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Frontiers of Medicine

ISSN 2095-0217

ISSN 2095-0225(Online)

CN 11-5983/R

Postal Subscription Code 80-967

2018 Impact Factor: 1.847

Front. Med.    2017, Vol. 11 Issue (1) : 53-61     DOI: 10.1007/s11684-017-0502-2
RESEARCH ARTICLE |
Poor adherence to P2Y12 antagonists increased cardiovascular risks in Chinese PCI-treated patients
Yang Sun,Chenze Li,Lina Zhang,Dong Hu,Xudong Zhang,Ting Yu,Min Tao,Dao Wen Wang(),Xiaoqing Shen()
Division of Cardiology, Department of Internal Medicine, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430030, China
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Abstract  

Low adherence to secondary prevention medications (ATM) of patients after acute coronary syndrome (ACS) is associated with poor clinical outcomes. However, literature provides limited data on assessment of ATM and risks associated with poor in Chinese patients with ACS. In the current work, ATM was assessed in consecutively recruited patients with ACS in Tongji Hospital from November 5, 2013 to December 31, 2014. A total of 2126 patients were classified under low adherence (proportion of days covered (PDC)<50%) and high adherence (PDC>50%) groups based on their performance after discharge. All patients were followed up at the 1st, 6th, and 12th month of discharge while recording ATM and major adverse cardiac events (MACE). Bivariate logistic regression was used to identify the factors associated with ATM. Cox regression was used to analyze the association between ATM and MACE within one year after discharge. Results showed that coronary artery bypass grafting (CABG) alone had significantly lower proportion of high adherence to P2Y12 antagonists (83.0% vs. 90.7%, P<0.01) than patients treated with percutaneous coronary intervention (PCI) only. Moreover, in patients undergoing PCI, high adherence to P2Y12 antagonists decreased the risk of MACE (hazard ratio=0.172, 95% confidence interval: 0.039–0.763; P=0.021). In conclusion, PCI-treated patients are more prone to remaining adherent to medications than CABG-treated patients. High adherence to P2Y12 antagonists was associated with lower risk of MACE.

