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Does age modify the relationship between adherence to secondary prevention medications and mortality after acute myocardial infarction? A nested case-control study

  • Pharmacoepidemiology and Prescription
  • Published:
European Journal of Clinical Pharmacology Aims and scope Submit manuscript

Abstract

Purpose

Clinical trials have shown that evidence-based secondary prevention medications reduce mortality after acute myocardial infarction (AMI). Yet, these medications are generally underused in daily practice, and older people are often excluded from drug trials. The purpose of this study was to examine whether the relationship between adherence to evidence-based drugs and post-AMI mortality varies with increasing age.

Methods

The study population was defined as all residents in the Local Health Authority of Bologna (Italy) hospitalized for AMI between January 1, 2008 and June 30, 2011, and followed up until December 31, 2012. Medication adherence was calculated as the proportion of days covered (PDC) for filled prescriptions of angiotensin-converting enzyme inhibitors/angiotensin receptor blockers, β-blockers, antiplatelet drugs, and statins; patients were classified as adherent (PDC ≥75 %) or nonadherent (PDC <75 %). We used incidence density sampling, and the moderating effect of age on the relationship between adherence and mortality was investigated through conditional multiple logistic regression analysis.

Results

The study population comprised 3963 patients. During the 5-year study period, 1085 deaths (27.4 %) were observed. For both younger and older patients, adherence to polytherapy (three or four medications) was associated with lower mortality (adj. rate ratio = 0.41; P < 0.001). A significant inverse relationship was found between adherence to each of the four medications and mortality, although the risk reduction associated with antiplatelet therapy declined after the age of 70–75.

Conclusions

The beneficial effect of evidence-based polytherapy on mortality following AMI is observed also in older populations. Nevertheless, the risk-benefit ratio associated with antiplatelet therapy is less favorable with increasing age.

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Notes

  1. Deaths from external causes, not included in the outcome measure, were 29 injuries of head, thorax, pelvis, hip, lower limb, or multiple body regions; 1 foreign body aspiration; and 1 sinus barotrauma.

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Compliance with ethical standards

Funding

This study was not funded.

Conflict of interest

The authors declare that they have no conflict of interest.

Ethical approval

This study was conducted in conformity with the regulations on data management of the Regional Health Authority of Emilia-Romagna and with the Italian Code of conduct and professional practice applying to processing of personal data for statistical and scientific purposes (art. 20-21, legislative decree 196/2003 [http://www.garanteprivacy.it/web/guest/home/docweb/-/docweb-display/docweb/1115480] published in the Official Journal no. 190 of 2004-08-14), which explicitly exempts the need for ethical approval for using anonymous data (Preamble #8). Data were anonymized at the Regional Statistical Office, where each patient was assigned a unique identifier; this identifier eliminates the ability to trace the patient’s identity or other sensitive data. Thus, for this type of study formal consent is not required.

Informed consent

As anonymized administrative data are used routinely for healthcare management, no specific written informed consent was needed to use the patient information.

Contributions of authors

J. Lenzi: conception and design, analysis and interpretation of data, drafting the article and revising it critically for important intellectual content, and final approval of the version to be published.

P. Rucci: interpretation of data, drafting the article and revising it critically for important intellectual content, and final approval of the version to be published.

I. Castaldini: analysis of data, revising the article critically for important intellectual content, and final approval of the version to be published.

A. Protonotari: interpretation of data, revising the article critically for important intellectual content, and final approval of the version to be published.

G. Di Pasquale: interpretation of data, revising the article critically for important intellectual content, and final approval of the version to be published.

M. Di Martino: conception and design, revising the article critically for important intellectual content, and final approval of the version to be published.

E. Perrone: interpretation of data, revising the article critically for important intellectual content, and final approval of the version to be published.

P. Forti: interpretation of data, revising the article critically for important intellectual content, and final approval of the version to be published.

M.P. Fantini: guarantor for the study, conception and design, interpretation of data, revising the article critically for important intellectual content, and final approval of the version to be published.

Author information

Authors and Affiliations

  1. Department of Biomedical and Neuromotor Sciences, Alma Mater Studiorum–University of Bologna, Via San Giacomo 12, 40126, Bologna, Italy

    Jacopo Lenzi, Paola Rucci, Enrica Perrone & Maria Pia Fantini

  2. Department of Programming and Control, Directorate-General Staff, Bologna Local Healthcare Authority, Via Castiglione 29, 40124, Bologna, Italy

    Ilaria Castaldini & Adalgisa Protonotari

  3. Department of Cardiology, Maggiore Hospital, Via Bartolo Nigrisoli 2, 40133, Bologna, Italy

    Giuseppe Di Pasquale

  4. Department of Epidemiology, Lazio Regional Health Service, Via Santa Costanza 53, 00198, Rome, Italy

    Mirko Di Martino

  5. Department of Medical and Surgical Sciences, Alma Mater Studiorum–University of Bologna, Via Albertoni 15, 40138, Bologna, Italy

    Paola Forti

Authors
  1. Jacopo Lenzi
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  2. Paola Rucci
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  3. Ilaria Castaldini
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Corresponding author

Correspondence to Jacopo Lenzi.

Electronic supplementary material

Below is the link to the electronic supplementary material.

Online Resource 1

Diagnosis codes for identification of acute myocardial infarction cases (PDF 11 kb)

Online Resource 2

Description of data sources (PDF 11 kb)

Online Resource 3

List of potential confounders considered for inclusion in primary and secondary analysis (PDF 67 kb)

Online Resource 4

Description of confounder selection methods for multivariable conditional logistic regression (PDF 11 kb)

Online Resource 5

Effects of medication adherence on cardiovascular mortality after acute myocardial infarction (PDF 78 kb)

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Lenzi, J., Rucci, P., Castaldini, I. et al. Does age modify the relationship between adherence to secondary prevention medications and mortality after acute myocardial infarction? A nested case-control study. Eur J Clin Pharmacol 71, 243–250 (2015). https://doi.org/10.1007/s00228-014-1793-8

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  • DOI: https://doi.org/10.1007/s00228-014-1793-8

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