Effects of Nonpersistence With Medication on CV Disease
Effects of Nonpersistence With Medication on CV Disease
Individuals after a cardiovascular (CV) event represent a high-risk population, in which angiotensin-converting enzyme inhibitors (ACE-Is) and angiotensin receptor blockers (ARBs) have been shown to reduce CV death, myocardial infarction (MI), stroke, and heart failure. Nonpersistence with medications is associated with increased risk for CV events and death in hypertension, after acute coronary syndromes and heart failure. Furthermore, health care costs are higher in nonpersistent populations owing to subsequently increased risk of events, and poor adherence is a major cause of hospital readmissions. In clinical trials with statins, β-blockers, and antihypertensive agents, individuals with poor persistence had worse outcomes than did persistent individuals. In high-risk populations without heart failure, data are sparse. The characteristics of patients and the influence of CV events on persistence have not been evaluated, although identification of patients at risk and the reasons for discontinuation are important to develop strategies to improve persistence and outcomes. Previous studies did not evaluate the impact of time of discontinuation, the impact of discontinuation on events versus the impact of events on persistence, or the impact of reasons for discontinuation on event rates. In the Ongoing Telmisartan Alone and in combination with Ramipril Global Endpoint Trial (ONTARGET), we studied the effects of persistence with study medication in high risk on contemporary accompanying treatments. Because all patients were on Renin-Angiotensin-System (RAS) inhibitors with similar effects on outcomes, we were able to study persistence and CV outcomes in a very large population and whether stopping study medication is associated with CV outcomes and whether, in turn, nonfatal events affect medication persistence.
Background
Individuals after a cardiovascular (CV) event represent a high-risk population, in which angiotensin-converting enzyme inhibitors (ACE-Is) and angiotensin receptor blockers (ARBs) have been shown to reduce CV death, myocardial infarction (MI), stroke, and heart failure. Nonpersistence with medications is associated with increased risk for CV events and death in hypertension, after acute coronary syndromes and heart failure. Furthermore, health care costs are higher in nonpersistent populations owing to subsequently increased risk of events, and poor adherence is a major cause of hospital readmissions. In clinical trials with statins, β-blockers, and antihypertensive agents, individuals with poor persistence had worse outcomes than did persistent individuals. In high-risk populations without heart failure, data are sparse. The characteristics of patients and the influence of CV events on persistence have not been evaluated, although identification of patients at risk and the reasons for discontinuation are important to develop strategies to improve persistence and outcomes. Previous studies did not evaluate the impact of time of discontinuation, the impact of discontinuation on events versus the impact of events on persistence, or the impact of reasons for discontinuation on event rates. In the Ongoing Telmisartan Alone and in combination with Ramipril Global Endpoint Trial (ONTARGET), we studied the effects of persistence with study medication in high risk on contemporary accompanying treatments. Because all patients were on Renin-Angiotensin-System (RAS) inhibitors with similar effects on outcomes, we were able to study persistence and CV outcomes in a very large population and whether stopping study medication is associated with CV outcomes and whether, in turn, nonfatal events affect medication persistence.
