Hard Pill to Swallow: Medication Adherence in Cardiovascular Disease

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In the United States, medication adherence has evolved into a major public health problem, particularly as it relates to the management of cardiovascular disease (CVD), which is responsible for 1 in 4 deaths among American each year.^1-2

Poor adherence to drugs prescribed to prevent heart failure (HF) is associated with an increased number of emergency department visits related to CVD.³ In addition, failure to adhere to medication for hypertension increases the risk of hospitalization, re-hospitalization, and premature death by more than 5 times. If only 70% of patients with hypertension were adherent to their regimens, 46,000 deaths could be avoided annually.^4-5

“It’s a huge problem,” Steven Nissen, MD, chairman of the Robert and Suzanne Tomsich Department of Cardiovascular Medicine at Cleveland Clinic’s Sydell and Arnold Miller Family Heart & Vascular Institute, told MD Magazine^®. “We have great therapies. If people take them, they work. But medication adherence has always been a problem.”

Many Americans simply are not adherent to their medication regimens, and when that is the case for more than 50% of patients with heart disease, it becomes a major problem.⁶ This does not sit well with Nisha Jhalani, MD, the director of clinical and educational Services at the Center for Interventional Vascular Therapy at NewYork-Presbyterian Hospital/Columbia University Medical Center.

“The crux of long-term cardiology care is the medications,” Jhalani told MD Magazine^®. “Many American patients aren’t adherent with their medications. One study showed 24% of patients, after a heart attack, didn’t even fill their medications within 1 week.” ⁷

Gregg C. Fonarow, MD, director of the Ahmanson-UCLA Cardiomyopathy Center, co-chief of UCLA’s Division of Cardiology, and co-director of UCLA’s Preventative Cardiology Program, told MD Magazine^® that adherence is a critical part of not just treatment, but prevention of CVD—and that problem, he said, is not just an American issue.

Won't Patients Take Their Meds?

“Even the World Health Organization has recognized that this is a worldwide problem,” Fonarow told MD Magazine^®. “When Bill Clinton was prescribed a statin and didn’t adhere to it by his choice, against physician advice, he ultimately required a coronary intervention type of surgery, so this impacts us at all levels. It’s so common.”There are multiple reasons behind the national refusal to take medications. One obvious factor is cost.

“One reason that’s pretty important in a city like Cleveland is poverty,” Nissen said. “We’re the only developed country that does not have universal health care. It’s, frankly, a national embarrassment. People can’t afford their medications, and their cost has skyrocketed.”

Jhalani noted an anecdote of a patient she treated who was only taking half of her prescribed dose of blood pressure medication. She understood that she needed it and wanted to at least take something. “She couldn’t afford to fill it for the whole month,” Jhalani said.

“That happens all the time,” Nissen said. “We just don’t have a good safety net for these people, and it results in their health being severely compromised.”

Although Fonarow pointed out that cost alone can’t explain the nation’s adherence problem. Even generics, often the most affordable medicines, have lower adherence rates than physicians would like to see.

“You see this [even] in situations where there’s universal health insurance and coverage for medications,” he said.

Having too many pills to take is another frequent complaint physicians hear from patients, and it’s one Randall Zusman, MD, director of the Division of Hypertension at the Massachusetts General Hospital Heart Center and associate professor of medicine at Harvard Medical School, has heard before.

“People don’t like to take medication, and I don’t really blame them,” Zusman told MD Magazine^®. “When they’re taking a dozen or more pills a day, it can become burdensome, especially if they have to be taken more than once or twice a day. Taking something multiple times can be a challenge for even the most adherent patient.”

This is even more salient for patients with CVD, who frequently experience multiple serious disorders atop their heart issues, such as lung problems and diabetes. This means they are prescribed multiple medications, all of which are important for their continued health. For some heart patients, this is a drastic change and difficult to adapt to.

“People are often being diagnosed with something brand new and then transitioning from being very sick in the hospital to the outpatient setting,” Jhalani said. “That’s where we lose a lot of patients. If it’s a new diagnosis and a lot of medications are being started, it can get very overwhelming, especially for those who came in with no health problems.”

Additionally, Fonarow said, there a general misperception where patients tend to believe that the more medications they are on, the sicker they are, rather than the more medications they are on, the better their health outcome is going to be.

“Patients ask, ‘How do I know the medication is working?’” he said. “’I started on it. I feel no different. Why do I need to continue on it?’”

Another compounding part of the problem is the asymptomatic, yet potentially deadly, nature of CVD. High blood pressure, for example, is often completely so. “It’s called the silent killer for a reason. Without symptoms, it’s easy for patients to forget to take medication or feel they don’t need to,” Jhalani said.

“People will take their pain meds because if they don’t, they suffer the pain,” Zusman said. “But for something that’s symptomless and painless, like blood pressure or cholesterol, they often won’t do so.”

Adverse effects are another often-used justification for nonadherence, Zusman added. “Patients believe that some of the things they’re experiencing are [an adverse] effect of their medication, whether they are or not, so they will choose to discontinue the medication and then have to pay the consequences of not having taken it,” he said.

And finally, some patients simply do not want to take medication or honestly do not think they need to—no matter what the doctor says. “With the dependence on the internet that we now all live with, there’s a chronic problem to resolve with patients,” Zusman said. “Dr. Google didn’t do well in medical school, but he’s very popular.”

