US Pharm. 2018:43(2)HS-8-HS-12
ABSTRACT: Myocardial infarction (MI) is defined as the irreversible necrosis of the cardiac muscle secondary to prolonged ischemia. The estimated annual incidences of new and recurrent MI events are 550,000 and 200,000, respectively. Recovery from an MI can take a physical and emotional toll on the affected patient and loved ones. Recurring MIs may put patients at risk for reduced quality of life, heart failure, and death. Post-MI therapy and secondary prevention of MI involve the use of medication therapy and lifestyle modifications. The pharmacist’s role in post-MI recovery and recurrence prevention includes medication education and helping patients maintain adherence to pharmacologic and nonpharmacologic treatment.
Myocardial infarction (MI)—the irreversible necrosis of the cardiac muscle secondary to prolonged ischemia—is a leading cause of cardiovascular disease morbidity and mortality and is a frequent cause of hospital admissions in the United States.1,2 MIs are also associated with significant short- and long-term mortality and morbidity.1 MI typically results from an imbalance between oxygen supply and demand that is most often caused by plaque rupture with thrombus formation in an epicardial coronary artery, leading to an acute reduction of blood supply to a portion of the myocardium.2 The majority of MIs are the result of coronary artery disease.3 An estimated 90% of MIs are the result of an acute thrombus that obstructs an atherosclerotic coronary artery.2 Other possible causes of MI may include coronary occlusion secondary to vasculitis; use of drugs including cocaine, ephedrine, and amphetamines; coronary trauma; coronary anomalies, such as aneurysm of the coronary arteries; and factors that may increase oxygen requirements, such as heavy exertion or untreated hyperthyroidism.2,4
Statistics indicate that one individual in the U.S. will suffer an MI every 42 seconds, and the estimated annual incidences of new and recurrent MI events are 550,000 and 200,000, respectively.1,5
Acute MI is associated with a 30% mortality rate; about 50% of deaths occur prior to arrival at the hospital.2 An additional 5% to 10% of survivors die within the first year after MI.2 Approximately 50% of all patients with MI are rehospitalized within 1 year of their index event.2 Prognosis varies from patient to patient and is dependent primarily on the extent of the infarct, the residual left ventricular function, and whether the patient underwent revascularization.2
Pharmacists are in a pivotal position to provide patients recovering from MI with pertinent information about the safe and efficacious use of their prescribed medications, as well as increase awareness about pharmacologic and nonpharmacologic measures to prevent a second MI.
Life After MI
Life after MI can be challenging and overwhelming for both the patient and loved ones. The recovery period can be a confusing, emotional time. Challenges that patients may face include initiation of new medications, medication access and adherence, and medication-related adverse effects.6 During the recovery time, affected patients and loved ones may need information to answer their questions and allay their concerns. For some individuals, the stress and anxiety related to the recovery period may lessen over time; however, a substantial number of patients continue to experience emotional symptoms that may impair their daily functioning.7 Symptoms of depression occur in an estimated 33% of patients who have experienced MI, and about one in five suffers from major depressive disorder.7,8 Anxiety is also prevalent, with estimates ranging from 30% to 40% of patients following hospitalization for MI.7,9
The post-MI treatment plan is intended to improve patient outcomes, prevent hospital readmission, and prevent another MI.10 American Heart Association (AHA) guidelines recommend comprehensive care plans that include patient education regarding medication adherence, timely follow-up, dietary interventions, physical activities, and cardiac rehabilitation.10 Patient education should include both oral and written communication. Studies have demonstrated that a commitment to cardiac rehabilitation; adherence to medication regimens; management of comorbidities; lifestyle modifications, including diet and weight loss, if warranted; and routine follow-up with primary caregivers can improve patient outcomes and quality of life.10
Medication Therapy and Secondary Prevention of MI
Recurring MIs may put individuals at risk for reduced quality of life, heart failure, and death, making secondary prevention crucial.11 In individuals who have experienced MI, secondary prevention guidelines have recommended intensive treatment and control of vascular risk factors such as hypertension, dyslipidemia, diabetes mellitus, and smoking to reduce the risk of recurrent MI, other nonfatal cardiovascular disease events, and death.12 In general, post-MI care and secondary prevention consist of both nonpharmacologic and pharmacologic measures.
