Evidence-based medication adherence among seniors in the first year after heart failure hospitalisation and subsequent long-term outcomes: a restricted cubic spline analysis of adherence-outcome relationships

Abstract

Purpose Non-adherence to heart failure (HF) medications is associated with poor outcomes. We used restricted cubic splines (RCS) to assess the continuous relationship between adherence to renin-angiotensin system inhibitors (RASI) and β-blockers and long-term outcomes in senior HF patients. Methods We identified a population-based cohort of 4234 patients, aged 65–84 years, 56% male, who were hospitalised for HF in Western Australia between 2003 and 2008 and survived to 1-year post-discharge (landmark date). Adherence was calculated using the proportion of days covered (PDC) in the first year post-discharge. RCS Cox proportional-hazards models were applied to determine the relationship between adherence and all-cause death and death/HF readmission at 1 and 3 years after the landmark date. Results RCS analysis showed a curvilinear adherence-outcome relationship for both RASI and β-blockers which was linear above PDC 60%. For each 10% increase in RASI and β-blocker adherence above this level, the adjusted hazard ratio for 1-year all-cause death fell by an average of 6.6% and 4.8% respectively (trend p < 0.05) and risk of all-cause death/HF readmission fell by 5.4% and 5.8% respectively (trend p < 0.005). Linear reductions in adjusted risk for these outcomes at PDC ≥ 60% were also seen at 3 years after landmark date (all trend p < 0.05). Conclusion RCS analysis showed that for RASI and β-blockers, there was no upper adherence level (threshold) above 60% where risk reduction did not continue to occur. Therefore, interventions should maximise adherence to these disease-modifying HF pharmacotherapies to improve long-term outcomes after hospitalised HF.

Safety, tolerability and efficacy of up‐titration of guideline‐directed medical therapies for acute heart failure in elderly patients: A sub‐analysis of the STRONG‐HF randomized clinical trial

“…Use of GDMT at the time of enrolment (∼2 days before discharge from an AHF admission) was similarly sparse in both younger and older patients, except for beta‐blockers that were more frequently used by older individuals. Although the low utilization of GDMT in the current study before enrolment was part of the inclusion criteria for the study, registry data published previously have shown that in various regions of the world, prescription of and adherence to GDMT is significantly lower in older patients with AHF 12–17 …”

“…Although the low utilization of GDMT in the current study before enrolment was part of the inclusion criteria for the study, registry data published previously have shown that in various regions of the world, prescription of and adherence to GDMT is significantly lower in older patients with AHF. [12][13][14][15][16][17] There is a common assumption that older age identifies a vulnerable population of patients. 18 Further, these patients may be even more susceptible in the early post-discharge phase.…”