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P. Michael Ho, MD, PhD; David J. Magid, MD, MPH; Susan M. Shetterly, MS; Kari L. Olson, PharmD, BCPS; Pamela N. Peterson, MD, MPH; Frederick A. Masoudi, MD, MPH; John S. Rumsfeld, MD, PhD

Arch Intern Med. 2008;168(3):271-276.

Background  Despite the importance of blood pressure (BP) control in secondary prevention, a significant proportion of patients with coronary disease have uncontrolled BP.

Methods  This retrospective cohort study of patients with coronary disease (N = 10 447) evaluated the impact of medication nonadherence and therapy intensification on reaching target BP goals. Medication adherence was calculated as the proportion of days covered for filled prescriptions of antihypertensive medications. Therapy intensification included dosage increase or increase in number of antihypertensive medications. The primary outcome was uncontrolled systolic BP (SBP) over time, using a latent class model that incorporated longitudinal SBP data and assigned patients to SBP trajectory groups. Multivariable regression evaluated the association between medication nonadherence (ie, proportion of days covered, <0.80) and therapy intensification with SBP control over time, with adjustment for demographics and clinical characteristics.

Results  Three SBP trajectory groups were identified: (1) patients with BP that remained controlled (ie, SBP, 140 mm Hg) over time (n = 9114 [87.2%]); (2) patients with high BP that became controlled (n = 779 [7.5%]); and (3) patients with BP that remained high over time (n = 554 [5.3%]). In multivariable analyses, therapy intensification (odds ratio, 1.31; 95% confidence interval, 1.01-1.70) and medication nonadherence (odds ratio, 1.73; 95% confidence interval, 1.34-2.24) were associated with uncontrolled BP compared with high SBP that became controlled over time.

Conclusions  These findings suggest that medication nonadherence can help explain why BP levels remained elevated despite intensification of antihypertensive medications. Successful BP control is seen with a combination of intensification and adherence, suggesting that therapy intensification must be coupled with interventions to enhance medication adherence.

Author Affiliations: Cardiology Section, Denver Veterans Affairs Medical Center, Denver, Colorado (Drs Ho and Rumsfeld); Departments of Medicine (Drs Ho, Peterson, Masoudi, and Rumsfeld) and Preventive Medicine and Biometrics (Dr Magid), University of Colorado Health Sciences Center, Denver; Department of Medicine, Denver Health Medical Center (Drs Peterson and Masoudi); and Institute for Health Research (Drs Ho, Magid, Peterson, Masoudi, and Rumsfeld and Ms Shetterly) and Department of Pharmacy and Clinical Pharmacy Cardiac Risk Service (Dr Olson), Kaiser Permanente of Colorado, Aurora.

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