In addition to lifestyle modification, which may include smoking cessation, diet, weight loss, and exercise, cardiac rehabilitation is a key part of guideline-recommended nonpharmacologic treatment.11 According to a meta-analysis of 34 randomized, controlled trials, exercise-based cardiac rehabilitation after MI reduces the risk of reinfarction and cardiac mortality.11
Current clinical guidelines for MI recommend secondary prevention with certain drugs, if not contraindicated, including aspirin, P2Y12-receptor inhibitors, statins, beta-blockers, and ACE inhibitors or angiotensin receptor blockers (ARBs), all of which have demonstrated long-term survival benefits for post-MI patients (Table 1).3,11,13 The benefit of aspirin use for secondary prevention is well established.3,14 Extensive evidence from hundreds of clinical trials has shown that daily low-dose (typically 75 mg-162 mg) aspirin reduces the risk of vascular events such as MI, stroke, and vascular death in patients who have experienced MI or stroke or who are at high risk for vascular disease as determined by the Framingham Risk Score.14
Importance of Adherence
Various randomized studies have demonstrated the effectiveness of patient adherence to nonpharmacologic and pharmacologic measures such as smoking cessation, increased physical activity, and compliance with use of medications such as aspirin, beta-blockers, ACE inhibitors, and statins in decreasing mortality and reinfarction, as well as improving patient outcomes.15-17
It is important to note that the effectiveness of these guideline-recommended preventive therapies relies on patient adherence.18-21 However, nonadherence to these medications following MI occurs regularly and is associated with augmented risks of mortality and hospital readmission.22 Several studies have demonstrated that adherence is more difficult to achieve as the number of medications increases.6 Faridi and colleagues found a compliance rate for secondary MI-prevention therapies as low as 63% after 3 months and 54% after a year.22 The study also reported that many patients of lower socioeconomic status are likely to have substantial barriers to healthcare (e.g., lack of transportation, poor medical literacy, and inadequate social support) and that these barriers likely contribute to the association between timing of follow-up and medication adherence.22
In another study, Matthews and colleagues demonstrated that even soon after MI, a considerable proportion of patients report suboptimal adherence to prescribed medications.23 Signs of depression and patient-reported financial hardship because of medication expenses were independently associated with a higher likelihood of medication nonadherence.23 Reasons for nonadherence included poor communication of the need and rationale for each of the discharge medications, and the possible adverse effects that patients may encounter.23 Provider explanation of potential adverse effects of medications prescribed at discharge was independently associated with better short-term adherence.23 Lack of adherence to secondary preventive care contributes to a greater likelihood of disease recurrence and treatment complications, and it may be a driver of increased healthcare costs.23,24
A 2017 study conducted in the U.S. reported that almost 40% of the patients who initiated use of ACE inhibitors/ARBs, beta-blockers, or statins following hospitalization for MI became nonadherent during the first treatment year.18 The study also concluded that patients who were compliant with ACE inhibitors/ARBs and statin therapy, but noncompliant with beta-blocker treatment, had a comparable mortality risk to those compliant with all three therapies, suggesting that the role of post-MI beta-blockers in the statin and ACE inhibitor/ARB era deserves additional investigation.18 Noncompliance with ACEI/ARB or statins in any combination and nonadherence to all three therapies, in particular, was linked to greater mortality.18 Study results also showed that adhering to multiple therapies is often a challenge for patients, especially those with multiple comorbidities.18 The incidence of adverse effects, along with the physical and cognitive challenges of taking multiple medications, impacted patient compliance.18
Role of the Pharmacist
As one of the most accessible healthcare professionals, pharmacists can be an indispensable asset to patients recovering from MI. Pharmacists may encourage patients to take an active role in managing their health, especially with regard to adhering to medication regimens, by recommending the use of pill reminders or pill boxes and refill-reminder programs. During counseling, pharmacists can remind patients to adhere to lifestyle modifications such as smoking cessation, establish exercise routines when appropriate, and eat a balanced diet low in saturated fat. Patients should be reminded to maintain a healthy weight, control their blood pressure, and maintain healthy cholesterol levels by keeping LDL cholesterol and triglycerides below recommended levels.
