I read with interest the recent publication by Bansilal et al. (1) as well as the accompanying editorial by Armstrong and McAlister (2). The continued attentiveness to medication adherence as a significant clinical variable is encouraging. It should be noted that an evaluation of the baseline characteristics of the nonadherent, partially adherent, and fully adherent populations showed no significant differences in any of the measured individual medical conditions. In contrast, the less adherent groups were more likely to be from areas with lower median income and were also more likely to be African-American or Hispanic. Prior studies have shown that adverse cardiovascular outcomes and poor utilization of evidence-based discharge care after myocardial infarction are independently associated with each of these groups (3,4). Even so, the authors attempted to minimize confounding by appropriately adjusting for race and income. However, there are likely other socioeconomic variables such as education level, social support, employment status, and cultural differences that were not fully captured in this data set which may have impacted both adherence as well as cardiovascular outcomes. The differences in characteristics between adherent and less adherent groups further emphasize the need to better incorporate these types of socioeconomic variables into our methods of identifying and managing high-risk patients in both routine clinical care as well as clinical research studies, particularly in relation to medication adherence.

It is also worth emphasizing that although medication adherence is complicated by various socioeconomic factors that are often difficult to measure, let alone modify, Armstrong and McAlister are correct in pointing out that progress in this area remains both necessary and possible. We should remain optimistic that innovative studies such as the ongoing ARTEMIS (Affordability and Real-world Antiplatelet Treatment Effectiveness After Myocardial Infarction Study) trial (5), a multicenter randomized trial of copayment vouchers for P2Y12 inhibitors after myocardial infarction, will help find ways to impact both adherence and cardiovascular outcomes. The most important initial intervention, however, will remain our decision to discuss the importance of medication adherence with our patients, as a problem never discussed will likely be a problem never solved.

Author: Kamil F. Faridi
Published By: Journal of the American College of Cardiology

Please note: Dr. Faridi has reported that he has no relationships relevant to the contents of this paper to disclose. P.K. Shah, MD, served as Guest Editor-in-Chief for this paper. Paul Armstrong, MD, served as Guest Editor for this paper.

1. Bansilal S., Castellano J.M., Garrido E., et al. (2016) Assessing the impact of medication adherence on long-term cardiovascular outcomes. J Am Coll Cardiol 68:789–801.
2. Armstrong P.W., McAlister F.A. (2016) Searching for adherence: can we fulfill the promise of evidence-based medicines? J Am Coll Cardiol 68:802–804.
3. Bucholz E.M., Ma S., Normand S.L., Krumholz H.M. (2015) Race, socioeconomic status, and life expectancy after acute myocardial infarction. Circulation 132:1338–1346.
4. Guzman L.A., Li S., Wang T.Y., et al. (2012) Differences in treatment patterns and outcomes between Hispanics and non-Hispanic Whites treated for ST-segment elevation myocardial infarction: results from the NCDR ACTION Registry-GWTG. J Am Coll Cardiol 59:630–631.
5. Doll J.A., Wang T.Y., Choudhry N.K., et al. (2016) Rationale and design of the Affordability and Real-world Antiplatelet Treatment Effectiveness after Myocardial Infarction Study (ARTEMIS): a multicenter, cluster-randomized trial of P2Y12 receptor inhibitor copayment reduction after myocardial infarction. Am Heart J 177:33–41.