Aderenta si Aderenta si controlul riscului controlul riscului cardiovascularcardiovascular

Alexandru AndritoiuSp. Militar Craiova

Subiecte

• Riscul CV • Aderenta• Nonaderenta • Complianta• Persistenta

Riscul CVRiscul CV

• Total (global)-absolut-relativ• Formule de calcul probabilistic intr-o

populatie tinta

Riscul global-CADRiscul global-CAD

• Riscul global este un calcul al riscului absolut de a avea un eveniment coronarian (deces, IMA) intr-un interval de timp specificat (10 ani).

• Cunoasterea RCV permite medicului sa prescrie terapii tintite in copul reducerii riscului (antihipertensive, statine, aspirina).

Permite aflarea raspunsului la Permite aflarea raspunsului la intrebarile intrebarile

• Cine va beneficia de interventiile terapeutice? • Cand trebuie inceput tratamentul

farmacologic si non-faramacologic?• La cine, aceste interventii sunt cost-

eficiente?. • Calculul risului CV poate ajuta in luarea celei

mai bune decizii de management.

Calcululul Riscului Global

Calculul riscului CV global este recomandat in toate ghidurile nationale ca punct de plecare in decizia terapeutica

• Framingham CardioVascular Risk Score (Framingham Heart Study)-USA

• Prospective Cardiovascular Munster Heart Study (PROCAM)

• Systematic Coronary Risk Evaluation system (SCORE)

• United Kingdom Prospective Diabetes Study (UKPDS) for diabetics,

• Reynolds Risk Score • NHANES (include the obesity as a risk factor)

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SCORESCORE

European Heart Journal

Mædica A Journal of Clinical Medicine, Volume 2 No.4 2007

• HTA 39%• Hiper-Col 31.4%• DZ 11.8%• Fumatul 21.7%• Obezitatea 26.3%

Controlul FRCVControlul FRCV

• HTA-stil de viata, dieta, medicatie;• Colesterol-dieta, medicatie (statine);• Fumatul- consiliere, medicatie;• Diabet-dieta, medicatie;• Istoric familial (ereditate)-……• Sexul Masculin-…..

FR influentabili/neinflentabili

Definitii, termeni si Definitii, termeni si concepteconcepte

The World Health Organization:The World Health Organization:

Adherence: - the degree to which the person’s behavior corresponds with the

agreed recommendations from a healthcare provider.Compliance:- the degree to which a patient correctly follows medical advice.- patient is passively following the physician’s orders, while

adherence acknowledges that the patient is part of the decisionmaking process, making this the preferred term.

Persistence:the duration of time over which a patient continues to fill the

prescription.Non-acceptance: - some patients may never start treatment (a type of non-

adherence)Concordance: - the degree of accordance of therapeutic goals of patient and

therapist is defined as ‘concordance

Non-AderentaNon-Aderenta

OMS/WHO: • ,,poor adherence is the primary reason for

suboptimal clinical benefit in many circumstances.

• ,,medication non-adherence has been associated with increased hospitalizations, loss of productivity, premature deaths, and increased treatment costs”.

Non-adherence to medications is widely recognized as a major public health concern and contributes to

patient morbidity, mortality and healthcare costs

Ce este aderenta pe termen Ce este aderenta pe termen lunglung

(long-time adherence)?(long-time adherence)?

• 12 luni dupa externare• 24 luni

Non-Non-AderenAderenta pe termen lungta pe termen lung

Greater prescribing/filling complexity was associated with lower levels of adherence.

Some studies suggest that long-term adherence of chronically prescribed CV medications such as anti-hypertensives or statins may be as low as 50%.

• 1996-primul simpozion

• 2006-primul simpozion european

• 2009 ESPACOMP

ESPACOMP is a non-profit association established to promote the science concerned with the quantitative

assessment of what patients do with medicines they have been prescribed.

Cum masuram aderenta?

• Nu este o metoda gold-standard• Criterii directe:- conc. medicamentului sau metabolitilor

sai in prodise biologice (sange/urina)• Criterii indirecte:- chestionare, met. electronice,

contabilizare Rp, masurarea unor markeri biologivie (LDL-Col), etc.

