36 Chapter 2 practice, time pressure and case complexity among others (83). Articles considering the prescription rates adequate still noted that medication use decreased with time after diagnosis (59,75), indicating that there is room to improve medication adherence and secondary prevention of CHD (59). It is noteworthy that some publications report that achievement of cardiovascular risk factor targets was inadequate despite high levels of medication use (59,66,67,75,80), which may be attributed to the use of suboptimal doses (59). Time trends We observed increased use of most cardioprotective medications. These trends are in line with large surveys conducted in Europe that report an increase of the use of cardioprotective medications from 1999 and 2004 to 2013 (84,85). These changes may be attributed in part to the implementation of evidence-based clinical guidelines and public health policies in many South American countries. Mendis et al (77) previously highlighted the lack of clinical guidelines as a potential factor contributing to the low treatment rates in the PREMISE study. Guideline recommendations have changed in the last decades. For example, the target LDL cholesterol level recommended in guidelines by scientific societies has become lower, from 100 mg/dl in guidelines from 2008 and 2001 (86,87), to 75mg/dl (88), and finally to 70mg/ dl in the most recent guidelines (89–92). The recommendation to prescribe statins to CHD patients changed accordingly, and the most recent recommendations from scientific societies and clinical guidelines recommend statin use in CHD patients regardless of their cholesterol level. These changes may promote a higher intake of statin use, which is in line with research showing a decrease in cholesterol levels globally and also in the South American region (93). The gradual investment and unfolding of public healthcare systems with wide coverage, such as the Sistema Unico de Saúde (SUS) in Brazil, has promoted the use of medication by a growing primary care network and provision of drugs free of charge (48). Although there are still barriers to medication access, the growing coverage of public healthcare systems has allowed more CHD patients to access recommended medications. Determinants of medication use Participant’s characteristics Several studies found female sex and younger age to be independent predictors for lower use of medication (48,94–97). Women often receive less prescriptions and have lower adherence to medication, which has been attributed to physician and patients factors like presentation of distinct symptoms, and underestimation of disease severity and fear of side effects (48,94–97). In our meta-regression models, however, the percentage of women included in the study was not significantly associated with higher use of any medication class. The lower use of medication in younger patients may be explained by better medication adherence in patients with known risk factors, like older age (12). High SES showed an independent and strong association with medication use in many studies. Lack of affordability could be a reason for this difference (76), however many
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