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    "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">Hypertension is recognized as one of the most important risk factors for cardiovascular disease and its complications&#46;<a class="elsevierStyleCrossRefs" href="#bib0045"><span class="elsevierStyleSup">1&#44;2</span></a> Despite the use of increasingly effective antihypertensive drugs and growing societal awareness of its consequences&#44; a significant proportion of the population still have uncontrolled hypertension&#46; Among the various reasons for this&#44; nonadherence to drug therapy is a major issue&#46; This problem usually receives little attention in medical publications and meetings&#44; but must be addressed if we wish to reduce the burden of cardiovascular disease in society&#46; The evidence is clear and warrants attention&#58; around half of patients stop taking long-term cardiovascular medication within a year of being prescribed&#44; and those who do not follow their treatment regimen have worse quality of life&#44; more hospitalizations&#44; and more cardiovascular events&#46;<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">3</span></a> Those who think that poor therapeutic adherence has a positive side&#44; such as money saved on medications&#44; are mistaken&#58; this potential saving is largely offset by substantial increases in direct and indirect costs&#44; including for hospitalizations and procedures&#44; with the result that in some countries poor therapeutic adherence is estimated to account for 3-10&#37; of total healthcare costs&#46;<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">4</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">Given the importance of this factor in combating cardiovascular disease&#44; it is astonishing how little research has been carried out on the subject&#46;</p><p id="par0015" class="elsevierStylePara elsevierViewall">Improving therapeutic nonadherence requires understanding of the extent&#44; causes&#44; and mechanisms of this complex phenomenon&#46; In this task&#44; challenges arise immediately in the way that the scale of the problem is assessed&#46; Unfortunately&#44; clinicians&#8217; knowledge of whether a given patient is taking the prescribed medication appears to amount to little more than a coin toss&#46;<a class="elsevierStyleCrossRefs" href="#bib0065"><span class="elsevierStyleSup">5&#44;6</span></a> The ability to measure therapeutic adherence objectively is therefore a prerequisite for assessing the impact of any intervention&#46; There are various direct and indirect ways to assess therapeutic adherence&#46; Direct methods include observation of the patient taking the drug&#44; measuring blood levels of the drug or its metabolites&#44; and measurement of biomarkers&#46; However&#44; such direct methods are clearly impractical for routine clinical use&#46; Indirect methods include questionnaires&#44; self-reporting&#44; pill counts&#44; rates of prescription refills and electronic medication monitors&#44; among others&#46;<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">7</span></a> Their ease of use&#44; speed and low cost make questionnaires some of the most commonly used tools for studying adherence to therapy&#44; although they may be biased by patients&#8217; tendency to overstate their own compliance&#46;</p><p id="par0020" class="elsevierStylePara elsevierViewall">It is against this background that an article by Cabral et al&#46; on this question is published in this issue of the <span class="elsevierStyleItalic">Journal</span>&#46;<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">8</span></a> The authors have translated the 8-item Morisky Medication Adherence Scale into European Portuguese and validated it in a population of 472 medicated hypertensive patients who were surveyed at nine community pharmacies and one public hospital&#46; The European Portuguese version of this scale has a similar structure to the original scale and has good psychometric properties&#44; and is thus validated for clinical and research use in this country&#46; The authors are to be commended for providing Portuguese clinicians and researchers with a helpful tool to measure therapeutic adherence&#46;</p><p id="par0025" class="elsevierStylePara elsevierViewall">Incidentally&#44; they also give us an idea of the scale of the challenge that we are facing&#58; 28&#37; of patients revealed low adherence&#44; 38&#37; moderate adherence&#44; and only 34&#37; reported high adherence to antihypertensive treatment&#46; If these numbers are truly representative of the situation in Portugal&#44; it may well be said that we are facing an elephant in the room&#58; an obvious problem that no-one is mentioning&#46; Let the article by Cabral et al&#46; serve as a stimulus&#44; since this subject deserves greater attention from us all&#46;</p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Conflicts of interest</span><p id="par0030" class="elsevierStylePara elsevierViewall">The author has no conflicts of interest to declare&#46;</p></span></span>"
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Editorial comment
Therapeutic adherence: The elephant in the room
Adesão terapêutica – o elefante na sala
António Miguel Ferreira