Consecintele nonaderentei la pacientii

cu RCV inalt

Gehi AK, Ali S, Na B, Whooley MA. Self-reported medication adherence and cardiovascular events in patients with stable coronary heart disease: the heart and soul study. Arch Intern Med. 2007;167(16):1798–1803.

• 1.015 pts. CAD• chestionar-aderenta Follow-up 4 ani• 4.4x risc de stroke• 3.8x risk de deces

Cauze de Non-AderentaCauze de Non-Aderenta

• Legate de medic• Legate de pacient• Legate de sistem

Cauze de NonaderentaCauze de Nonaderenta

Baroletti S, Circulation. 2010;121:1455-1458

Aderenta la medicatia CV Aderenta la medicatia CV

• In SUA numai 50% dintre pts. continua tratamentul cu statine la 6 luni, si doar 30-40% la 1 an!

• Beneficiile tratamentului cu statine este pus sub semnul intrebarii in populatia generala.

• Riscurile intreruperii tratamentului cu statine sunt devastatatoare, in ciuda beneficiilor certe demonstrate in trial-urile clinice.

Aderenta la statine

9.014 patients with previous CAD

Results: monitoring of cholesterol concentration had

modest ability for detecting complete non-adherence and non-persistence.

BMJ 2011;342:d12

Diabetes Care 28:595–599, 2005

CONCLUSIONS:• Adherence to statin therapy, (as reflected by MPR), is

closely related to LDL cholesterol goal attainment in patients with diabetes and dyslipidemia.

• The probability of goal achievement appears to increase substantially when the MPR is 0.80.

• Pharmacy records can be used to identify patients who are poorly compliant with statin therapy and at high risk for failure to attain LDL cholesterol goals.

Motivele intreruperii Motivele intreruperii tratamentului tratamentului

cu statine-o dilema actuala?cu statine-o dilema actuala?

• Efectele adverse (diabet?, rabdomioliza)• Costuri (original vs generic)• Lipsa de incredere in produs• Campania anti-statine in mediul on-line• Comunicare, educatie, follow-up• Unii pts intrerup o perioada, dupa care

reiau tratamentul!

Riscurile terapiei cu statine Riscurile terapiei cu statine sunt determinate genetic!sunt determinate genetic!

Results• Statins were prescribed for 67% patients, but

only 41% used the drug• In spite of being indicated, statins were not

prescribed in 33% patients• Of 26% patients, nonadherent to statins, - 67% did not use the drug due to its high cost,- 31% due to the lack of instruction, - 2% due to side effects.

Arq Bras Cardiol, volume 76 (nº 2), 115-8, 2001

Adherence With Statin Therapy in Elderly Patients With and Without

Acute Coronary Syndromes Cynthia A. Jackevicius, Muhammad

Mamdani, Jack V. Tu JAMA. 2002;288(4):462-467.

Conclusions:  Elderly patients with and without recent ACS have

low rates of adherence to statins. This suggests that many patients initiating statin

therapy may receive no or limited benefit from statins because of premature discontinuation.

Adherence With Statin Therapy in Elderly Patients With and Without Acute Coronary Syndromes

JAMA. 2002;288(4):462-467. doi:10.1001/jama.288.4.462

All curves are based on a Cox proportional hazards model adjustedfor covariates. The median follow-up was 494 days for acute coronary syndrome,430 days for coronary artery disease, 235 days for primary prevention, and303 days for overall.

Aderenta la statine este Aderenta la statine este diferita de a celorlate diferita de a celorlate

medicamente CV?medicamente CV?

• (1) Aspirina: 71%• (2) B-blocante: 46%• (3) Statine: 44%• 1+2+3: 21%

Duke University

28 studies were included:• 19 studies evaluating outcomes associated with statin adherence • 6 studies with statin discontinuation • 3 studies with statin persistence

The included studies consistently reported increased risks of CVD and mortality associated with poor adherence with respect to both execution of regimen and stopping of therapy.