Keywords acute coronary syndromes      adherence to secondary prevention medications      clinical outcome     
Corresponding Authors: Dao Wen Wang,Xiaoqing Shen   
Just Accepted Date: 28 December 2016   Online First Date: 17 February 2017    Issue Date: 20 March 2017
URL:  
http://academic.hep.com.cn/fmd/EN/10.1007/s11684-017-0502-2     OR     http://academic.hep.com.cn/fmd/EN/Y2017/V11/I1/53
Fig.1  Flowchart of study cohort identification and exclusion. ACS, acute coronary syndrome.
Characteristics  
No. of patients 2126
Age (year) 59.32±10.183
Gender
Male, n (%) 1580 (74.3%)
Female, n (%) 546 (25.7%)
Psychosocial characteristics
Medical insurance types
Urban workers medical insurance, n (%) 312 (22.3%)
Urban residents medical insurance, n (%) 520 (37.2%)
NCMS, n (%) 346 (24.7%)
Free medicare, n (%) 6 (0.4%)
No medical insurance, n (%) 164 (11.7%)
Other medical insurance, n (%) 51 (3.6%)
Education level
Low education level, n (%) 394 (26.6%)
Medium education level, n (%) 853 (57.6%)
High education level, n (%) 234 (15.8%)
Comorbid conditions
Hypertension, n (%) 1299 (61.1%)
Diabetes mellitus, n (%) 486 (22.9%)
Hyperlipemia, n (%) 757 (35.6%)
Heart failure, n (%) 440 (20.7%)
Atrial fibrillation, n (%) 80 (3.8%)
CRD, n (%) 57 (2.7%)
Stroke, n (%) 98 (4.6%)
ACS types
STEMI, n (%) 384 (18.1%)
Non-STEMI, n (%) 273 (12.8%)
UA, n (%) 1469 (69.1%)
ACS treatment
Conservative, n (%) 434 (20.4%)
PCI only, n (%) 1616 (76.0%)
CABG only, n (%) 73 (3.4%)
PCI+ CABG, n (%) 3 (0.1%)
ICD, n (%) 26 (1.2%)
Radiofrequency ablation, n (%) 13 (0.6%)
Tab.1  Baseline characteristics of the study population
 Characteristics ACS population PCI population
High adherence Low adherence P value High adherence Low adherence P value
Age (year) 59.26±10.217 57.86±10.824 0.197 58.90±10.192 61.32±10.468 0.15
Gender 0.972 0.873
Male, n (%) 1265 (74.6%) 70 (74.5%) 1121 (75.2%) 29 (76.3%)
Female, n (%) 430 (25.4%) 24 (25.5%) 370 (24.8%) 9 (23.7%)
Psychosocial characteristics
Medical insurance types 0.43 0.747
Urban workers medical insurance, n (%) 264 (24.3%) 9 (15.0%) 240 (24.9%) 4 (15.4%)
Urban residents medical insurance, n (%) 407 (37.4%) 27 (45.0%) 361 (37.5%) 12 (46.2%)
NCMS, n (%) 283 (26.0%) 15 (25.0%) 244 (25.4%) 7 (26.9%)
Free medicare, n (%) 5 (0.5%) 0 (0%) 5 (0.5%) 0 (0.0%)
No medical insurance 129 (11.9%) 9 (15.0%) 112 (11.6%) 3 (11.5%)
Education level 0.586 0.079
Low education level, n (%) 316 (26.1%) 18 (28.1%) 275 (25.2%) 11 (39.3%)
Medium education level, n (%) 703 (58.1%) 39 (60.9%) 642 (58.7%) 16 (57.1%)
High education level, n (%) 190 (15.7%) 7 (10.9%)     176 (16.1%) 1 (3.6%)  
ACS types     0.79       0.293
STEMI, n (%) 348 (20.5%) 18 (19.1%) 323 (21.7%) 12 (31.6%)
Non-STEMI, n (%) 240 (14.2%) 15 (16.0%) 215 (14.4%) 6 (15.8%)
UA, n (%) 1107 (65.3%) 61 (64.9%) 953 (63.9%) 20 (52.6%)
ACS treatment <0.01 ? ?
Conservative, n (%) 172 (10.1%) 48 (51.1%) ? ?
PCI only, n (%) 1491 (88.0%) 38 (40.4%) ? ?
CABG only, n (%) 29 (1.7%) 8 (8.5%) ? ?
PCI+ CABG, n (%) 3 (0.2%) 0 (0.0%) ? ?
Comorbid conditions
Hypertension, n (%) 1014 (59.8%) 63 (67.0%) 0.194 878 (58.9%) 27 (71.1%) 0.132
Diabetes mellitus, n (%) 394 (23.2%) 22 (23.4%) 0.972 347 (23.3%) 9 (23.7%) 0.953
Hyperlipemia, n (%) 642 (37.9%) 31 (33.0%) 0.34 596 (40.0%) 17 (44.7%) 0.554
Heart failure, n (%) 354 (20.9%) 20 (21.3%) 0.928 288 (19.3%) 6 (15.8%) 0.586
Atrial fibrillation, n (%) 56 (3.3%) 4 (4.3%) 0.553 49 (3.3%) 3 (7.9%) 0.136
CRD, n (%) 50 (2.9%) 2 (2.1%) 1 34 (2.3%) 1 (2.6%) 0.59
Stroke, n (%) 74 (4.4%) 3 (3.2%) 0.795 62 (4.2%) 3 (7.9%) 0.217
ICD, n (%) 14 (0.8%) 0 (0.0%) 1 11 (0.7%) 0 (0.0%) 1
Radiofrequency ablation, n (%) 5 (0.3%) 1 (1.1%) 0.277   5 (0.3%) 0 (0.0%) 1
Tab.2  Baseline characteristics of the study population according to adherence to P2Y12 antagonists
ACS population PCI population
MACE group Total P value Power MACE group Total P value Power
Aspirin 2 (2.2%) 91 0.788 0.181 1 (2.4%) 41 0.966 0.065
P2Y12 antagonists 3 (3.1%) 94 0.912 0.101 3 (7.9%) 38 0.029 0.999
Statins 1 (0.9%) 117 0.218 0.920 1 (1.7%) 60 0.726 0.168
ACEIs/ARBs 6 (2.9%) 208 0.84 0.097 5 (3.1%) 161 0.623 0.112
b-blockers 5 (3.0%) 164 0.708 0.148 3 (2.7%) 113 0.748 0.087
Tab.3  Low ATM between the groups with MACE vs. without MACE in the study
Fig.2  Estimated rates of MACE per adherence to P2Y12 antagonists in ACS population. The panel shows outcomes of the study population. X-axis presents days after discharge and Y-axis indicates cumulative rates of MACE. The inset graph in each panel shows the same curves on a larger scale. MACE: major adverse cardiac events.
Fig.3  Estimated rates of MACE per adherence to P2Y12 antagonists in PCI population. The panel shows the outcomes for the PCI population. X-axis represents days after discharge, and Y-axis shows cumulative rates of MACE. The inset graph in each panel shows the same curves on a larger scale. MACE: major adverse cardiac events.
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