholar
  57. 57.•
    Choudhry NK, Fischer MA, Avorn J, Liberman JN, Schneeweiss S, Pakes J, et al. The implications of therapeutic complexity on adherence to cardiovascular medications. Arch Intern Med. 2011;171:814–22. This study highlights the impact of therapeutic complexity on adherence, demonstrating that beyond number of medications, refill consolidation and number of different prescribers have important effects on adherence.PubMedCrossRefGoogle Scholar
  58. 58.
    Smith DH, Kramer JM, Perrin N, Platt R, Roblin DW, Lane K, et al. A randomized trial of direct-to-patient communication to enhance adherence to beta-blocker therapy following myocardial infarction. Arch Intern Med. 2008;168:477–83.PubMedCrossRefGoogle Scholar
  59. 59.•
    Ito K, Shrank WH, Avorn J, Patrick AR, Brennan TA, Antman EM, et al. Comparative cost-effectiveness of interventions to improve medication adherence after myocardial infarction. Health Serv Res. (in press). This study demonstrates that interventions that improve adherence post myocardial infarction are cost-saving.Google Scholar
  60. 60.
    Choudhry NK, Avorn J, Antman EM, Schneeweiss S, Shrank WH. Should patients receive secondary prevention medications for free after a myocardial infarction? An economic analysis. Health Aff (Millwood). 2007;26:186–94.CrossRefGoogle Scholar
  61. 61.
    Choudhry NK, Patrick AR, Antman EM, Avorn J, Shrank WH. Cost-effectiveness of providing full drug coverage to increase medication adherence in post–myocardial infarction medicare beneficiaries. Circulation. 2008;117:1261–8.PubMedCrossRefGoogle Scholar
  62. 62.
    Chernew ME, Shah MR, Wegh A, Rosenberg SN, Juster IA, Rosen AB, et al. Impact of decreasing copayments on medication adherence within a disease management environment. Health Aff (Millwood). 2008;27:103–12.CrossRefGoogle Scholar
  63. 63.••
    Choudhry NK, Avorn J, Glynn RJ, Antman EM, Schneeweiss S, Toscano M, et al. Full coverage for preventive medications after myocardial infarction. N Engl J Med. 2011;365:2088–97. This randomized trial of full coverage vs standard coverage for preventive medications after myocardial infarction demonstrates that the former was associated with improvements in adherence and major vascular events without increasing costs.PubMedCrossRefGoogle Scholar
  64. 64.
    Shah ND, Dunlay SM, Ting HH, Montori VM, Thomas RJ, Wagie AE, et al. Long-term medication adherence after myocardial infarction: experience of a community. Am J Med. 2009;122:961 e967–913.Google Scholar
  65. 65.•
    Kwan G, Balady GJ. Cardiac rehabilitation 2012: advancing the field through emerging science. Circulation. 2012;125:e369–73. This is a review of the benefits of cardiac rehabilitation.PubMedCrossRefGoogle Scholar
  66. 66.
    Kripalani S, Yao X, Haynes RB. Interventions to enhance medication adherence in chronic medical conditions: a systematic review. Arch Intern Med. 2007;167:540–50.PubMedCrossRefGoogle Scholar
  67. 67.•
    Cutrona SL, Choudhry NK, Fischer MA, Servi AD, Stedman M, Liberman JN, et al. Targeting cardiovascular medication adherence interventions. J Am Pharmts Assoc. 2012;52:381–97. This study examines various approaches to improving adherence, finding that targetted interventions are more effective than broad interventions.CrossRefGoogle Scholar
  68. 68.•
    Cutrona SL, Choudhry NK, Fischer MA, Servi A, Liberman JN, Brennan TA, et al. Modes of delivery for interventions to improve cardiovascular medication adherence. Am J Manage Care. 2010;16:929–42. This study examines the impact of different modes and locations of adherence interventions.Google Scholar
  69. 69.•
    Lambert-Kerzner A, Del Giacco EJ, Fahdi IE, Bryson CL, Melnyk SD, Bosworth HB, et al. Patient-centered adherence intervention after acute coronary syndrome hospitalization. Circ Cardiovasc Qual Outcomes. 2012;5:571–6. This paper describes an ongoing trial of a multifaceted intervention to improve adherence after myocardial infarction.PubMedCrossRefGoogle Scholar
  70. 70.•
    Choudhry NK. Promoting persistence: improving adherence through choice of drug class. Circulation. 2011;123:1584–6. This paper highlights the impact of provider prescribing choice on medication adherence.PubMedCrossRefGoogle Scholar
  71. 71.
    Peters E, Dieckmann N, Dixon A, Hibbard JH, Mertz CK. Less is more in presenting quality information to consumers. Med Care ResRev MCRR. 2007;64:169–90.CrossRefGoogle Scholar
  72. 72.•
    Shrank WH, Parker R, Davis T, Pandit AU, Knox JP, Moraras P, et al. Rationale and design of a randomized trial to evaluate an evidence-based prescription drug label on actual medication use. Contemp Clin Trials. 2010;31:564–71. This study examines patient beliefs about effective communications about their medical regimens.PubMedCrossRefGoogle Scholar
  73. 73.•
    Misono AS, Cutrona SL, Choudhry NK, Fischer MA, Stedman MR, et al. Healthcare information technology interventions to improve cardiovascular and diabetes medication adherence. Am J Manag Care. 2010;16:SP82–92. This study explores the impact of health information technology based interventions on medication adherence.PubMedGoogle Scholar
  74. 74.••
    Anderson JL, Adams CD, Antman EM, Bridges CR, Califf RM, Casey Jr DE, et al. 2011 ACCF/AHA focused update incorporated into the ACC/AHA 2007 guidelines for the management of patients with unstable angina/non-st-elevation myocardial infarction: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. Circulation. 2011;123:e426–579. These are the 2011 guidelines for patients with non-ST segment elevation acute coronary syndromes.PubMedCrossRefGoogle Scholar
  75. 75.•
    Roe MT, Messenger JC, Weintraub WS, Cannon CP, Fonarow GC, Dai D, et al. Treatments, trends, and outcomes of acute myocardial infarction and percutaneous coronary intervention. J Am Coll Cardio. 2010;56:254–63. This is a contemporary examination of patterns of care for patients with acute myocardial infarction.CrossRefGoogle Scholar
  76. 76.
    Gellad WF, Grenard J, McGlynn EA. A review of barriers to medication adherence: a framework for driving policy options. RAND Corporation. 2009. Available at Accessed August 19, 2012.

Copyright information

© Springer Science+Business Media New York 2012

Authors and Affiliations

  1. 1.Brigham and Women’s HospitalHarvard Medical SchoolBostonUSA

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