J Manag Care Pharm. 2014;20(1):51-57

Conclusion: • patients adherence levels tend to decline over time • a transition to levels of adherence lower than a

PDC of 80% was associated with increased risk of CV events

Heart 2002;88:229–233

ConclusionsConclusionsGood adherence to statin treatment was associated with lower risk of recurrent MI.

Am J Manag Care. 2014;20(4):e105-e112

Can Fam Physician 2007;53:2144-2145; Morisky DE. Med Care 1986;24(1):67-74.

• The good adherence (89%) in this study may be based on the systematic feedback of treatment results.

• the percentage side effects (27 %) is much higher than the incidence of adverse effects of statins in RCT’s (5-10%)

Care factori influenteaza Care factori influenteaza aderenta la tratament ?aderenta la tratament ?

• Statin therapy for patients with cardiovascular conditions (first-year measure)

• Statin therapy for patients with diabetes (first-year measure).

The Healthcare Effectiveness Data The Healthcare Effectiveness Data and Information Set (HEDIS)and Information Set (HEDIS)

Proposed New Measure for Proposed New Measure for HEDIS 2016:HEDIS 2016:

Statin Therapy for Patients Statin Therapy for Patients With Cardiovascular DiseaseWith Cardiovascular Disease

• Received Statin Therapy. The percentage of members who were identified as having clinical ASCVD and were dispensed at least moderate intensity statin therapy during the measurement year.

• Statin Adherence 80 percent. The percentage of members who were identified as having clinical ASCVD and were dispensed at least moderate-intensity statin therapy that they remained on for at least 80 percent of the treatment period.

The CMA was better for patients with increasing CV risk.CMA at 15 months varied from an average of 56% (67% with a CMA ≤ 80%) for those with one risk factor to 72% (43.3% with a CMA ≤ 80%) for patients with three or more risk factors

Aderenta in tratamentul Aderenta in tratamentul HTAHTA

• Controlul TA optim-un deziderat neatins in populatie

• Nonaderenta-cauza de falsa HTA rezistenta

Medicatia antihipertensiva• Aderenta buna-Ca bloc, IECA• Aderenta scazuta-Beta bloc, diuretic

Patient adherence and the treatment of hypertension

• Nonadherence to antihypertensive medication is common.

• The latest National Health and Nutrition Examination Survey (NHANES) found that about 74 percent of hypertensive patients in the United States are being treated, and 72 percent of those being treated have their blood pressure well controlled (which was defined as a pressure below 140/90mmHg)

• In a study of 149 hypertensive patients who were monitored with electronic pill boxes, 42 percent were nonadherent, defined as taking less than 80 percent of prescribed antihypertensive medication .

Kaplan N et al. UpToDate 2015

Adherence to diabetes Adherence to diabetes medication: medication:

a systematic reviewa systematic review

Conclusions• Adherence to diabetes medication remains an ongoing

problem.• Of the 27 studies included in the present review, the

prevalence of adherence ranged from 38.5 to 93.1%.• Only six out of 27 studies (22.2%) reported prevalence of

adherence of ≥ 80% among their study population. • Depression and medication cost were found to be

consistent and potentially modifiable predictors for diabetes medication-taking behaviour.

Krass I et al. 2015, 32,6:725-737

Aderenta la dieta Aderenta la dieta mediteraneanamediteraneana

• Dieta mediteraneana reduce RCV• Efectele aderentei crescute:-reduce LDL-Col. oxidat-reduce RLO-reduce procesele inflamatorii-imbunatateste controlul TA-previne sdr. metabolic

Pitsavos C et al. . Am J Clin Nutrition (The ATTICA Study) 2005

Spania, Grecia, Italia

Adherence to the Mediterranean diet was mainly poor in roughly half of the populations investigated. Major determinants of adherence were social and demographic factors

NFS Journal 3 (2016) 13–19

Ann Pharmacother 2010;44:1905-13.

• The pharmaceutical care program (frequent counseling sessions - every 3 months) resulted in a significantly lower rate of discontinuation within 6 months after initiating therapy versus usual care.

• Median MPR was very high (>99%)!

ConcluzieConcluzie