medication adherence – ABC CARDIOL

IJCS

Original Article

Assessment of Adherence to Drug Therapy in Patients with Heart Failure Followed at a Specialized Outpatient Clinic

Breno Gabriel Araújo Sampaio de Jesus et al. Felipe Barros Oliveira Felipe Caires Araújo Meira Lívia Brito Oliveira … Fabio Figueirêdo Costa Adriana Lopes Latado

Abstract

Background:

Heart failure (HF) is a severe syndrome with high global prevalence. Despite safe and effective pharmacological therapies, its prognosis remains unfavorable, and low treatment adherence is the leading cause of rehospitalizations and worse outcomes.

Objective:

To assess treatment adherence and its determinants in patients with HF followed at cardiology outpatient clinics of a specialized hospital.

Methods:

A single-center, cross-sectional, observational study was conducted, with data collection via in-person interviews. Treatment adherence was measured using the Brief Medication Questionnaire (BMQ). Variables associated with adherence with p < 0.10 were included in a multivariate model, considering a significance level of 5%.

Results:

A total of 200 patients were included; 79.6% showed low adherence according to the BMQ, and 52.6% showed low adherence in the “regimen” domain. Only 3 (1.6%) patients presented no barriers to adherence. In multivariate analysis, being married (odds ratio [OR] 0.40; 95% confidence interval [CI] 0.16–0.96; p = 0.042), prior acute coronary syndrome (ACS) (OR 0.21; 95% CI 0.08–0.51; p < 0.001), education level (OR 0.90; 95% CI 0.82–0.98; p = 0.018), higher number of prescribed medications (OR 1.44; 95% CI 1.03–2.05; p = 0.037), and HF with improved ejection fraction (OR 2.76; 95% CI 1.06–7.63; p = 0.042) were independent predictors of low adherence.

Conclusion:

Low therapeutic adherence among patients with HF is prevalent and influenced by socioeconomic factors, social support, polypharmacy, and clinical characteristics. The results reinforce the need for health education and the simplification of therapeutic regimens.

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Original Article

Therapeutic Adherence According to the Morisky Scale in Patients with Hypertension

Vinícius Encenha Lanza et al. Gabriel Oliveira Silva Celi Cristina Calamita Quiroga Margaret Assad Cavalcante … Weimar Kunz Sebba Barroso Andréa Araujo Brandão Eduardo Costa Duarte Barbosa Marcus Vinicius Bolivar Malachias Marco Mota Gomes Celso Amodeo Rui Manoel dos Santos Povoa Dalton Bertolim Précoma Antônio Carlos Sobral Sousa João Miguel Malta Dantas Evandro José Cesarino Pedro G. M. de Barros e Silva Paulo Cesar B. Veiga Jardim Renato D. Lopes

Abstract

Background

In view of the high prevalence of hypertension and the importance of adequate drug therapy in the prevention of complications, it is necessary to know the adherence to drug treatment in this population.

Objective

To verify adherence to antihypertensive drug treatment in Brazilian patients with hypertension using the Morisky-Green Test (MGT), relating it with demographic data.

Methods

Prospective, observational, multicenter, national registry study, with 2,578 hypertensive patients participating in study I, the Brazilian Cardiovascular Registry of Arterial Hypertension (I-RBH), recruited in the five regions of Brazil. The analyses carried out on the data were descriptive statistics, qui-square tests, ANOVA, and logistic regression, adopting 5% as the significance level for the tests.

Results

The research shows that 56.13% of patients in the sample were female; 56.71% were elderly (≥ 65 years); 55.86% were White; 52.37% were from the Southeast Region; and 59.74% were non-adherent. Logistic regression showed an independent relationship between patients’ age, ethnicity, and region with medication adherence.

Conclusion

Adherence to treatment is the key to reducing high rates of cardiovascular complications. The study brings a successful outcome in the relationship between the factors ethnicity, age, and region of patients with hypertension and medication adherence. To this end, it is necessary to understand these factors, considering systematic evaluation in the care of patients with hypertension and other chronic non-communicable diseases. This study is a significant contribution to multidisciplinary teams, as it highlights which risk factors interfere with medication adherence, incorporating better strategies in health education.

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IJCS

Editorial

Challenging Health Literacy, Patient Knowledge, and Adherence to Oral Anticoagulation in Primary Care Units

Alfredo José Mansur

Care of patients and therapeutics in clinical practice has evolved based on scientific and technological advances, mainly in patients living in societies with appropriate social, educational, and economic conditions, as well as supported facilities that are able to be elicited when needed. However social disparities, whether in social and economic background or in education can vary among population subsets in a way that may hinder the proper care necessary to fulfill expected results. These disparities influence adherence that may be less than optimal. Health literacy is a public concern recognized by different agencies, including the World Health Organization (WHO). Moreover, the healthcare network in different countries may vary.