Pharmacists may also play a role in reducing hospital readmissions by ensuring that appropriate evidence-based pharmacotherapy regimens have been prescribed during hospitalization; monitoring for drug duplications, medication errors, and adverse reactions; and performing medication reconciliation.15 Results from a study evaluating the effectiveness of pharmacist intervention with respect to reduction in hospital readmissions in post-MI patients and improvement in medication adherence and literacy concluded that pharmacists’ involvement in medication education improved medication adherence.25
Pharmacists can provide patients with key information about the safety and efficacy of prescribed therapy and how to identify and address potential adverse effects. In addition to medication dispensing, pharmacists can provide medication education and disease management information.15 Pharmacists can assess whether patients understand the proper use of their medication, provide guidance on drug interactions, dosing instructions, and adverse effects, and help patients understand why medication adherence is critical, reminding them about the role each medication plays in preventing another MI and addressing any concerns or barriers.15 Patients should also be encouraged to participate in cardiac rehabilitation programs, which are associated with improved medication adherence.26
Pharmacists may direct patients to patient-education resources such as those listed in Table 2, and to AHA recommendations (Table 3).27 Pharmacists may provide patients with pertinent information regarding risk factors and warning signs of MI and encourage them to maintain routine provider follow-up and have an open dialogue with their primary healthcare provider to establish a care plan to prevent or reduce the incidence of MI.
MIs are associated with significant short- and long-term mortality and morbidity. Recovering from an MI can be challenging as patients adapt to medication regimens and lifestyle changes that are critical in preventing recurrence of MI. Nonadherence to post-MI treatment regimens is common and increases the risk of hospital readmission and mortality. Pharmacists are in a key position to educate and encourage patients to take an active role in managing their health and preventing a second MI.
1. Jneid H, Addison D, Bhatt DL, et al. 2017 AHA/ACC clinical performance and quality measures for adults with ST-elevation and non-ST-elevation myocardial infarction: a report of the American College of Cardiology/American Heart Association Task Force on Performance Measures. J Am Coll Cardiol. 2017;70(16):2048-2090.
2. Zafari M. Myocardial infarction. Medscape. Published January 3, 2017. https://emedicine.medscape.com/article/155919-overview. Accessed November 20, 2017.
3. National Heart, Lung, and Blood Institute. Heart Attack. Updated January 27, 2015. www.nhlbi.nih.gov/health/health-topics/topics/heartattack. Accessed January 12, 2018.
4. United States National Library of Medicine. Heart attack. Published June 11, 2014. www.ncbi.nlm.nih.gov/pubmedhealth/PMH0062989/. Accessed January 12, 2018.
5. Mozaffarian D, Benjamin EJ, Go AS, et al. Heart disease and stroke statistics—2016 update: a report from the American Heart Association. Circulation. 2016;133:e38-e360.
6. Rothermal M. Pharmacists can help reduce acute myocardial infarction readmission rates. America’s Pharmacist. 2016;(7)34-35. www.ncpa.co/issues/APJUL16-Transitions_of_Care.pdf. Accessed January 12, 2018.
7. Smolderen K. Coping after an acute myocardial infarction: the role of depression and anxiety. American College of Cardiology. January 4, 2017. www.acc.org/latest-in-cardiology/articles/2016/12/29/11/08/coping-after-an-acute-mi. Accessed January 17, 2018.
8. Thombs BD, Bass EB, Ford DE, et al. Prevalence of depression in survivors of acute myocardial infarction. J Gen Intern Med. 2006; 21:30-38.
9. Roest AM, Martens EJ, Denollet J, de Jonge P. Prognostic association of anxiety post myocardial infarction with mortality and new cardiac events: a meta-analysis. Psychosom Med. 2010;72:563-569.
10. Mercado MG, Smith DK, McConnon ML. Myocardial infarction: management of the subacute period. Am Fam Physician. 2013;88(9):581-588.
11. Smith T. Strategies for preventing another MI. American Nurse Today. 2016;11(2):Epub. www.americannursetoday.com/strategies-preventing-another-mi/. Accessed January 12, 2018.
