Patients with acute coronary syndrome (ACS) (myocardial infarction or unstable angina) who report even subsyndromal levels of depressive symptoms are at increased risk of ACS recurrence or mortality.^1,2 This increased risk is observed over many years,³ is largely independent of other known risk factors for coronary heart disease (CHD),⁴ is strong,⁵ and has a dose-response association.⁶ The risk is particularly high for those whose depressive symptoms persist⁷ or are refractory to treatment.^8,9 Although the association is not found in every study¹⁰ or with every ACS patient subgroup,¹¹ systematic reviews,^1,2,12 recent international data,¹³ and other accumulating research indicate that depression is a marker of increased risk of CHD events and mortality in this patient population. There have been calls for depression to be recognized as a risk marker¹⁴ and recommendations that patients with CHD be regularly screened for depression and be referred for treatment.¹⁵ However, we do not know whether patients with CHD and depressive symptoms, including many with subsyndromal symptoms, should be treated.

Background: Nonadherence to statins limits the benefits of this common drug class. Individual studies assessing predictors of nonadherence haue produced inconsistent results. Objective: To identify reliable predictors of nonadherence to statins through systematic review and meta-analysis. Methods: Multiple databases, including MEDLINE, EMBASE, and PsycINFO, were searched (from inception through February 2009) to identify studies that evaluated predictors of nonadherence to statins. Studies were selected using a priori defined criteria, and each study was reviewed by 2 authors who abstracted data on study characteristics and outcomes. Relative risks were then pooled, using an inverse-variance weighted random-effects model. Results: Twenty-two cohort studies met inclusion criteria. Age had a U-shaped association with adherence; the oldest (≥70 years) and youngest (<50 years) subjects had lower adherence than the middle-aged (50-69 years) subjects. Women and patients with lower incomes were more likely to be nonadherent than were men (odds of nonadherence 1.07; 95% CI 1.04 to 1.11) and those with higher incomes (odds of nonadherence 1.18:95% CI 1.10 to 1.28), respectively. A history of cardiovascular disease predicted better adherence to statins (odds of nonadherence 0.68; 95% CI 0.66 to 0.78). Similarly, a diagnosis of hypertension or diabetes was associated with better adherence. Although there were too few studies for quantitative pooling, increased testing of lipid levels and lower out-of-pocket costs appeared to be associated with better adherence. There was substantial (l2 range 68.7-96.3%) heterogeneity between studies across factors. Conclusions: Several sociodemographic, medical, and health-care utilization characteristics are associated with statin nonadherence. These factors may be useful guides for targeting statin adherence interventions.

Background—: Observational studies suggest that there are differences in adherence to antihypertensive medications in different classes. Our objective was to quantify the association between antihypertensive drug class and adherence in clinical settings. Methods and Results—: Studies were identified through a systematic search of English-language articles published from the inception of computerized databases until February 1, 2009. Studies were included if they measured adherence to antihypertensives using medication refill data and contained sufficient data to calculate a measure of relative risk of adherence and its variance. An inverse-variance–weighted random-effects model was used to pool results. Hazard ratios (HRs) and odds ratios were pooled separately, and HRs were selected as the primary outcome. Seventeen studies met inclusion criteria. The pooled mean adherence by drug class ranged from 28% for β-blockers to 65% for angiotensin II receptor blockers. There was better adherence to angiotensin II receptor blockers compared with angiotensin-converting enzyme inhibitors (HR, 1.33; 95% confidence interval, 1.13 to 1.57), calcium channel blockers (HR, 1.57; 95% confidence interval, 1.38 to 1.79), diuretics (HR, 1.95; 95% confidence interval, 1.73 to 2.20), and β-blockers (HR, 2.09; 95% confidence interval, 1.14 to 3.85). Conversely, there was lower adherence to diuretics compared with the other drug classes. The same pattern was present when studies that used odds ratios were pooled. After publication bias was accounted for, there were no longer significant differences in adherence between angiotensin II receptor blockers and angiotensin-converting enzyme inhibitors or between diuretics and β-blockers. Conclusion—: In clinical settings, there are important differences in adherence to antihypertensives in separate classes, with lowest adherence to diuretics and β-blockers and highest adherence to angiotensin II receptor blockers and angiotensin-converting enzyme inhibitors. However, adherence was suboptimal regardless of drug class.