Non-Persistence with Medication as a Mediator for the Social Inequality in Risk of Major Adverse Cardiovascular Events in Patients with Incident Acute Coronary Syndrome: A Nationwide Cohort Study

Abstract

Christina Boesgaard Graversen,1 Jan Brink Valentin,2 Mogens Lytken Larsen,3 Sam Riahi,1,3 Teresa Holmberg,4 Søren Paaske Johnsen2 1Department of Cardiology, Aalborg University Hospital, Aalborg, Denmark; 2Danish Center for Clinical Health Services Research, Department of Clinical Medicine, Aalborg University, Aalborg, Denmark; 3Department of Clinical Medicine, The Faculty of Medicine, Aalborg University, Aalborg, Denmark; 4National Institute of Public Health, University of Southern Denmark, Copenhagen, DenmarkCorrespondence: Christina Boesgaard Graversen Email [email protected]: Low socioeconomic status is associated with higher risk of major adverse cardiovascular events (MACE) among patients with incident acute coronary syndrome (ACS). We examined whether non-persistence with antiplatelet and statin therapy mediated the income- and educational-related inequality in risk of MACE.Methods: Using national registers, all Danish patients diagnosed with incident ACS from 2010 to 2017 were identified. The primary outcome (MACE) comprised all-cause death, cardiac death and cardiac readmission. Risk of MACE was handled by discrete time analyses using inverse probability of treatment weights. The mediator variable comprised non-persistence to a combined 2-dimensional measure of statin and antiplatelet treatment. The mediation analysis was evaluated by population average effects.Results: The study population was 45,874 patients, of whom 16,958 (37.0%) were non-persistent with medication and 16,365 (35.7%) suffered MACE during the median follow-up of 3.5 years. Compared to patients with low income, the adjusted hazard ratio of MACE was lowered by 33% (HR: 0.67, 95% CI: 0.61– 0.72) in men and by 34% (HR: 0.66, 95% CI: 0.61– 0.72) in women with high income, respectively. Similar results were observed according to level of education. A socioeconomic difference in risk of non-persistence was found in men but not women and only in relation to income. The lower risk of non-persistence observed in high-income men mediated the lower risk of MACE by 12.6% (95% CI: 11.1– 14.1%) compared with low-income men.Conclusion: Non-persistence with medication mediated some of the income-related inequality in risk of MACE in men, but not women, with incident ACS.Keywords: acute coronary syndrome, social inequality, major adverse cardiovascular event, non-persistence with medication, register-based cohort study

Keywords

• acute coronary syndrome
• social inequality
• major adverse cardiovascular event
• non-persistence to medication
• register-based cohort study.