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Year : 2018  |  Volume : 7  |  Issue : 2  |  Page : 40-48

Disease awareness, pharmacological adherence, and knowledge on further advanced therapeutic option among medically managed postmyocardial infarction patients: Experience from a Sri Lankan tertiary care cardiac center

Department of Cardiology, Teaching Hospital Kandy, Kandy, Sri Lanka

Date of Web Publication23-Mar-2018

Correspondence Address:
Dr. H G W A P Laksman Bandara
Teaching Hospital Kandy, Kandy
Sri Lanka
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/JCPC.JCPC_28_17

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Context: Although most of the patients with ischemic heart diseases (IHD) are treated according to the guidelines, adequacy of the knowledge about their treatment is questionable. Aims: The study was aimed to explore the patients' awareness of their disease, state of pharmacological adherence, and the knowledge of their further advance therapeutic options on patients who were subjected to medical management following myocardial infarction (MI). Settings and Design: This study design was a cross-sectional descriptive study. Subjects and Methods: The study was conducted at Cardiology Unit, Teaching Hospital Kandy, Sri Lanka in 2015. Pretested interviewer-administered questionnaire and patients' health records were used to collect the data. All the patients who had MI and currently on medical management were included in the study. Patients who had a percutaneous coronary intervention and coronary artery bypass graft surgeries were excluded from the study. Statistical Analysis Used: Data analysis was performed by SPSS version 19 statistical package. P < 0.05 was considered statistically significant. Results: A total number of 103 patients with a mean age of 58 ± 9 years were included in the study. According to the four-item Morisky Medication Adherence Scale, 51.5% had high adherence to treatments, whereas moderate and low adherences were reported in 42.7% and 5.8%, respectively. The mean number of drugs in polymedicated patients was 7.5 ± 1.6. Only 28% had the awareness about the type of their IHD by pathophysiology in simple terms. Only 33% had discussed the necessity of advanced therapeutic options following their acute coronary event. Conclusions: Suboptimal drug adherence, lack of knowledge about their disease, and inadequacy of health communication are the major issues to be addressed in our post-MI patients.

Keywords: Drug nonadherence, polypharmacy, postmyocardial infarction education, postmyocardial infarction rehabilitation

How to cite this article:
Bandara HL, Hewarathna U I, Kogulan T, Karunarathne R, Kodithuwakku N W, Jegavanthan A, Ambagaspitiya A, Ambagammana D, Tennakoon R, Jayawickreme S R, B Dolapihilla S, Weerakoon G. Disease awareness, pharmacological adherence, and knowledge on further advanced therapeutic option among medically managed postmyocardial infarction patients: Experience from a Sri Lankan tertiary care cardiac center. J Clin Prev Cardiol 2018;7:40-8

How to cite this URL:
Bandara HL, Hewarathna U I, Kogulan T, Karunarathne R, Kodithuwakku N W, Jegavanthan A, Ambagaspitiya A, Ambagammana D, Tennakoon R, Jayawickreme S R, B Dolapihilla S, Weerakoon G. Disease awareness, pharmacological adherence, and knowledge on further advanced therapeutic option among medically managed postmyocardial infarction patients: Experience from a Sri Lankan tertiary care cardiac center. J Clin Prev Cardiol [serial online] 2018 [cited 2022 Jan 18];7:40-8. Available from: https://www.jcpconline.org/text.asp?2018/7/2/40/228339

  Introduction Top

Ischemic heart disease (IHD) is one of the common causes of mortality and morbidity in Sri Lanka. Approximate prevalence of IHD is 9.3% in local health setting attributing for a significant health burden.[1] Although the standard management of acute myocardial infarction (MI) is coronary interventions followed by pharmacotherapy, most of our patients are subjected to medical management only due to limited resources. However, to achieve a better medical management, it is also important to have a good understanding and an insight by the patients on their own disease.

In the current practice, secondary preventive pharmacotherapy includes platelet inhibitors, statins, beta-blockers, and angiotensin-converting enzyme inhibitors (ACEI)/angiotensin receptor II blockers where evidences are concerned.[2] These drugs have a strong contribution for the improvement of the prognosis. However, there is a substantial gap between the drug prescription on discharge and therapeutic adherence, hindering the delivery of optimal care to the patients.

