So, second week of ischemic heart disease, and I'm going to kind of deviate again a little bit from the content that you will be reading and want to talk today about patient compliance because so much of our outcomes for our therapies with coronary disease are patient-dependent and require, you know, work on their part. And so, I think this is a really hot topic and I just kind of wanted to get you to have a little bit more understanding around good outcomes and what's required. So, a few statistics, we're going to talk about medication compliance because here's the deal, and you've probably now been out in the clinic and in the hospital for a few weeks and think about the 40-year-old or 45-year-old that comes in with a cardiac event who came in on no medicines and now we're sending them home on five. They're going home on an aspirin, beta blocker, an ACE inhibitor, a statin, and another antiplatelet if they got a stent. So think about going from taking nothing to now taking five medications daily. So a few statistics on medication adherence, 3.8 billion prescriptions are written every year with over 50% of them taken incorrectly or not at all. In a survey of 1,000 patients, nearly 75% admitted to not always taking their medications as directed and you're like me, I'm probably on that list and I know better. Even for chronically ill patients who regularly fill their prescriptions, only about half the doses taken are taken as their providers intended. Poor compliance accounts for a third to two-thirds of drug-related adverse events that result in hospitalization. So patients that come in with overdose issues or maybe had stopped their meds, one-third to two-thirds of the time, that's the issue. Okay, this is where it drives it home. Cardiac patients that don't take their meds have increased risk of hospitalization and premature death, 5.4 times higher for hypertension, 2.8 times higher for dyslipidemia, and 1.5 times higher if they have heart disease. So this concept of you fixed my heart and now I don't need to do anything else is not the case. So here's some statistics that can kind of help maybe engage your patients in understanding of good secondary prevention. So what does this have to do with coronary disease? So I'm going to go back thinking about that 40-something-year-old. So let's talk about Jerry. He's a 48-year-old white male. He presented to the ED after two hours of substernal chest pain radiating to his left arm, nausea and diaphoresis, classic male presentation. The EKG showed ST elevation V1 through V4. He was immediately taken to the cath lab where his proximal LAD was 95% included. Stent was placed successfully. His ejection fraction on an LV gram was 40% with some anterior wall hypokinesis. Jerry remained hospitalized with troponin elevation to 60, and he was discharged two days after presentation. So let's talk about what happened to Jerry. So Jerry's discharge plan was he was discharged home on his aspirin, Topral XL, Lysinopril, Berlanta and Lipitor. The plan was to have him follow up three to five days at the cardiology clinic, and he was enrolled in cardiac rehab to start two weeks post-discharge. So again, this is a very, very common story, right? So Jerry's initial journey, his follow-up appointment he came for, he attended and all seemed very well. He was nervous about what had happened, but he was ready to take the bull by the horns and make sure this didn't happen again. He went to his first visit of cardiac rehab, but he found when he got there that only cardiac rehab hours that were available conflicted with his work. Insurance didn't pay for it. So now, because again, he's not a Medicare patient, so now we've got another issue. So Jerry did not return. For prescriptions after discharge, Jerry went to the pharmacy to fill his four new prescriptions. Prior to the admission, he wasn't on anything. The initial cost was $375 for the first 30 days. He was also handed a stack of informational pamphlets outlining the many side effects, including bleeding, erectile dysfunction and fatigue. So can you imagine what Jerry was thinking? I mean, certainly he was nervous about his cardiac event, but we are not making this easy for him to follow through on the things that we recommended. So fast forward five years. Jerry develops a new shortness of breath. He's unable to keep up with his previous activities. At this point, he's 53 years old. He's noting that his pants are getting tight and his socks are leaving marks. What is happening? After two courses of oral antibiotics for bronchitis, a provider finally checks the chest x-ray and finds vascular congestion. His BNP was 1,400, his echo was ordered and the EF was 30% with global hypokinesis. Jerry now has a dilated cardiomyopathy. In review of his history, he stopped his medications after the first six months and hasn't had any follow-up since. Again, $375 a month in a patient that had already had not been on anything and we