Medication Underuse in Aging Outpatients with Cardiovascular Disease: Prevalence, Determinants, and Outcomes in a Prospective Cohort Study.

Cardiovascular disease is a leading cause of death in older people, and the impact of being exposed or not exposed to preventive cardiovascular medicines is accordingly high. Underutilization of beneficial drugs is common, but prevalence estimates differ across settings, knowledge on predictors is limited, and clinical consequences are rarely investigated.Using data from a prospective population-based cohort study, we assessed the prevalence, determinants, and outcomes of medication underuse based on cardiovascular criteria from Screening Tool To Alert to Right Treatment (START).Medication underuse was present in 69.1% of 1454 included participants (mean age 71.1 ± 6.1 years) and was significantly associated with frailty (odds ratio: 2.11 [95% confidence interval: 1.24-3.63]), body mass index (1.03 [1.01-1.07] per kg/m2), and inversely with the number of prescribed drugs (0.84 [0.79-0.88] per drug). Using this information for adjustment in a follow-up evaluation (mean follow-up time 2.24 years) on cardiovascular and competing outcomes, we found no association of medication underuse with cardiovascular events (fatal and non-fatal) (hazard ratio: 1.00 [0.65-1.56]), but observed a significant association of medication underuse with competing deaths from non-cardiovascular causes (2.52 [1.01-6.30]).Medication underuse was associated with frailty and adverse non-cardiovascular clinical outcomes. This may suggest that cardiovascular drugs were withheld because of serious co-morbidity or that concurrent illness can preclude benefit from cardiovascular prevention. In the latter case, adapted prescribing criteria should be developed and evaluated in those patients

Presence of medication underuse was associated with frailty, BMI, and the number of drugs.

<p>Selected model variables and their association with medication underuse in a multivariate logistic regression model (*** < 0.001; ** < 0.01; and * < 0.05).</p

Medication underuse did not affect cardiovascular outcomes, but rather deaths due to non-cardiovascular causes.

<p>(A) Kaplan-Meier plot of relevant cardiovascular events for appropriate use and medication underuse (<i>P</i> value calculated by the log-rank test). (B) cumulative incidence functions of relevant (black) and competing events (gray) according to status of medication underuse (<i>P</i> value calculated by the Gray test) (solid line: appropriate use; dotted line: underuse).</p

Adapted START criteria for determination of cardiovascular medication underuse.

<p>^a a documented history of atherosclerotic coronary, cerebral, or peripheral vascular disease included previous myocardial infarction, stroke, coronary intervention (bypass surgery or balloon catheterization of the coronary arteries), pulmonary embolism, and deep vein thrombosis.</p><p>^b hypertension, hypercholesterolemia, and smoking history</p><p>Adapted START criteria for determination of cardiovascular medication underuse.</p