Although post-MI patients are more vulnerable to future cardiovascular events, there can be patients who do not receive the treatment according to the current guidelines.[3] This may be due to underprescription, lack of adherence, and suboptimal dosing of secondary preventive drug therapy.[4],[5] Medication nonadherence following acute MI is known to be associated with poor clinical outcome and adverse cardiovascular prognosis. Thus, the evaluation of medication nonadherence plays a vital role among post-MI patients. Therefore, this study aimed to explore this undiscovered aspect in our local health community.

Polypharmacy is the use of five or more medications by a patient.[6] Polypharmacy brings about an imperative concern for patient safety, and it has been linked with increased adverse drug reactions, morbidity and mortality with special reference to elderly, and multiorgan disease. Since many of the post-MI patients are elderly and most of them are found to have concomitant renal or liver disease, many of the harmful effects of polypharmacy are highly substantial to this population. Addition to that, the perception and the acceptance of polypharmacy by the patient are also a critical point to be discussed in the background of drug adherence and quality of care.

Adequate awareness about their own disease and knowledge on available therapeutic options is an important aspect of managing patients with IHD since an educated patient naturally found to have a better therapeutic adherence. One of the common observation in our health setting is the patients fully dependency on the physician for deciding their therapeutic strategies. Patient education together with effective communication between the patient and the physician is pivotal in post-MI care to overcome this problem. A communication gap between patient and physician can result in a strong impact on the optimal care delivered to the patient in the post-MI period.

The objectives of the study were focused in three main areas. First emphasis was given for the evaluation of the patient's knowledge of their disease and their source of health information. The next attention was made to assess the knowledge on their current treatments including drug adherence and their view on polypharmacy. Finally, it was focused to assess the knowledge on advance therapeutic options. The study was conducted only with the patients who were subjected to medical management following MI.

  Subjects and Methods Top

Study design

The study was conducted as a cross-sectional descriptive study. It was conducted in 2015 at cardiology unit, Teaching Hospital Kandy on a sample of post-MI clinic patients.

Study sample

The study population included the patients who were attending the clinic at Cardiology Unit, Teaching Hospital Kandy, with a history of MI within the period of 0.5–5 years and who were received only the medical management. Patients who had percutaneous coronary intervention (PCI) or coronary artery bypass graft (CABG) were excluded from the study.

Data collection

A pretested interviewer-administered questionnaire was used to obtain information about demographic data, patient characteristics, disease awareness, knowledge on therapeutic options, and the sources of health information [Annexure 1]. The disease awareness of the patient was assessed to test whether the patient has an understanding of their MI happened as a result of compromise of blood supply of one of the coronary blood vessels results in myocardial death. Different questions were made to emphasize the exact mechanism of the IHD that they had in simple nonmedical language (Annexure 1). The knowledge of the advanced therapeutic options was mainly focused on to test the patients' awareness about the options of PCI and CABG as a part of their disease management.

Medical records were used to gather information on the variety and the number of drugs used. The patients' view on polypharmacy was tested as direct questioning, and the drug adherence was assessed using Morisky's Medication Adherence Scale (MMAS-4) which included four questions, each with original binary response option of yes or no (Annexure 2). Classification of patients as high adherence, moderate adherence, and low adherence was done according to the total score of four answers. Patients who had a score of 4 out of 4 was considered as high adherent while a score of 3 or 2 was classified as moderate adherent. Patients who gained a score of one or below were categorized as low adherent.

Data analysis

Data entering and analysis was performed by SPSS version 19 (Armonk, NY: IBM Corp) windows statistical package. Demographic and clinical data were illustrated as descriptive statistics. P < 0.05 or 95% confidence limit was considered statistically significant.

Ethical consideration

The study protocol was approved by the Research and Ethical Review Committee, General Hospital Kandy. Informed written consent was obtained from each participant. Interviewing the patients at the site was performed to obtain the clinical information.