In Brazil, reports of experiences in primary care facilities, which present interesting opportunities to add to the clinical experience, were evaluated in the city of Divinópolis, in the southeastern region of Brazil, with estimated population of 242,505 inhabitants. Primary care facilities in Divinópolis are organized in 43 primary care units. In the current study, the authors evaluated 162 participants (mean age 64.8±12.7 years-old, 55.6% women) concerning chronic treatments with warfarin, 50% of which were identified due to nonvalvular atrial fibrillation or venous thromboembolism. Participants were evaluated with tests devised to check for oral anticoagulation knowledge, adherence to treatment, health literacy, and the medication complexity index. The relationship of the studied variables with the therapeutic range of INR was unclear; the sample size may well have been a key limitation to estimating associations. The mean follow-up time was 16.5 months after recruitment in March 2020. There were 16 deaths, two of which may have been related to hemorrhage and two possibly related to thromboembolism. The study revealed insufficient knowledge about warfarin therapy and low health literacy in primary care facilities.

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Original Article

Adherence and Quality of Life in Non-Valvular Atrial Fibrillation With Direct Oral Anticoagulants Versus Vitamin K Antagonists: A Systematic Review

Vanelise Zortea et al. Karine Duarte Curvello Diogo Pilger Antonios Douros … Lisiane Freitas Leal Tatiana da Silva Sempé Tatiane da Silva Dal Pizzol

Abstract

Background

Direct anticoagulants (DOACs) and vitamin K antagonists (VKAs) differ in pharmacokinetic characteristics, intensity of required laboratory monitoring, and costs. These differences could affect patients’ adherence to treatment and quality of life (QoL).

Objective

To assess whether patients with non-valvular atrial fibrillation (AF) using DOACs have better treatment adherence and QoL when compared to patients using VKAs.

Methods

We conducted a systematic review in Medline, Embase, LILACS, SciELO, CINAHL, and Cochrane Central, until June 9, 2021. We included studies that estimated and compared treatment adherence and QoL between DOACs and VKAs in adults with non-valvular AF. The methodological quality of the studies was assessed using the Joanna Briggs Institute (JBI) tools. The protocol was registered in the PROSPERO (CRD 42020165238).

Results

Sixteen studies, including 122,458 patients with non-valvular AF, evaluated adherence, and eleven studies, including 5,687 patients, assessed QoL. A variety of methods was used to measure adherence. Eleven studies showed no difference in adherence between DOACs and VKAs, while three studies favored VKAs over DOACs and two studies favored DOACs over VKAs. QoL was measured by specific (n = 3) or generic questionnaires (n = 8); results favored DOACs over VKAs in four studies, while in the other seven studies the results showed no difference between the groups. Meta-analyses were not performed due to high methodological heterogeneity among studies.

Conclusions

Available evidence regarding treatment adherence and QoL with DOACs and VKAs is characterized by methodological heterogeneity and conflicting findings.

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IJCS

Editorial

The Role of Pharmacists in Antihypertensive Pharmacotherapy

Christianne Bretas Vieira Scaramello et al. Flavia Valeria dos Santos Almeida

Hypertension encompasses a preventable risk factor associated with a significant global burden of cardiovascular disease (CVD) and premature death. Its prevalence is rising worldwide due to population aging, unbalanced diets, and sedentary, especially in low- and middle-income countries. Prevalence data in Brazil vary according to the database. However, about 30% of adults present blood pressure of 140/90 mmHg or more, with CVD representing 22.6% premature passing. This link between hypertension and CVDs-related deaths highlights the relevance of blood pressure control.

In 2021, the World Health Organization elaborated evidence-based guidance for the pharmacological treatment of nonpregnant adults with an accurate diagnosis of hypertension who have already received counseling for lifestyle modification. It is crucial to set blood pressure threshold to pharmacological therapy beginning and treatment targets. In addition, the determination of follow-up visits to adjust monotherapy or dual therapy embracing single or dual pill combination medications is mandatory. Comorbidities, unwanted effects, cost, and acceptability must also be evaluated. In 2020, the Brazilian Society of Cardiology also published decision and therapeutic goals for hypertension management.