Serviço de Cardiologia, Hospital de Santa Cruz, CHLC, Carnaxide, Portugal
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    "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">Hypertension is recognized as one of the most important risk factors for cardiovascular disease and its complications&#46;<a class="elsevierStyleCrossRefs" href="#bib0045"><span class="elsevierStyleSup">1&#44;2</span></a> Despite the use of increasingly effective antihypertensive drugs and growing societal awareness of its consequences&#44; a significant proportion of the population still have uncontrolled hypertension&#46; Among the various reasons for this&#44; nonadherence to drug therapy is a major issue&#46; This problem usually receives little attention in medical publications and meetings&#44; but must be addressed if we wish to reduce the burden of cardiovascular disease in society&#46; The evidence is clear and warrants attention&#58; around half of patients stop taking long-term cardiovascular medication within a year of being prescribed&#44; and those who do not follow their treatment regimen have worse quality of life&#44; more hospitalizations&#44; and more cardiovascular events&#46;<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">3</span></a> Those who think that poor therapeutic adherence has a positive side&#44; such as money saved on medications&#44; are mistaken&#58; this potential saving is largely offset by substantial increases in direct and indirect costs&#44; including for hospitalizations and procedures&#44; with the result that in some countries poor therapeutic adherence is estimated to account for 3-10&#37; of total healthcare costs&#46;<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">4</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">Given the importance of this factor in combating cardiovascular disease&#44; it is astonishing how little research has been carried out on the subject&#46;</p><p id="par0015" class="elsevierStylePara elsevierViewall">Improving therapeutic nonadherence requires understanding of the extent&#44; causes&#44; and mechanisms of this complex phenomenon&#46; In this task&#44; challenges arise immediately in the way that the scale of the problem is assessed&#46; Unfortunately&#44; clinicians&#8217; knowledge of whether a given patient is taking the prescribed medication appears to amount to little more than a coin toss&#46;<a class="elsevierStyleCrossRefs" href="#bib0065"><span class="elsevierStyleSup">5&#44;6</span></a> The ability to measure therapeutic adherence objectively is therefore a prerequisite for assessing the impact of any intervention&#46; There are various direct and indirect ways to assess therapeutic adherence&#46; Direct methods include observation of the patient taking the drug&#44; measuring blood levels of the drug or its metabolites&#44; and measurement of biomarkers&#46; However&#44; such direct methods are clearly impractical for routine clinical use&#46; Indirect methods include questionnaires&#44; self-reporting&#44; pill counts&#44; rates of prescription refills and electronic medication monitors&#44; among others&#46;<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">7</span></a> Their ease of use&#44; speed and low cost make questionnaires some of the most commonly used tools for studying adherence to therapy&#44; although they may be biased by patients&#8217; tendency to overstate their own compliance&#46;</p><p id="par0020" class="elsevierStylePara elsevierViewall">It is against this background that an article by Cabral et al&#46; on this question is published in this issue of the <span class="elsevierStyleItalic">Journal</span>&#46;<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">8</span></a> The authors have translated the 8-item Morisky Medication Adherence Scale into European Portuguese and validated it in a population of 472 medicated hypertensive patients who were surveyed at nine community pharmacies and one public hospital&#46; The European Portuguese version of this scale has a similar structure to the original scale and has good psychometric properties&#44; and is thus validated for clinical and research use in this country&#46; The authors are to be commended for providing Portuguese clinicians and researchers with a helpful tool to measure therapeutic adherence&#46;</p><p id="par0025" class="elsevierStylePara elsevierViewall">Incidentally&#44; they also give us an idea of the scale of the challenge that we are facing&#58; 28&#37; of patients revealed low adherence&#44; 38&#37; moderate adherence&#44; and only 34&#37; reported high adherence to antihypertensive treatment&#46; If these numbers are truly representative of the situation in Portugal&#44; it may well be said that we are facing an elephant in the room&#58; an obvious problem that no-one is mentioning&#46; Let the article by Cabral et al&#46; serve as a stimulus&#44; since this subject deserves greater attention from us all&#46;</p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Conflicts of interest</span><p id="par0030" class="elsevierStylePara elsevierViewall">The author has no conflicts of interest to declare&#46;</p></span></span>"
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Revista Portuguesa de Cardiologia (English edition)
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