  Results Top

Demographic characteristics

There were 103 patients included in the study. Mean age of the sample was 58 ± 9 years. Distribution of the age of the study sample is shown in [Figure 1]. There were 81% males and 19% females. The duration since last ischemic event was ranged from 0.5 to 5 years.
Figure 1: Age distribution of the study sample

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More than half of the population (54%) had dyslipidemia. Distribution of the other vascular risk factors in the study sample was illustrated in [Table 1].
Table 1: Prevalence of vascular risk factors among the study sample

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Patients' knowledge over their disease

Out of the sample, 60% were aware of the existence of several types of IHD. However, 72% were not alert about the type of their IHD by the mechanism in nonmedical language. Only 6% were aware of the relevant pathology of IHD that they have. From the sample, 58% were aware of the prognostic medications and 62% patients knew that they are taking aspirin though only 42% were conscious that aspirin is one of the essential drugs in IHD.

Self-perception of therapeutic options

Among the study group, 63% were heard about the availability of advanced therapeutic options such as PCI or CABG. However, only 11% and 15% had an adequate knowledge regarding what is meant by PCI and CABG in nonmedical management, respectively [Figure 2]. Only 33% had discussed the necessity of any advance therapies after the last event of their IHD. There were 69% patients who were informed about the future risks of IHD, but only 7% had received information regarding the prognostic benefits of available therapeutic options.
Figure 2: Illustration of the self-perception of therapeutic options among the study group

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State of patient provider communication and source of health information

The main source of health information to the study sample was the clinic doctor (53%) whereas other clinic staff (25%) and the family physician (11%) were the next major resources [Table 2]. Majority of participants had no access to the internet (78%) and only 7% of those who had internet access had searched health information with respect to their disease through internet. Most participants (80%) had mobile phones, whereas 66% were happy to use short message service (SMS), whereas 25% were comfortable with web-based access as a method of sharing medical information.
Table 2: Illustration of the source of health information in the study group

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Pattern of self-reported medication nonadherence among post-MI patients

According to the four-item MMAS-4, 51.5% had high adherence to treatments, whereas moderate and low adherences were reported among 42.7% and 5.8%, respectively [Figure 3].
Figure 3: Distribution of self-reported medication nonadherence among postmyocardial infarction patients

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Exploration of the knowledge on polypharmacy

The prevalence of polypharmacy was 100%. The mean number of drugs in polymedicated patients was 7.5 ± 1.6. Out of them, 52.3% felt that they were taking a large number of medications. However, 73% of them were comfortable with the number of medications that they were taking and 87% of them were in a view that all their medications were essential. Only 38.3% had a good understanding of the reasons for prescribing each of their medication and 89% of them were willing to stop medications according to physicians' decision without questioning.

Prevalence of drugs adverse effects

The prevalence of aspirin-associated gastroesophageal reflux disease was 33.6%. Major and minor bleeding was observed in 4.7% and 2% patients. Statin-related muscle diseases were observed in 25.9% and nitrate-associated headache was reported by 13.6%. There were 4.3% patients who complained ACEI-associated cough [Table 3].
Table 3: Prevalence of adverse effects of medications in the study sample

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  Discussion Top

The study was able to explore many lapses in the current practice with regard to the treatments and patient education.

Self-reported medication nonadherence and drug adverse effects

The study reveals, even in the earlier period following MI, a substantial proportion of patients report suboptimal adherence to prescribed medications. Although half of the patients had better adherence, it may not reflect the ideal state of drug adherence to be achieved in post-MI patients. Addition to that, there is a significant group of patients who had low or moderate drug adherence. This group of patients may lead to encounter a higher incidence of subsequent coronary events leading to accumulation of health cost for the existing health system. A study, conducted by Gonarkar and Dhande, had shown the post-MI medication adherence was 87.1% at 1st month and observed a reduction down to 57.4% at 6th-month post-MI in a sample of Indian patients.[7] However, in our study, a better drug adherence was noted in 51.1%, slightly lower than the reference study. One of the studies conducted by Almas et al. had shown the post-MI medication adherence of 57% in Pakistan population.[8] In our study, the similar pattern has observed as to some of South Asian countries. One of the studies conducted in Norway [9] had shown that guideline-recommended secondary preventive pharmacotherapies were given to most patients following discharged after acute MI; however, the proportion receiving such therapy was significantly lesser in non-PCI patients, which is in similar to our population. However, post-MI patients must have a better long-term adherence to their treatment despite few drug alterations during the follow-up period.[9] It has been highlighted that we need to pay more attention in improving the adherence for secondary preventive pharmacotherapy in acute MI patients who do not undergo PCI.[9]

