Sex differences in risk factor control and medication adherence post-ACS: insights from the TEXTMEDS randomised clinical trial

Clinical Snapshot

Key Findings

• P Value: Statistically significant for primary outcomes (p<0.05)

• Effect Size: Females less likely to achieve LDL-C targets (aOR 0.61) and medication adherence (aOR 0.68), but more likely to maintain healthy BMI (aOR 1.47)

• Primary Outcome: Sex differences in secondary prevention target achievement and medication adherence

• Nnt Or Sensitivity: Medication adherence association weakened after socioeconomic adjustment (aOR 0.71, 95% CI 0.50-1.03)

• Confidence Interval: LDL-C: 95% CI 0.45-0.82; Medication adherence: 95% CI 0.50-0.92; BMI: 95% CI 1.04-2.06

Clinical Application

Findings can inform sex-specific secondary prevention strategies in existing cardiac rehabilitation and follow-up programs Highly relevant to Australian practice - aligns with NHFA/CSANZ guidelines for secondary prevention, may inform PBS medication reviews and GP management plans for post-ACS patients Post-ACS patients in Australian healthcare settings, particularly relevant for secondary prevention programs

Abstract

INTRODUCTION: Poor adherence to risk factor control and life-saving medications is a key factor affecting long-term patient prognosis. Evidence indicates that sex plays a significant role in the uptake of both pharmacological and non-pharmacological interventions, ultimately influencing long-term outcomes. This study aimed to quantify sex differences in risk factor management and medication adherence following acute coronary syndrome (ACS). METHODS: This is a secondary analysis of the TEXTMEDS randomised clinical trial - a single-blind, multicentre randomised controlled trial of patients post-ACS. We compared sex differences in achieving clinical and lifestyle targets for secondary prevention, namely blood pressure control (<140/90 mm Hg), low-density lipoprotein cholesterol (LDL-C) (<1.8 mmol/L), healthy body mass index (BMI) (<25 kg/m²), regular physical activity (Global Physical Activity Questionnaire score ≥600), smoking status and adherence to cardioprotective medications (aspirin, beta blockers, ACE/angiotensin receptor blockers, statins, antiplatelets), using adjusted logistic regression models. Medication adherence was defined as taking ≥80% of prescribed doses in the month prior to follow-up, across all five drug classes, unless contraindicated. RESULTS: Of 1379 patients (mean age 58.5±10.7 years; 1095 (79.4%) male), females were less likely than men to achieve LDL-C targets (adjusted OR (aOR): 0.61, 95% CI 0.45 to 0.82) and engage in regular physical activity (aOR: 0.61, CI 0.47 to 0.80), but more likely to achieve a healthy BMI (aOR: 1.47, CI 1.04 to 2.06). Female patients are less likely to adhere to their medication compared with male counterparts (aOR: 0.68, CI 0.50 to 0.92). However, this association weakened and lost statistical significance after further adjustment for socio-economic factors (aOR: 0.71, CI 0.50 to 1.03). There were no significant interactions between sociodemographic or clinical factors and sex in relation to overall medication adherence (P-interactions >0.05). CONCLUSION: This study reveals that female patients are less likely to achieve LDL-C targets and engage in physical activity but more likely to maintain a healthy BMI. Although females showed lower medication adherence, this association weakened after adjusting for socio-economic factors. These findings highlight the importance of sex-sensitive strategies focusing on risk factor control and medication adherence for improving cardiovascular health outcomes. TRIAL REGISTRATION NUMBER: ACTRN12613000793718.

References

1. 1.Mishra, S. R., Marschner, S., Min, H., Mahendran, S., Thiagalingam, A., Poulter, R., Redfern, J., Brieger, D. B., Thompson, P. L., Hillis, G. S., Collins, N., Shetty, P., McGrady, M., Hamilton-Craig, C., Kangaharan, N., Atherton, J., Maiorana, A., Klimis, H., Juergens, C., & Chow, C. K. (2026). Sex differences in risk factor control and medication adherence post-ACS: insights from the TEXTMEDS randomised clinical trial. Open Heart, 13(1), e003856. https://doi.org/10.1136/openhrt-2025-003856