probably scared him related to all the side effects that were outlined for him if he were to continue these medications. I will tell you that is not an uncommon scenario. So one more statistic. Within two years of initiating therapy, only half of MI patients were still taking their prescribed statin, beta blockers, ACE inhibitors and or ARBs. So what this means is that we spend so much time on STEMI care, so much time on appropriate care during the hospitalization. Even now, we're doing a lot of work around transitional care, making sure they're getting the early visit. But here's a case in which, yeah, he did though, he got through that part of it and then everything dropped off. So again, you can look at this a couple different ways and certainly Jerry has some responsibility. But I would argue when you think about what Jerry was bombarded with and the way cardiac rehab was set up and the way his insurance didn't cover it and the way his prescriptions were so expensive, we didn't do anything to set Jerry up for success. So compliance is complex and multifactorial, some barriers. So a recent study of 10,000 patients looked at beliefs and behaviors. Forgetfulness was a common at 20, you know, why did they not take their med? 94% of the time was forgetfulness. Perceived side effects, 20% of the time. And again, I'm not saying that we don't need to share potential side effects with our patients, but I don't think we do it in a very effective manner. We don't allow it to put it in perspective for them and we don't do a good job of risk versus benefit. So we give them all of this written material. It's almost worse when they read it because then they read all of these things, they think it's all going to happen. So of course, why would they take their medication? Cost issues is 17% and then patient perception of no need for medication is 14%. And I can almost guarantee in Jerry's scenario, it was the last three things. And the concept of no need for medication after a couple months, that anxiety over the event has subsided. He's feeling better. He's back to normal activity. I don't need any of that and it's expensive. So again, it's not an uncommon scenario. Noncompliance is highest when symptoms aren't experienced. So if you think about hypertension, hyperlipidemia, those things typically don't have symptoms associated with it. So that is a ripe environment for patients to think that they don't need those medications. So what can we do about it? I think there's a few things. And as the APP part of the team, I think we're geared up really well to be part of this. We need to give more information. On average, a physician spends discussing all aspects of a newly prescribed medication is 49 seconds. So what can you outside of that you need this, what can they possibly learning in 49 seconds? When you ask the patients, no instructions were given by the provider anywhere from 19 to 39% of the time. New prescription instructions discussed less than 60% of the time and new prescription side effects discussed less than 33% of the time. And if we don't discuss it with them, they're going to get the written materials. So we need to put it in perspective. So what are the things we can do? Number one, keep the regimen as simple as possible. Once daily versus four times daily, 80% compliance versus 50% compliance. Medication refills and synchronization. So the average patient taking statin takes a total of 11 other medications. It means five pharmacy visits over a three-month period and only picks up half of the refills at any one time. 10% of statin users take 23 medications. I think that's really powerful. So it's fragmented care. So we talk a lot about the frustrations over medication reconciliation, but the importance of it and streamlining and getting it cleaned up and empowering our patients to be able to do the right thing. When we talk about noncompliance, so many times we're pointing the fingers back at them, but I would really argue that much of the time it's our responsibility and we didn't do a good job. We didn't make it easy for them to be successful. So with that, I'm going to let you finish your content around ischemic heart disease. And again, it's so important. We are saving a lot of lives with our STEMI programs, with our PCI programs, you know, with just really being great at even secondary prevention, but I think we're really good at the onset. And I think that we don't do a good job of engaging our patients long-term and what happens when they fall off, they show up with heart failure. And so when we move to our heart failure talks, the statistics are staggering and they're really not getting any better, even though we're better at managing it. So a little food for thought. Good luck of the content this week. Feel free again to reach out if you have any questions and we appreciate you being with us.

patient compliance

coronary disease

medication adherence

dilated cardiomyopathy

heart failure