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Original Article

Pharmaceutical Care in Primary Care: an Experience with Hypertensive Patients in the North of Brazil

Ilvia Silva Gomes et al. Elaine Menezes Rossi Samara Jamile Mendes Brigitte Rieckmann Martins dos Santos Wilson Sabino

Abstract

Background:

Uncontrolled blood pressure has been associated with poor adherence to drug treatment.

Objectives:

To assess blood pressure control in hypertensive patients attending primary health centers after implementation of a pharmaceutical follow-up program in a city of the north of Brazil.

Methods:

Observational, cross sectional, descriptive study with 163 hypertensive patients attending public primary health care centers – one located on the riverside and one in the urban area of the city of Santarem, western Pará, Brazil. Adherence to the anti-hypertensive treatment was assessed using the eight-item Morisky test. Pharmacotherapy follow-up (Dader method) of patients with uncontrolled hypertension and non-adherent to anti-hypertensive treatment was performed. Results of the normality test showed that the data did not follow a normal distribution. Continuous variables were then compared using the Wilcoxon signed-rank test, and categorical variables by the likelihood ratio and the McNemar tests. Statistical significance was set at 5%.

Results:

Of the total sample, 94.5% were not adherent to anti-hypertensive drug therapy and 77.2% had uncontrolled hypertension. Adherence rate was higher in men than women (p=0.006). Pharmacotherapy follow-up improved blood pressure levels, particularly systolic blood pressure (p<0.001).

Conclusion:

An individualized pharmacotherapeutic follow-up, considering regional and cultural specificities, can contribute to the treatment of hypertensin in the primary care.

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Editorial

Blood Pressure Control and Therapeutic Adherence – The Challenges of Hypertension

Elizabeth Silaid Muxfeldt

Blood pressure control is the greatest challenge in the treatment of hypertension.^, The control rate varies from 10% to 32% among continents, and it is related to the development level of each country, with averages ranging from 27% in low- and middle-income countries to 51% in high-income countries. In Brazil, the rates of awareness (22% – 77%), treatment (11% – 78%), and blood pressure control (10% – 36%) also vary depending on the population studied. Clinical inertia, inappropriate lifestyle, and poor therapeutic adherence are the main reasons for difficulty in reaching the therapeutic target.

Several factors affect adherence to treatment, including sociodemographic factors, as well as factors related to patients, drug treatment, and healthcare providers.^, The main sociodemographic factors are age (younger and very elderly patients), poverty, ethnicity (minorities), and lack of social support. Few studies have assessed the difference in adherence between men and women, and they present controversial results.

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Original Article

Clinical Characteristics and Therapeutic Adherence of Women in a Referral Outpatient Clinic for Severe Hypertension

Pedro Henrique Barletta et al. Eduardo Faria Soares de Magalhães Vitor Fernandes de Almeida Júlia Lasserre Moreira … Murilo Jorge da Silva Cristiano Macedo Roque Aras

Abstract

Background

Cardiovascular disease is the main cause of death worldwide. There is a lack of studies addressing this issue in women and its risk factors, such as hypertension.

Objective

To evaluate the clinical and therapeutic profile of women with hypertension and to determine which factors are related to treatment adherence and blood pressure control.

Methods

Cross-sectional study of 181 hypertensive women treated at an outpatient referral clinic. Data were obtained from medical records, face-to-face interviews, and physical examination, using a standardized form. Statistical analysis was performed with prevalence ratio, chi-square and Student’s t test. Significance was accepted at p<0.05.

Results

Most patients were mixed-race or black (91.7%) and the mean age was 66.09 years. Only 44.2% of patients had controlled blood pressure. The prevalence of stroke was 14.9%, whereas the prevalence of coronary artery disease was 19.3%. The mean number of oral antihypertensive drugs prescribed to each individual was 3.41. A history of stroke was more often found in patients with uncontrolled blood pressure (p=0.013) and in those using three or more antihypertensives (p=0.023). Eighty patients (44.2%) had high treatment adherence. Depression was more frequently reported by patients with poorer adherence to treatment (p=0.026).

Conclusion

Women with hypertension presented a high prevalence of cardiovascular risk factors and cardiovascular events, including a significantly higher prevalence of stroke in those with uncontrolled hypertension. Self-reported depression may help identify patients at risk of nonadherence to treatment.

