Assessment of Medication Adherence in Cardiovascular Patients in Tertiary Care Hospital: A Prospective Observational Study

The muscular heart is an organ that draws deoxygenated blood from every area of the body and exhales carbon dioxide. The blood is then transported from the lungs and distributed to every region of the body.¹ Heart-related illnesses are often referred to as Cardiovascular Disease (CVD) namely atherosclerosis (typically composed of fatty deposits (arteries)), Heart attacks and heart failure which are caused by the high levels of fatty tissue blocking the coronary arteries.² Multifactorial disorder, which includes multiple congenital and acquired illnesses, is one of the primary causes of cardiovascular disease modality and mortality worldwide. The third most common cause of death worldwide is Cardiovascular Disease (CVD).

The World Health Organization (WHO) estimates that approximately 17.3 million people worldwide die each year from cardiovascular disease, and that number will rise to 23 million by the year 2030.³ The risk factors in CVD patients include unhealthy nutrition, physical inactivity, dyslipidemia, hyperglycemia, high blood pressure, obesity, considerations of selection of population, and race/ethnicity, thrombosis/smoking, kidney dysfunction, and genetics/familial hypercholesterolemia.⁴

A heart attack or stroke could be the initial symptom of a hidden illness. Heart attack signs and symptoms includes chest pain or discomfort in the middle; and/or arm, left shoulder, elbow, jaw, or back pain or discomfort. Sudden weakness of the face, arm, or leg, usually on one side of the body, is the most typical sign of a stroke. Other signs include severe headache with no apparent cause, numbness of the face, arm, or leg, particularly on one side of the body; confusion; difficulty speaking or understanding speech; difficulty seeing with one or both eyes; difficulty walking; dizziness and/or loss of balance or coordination; and/or fainting or unconsciousness.⁵

Medication adherence, as defined by the World Health Organization, is the extent to which the person’s behaviour corresponds with the agreed recommendations from a health care provider. It was a useful starting point for the nonadherence key associated with treatment effectiveness, but it is more crucial for medications prescribed for chronic conditions. Medication adherence often refers to whether a patient continues to take their prescribed medication as directed (e.g., twice daily, three times daily). Secondary cardiac risk factors can be avoided with proper lifestyle changes and medication compliance. The main issue and risk factor for the patient’s life is non-adherence to prescriptions after discharge. This will result in a poor health outcome, higher healthcare costs, and a worsening of the disease. It is widespread and linked to poor outcomes and increased healthcare costs.^6,7 Hence this study aimed to assess the medication adherence in CVD patients.

The study was a Prospective observational study which was carried out for a duration of 6 months involving the inpatients of Cardiology Department of Vivekananda General Hospital, hubballi. Both males and females who were above 18 years of age admitted to the hospital and who underwent cardiac related problems were included in the study. Subjects who are not willing to participate in the study and the discharged against medical advice (DAMA) cases were excluded.

Total 210 subjects were enrolled and analyzed during our study period. The study included the subjects from inpatient cardiology department in Vivekananda General Hospital, Hubballi. As shown in Table 1. Among 210 subjects,128 were male (61.00%) and 82 were female (39.04%). The subjects were categorized into seven age groups i.e., 21-30, 31-40, 41-50,51-60, 61-70, 71-80 and 81-90 years. The mean age of the study population was found to be 58.62 ± 26.02. Age group 61-70 years were in majority accounting for the 28.57% (n=60) of the total population whereas age group 21-30 years were minimal in number i.e., 2.38% (n=5). The study population included 43 smokers, 56 alcoholics, 24 subjects engaged in both drinking and smoking and 59 subjects involved in chewing gutka.

In our study, the most commonly seen co-morbidities were HTN (n=65) and Diabetic mellitus (n=58). RHD, TB and Appendicitis having the same frequency (n=1) were the least seen comorbidity in our study population. The other co-morbidities were COPD (n=15), Hypothyroidism (n=10), Pulmonary edema (n=5) and IHD (n=6). The subjects having HTN and DM as the comorbidity in our study are at high risk of developing the heart diseases.

The subjects of study population were classified based on employment status as employed and unemployed. Employed category included 153 subjects who are Farmer, Driver, Teacher, Vendor, Carpenter, Merchant and Engineer. Unemployed category included 57 subjects like home maker and retired officers. The study subjects were divided according to their residence as 56.2% (n=118) Rural and 44.0% (n=92) urban. The study also found that among 210 subjects 74.3% (n=156) are married, 11.9% (n=25) are unmarried and remaining 13.8% (n=29) are widowed. According to the body mass index, subjects were categorized into Normal weight, Obesity-class 1, Obesity class-2, Pre-obesity and underweight having the frequency of 70, 80, 34, 10, and 16 respectively. The data reveals that overweight and obesity increase the risk of developing Heart failure and other conditions of cardiovascular diseases. Majority of the study subjects stayed at hospital for their medication and treatment. 53 subjects stayed upto 5-10 days,76 subjects stayed upto 10-15 days, 37 subjects stayed upto 1-4 days while 44 subjects stayed for more than 15 days.

Level of Medication Adherence towards Cardiovascular disease.

Among 210 patients, 53.08% (n=113) had a Good level of medication adherence, 46.19% (n=97) had a Bad level of medication adherence towards cardiovascular drugs as shown in Table 2.

As shown in Table 3, among 210 subjects, the study determined that there was insignificance (p > 0.05) association seen between the gender and medication adherence, age and medication adherence and also seen with the level of educational status and medication adherence towards cardiovascular treatment.

