The Old Problem of Adherence in the Control of Arterial Hypertension

Keywords
Internal Medicine; Cardiology; Doenças Cardiovasculares

In medical treatment of chronic diseases, for example, arterial hypertension, diabetes mellitus, and dyslipidemia, the main objective is the implementation of primary prevention or, failing that, secondary prevention of cardiovascular events, to achieve adequate control of cardiovascular prevention. Thus, the following measures are very necessary: 1. adequate patient education, 2. pharmacological prescription based on cardiovascular risk, and 3. adequate adherence to the prescribed treatment. This last point is, without a doubt, the most difficult to achieve.

The health interventions recommended by the World Health Organization for the control of these diseases focus on pharmacological treatments and general recommendations to take care of one's diet and adopt healthy lifestyles, but the growth in prevalence shows that until now these treatments have been insufficient; that is, the therapeutic adherence of patients suffering from these diseases is low. This low adherence occurs because of personal therapeutic barriers and those of health systems.¹

Therapeutic barriers are directly related to the social determinants of health, since the risk factors are much greater in poor populations, due to the existing inequity in terms of access to education and health services. These precarious socioeconomic conditions mean that patients do not always have access to medications and laboratories. To this we must add the presence of myths and beliefs in people against treatments, violence, lack of family support, sedentary lifestyle, and alcohol consumption .²

Adherence is defined as the extent to which a person's behavior (in terms of taking medications, following diets, or making lifestyle changes) matches medical or health advice.³

Adherence is a complex and multifactorial phenomenon, because it involves a wide variety of situations (taking medication, going to appointments, risk behaviors, family environment, socioeconomic level, etc.). This behavior is not permanent, because it may or may not occur temporarily. As therapeutic adherence implies a relationship focused on the needs of the person, their values and knowledge must be considered; they must be adequately informed, and their choice of therapeutic alternatives must be respected. That is, we must migrate from the paternalistic model, in which the patient does not have active participation, to a model of shared decisions. It is, therefore, considered an error to hold a patient responsible for being non-adherent or non-compliant, attributing exclusive responsibility for a problem as complex and multifactorial as therapeutic adherence.⁴

The study Therapeutic Adherence According to Morisky Scale in Hypertensive Patients was published in this issue of the International Journal of Cardiovascular Sciences (IJCS) .⁵ The Morisky Scale is a questionnaire that consists of 10 questions about beliefs and barriers to therapeutic adherence, which is a modification of the DAI and Morisky Green questionnaires, with a score from 0 to 10, considering that the limits of this percentage, which defines good compliance or adherence, is the consumption of 80% to 110% of the prescribed tablets.

This study is a multicenter registry carried out at the national level, originating from the Brazilian Cardiovascular Registry of Arterial Hypertension (I-RBH) and sponsored by the Brazilian Society of Cardiology.⁵

Between May 2013 and October 2015, 2,675 patients were recruited from this national registry, from 49 Brazilian research centers.⁵

This study demonstrated a relationship between sociodemographic characteristics and therapeutic adherence. As well as the ethnicity of the patients, no relationship was found to the gender of the patients. One of the most interesting data from the registry is that a relationship was found in terms of the regions of the country, with significant changes in the Northeast and Southeast.⁵

Considered the first prospective registry in Brazil, there is no doubt that gaps have been shown in the treatment of arterial hypertension, which allows the authors to propose interventions to improve adherence and, of course, extend them to the rest of Latin America, in order to improve blood pressure control.⁵

This registry is the best example of the fact that, although arterial hypertension is probably the most common disease addressed in daily practice, we are still far from controlling it. The registry also opens the doors to tools (Morisky Scale) to improve adherence and gives us an example in Latin American of how to proceed in the use of tools, in order to achieve better adherence and control of the prognosis of cardiovascular disease.

I would like to conclude by quoting the words of the researchers in their final comments, but not before congratulating them for the excellent design and results shared in the registry : "Adherence to treatment is the key to reducing high rates of cardiovascular complications. It is necessary to understand this fact, considering its systematic evaluation in the care of patients with hypertension and other non-communicable chronic diseases."⁵

• Editorial referring to the article: Therapeutic Adherence According to the Morisky Scale in Patients with Hypertension

References

• ¹
  Organización Panamericana de la Salud. Estrategia Regional y Plan de Acción para Un enfoque Integrado sobre la Prevención y el Control de las Enfermedades Crónicas [Internet]. Washington: Organización Panamericana de la Salud; 2007 [cited 2024 Feb 26]. Available from: http://bvsper.paho.org/texcom/nutricion/reg-strat.pdf https://doi.org/10.1590/s0036-36342002000100014
  » http://bvsper.paho.org/texcom/nutricion/reg-strat.pdf» https://doi.org/10.1590/s0036-36342002000100014
• ²
  Organización Mundial de la Salud. Adherencia a los Tratamientos a Largo Plazo: Pruebas para la Acción [Internet]. Washington: Organización Panamericana de la Salud; 2004 [cited 2024 Feb 26]. Available from: https://www.paho.org/hq/dmdocuments/2012/WHO-Adherence-Long-Term-Therapies-Spa-2003.pdf
  » https://www.paho.org/hq/dmdocuments/2012/WHO-Adherence-Long-Term-Therapies-Spa-2003.pdf
• ³
  Jay S, Litt IF, Durant RH. Compliance with Therapeutic Regimens. J Adolesc Health Care. 1984;5(2):124-36. doi: 10.1016/s0197-0070(84)80012-1.
  » https://doi.org/10.1016/s0197-0070(84)80012-1
• ⁴
  Pisano González MM, González Pisano A. Modifying Habits and Treatment Adherence, Essential for Controlling the Chronic Disease. Enferm Clin. 2014;24(1):59-66. doi: 10.1016/j.enfcli.2013.10.006.
  » https://doi.org/10.1016/j.enfcli.2013.10.006
• ⁵
  Lanza VE, Silva GO, Quiroga CCC, Cavalcante MA, Barroso WKS, Brandão AA et al. Therapeutic Adherence According to the Morisky Scale in Patients with Hypertension. Int J Cardiovasc Sci. 2024; 37:e20220138. doi: 10.36660/ijcs.20220138
  » https://doi.org/10.36660/ijcs.20220138

Publication Dates

• Publication in this collection
  05 Apr 2024
• Date of issue
  2024