Article Figures & Data
Figures
- Figure 1
Adapted PRISMA flowchart.
CAD = coronary artery disease; PRISMA = Preferred Reporting Items for Systematic Reviews and Meta-Analyses.
- Figure 2
Factors influencing medication-taking behavior in coronary artery disease.
Tables
Sample Focus Methodology Coronary artery disease Medications Qualitative Coronary heart disease Medicines Ethnography Ischemic heart disease Adherence Interview Myocardial infarction Compliance Focus group Heart attack Persistence Thematic analysis Coronary artery bypass graft Concordance Myocardial infarction Number Author, Year Sample Size (Setting) Patients’ Age and Sex Country Methods Relevancea Pharmaceutical Funding 1 Roebuck et al,27 2001 31 (CAD; 6 wk after discharge) Median age = 63 y (28–74 y), 21 male United Kingdom Interviews SAT No 2 Wiles and Kinmonth,28 2001 25 (CAD; 2 and 16 wk after discharge) Ages 34–80 y, 13 male England Interviews SAT No 3 Bergman and Berterö,29 2001 8 (CAD; 5–8 mo after diagnosis) Ages 49–68 y, 5 male Sweden Interviews SAT No 4 Kärner et al,30 2002 23 (AMI; 1 y after CHD event) Mean age = 51 y female, 57 y male; 14 male Sweden Interviews SAT No 5 Webster et al,31 2002 35 (AMI and spouses; 2–3 wk after discharge) Average age = 65 y, 25 male England Interviews SAT No 6 Tolmie et al,32 2003 33 (CAD or high risk of CAD; 1–7 y after statin initiation) Ages 24–80 y, 20 male Scotland Interviews SAT Yes 7 Kärner et al,33 2004 25 (spouses of CHD patients; 1 y after cardiac event) Ages 36–68 y, 8 male Sweden Interviews SAT Not mentioned 8 Attebring et al,34 2005 20 (first AMI; median 7.5 wk after discharge) Median age = 61.5 y (34–79 y), 12 male Sweden Interviews KA No 9 Lehane et al,35 2008 10 (CAD; average length of treatment 2.5 y) Ages 51–69 y, 7 male Ireland Interviews KA Yes 10 Wang et al,36 2008 17 (first AMI; average 18 d after discharge) Mean age = 57 y (39–73 y), 14 male China Focus groups SAT Not mentioned 11a Decker et al,37 2008 22 (NSTEMI with DES) Ages 41–77 y, 13 male United States Interviews (telephone) KA Yes 11b Garavalia et al,38 2009 40 (AMI) Ages 44–78 y, 20 male United States Interviews (telephone) KA Yes 11c Garavalia et al,39 2011 22 (AMI with DES) Mean age = 53 y (45–77 y), 13 male United States Interviews (telephone) KA Yes 12 West et al,40 2010 32 (CHD admission; 3 mo after discharge) Aged ≥62 y, all female United States Interviews SAT No 13 White et al,41 2010 15 (cardiac rehabilitation attendees; during program and 9 mo after it) Aged 42–72 y, 11 male England Interviews SAT Not mentioned 14 Speechly et al,42 2010 13 (CHD; 8 diagnosed ≥5 y, 5 diagnosed <5 y) Aged 50–75 y, 6 male Australia Interviews SAT Yes 15 Rushworth et al,43 2012 20 (PCI; after phase 1 cardiac rehabilitation) Median age = 60.5 y, 15 male Scotland Interviews and questionnaires KA No -
AMI = acute myocardial infarction; CAD = coronary artery disease; CHD = coronary heart disease; DES = drug-eluting stent; KA = key article; NHS = National Health Service; NIH = National Institutes of Health; NSTEMI = non–ST-elevation myocardial infarction; PCI = percutaneous coronary intervention; SAT= satisfactory article.
