title: Effects of nonpersistence with medication on outcomes in high-risk patients with cardiovascular disease.
abstract: BACKGROUND
  The impact of nonpersistence on events and of events on persistence is unclear. We studied the effects of nonpersistence on outcomes and events on nonadherence in a randomized placebo controlled trial in 40 countries on 25,620 patients.
  
  
  METHODS
  In the ONgoing Telmisartan Alone and in combination with Ramipril Global Endpoint Trial (ONTARGET), persistent patients (n = 20,991) were compared with individuals who had permanently stopped study medications (n = 4,629).
  
  
  RESULTS
  Older age, female gender, less physical activity, less education, and history of stroke/transient ischemic attack, depression, and diabetes were associated with nonpersistence. After adjustment, nonpersistence was associated with the composite end point of cardiovascular death, myocardial infarction, stroke, or hospitalization for heart failure (hazard ratio 1.24, 99% CI 1.09-1.40, P < .0001), cardiovascular death alone (1.87, 1.60-2.19, P < .0001), and heart failure hospitalization alone (1.32, 1.04-1.67, P = .0023). Cardiovascular events increased when medications were stopped, whereas noncardiovascular outcomes did not. Nonpersistence rapidly increased within the first year after nonfatal events such as myocardial infarction (hazard ratio 3.37, 99% CI 2.72-4.16, P < .0001), stroke (3.25, 2.59-4.07, P < .0001), and hospitalization for heart failure (3.67, 2.95-4.57, P < .0001). Persistence was poorer with more frequent and earlier events. Patients stopping medication after an event were at greater risk for subsequent events.
  
  
  CONCLUSIONS
  Improving medications persistence could interrupt this vicious circle and may improve outcomes.
authors.affiliation: Klinik für Innere Medizin III, Universitätsklinikum des Saarlandes, Homburg, Germany. michael.boehm@uks.eu
authors.forename: Michael
authors.initials: M
authors.lastname: Böhm
authors.forename: Helmut
authors.initials: H
authors.lastname: Schumacher
authors.forename: Ulrich
authors.initials: U
authors.lastname: Laufs
authors.forename: Peter
authors.initials: P
authors.lastname: Sleight
authors.forename: Roland
authors.initials: R
authors.lastname: Schmieder
authors.forename: Thomas
authors.initials: T
authors.lastname: Unger
authors.forename: Koon
authors.initials: K
authors.lastname: Teo
authors.forename: Salim
authors.initials: S
authors.lastname: Yusuf
mesh_terms: D000368:Aged; D000806:Angiotensin-Converting Enzyme Inhibitors / Q000627:therapeutic use*; D001562:Benzimidazoles / Q000627:therapeutic use; D001565:Benzoates / Q000627:therapeutic use; D002318:Cardiovascular Diseases / Q000188:drug therapy*; D004359:Drug Therapy, Combination; D005260:Female; D006801:Humans; D008297:Male; D055118:Medication Adherence; D008875:Middle Aged; D009203:Myocardial Infarction; D016016:Proportional Hazards Models; D017257:Ramipril / Q000627:therapeutic use; D012306:Risk; D000077333:Telmisartan
chemical_list: D000806:Angiotensin-Converting Enzyme Inhibitors; D001562:Benzimidazoles; D001565:Benzoates; D017257:Ramipril; D000077333:Telmisartan