Interactive Smartphone App Can Motivate MI Patients to Take Their Meds

A smartphone-based app can encourage patients to reliably take their twice-daily ticagrelor pills during the 6 months after an MI, according to results from a small randomized study conducted in Sweden. There also are hints that use of the support tool might lead to lifestyle changes and better quality of life.

Patients in the study all were given access to a phone-based diary to register their ticagrelor use. Beyond that, they were randomized either to receive a more intensive app or to serve as controls. The app included not only the ticagrelor diary but also modules related to exercise, weight, and smoking; the option to register blood pressure, LDL cholesterol, and blood glucose measurements; regular individualized feedback via text message; and general information about the cause, symptoms, and treatment of MI.

Outside of the trial itself, which was recently published in the American Heart Journal, the app “has been launched in Sweden and is [being used] in the healthcare system by a steadily increasing number of cardiology clinics,” senior author Christoph Varenhorst, MD, PhD (Uppsala University, Sweden), told TCTMD in an email. “We expect this app to be an easily accessible [support tool] for MI patients in other countries and hope that the use of apps in general could become an integrated and important part of patient treatment in the future.”

Commenting on the study, Tracy Wang, MD (Duke Clinical Research Institute, Durham, NC), told TCTMD that a key component of a successful app is the ability to speak at a level appropriate to each patient’s health literacy. It’s unclear how well the Swedish app accomplishes this, Wang noted. “The second piece is, how much does the app really appeal to the patient’s psychology?” Specifically, she said, there must be something about the app that engages patients to the point that they want to use it again and again, day after day.

As for feedback the researchers had received, Varenhorst reported that “most patients enjoyed using the app and appreciated both the ‘friendly reminders,’ not only on drug adherence but also [on how] to maintain a healthy lifestyle, and the information modules related to their disease and the treatments given.”

More than 80% of those in the app group of the trial had positive things to say about the tool, the paper notes, with most patients saying they’d like to continue using it and would recommend it to others.

Better Adherence at 6 Months

For the multicenter SUPPORT study, investigators led by Nina Johnston, MD, PhD (Uppsala University), randomized 174 post-MI patients (mean age 58 years; 81% men) receiving ticagrelor to either the full interactive app or the simplified diary.

These tools were given on top of the usual follow-up care provided via the Swedish healthcare system. “Secondary preventative care in Sweden is very much standardized,” the paper notes. There, all patients under 75 years old make at least two postdischarge visits to their cardiology clinic: at 2 weeks with a trained nurse and after 6 to 8 weeks with a physician. “In uncomplicated cases, the patient is thereafter referred to primary care for follow-up,” the researchers explain. “Also, all patients receive a recommendation, together with family members, to participate in educational and physical training programs,” though such rehab is optional.

The researchers found that at 6 months, patient-reported drug adherence—as measured by a score that placed greater emphasis on treatment gaps of at least four consecutive doses than on occasional missed doses—was significantly better for the app group than for controls (P = 0.025). There also were nonsignificant trends toward more smoking cessation, more physical activity (median change in exercise minutes per week), and greater improvement in quality of life (change in EQ-5D visual analogue scale) between baseline and follow-up among patients assigned to the app.

Patients in the app group were no more likely than controls to discontinue use of the diary and overall they gave a higher “usability” rating to their tool.

To TCTMD, Varenhorst said that an additional trial testing hard clinical endpoints “is highly warranted,” suggesting Sweden would “be an ideal environment for such a study.”

The Point is Overall Risk Reduction

Wang observed that “there’s been a big wave of evolution” in apps related to cardiovascular health. Features like blood pressure cuffs that can communicate via Bluetooth are being explored, as are programs that go beyond a standalone app to provide additional support via telemedicine. The latter might be especially important in countries with less rigorous follow-up care after MI, she stressed.

One thing that is difficult to tell when reading the current paper is how often patients actually used the app, which seems to be fairly self-contained rather than sending regular reports to healthcare providers, Wang noted. In an optimal scenario, “not only are patients entering data but actually someone or something is monitoring that data and can potentially have the ability to act on [it] before the patient has to come for their next clinical encounter,” she said.

“It’s about risk reduction,” not only about drug adherence, Wang emphasized. “We’re not taking medications for medications’ sake. We’re taking medications so we can reduce the clinical risk factors.”

Adherence to antiplatelet therapy of course critical for patients implanted with stents after an MI, she said. But particular to ticagrelor and other drugs with a short half-life, Wang explained, is the need for twice daily dosing. “That is particularly important. In my practice if I can, I try to give a once-a-day medication and I try to batch all the medications together [to be taken at one sitting],” she reported, adding that “this drug really requires someone to be faithful about taking it” without missing too many doses in a row.

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