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Comment & Response
June 26, 2019

Studies Evaluating Statin Adherence and Outcome Should Adjust for Smoking Persistence and Antiplatelet Treatment Discontinuation—Reply

Author Affiliations
  • 1Division of Cardiovascular Medicine, Stanford University School of Medicine, Stanford, California
  • 2Stanford Cardiovascular Institute, Stanford University School of Medicine, Stanford, California
  • 3Veterans Affairs Health System, Palo Alto, California
JAMA Cardiol. 2019;4(8):832-833. doi:10.1001/jamacardio.2019.1969

In Reply In response to our recent article,1 Ennezat et al note the importance of smoking and adherence to antiplatelet agents in risk adjustment for atherosclerotic cardiovascular disease mortality. We wholly agree that some health behaviors, such as not smoking, eating well, exercising, and medication adherence, are intimately linked to atherosclerotic cardiovascular disease outcomes. It is certainly possible that these behaviors may contribute to the healthy adherer effect, which may partially mediate the association of statin adherence with overall mortality. Unfortunately, smoking and other health behaviors are not captured in our Veterans Affairs administrative database, and we were thus unable to adjust for it in our analyses.