Adherence

Jhalani noted that there is a problem with patients thinking that their doctor is being overly cautious or that adding more meds to their regimens is overkill. “Every patient who has a stent, for example, should be on this medication even if their cholesterol is perfect,” she said. “But I think that just doesn’t hit home. Whereas we know that statins in anybody with coronary disease improve long-term outcomes.”Although it may not be a silver bullet, clear counseling of patients is essential to boosting compliance. Ensuring that patients know the reasons for their medications, and the consequences of not taking them, can be imperative in upping adherence.

“[Patients need to know] the reason to control their blood pressure is the prevention of stroke. The reason to control their cholesterol is the prevention of heart attack,” Zusman said.

Nissen also noted the implications of noncompliance, which can result in “catastrophic complications,” he said. “The first step is to talk to the patient; when you have a critical medication, make sure that they understand that stopping the medication can have life-threatening implications.”

Active questioning of patients goes hand-in-hand with clear counseling. Nissen said that good physicians will ask their patients the questions that can be uncomfortable, such as if they have troubles paying for their medications. If the physician can help by prescribing a generic, they should, even if they are not as good, he added, since it is “far better than nothing at all.”

“If you don’t ask, you don’t find out,” he said.

“I’ll see a patient with high blood pressure who’s on 4 medications, and every single visit their blood pressure is through the roof,” Jhalani said. “The natural reaction is to keep up-titrating the medications. But we need to take the time to say, ‘Wait a second, how are you taking this medication? Are you taking it every single day? Are you taking it at the right time?’ Really dig into the medication use.”

Another strategy that has worked for Jhalani’s outpatients is home monitoring. She advises patients with hypertension to keep a blood pressure cuff in their home. “I say, ‘Don’t change your medications based on it, but just see what happens. Right before you’re due for your next dose, just check and see. Even though you feel totally fine, your blood pressure may be 160 over 100,’” she said.

Along those lines, Jhalani also requires patients to bring their meds with them to appointments. “When the patient actually has the bottle in front of them, they are more likely to provide anecdotes about what they do at home,” she said. “Some patients will write down the indication for their medication on the pill bottle.”

She added that she and the patient can also see how many refills are remaining, which can provide supplementary clues. “If I know I prescribed all of the medications 6 months ago and there are 2 refills left for [one of the medications], but no refills left for another, there’s a disconnect,” she said.

Some physicians utilize coordinated care with the family as another strategy to improve adherence—especially for patients that are problematic or do not understand the importance of their medications.

“If you’ve endorsed a medication to a family member and shared your concerns, I think it goes a lot further,” Jhalani said.

“Our health system is really not set up for the true tracking of adherence,” Fonarow said. “Any list of medications is based on what the patient says they’re taking, but ideally, clinicians could see how often patients have renewed their prescriptions and verify whether those records match what they’re reporting.”

Research has also proved that starting patients on new cardiovascular medication regimens while they are still in the hospital is more effective than waiting until they are outpatients.

“We’ve shown much better outcomes when therapy was started in the hospital, taking advantage of that teachable moment,” Fonarow said.

Systematic discharge follow-up can also be somewhat effective. At NewYork-Presbyterian Hospital/Columbia University Medical Center, Jhalani said the discharge team are responsible for reiterating the risks of not taking medicines to patients. “Our nurses also do follow-up discharge phone calls 2 or 3 days after patients are released from the hospital to confirm that patients are doing OK and to ask whether they filled all of the medications or have any questions,” she said.

Really, whenever possible, a simplified regimen is easier for patients to follow.

“Combination pills are fantastic, although they are often a bit costlier and insurance may be an issue. Barring that, though, combining 2 pills, going from 5 drugs to maybe 3, is a really good feeling for a patient,” Jhalani said.

REFERENCES:

1. Cardiovascular disease: a costly burden for America. American Heart Association website. heart.org/HEARTORG/Advocate/Cardiovascular-Disease-A-Costly-Burden-for-America_UCM_491316_Article.jsp. Updated February 14, 2017. Accessed March 2018.

2. Heart disease facts. CDC website. cdc.gov/heartdisease/facts.htm. Updated November 28, 2017. Accessed March 2018.

3. Ho, PM, Bryson, CL, Rumsfeld, JS. Medication adherence: its importance in cardiovascular outcomes. Circulation. 2009;119(23):3028-3035. doi: 10.1161/CIRCULATIONAHA.108.768986.

4. Gwadry-Sridhar FH., Manias E, Zhang Y, et. al. A framework for planning and critiquing medication compliance and persistence using prospective study designs. Clin Ther. 2009;31(2):421-435. doi: 10.1016/j.clinthera.2009.02.021.

5. A tough pill to swallow: Medication adherence and cardiovascular disease. AHA website. heart.org/idc/groups/heart-public/@wcm/@adv/documents/downloadable/ucm_460769.pdf. Published February 2014. Accessed March 2018.

6. Kravitz RL, Hays RD, Sherbourne CD, et. al. Recall of recommendations and adherence to advice among patients with chronic medical conditions. Arch Intern Med. 1993;153(16):1869-1878. doi: 10.1001/archinte.1993.00410160029002.

7. Jackevicius CA, LI P, Tu JV. Prevalence, predictors, and outcomes of primary nonadherence after acute myocardial infarction. Circulation. 2008;117(8):1028-1036. doi: 10.1161/CIRCULATIONAHA.107.706820.