title: Effect of adherence to evidence-based therapy after acute myocardial infarction on all-cause mortality.
abstract: OBJECTIVE
  Our aim is to estimate the effect of nonadherence to evidence-based cardioprotective medications on all-cause mortality in survivors of acute myocardial infarction (AMI).
  
  
  METHODS
  A patient-based retrospective cohort study of 1-year survivors of AMI, members of a health organization in Israel, between 2005 and 2010 was used. Adherence was measured using the proportion-of-days-covered metric and defined as a proportion of days covered ≥80%. In order to determine the independent impact of medication nonadherence on all-cause mortality, Cox proportional hazards models were constructed, adjusting for patient demographic and clinical characteristics.
  
  
  RESULTS
  Of 4655 patients prescribed at least one medication, 864 died during an 8-year follow-up (median 4.5 years). Except for beta-blockers, medication nonadherence was significantly associated with increased adjusted all-cause mortality risk for aspirin [hazard ratio (HR), 1.28; 95% confidence interval (CI), 1.11-1.47], statins (HR, 1.36; 95%CI, 1.18-1.57), and angiotensin-converting enzyme inhibitors/angiotensin receptor blockers only among ischemic heart disease patients with documented heart failure (HR, 1.57; 95%CI, 1.16-2.14). Multidrug-combined therapy exerted incremental survival benefit in a dose-response gradient, exceeding that of single-component treatment. The highest risk of mortality was observed in patients adherent to none of the medications compared with adherents to all medications, with a 38% increase in risk of mortality (HR, 1.38; 95%CI, 1.06-1.80).
  
  
  CONCLUSIONS
  Outpatient nonadherence to evidence-based cardioprotective medications in patients with AMI is common, and in the case of aspirin, statin or combined therapy is associated with a marked risk increase in all-cause mortality. Further research is needed to elucidate the role of angiotensin-converting enzyme inhibitor/angiotensin receptor blocker in patient subgroups.
authors.affiliation: Department of Cardiology, Bnai Zion Medical Center, The Bruce Rappaport Faculty of Medicine, Technion Israel Institute of Technology, Haifa, Israel.|Leumit Health Services, Karmiel, Israel.
authors.forename: Hatem
authors.initials: H
authors.lastname: Hamood
authors.affiliation: School of Public Health, University of Haifa, Haifa, Israel.
authors.forename: Rola
authors.initials: R
authors.lastname: Hamood
authors.affiliation: School of Public Health, University of Haifa, Haifa, Israel.
authors.forename: Manfred S
authors.initials: MS
authors.lastname: Green
authors.affiliation: School of Public Health, University of Haifa, Haifa, Israel.
authors.forename: Ronit
authors.initials: R
authors.lastname: Almog
mesh_terms: D000368:Aged; D002316:Cardiotonic Agents / Q000008:administration & dosage* / Q000627:therapeutic use; D015331:Cohort Studies; D019317:Evidence-Based Medicine / Q000379:methods / Q000706:statistics & numerical data; D005260:Female; D005500:Follow-Up Studies; D006801:Humans; D008297:Male; D008875:Middle Aged; D009026:Mortality / Q000639:trends; D009203:Myocardial Infarction / Q000188:drug therapy / Q000401:mortality; D012189:Retrospective Studies; D055502:Secondary Prevention / Q000379:methods* / Q000706:statistics & numerical data; D016896:Treatment Outcome; D016903:Drug Monitoring
chemical_list: D002316:Cardiotonic Agents
keywords: medication adherence; mortality; myocardial infarction; pharmacoepidemiology; secondary prevention