Long-term adherence to evidence based secondary prevention therapies after acute myocardial infarction

J Gen Intern Med. 2008 Feb;23(2):115-21. doi: 10.1007/s11606-007-0351-9. Epub 2007 Oct 6.


Background: After acute myocardial infarction (AMI), treatment with beta-blockers and angiotensin-converting enzyme inhibitors (ACEI) is widely recognized as crucial to reduce risk of a subsequent AMI. However, many patients fail to consistently remain on these treatments over time, and long-term adherence has not been well described.

Objective: To examine the duration of treatment with beta-blockers and ACEI within the 24 months after an AMI.

Design: A retrospective, observational study using medical and pharmacy claims from a large health plan operating in the Northeastern United States.

Subjects: Enrollees with an inpatient claim for AMI who initiated beta-blocker (N = 499) or ACEI (N = 526) therapy.

Measurement: Time from initiation to discontinuation was measured with pharmacy refill records. Associations between therapy discontinuation and potential predictors were estimated using a Cox proportional hazards model.

Results: ACEI discontinuation rates were high: 7% stopped within 1 month, 22% at 6 months, 32% at 1 year and 50% at 2 years. Overall discontinuation rates for beta-blockers were similar, but predictors of discontinuation differed for the two treatment types. For beta-blockers, the risk of discontinuation was highest among males and those from low-income neighborhoods; patients with comorbid hypertension and peripheral vascular disease were less likely to discontinue therapy. These factors were not associated with ACEI discontinuation.

Conclusion: Many patients initiating evidence-based secondary prevention therapies after an AMI fail to consistently remain on these treatments. Adherence is a priority area for development of better-quality measures and quality-improvement interventions. Barriers to beta-blocker adherence for low-income populations need particular attention.

Publication types

  • Research Support, Non-U.S. Gov't
  • Research Support, U.S. Gov't, P.H.S.

MeSH terms

  • Adrenergic beta-Antagonists / therapeutic use*
  • Aged
  • Angiotensin-Converting Enzyme Inhibitors / therapeutic use*
  • Cohort Studies
  • Female
  • Health Maintenance Organizations
  • Humans
  • Insurance, Health, Reimbursement
  • Kaplan-Meier Estimate
  • Male
  • Middle Aged
  • Myocardial Infarction / rehabilitation*
  • Patient Compliance*
  • Retrospective Studies
  • Secondary Prevention


  • Adrenergic beta-Antagonists
  • Angiotensin-Converting Enzyme Inhibitors