However, it was observed that the males are highly adherent than the females towards the medication adherence. The age category of 41-50 years had the highest adherence and the bad adherence was seen in category of 81-90 years of age. Literate participants were more adhere than those of illiterate participants towards the cardiovascular treatment.

The study determined that there was a significant association between residence and medication adherence towards cardiovascular medications. The majority of the subjects from rural residence 55.23% (n=116) had a bad adherence to the cardiovascular drugs. The findings revealed that residents from the urban area were good adherence to the cardiovascular medication as compared to the rural patients.

The mean age of the study population was found to be 58.62 ± 26.02. Subjects with age group of 61-70 years were in majority accounting for 28.57% (n=60) of the total population and the age group 21-30 years were in minimal accounting for 2.38% (n=5). Contrary to the study conducted by M. Reshma et al.,⁸ subjects with age group of 41-50 years and 51-60 years were in majority and subjects greater than 80 years were minimal in number

Our study has demonstrated that incidence of atrial fibrillation, heart failure, and hemorrhagic stroke is positively correlated with alcohol intake, which is followed by smoking. Moderate drinking is related with a lower risk of coronary heart disease and ischemic stroke. Yet, those that chew gutka reported higher blood pressure.

In our study out of 210 subjects, 43 were engaged in habits such as smoking, 56 were alcoholics, 59 were involved chewing gutka and 24 were indulged in both drinking alcohol and smoking. A similar study was conducted by Bibirsa Sefera et al.,⁹ where 31 were alcoholic, 38 were smokers and 62 were involved in khat chewing.

The study demonstrated that chronic high blood pressure, strains the heart and makes it harder to pump the blood in hypertensive subjects, whereas, Blood arteries become less elastic and narrow as a result of high blood glucose levels, which restricts blood flow.

In this study the most commonly seen comorbidities were HTN (65) and DM (58) whereas the least found comorbidities were RHD (1), TB (1), Appendicitis (1). The other comorbidities found in the subjects were COPD (15), Hypothyroidism (10), Pulmonary edema (5). A similar study by conducted by Asmita et al.,¹⁰ which revealed the similar results.

In our study we classified the subjects based on the employment status such as employed and unemployed. Out of 210 subjects, employed category included 43 subjects and unemployed category included 67 subjects. A study by Bibirsa Sefera et al.,⁹ showed contradictory results that is unemployed category included 34 subjects and employed category included 203 subjects.

In our study 116 (55.23%) subjects were from rural area and 94 (44.76%) subjects were from urban area. Similar results were revealed by Bibirsa Sefera et al.⁹ study. Whereas the study conducted by Aikaterini et al.¹¹ revealed, 62 (77.5%) subjects were from urban area and 18 (22.5%) were from rural areas.

Among 210 study subjects 156 (74.3%) were married, 25 (11.9%) were unmarried and 29 (13.8%) were widows. Similar result was showed by Bibirsa Sefera et al.⁹ study.

Our study demonstrated that obese subjects were highly associated with increased to develop CVD. In current study out of 210 study subjects, 16 belongs to under-weight, 70 had normal weight, 80 belongs to the obesity class-1, 34 belongs to obesity class-2 and 10 belongs to pre-obesity class. A study Francisco Lopez-Jimenez et al.¹² revealed the similar results

Out of 210 study subjects, 53 stayed up-to 5-10 days, 76 stayed up-to 10-15 days, 37 stayed 1-4 days and 44 stayed for more than 15 days. A study conducted by M. Reshma et al.⁸ showed 81 stayed for 1-3 days, 51 stayed for 4-6 days and 18 stayed for more than 6 days.

The Medication Adherence Rating Scale (MARS) grading was used to measure patient’s non-adherence to medication. This tool aids CVD patients in self-reporting adherence. The purpose of this study was to examine the level of adherence to prescribed treatment among CVD patients.

We revealed that a large percentage of subjects (46.19%) were non-adherent to their treatment. These findings were dispute to the finding of Satish Balaji et al.¹³ study.

Among 210 study subjects, it was observed that male subjects were highly adherent (good) to prescribed medication as compared to the female subjects. A similar study was carried by Satish Balaji et al.¹³ where both male and female showed equal adherence to the prescribed medication.

Our study also determined that the age category (41-50 years) had highest adherent (good), while age (81-90) had least (bad) adherence. A study by Satish Balaji et al.¹³ revealed that the age group of (56-65 years) had high adherence.

Our study also demonstrated that literates were highly adherent to treatment, whereas the illiterates showed poor adherence. Our findings were similar with the findings of study by Satish Balaji et al.¹³ and Ali Hussein Al-Ganmi et al.¹⁴

The current study also reported that urban subjects showed high adherence, whereas the rural subjects showed low adherence. Our findings were similar with the findings of study by Sameer Bansilal et al.¹⁵

Non-adherence to medication is still a significant problem for cardiovascular patients. Non-adherence was linked to getting older, using lots of medications, undergoing extensive therapy, and forgetfulness. Several patients with cardiovascular conditions quit taking their medications as soon as they began to feel better. According to the data, socio-demographic factors are substantially associated with the cardiovascular medication adherence. Such characteristics such as gender, age, educational level and residence. According to the finding there was no significant relationship between the respondent age and their medication adherence to CVD therapy. The study highlighted the importance of improving the CVD medication adherence, particularly for the patients who reside in rural areas and illiterate as well as educating them with more information about the cardiovascular disease and its treatment.

The authors are thankful to the Vice-Chancellor, Registrar and Dean of Pharmacy, KLE Academy of Higher and Research, Belagavi. We would also like to thank Medical and Hospital Staff of Vivekananda General Hospital, Hubballi for providing necessary support.