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Original Article

Influence of Factors Affecting Quality of Life on in-Hospital Cardiovascular Events of Patients with Acute Myocardial Infarction with and without ST-segment Elevation

Monique Tavares de Jesus et al. Ingrid Maria Novais Barros de Carvalho Costa Danielle Góes da Silva José Rodrigo Santos Silva … José Augusto Soares Barreto-Filho Marcos Antonio Almeida-Santos Joselina Luzia Meneses Oliveira Mirella Dornelas Batalha Moreira Buarque Fabrício Anjos de Andrade Antônio Carlos Sobral Sousa

Abstract

Background

Acute myocardial infarction (AMI), with and without ST-segment elevation (STEMI and NSTEMI, respectively), is the principal cause of cardiovascular morbidity and mortality in Brazil and around the world. Modifiable risk factors (RF) and quality of life (QOL) may correlate with the type of AMI.

Objective

To evaluate the influence of QOL and RF on the type of AMI and in-hospital cardiovascular events in STEMI and NSTEMI patients.

Methods

This was an observational, cross-sectional study. Patients with AMI attending four referral hospitals (three private and one public) for cardiovascular disease treatment were assessed for QOL using the Brazilian version of the 36-item short form survey. A p < 0.05 was considered statistically significant.

Results

We evaluated 480 volunteers; 51% were treated in one of the private hospitals. In total, 55.6% presented with STEMI, and 44.4% with NSTEMI. Patients from the public hospital were 8.56 times more likely to have STEMI compared to those from the private hospitals. There was a higher prevalence of smokers in STEMI (p < 0.028) patients. QOL was not associated with the type of AMI. A negative patient perception of the physical health and pain domains was observed. Although a significant difference between the physical and the mental health domains was not observed, individual domains were correlated with some in-hospital outcomes.

Conclusion

There was a higher prevalence of smokers among individuals with STEMI. Domains of QOL showed a statistically significant relationship with the occurrence of in-hospital cardiovascular events, with no difference between the types of AMI.

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Original Article

Drug Profile and Therapeutic Adherence of African-Brazilians with Apparent Resistant Hypertension

Pedro Henrique Andrade Araújo Salvatore Barletta et al. Júlia Lasserre Moreira Vitor Fernandes de Almeida Mateus Andrade Bomfim Machado … Breno Lima de Almeida Tayla Samanta Silva dos Santos Yana Mendonça Nascimento Thaise Almeida Silva Roque Aras Cristiano Macedo

Abstract

Background

Resistant hypertension (RH) is manifested by the presence of blood pressure values resistant to antihypertensive therapy. RH is highly prevalent among black individuals, increasing cardiovascular risk in this population and requiring effective control of this comorbidity.

Objectives

To investigate the medication profile and therapeutic adherence in black people with apparent RH.

Methods

This is a cross-sectional study, with a convenience sample of individuals with apparent RH. Data were obtained from medical records. Therapeutic adherence was assessed using the Morisky Therapeutic Adherence Scale of 8 items (MMAS-8) and statistical analysis was performed using the SPSS, version 23. Significance was set at p <0.05.

Results

Of the 120 individuals, 90 (75%) were women and 72 (60%) were black. Mean SBP was 153.09 (SD 25.59) mm Hg and mean DBP, 90.82 (SD 16.91) mm Hg, with a statistical difference in relation to the target pressure for SBP. Regarding the medication profile, 79.2% of the individuals used the recommended regimen for RH (ACEI / ARB + Diuretic + CCB), with the fourth most used drug being beta-blockers. The average score in MMAS-8 was 6.62 (SD 1.38) points, with 19.2%, 50.0%, and 30.8% showing low, medium, and high adherence, respectively.

Conclusions

It was evidenced that two-thirds of the individuals did not have high therapeutic adherence and not all used the ideal regimen for the management of RH, nor full doses. Thus, most individuals were probably affected by pseudoresistance, which was initially diagnosed as apparent RH. (Int J Cardiovasc Sci. 2021; [online].ahead print, PP.0-0)

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Editorial

The Challenge of Controlling Resistant Hypertension

Marcus Vinicius Bolivar Malachias

Hypertension is the main risk factor for cardiovascular disease, stroke, disability and death. Despite the accumulated knowledge about hypertension and many treatment options, some hypertensive patients do not achieve the recommended blood pressure goals even receiving non-pharmacological treatment and three antihypertensive drugs. These individuals have the so-called “resistant hypertension” and are at increased risk of involvement of target organs, higher morbidity and mortality.

Several international scientific societies, including the Brazilian Society of Cardiology, have dedicated to publishing evidence-based guidelines for the management of arterial hypertension,^, and specific position statements on resistant hypertension have also been produced.^, The Department of Hypertension of the Brazilian Society of Cardiology is about to issue an updated statement on the subject.

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