By January W. Payne
Washington Post Staff Writer
Tuesday, September 26, 2006

A new study shows that more than half of patients who had had a heart attack -- and had health and prescription drug coverage -- weren't consistently taking a medication known to reduce the risk of another heart attack and improve survival.

The study fits into a pattern of findings showing that even people with very serious illness fail to follow medical practices known to save lives and improve outcomes. Some patients quit following directions when their symptoms disappear. In some cases their health care providers don't follow up and monitor compliance. Sometimes their doctors don't recommend the proper care in the first place.

People who have had a heart attack "have a chronic condition that needs to be cared for over time," said Jessie Gruman, president of the Center for the Advancement of Health, a group that encourages adoption of effective medical practices. "There are requirements for behavior" to produce good outcomes, she said, including diet, exercise, rest and medications.

The current study, published in the September issue of the American Heart Journal, examines adherence to beta blocker therapy, which is used to treat high blood pressure, relieve chest pain and prevent future heart attacks. Researchers found that only 45 percent of heart attack patients were still taking them 360 days after being discharged from the hospital. About 7.2 million U.S. adults have had heart attacks, the study reports.

The study was based on prescription claims data from more than 17,000 patients participating in 11 health plans and representing 48 states, including Maryland and Virginia, and the District.

"It definitely reinforced that there is definitely a problem with consistent long-term use with some of these medications, which we know save lives," said lead author Judith M. Kramer, principal investigator at the Duke University Center for Therapeutics. "We need to look at what we can do to make this better."

Heart attack patients are typically put on a regimen that includes not only beta blockers but also aspirin (used to reduce risk of a repeat heart attack or a stroke), statins (or other medication to reduce cholesterol levels), exercise, a healthy diet and often an ACE inhibitor (a drug used to treat high blood pressure). It's a routine that studies show can aid survival and reduce the risk for future serious cardiac problems if it is followed consistently.

Yet compliance is poor. In one large study published in the journal Circulation in January, only 39 percent of patients with coronary artery disease reported following the recommended three-drug regimen.

Patients tend to slack off when it comes to diet and exercise, too. Less than 50 percent of people keep up regular exercise regimens for even six months after completing cardiac rehabilitation programs, which teach patients healthy exercise and diet habits, according to a study published in 2003 in the Journal of Cardiopulmonary Rehabilitation.

A 2006 German study published in the journal Heart found that one year after completing cardiac rehab, 49 percent of patients maintained a healthy diet. About 42 percent continued the diet three years after rehab.

A study of 40 women published in Nursing Research in 1998 found that only 27 percent exercised at least three times a week in the three months after finishing cardiac rehab.

What remains to be explored, experts said, is the question of why compliance is so poor, even for patients who have had recent life-threatening conditions. Some patients, for example, may have been told by their doctors to stop taking the drugs due to side effects or other concerns.

Some patients appear not to have followed the instructions even immediately after release from the hospital. The current study reports that only 69 percent of patients took beta blockers in the first 30 days after hospital discharge, which suggests that many of them "may not have initially filled their discharge prescriptions," the authors wrote.

The report reinforces the idea that some patients may see their medications as a "daily reminder of how sick they are," Kramer said. "There are all kinds of very complex factors that go into patients' taking their medications," including how many other medications they're taking and the cost -- even if they're only paying a co-pay, she said.

Doctors and researchers have for years looked for ways to improve adherence to beta blocker therapy, which since the 1980s has been known to offer key benefits to heart attack patients. Kramer said numerous studies have shown that long-term use of beta blockers aids survival and decreases the risk of future heart attacks.

The Joint Commission on Accreditation of Healthcare Organizations instituted a quality measure for prescribing beta blocker therapy after a heart attack in 2002. Since then, studies show these drugs are prescribed nearly every time a heart attack patient is discharged. But this doesn't mean all patients get their prescriptions filled.

"We've been led a bit astray [by] looking at quality of care" based on whether a heart attack patient is given a prescription upon discharge, said Mandeep Mehra, head of cardiology at the University of Maryland School of Medicine. The new study "says, 'Hey, guys, less than half your patients are actually on these medications' " after one year, he said.

What could help improve adherence rates is incorporating the "human element" into cardiac care, said Nieca Goldberg, a New York cardiologist and spokeswoman for the American Heart Association. That means taking extra time during doctor visits to discuss how patients feel about their medications and explain the importance of healthy habits such as eating right and exercising regularly.

That's what Mehra calls an "education gap," in which clinicians don't sufficiently communicate to patients the "value and side effects of beta blockers to patients." Some patients assume that depression, fatigue and sexual dysfunction occur due to beta blockers, but studies indicate that the "frequency of [these] side effects is so low that we over-attribute [the side effects] and stop the drugs." ·

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