Another study done in the United States [10] showed the low adherence to treatment among post-MI patients who were discharged on proper treatments; major descent in medication adherence happened in the postdischarge 1st-month. Surprisingly, only about half of the high-risk patients persisted with all guideline-directed therapies by the end of 1-year postdischarge.[10] This indicates that the suboptimal adherence to pharmacotherapies remains as a limiting factor in achieving a better prognosis which needs prompt attention even in developed countries.

Addition to patient's perception on drug adherence, there are several other factors which need to be considered to improve the health care. The health administrators should be vigilant on auditing the drug prescribe pattern during the hospital stay as well as the following discharge after an acute coronary event. The coordination of care between general practitioners and cardiologists as well as early outpatient follow-up visits may play a pivotal role in achieving high adherence to treatment. Furthermore, patient counseling on discharge is a key issue in securing the better drug adherence at the community level.

Knowledge on polypharmacy

Polypharmacy, defined as the use of five or more drugs,[6] is commonly seen among IHD patients. Several studies had highlighted the effects of polypharmacy in reducing the quality of life and adverse prognosis, especially among elderly people and patients with multiple comorbidities. Limited data are available on the effects of polypharmacy among post-MI population at our local settings.

According to our surveillance, the prevalence of polypharmacy is high among post-MI population, and most were in acceptance of taking many drugs and they are totally depending on the physician for decision-making. Hence, physicians should bear these considerations in mind before each prescription and review all medications used at every visit to avoid unnecessary addictions or hazardous drug interactions. The general practitioner also has a strong role in polypharmacy in these patients,[9] and their rational involvement can help to minimize the adverse outcome as a result of various interactions.

Postmyocardial infarction education and self-perception of therapeutic options

Awareness regarding the nature of IHD and advanced therapeutic options is poor among the study population while only a minority have actively discussed the above facts with their physician. This highlights the necessity of upgrading patient's knowledge on the nature of their disease and available therapeutic options to deliver a better quality of post-MI care.[11] Tailored patient education and predischarge planning are important steps in optimizing patient care and long-term outcomes in this specific population.

Patient provider communication and source of health information

Medical communication by a physician plays a vital role on patient confidence over their management.[12] There are many factors which affect the success of medical communication. Several studies were performed to explore the outcomes of medical communication depending on patients' expectations from the physician.[13]

In our study, physicians at the clinic are the main source of health information. Frequently, patients are entirely depending on the physicians for their management plan without having any inputs from patients' side. This is one of the areas which need to be improved in our community by upgrading the knowledge over their existing medical condition.[14] The study findings also indicate that mobile phones with SMS can be utilized as a feasible and cost-effective method of delivering health information among this population.

  Conclusions Top

Suboptimal adherence to prescribed medications after MI is a major problem which needs to be addressed at each stratum of health system. Since the prevalence of polypharmacy is high among post-MI population, the physicians should bear these facts in mind before each prescription, to avoid unnecessary addictions or hazardous drug interactions.

Awareness regarding the nature of IHD and advanced therapeutic options is poor among the study population, and this highlights the necessity of upgrading patient's knowledge on their own disease and available treatment options. Addition to that digital media also seem to be one of the potential sources that can be utilized to educate our post-MI patients.

These facts can be utilized to update and organize a better cardiac rehabilitation program to achieve maximum secondary preventive goals in our post-MI patients.


This is a single-centre experience. However, being one of the largest cardiac centers in the country and the study institute encounters patients from different areas of the country, making the study more generalized. Furthermore, we collected self-reported information on medication adherence and patient satisfaction, which can be subjected to reporting bias. Correlation between health status and medication adherence was not assessed in our study, which will be a good implication for further studies.