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↵a According to system of Dixon-Woods et al.24
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Second-Order Construct Explanatory Notes Articles Promote persistence Adapting to the sick role Learning to overcome anxieties and worries about medications by internalizing life changes after a cardiac event 8, 11a Understanding myocardial infarction as indicating future vulnerability Perceived vulnerability to future myocardial infarction motivated preventive action 2 Ambivalence toward persistence Uncertainty about disease and prognosis Confusion about the damage caused by cardiac event and the success of the cardiac intervention 10, 15 Deter persistence Fatalistic approach to disease An overwhelming perceived threat of illness driven by personal experiences, family history, and anecdotal accounts 2, 4, 5, 11a, 11b Absence of symptoms challenging perceived need for treatment Lack of symptoms suggesting that one is cured, with no noticeable change if medications are missed 4, 6, 11a, 11b, 14 Level of appreciation about the link between risk factor and disease Lacking awareness about the causes of coronary artery disease 6, 11c, 13 Understanding acute myocardial infarction as an acute event Little feeling of future vulnerability of acute myocardial infarction, encouraged by misinterpretation of patient information literature quoting expected time to recovery 2 Second-Order Construct Explanatory Notes Articles Promote persistence Unconditional acceptance of treatment A high regard for clinician advice making prescriptions nonnegotiable 2, 6, 10, 13, 15 Perceived security from medication taking Taking medications gives a sense of control and is likely to reduce risk of death and recurrent events 4, 8, 9, 14, 15 Symptomatic improvements in physical health promote persistence Positive reinforcements about benefits of medications from noticeable improvements in symptoms 4, 9, 12, 14 Routines and physical aids Incorporating medication taking into daily routine and using blister packs facilitates persistence 9, 12, 13, 15 Motivation for persistence driven by belief that medication will prevent further cardiac events Belief that medication taking will reduce the risk of death and cardiac events 7, 8, 15 Family members as supporters Providing help to sort medications and acting as reminders 5, 9, 12 Medications more powerful than lifestyle Belief that medications are more powerful in their action than life-style changes 14 Perceived physical dependence on medications Belief that their body is physically dependent on medications because they have been used for so long 9 Ambivalence toward persistence Influenced by experiences of friends and family Using the experiences of others to shape their own decisions about medication taking 2, 6, 9 Health literacy Medication information may or may not be relevant to individual health literacy 9, 15 Deter persistence Confusion about specific medication indications Confusion about medications leading to misunderstandings about their relative importance 10, 11a, 11b, 11c, 12, 15 Concerns about medications effects on bodies Concerns about ability to function while taking the medications, including ability to work 1, 8, 10, 11a, 11b, 12, 15 Negative information in patient literature causing concern Knowledge of potential adverse effects (eg, from medication inserts, leaflets) leading to expectations that they would occur 6, 8, 15 Fear of long-term damage from medication taking Fear of damage to organs other than the heart, including cancer 7, 9, 10 Cost as a barrier Inability to afford medication or access clinic 11a, 11b, 11c Dislike taking tablets Dislike for tablet taking in itself, particularly long term 8, 10 Second-Order Construct Explanatory Notes Articles Promote persistence Importance of good relationship with prescribing clinician Valuing approachability and openness to discuss adverse effects 1, 5, 9, 11c, 13, 15 Importance of information given in suitable language Dialogue with clinician in language deemed appropriate 5, 6, 11a, 11c, 15 Importance of information at initiation Receiving adequate information when first starting treatment was deemed helpful 9, 11a Ambivalence toward persistence Adequate information about medication effects Wanting information about medication effects and using other resources (eg, Internet) if this is not provided by clinician 3, 8, 9, 11b, 15 Wanting individualized treatment I know this medication is good, but is it good for me? 8, 10, 12 Deter persistence Receiving conflicting information from health professionals Breakdown in transition of care between different health care settings 8, 11a, 11b, 11c Skeptical about advice from nonclinicians Heart disease considered too important to discuss with pharmacists 6, 15 Reluctance to seek information about drugs from clinicians Concerns about inconveniencing busy clinicians 6, 10 Perceived severity of illness reduced by clinician terminology Falsely reassured by misinterpreting jargon 2
The Article in Brief
Medication Taking in Coronary Artery Disease: A Systematic Review and Qualitative Synthesis
Mohammed A. Rashid , and colleagues
Background There is compelling evidence that cardiovascular medications help prevent coronary artery disease, but many patients discontinue treatment. This analysis of existing research seeks to understand the factors that influence patients' decisions to continue or stop taking medications.
What This Study Found Patients use complex decision-making processes when deciding whether to continue their medications. Some patients hold fatalistic beliefs about their disease, whereas others feel they have been cured by interventional procedures, both leading to decisions to discontinue medication. Patients who adapt to being a "heart patient" are positive about medication taking. Relationships with prescribing clinicians are critically important to patients; clinicians' inaccessibility and insensitive terminology negatively affect patients' perceptions of treatments. By adopting a more open approach, clinicians can engage patients in a discourse about their medications. Moreover, providing medication-specific information when initiating therapy, improving the transition between secondary and primary care, and explaining the risk of disease recurrence may help to modify patient attitudes toward drugs to prevent further cardiovascular disease.
Implications
- Strategies to encourage patients with coronary artery disease to continue taking medications should recognize the key role of the prescribing clinician.
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