12. Shah NS, Huffman MD, Ning H, Lloyd Jones DM. Trends in myocardial infarction secondary prevention: the National Health and Nutrition Examination Surveys (NHANES), 1999-2012. J Am Heart Assoc. 2015;4(4):e001709.
13. Pitts R, Daugherty SL, Tang F, et al. Optimal secondary prevention medication use in acute myocardial infarction patients with non-obstructive coronary artery disease is modified by management strategy: insights from the TRIUMPH registry. Clin Cardiol. 2017;40(6):347-355.
14. Godley RW, Hernandez-Vila E. Aspirin for primary and secondary prevention of cardiovascular disease. Tex Heart Inst J. 2016;43(4):318-319.
15. Cai H, Dai H, Hu Y, et al. Pharmacist care and the management of coronary heart disease: a systematic review of randomized controlled trials. BMC Health Serv Res. 2013;13:461.
16. Smith SC Jr, Allen J, Blair SN, et al. AHA/ACC guidelines for secondary prevention for patients with coronary and other atherosclerotic vascular disease: 2006 update: endorsed by the National Heart, Lung, and Blood Institute. Circulation. 2006;113(19):2363-2372.
17. Smith SC Jr, Benjamin EJ, Bonow RO, et al. AHA/ACCF secondary prevention and risk reduction therapy for patients with coronary and other atherosclerotic vascular disease: 2011 update: a guideline from the American Heart Association and American College of Cardiology Foundation. Circulation. 2011;124(22):2458-2473.
18. Korhonen MJ, Robinson JG, Annis AE. Adherence tradeoff to multiple preventive therapies and all-cause mortality after acute myocardial infarction. J Am Coll Cardiol. 2017:70(13):1543-1554.
19. Choudhry NK, Glynn RJ, Avorn J, et al. Untangling the relationship between medication adherence and post-myocardial infarction outcomes: medication adherence and clinical outcomes. Am Heart J. 2014;167:51-58.
20. Rasmussen JN, Chong A, Alter DA. Relationship between adherence to evidence-based pharmacotherapy and long-term mortality after acute myocardial infarction. JAMA. 2007;297:177-186.
21. Bansilal S, Castellano JM, Garrido E, et al. Assessing the impact of medication adherence on long-term cardiovascular outcomes. J Am Coll Cardiol. 2016;68:789-801.
22. Faridi KF, Peterson ED, McCoy LA, et al. Timing of first post discharge follow-up and medication adherence after acute myocardial infarction. JAMA Cardiol. 2016;1(2):147-55.
23. Mathews R, Peterson ED, Honeycutt E, et al. Early medication nonadherence after acute myocardial infarction: insights into actionable opportunities from the TRANSLATE-ACS study. Circ Cardiovasc Qual Outcomes. 2015;8(4):347-356.
24. Miedema MD, Cohn JN, Garberich RF, et al. Underuse of cardiovascular preventive pharmacotherapy in patients presenting with ST-elevation myocardial infarction. Am Heart J. 2012;164:259-267.
25. Budiman T, Snodgrass K, Komatsu C. Evaluation of pharmacist medication education and post discharge follow-up in reducing readmissions in patients with ST-segment elevation myocardial infarction. Ann Pharmacother. 2016;50(2):118-124.
26. Desai N. Impediments to adherence to post myocardial infarction medications. Curr Cardiol Rep 2013;15:322.
27. American Heart Association. Life after a heart attack. Updated January 11, 2018. www.heart.org/HEARTORG/Conditions/HeartAttack/LifeAfteraHeartAttack/Life-After-a-Heart-Attack_UCM_487069_Article.jsp#.WmKsG1NG02y. Accessed January 12, 2018.
28. Ittaman SV, VanWormer JJ, Rezkalla SH. The role of aspirin in the prevention of cardiovascular disease. Clin Med Res. 2014;12(3-4):147-154.
29. Warnica J. Acute myocardial infarction (MI). Merck Manual. Professional version. Updated September 2016. www.merckmanuals.com/professional/cardiovascular-disorders/coronary-artery-disease/acute-myocardial-infarction-mi. Accessed January 12, 2018.
30. Zagaria M. Myocardial infarction in women: milder symptoms, aspirin, and angioplasty. US Pharm. 2017;42(2):5-7.
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