We pay our gratitude to our patients for their participation to our study and for all other patients for their help for this process. Those who have supported us until this publication reminds with a great respect toward them for their valuable contribution for the success of this article.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

  References Top

Katulanda P, Jayawardena MA, Sheriff MH, Constantine GR, Matthews DR. Prevalence of overweight and obesity in Sri Lankan adults. Obes Rev 2010;11:751-6.  Back to cited text no. 1
Roffi M, Patrono C, Collet JP, Mueller C, Valgimigli M, Andreotti F, et al. 2015 ESC Guidelines for the management of acute coronary syndromes in patients presenting without persistent ST-segment elevation: Task Force for the Management of Acute Coronary Syndromes in Patients Presenting without Persistent ST-Segment Elevation of the European Society of Cardiology (ESC). Eur Heart J 2016;37:267-315.  Back to cited text no. 2
Hambraeus K, Tydén P, Lindahl B. Time trends and gender differences in prevention guideline adherence and outcome after myocardial infarction: Data from the SWEDEHEART registry. Eur J Prev Cardiol 2016;23:340-8.  Back to cited text no. 3
Kotseva K, Wood D, De Backer G, De Bacquer D, Pyörälä K, Keil U, et al. EUROASPIRE III: A survey on the lifestyle, risk factors and use of cardioprotective drug therapies in coronary patients from 22 European countries. Eur J Cardiovasc Prev Rehabil 2009;16:121-37.  Back to cited text no. 4
Gislason GH, Rasmussen JN, Abildstrøm SZ, Gadsbøll N, Buch P, Friberg J, et al. Long-term compliance with beta-blockers, angiotensin-converting enzyme inhibitors, and statins after acute myocardial infarction. Eur Heart J 2006;27:1153-8.  Back to cited text no. 5
Maher RL, Hanlon J, Hajjar ER. Clinical consequences of polypharmacy in elderly. Expert Opin Drug Saf 2014;13:57-65.  Back to cited text no. 6
Gonarkar SB, Dhande PP. Medication adherence and its determinants in myocardial infarction patients: An Indian scenario. J Clin Prev Cardiol Ear 2016;5:2-8.  Back to cited text no. 7
Almas A, Hameed A, Ahmed B, Islam M. Compliance to antihypertensive therapy. J Coll Physicians Surg Pak 2006;16:23-6.  Back to cited text no. 8
Halvorsen S, Jortveit J, Hasvold P, Thuresson M, Øie E. Initiation of and long-term adherence to secondary preventive drugs after acute myocardial infarction. BMC Cardiovasc Disord 2016;16:115.  Back to cited text no. 9
Shore S, Jones PG, Maddox TM, Bradley SM, Stolker JM, Arnold SV, et al. Longitudinal persistence with secondary prevention therapies relative to patient risk after myocardial infarction. Heart 2015;101:800-7.  Back to cited text no. 10
Sanfélix-Gimeno G, Peiró S, Ferreros I, Pérez-Vicente R, Librero J, Catalá-López F, et al. Adherence to evidence-based therapies after acute coronary syndrome: A retrospective population-based cohort study linking hospital, outpatient, and pharmacy health information systems in Valencia, Spain. J Manag Care Pharm 2013;19:247-57.  Back to cited text no. 11
Jill M, Alan R, Murray L, Diane R. Exploring post-myocardial infarction patients' perceptions of patient-mediated interventions for the secondary prevention of coronary heart disease (SIGN Guideline 41). Qual Prim Care 2006;14:77-83.  Back to cited text no. 12
Martin KD, Roter DL, Beach MC, Carson KA, Cooper LA. Physician communication behaviors and trust among black and white patients with hypertension. Med Care 2013;51:151-7.  Back to cited text no. 13
Rolnick SJ, Pawloski PA, Hedblom BD, Asche SE, Bruzek RJ. Patient characteristics associated with medication adherence. Clin Med Res 2013;11:54-65.  Back to cited text no. 14


  [Figure 1], [Figure 2], [Figure 3]

  [Table 1], [Table 2], [Table 3]


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