Unraveling the Impact of Medication Noncompliance in a Physically Active 76-Year-Old with Severe Carotid Artery Stenosis: A Case Report; From Atrial Fibrillation to Stroke and Carotid Endarterectomy

Unraveling the Impact of Medication Noncompliance in a Physically Active 76-Year-Old with Severe Carotid Artery Stenosis: A Case Report; From Atrial Fibrillation to Stroke and Carotid Endarterectomy | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Case Report Unraveling the Impact of Medication Noncompliance in a Physically Active 76-Year-Old with Severe Carotid Artery Stenosis: A Case Report; From Atrial Fibrillation to Stroke and Carotid Endarterectomy Nicholas Pfeifer, Kevin Hu, Eric Pedersen, Michael Del Core, Marco DiBlasi This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-7572283/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Cardiovascular disease remains the leading cause of morbidity and mortality worldwide despite significant progress in medication management. Medication noncompliance continues to pose a persistent challenge in achieving the best outcomes for patients. This report follows a 76-year-old male with cardiovascular disease for nine years. Despite his history and current symptoms, the patient consistently refused recommended medical therapies, attributing his health to his advanced fitness regimen and minimizing the need for any pharmacological intervention. Over time, his blood pressure and lipid levels remained poorly controlled, culminating in episodes of atrial fibrillation, significant carotid artery stenosis, and eventually a stroke requiring emergent carotid endarterectomy. Through educationally focused discussions regarding his medication compliance, the patient achieved significant control over his lab values. This case highlights the profound consequences of medication noncompliance as well as thoroughly reviews current literature to characterize various gaps in clinician-patient communication and how to improve interventional strategies. Cardiac & Cardiovascular Systems Carotid Stenosis Medication Noncompliance Stroke Radiology Health Literacy Figures Figure 1 Key Clinical Message Medication noncompliance in cardiovascular disease can lead to severe complications despite a patient’s perceived wellness. This case underscores the critical need for effective clinician-patient communication and targeted education to improve adherence and prevent life-threatening events like stroke. Introduction Atherosclerosis of the carotid artery is associated with a number of prominent risk factors, including age, hypertension, hyperlipidemia, diabetes, obesity, unhealthy diet, and family history. 1 , 2 Although the prevalence of carotid artery stenosis is relatively low at 3–5%, it is anticipated this will become more problematic due to increasingly unhealthy eating habits and sedentary lifestyle within the general population. 3 A particularly concerning complication of carotid stenosis is ischemic stroke, with studies finding that 33% of all strokes result from cervical carotid artery disease. 4 Recommended pharmacologic management of atherosclerotic disease, including for those with asymptomatic carotid stenosis, consists of statins, antihypertensives, antiplatelets, statins, and lifestyle interventions, with antiplatelets and antihypertensives being associated with lower risk of any stroke or cardiovascular death. 5 However, if the patient is symptomatic (i.e. recent TIA or stroke) or if the stenosis is measured > 50%, revascularization via carotid endarterectomy is indicated. 6 Regarding pharmacologic treatment, noncompliance and nonadherence are serious multifaceted risks to effective management. It is well documented that, in patients with risk factors or known atherosclerosis, outcomes are significantly worse in those that are noncompliant or nonadherent, including more hospitalizations with longer stays and increased cardiovascular events and mortality. 7 , 8 In seemingly healthy, active patients, adherence may be overlooked or even expected when compared to those with higher BMI, who are perceived to be less compliant. 9 In 2003, the WHO determined that adherence levels among those with chronic diseases in developed nations averaged about 50%. More specifically, preventable disease accounted for 27% of all US healthcare expenditure in 2016, and it has been estimated that the cost of nonadherence per person ranges from approximately $ 5,000- $ 50,000. 10 , 11 This case presents what may seem like nothing more than another account of chronic cardiovascular disease. However, it is the interplay of factors, including past medical history, lifestyle, and medication noncompliance, that make this case both intriguing and significant in terms of management of atherosclerotic disease and, more importantly, addressing noncompliance. Case History A 76 year-old male presented to the cardiology clinic with complaints of an irregular, paroxysmal heart rate. His intermittent palpitations had been occurring infrequently for about a year. The patient denied any dyspnea or anginal symptoms. He had documented hypertension, hypercholesterolemia, and hyperlipidemia in previous blood work. The patient had a history of proximal left anterior descending coronary artery myocardial infarction (MI) with stent placement 10 years ago. The patient verbalized that this MI event was very mild, happened while he was running, and had no associated chest pain throughout the incident. He was a former smoker, having smoked for five years about 55 years ago. The patient also reported drinking two to three alcoholic beverages a day and not sticking to any diet plans. The patient had an extensive family history of coronary artery disease (CAD), consisting of both his father and brother having MIs in their 40-50s while his second brother had a coronary artery stent placed for CAD. Despite his history, the patient still regards himself as very healthy. On examination, the patient’s blood pressure was 148/88 mmHg, had normal S1 and S2 heart sounds on auscultation, and had a BMI of 21.2 kg/m. Review of an echocardiogram three years prior was within normal limits. The patient was previously started on 5 mg Nebivolol and 81 mg Aspirin; however, he was no longer on these medications. During this visit, the patient recounted his own physically active lifestyle, discussing his life as an avid runner. He noted spending 3–4 years in the Marine Corp in his twenties, and afterwards had begun running marathons every year, stating that 10 years ago he was placing in the top of his age bracket in his races. Currently, he works out at the gym four days a week, incorporating track runs, swimming, and biking into his routine. The patient referenced his physical shape being the reason why he does not need medications. A 48-hour Holter monitor was performed, which demonstrated normal sinus rhythm with no arrhythmia. Over the course of the next five years, the patient would follow up annually with either his primary care physician (PCP) or cardiologist. Four out of the five of these visits, his blood pressure was significantly elevated (Table 1 ). The first year after presentation, the patient had no changes in symptoms, had an electrocardiogram (ECG) that only showed sinus bradycardia, and still a significantly elevated lipid profile. 5 mg of Amlodipine was recommended, but the patient did not start it. On year two of management, the patient was advised to start lisinopril and a PCSK-9 inhibitor, yet he declined treatment despite being counseled on the cardiovascular risks of not controlling his hypertension and hyperlipidemia. At his third year follow-up, the patient again was recommended lisinopril, but he declined. Four years after his initial visit, his blood pressure was significantly elevated again to 162/94 mmHg. One month after his four year follow-up, the patient presented to the emergency department for an irregular heartbeat that lasted over an hour. He reported earlier in the week, his smart watch detected atrial fibrillation. The patient had no associated chest pain, dyspnea, or light headedness. The patient’s blood pressure was 174/103 mmHg, his heart rate was 121 beats per minute, and his ECG confirmed atrial fibrillation with rapid ventricular response with premature ventricular complexes. The patient had unremarkable troponin, B-Type natriuretic peptide, and basic metabolic panel. His cholesterol and LDL were elevated to 265 mg/dL and 187 mg/dL, respectively. Chest X-ray showed no acute abnormality. The patient was treated with IV diltiazem to achieve heart control and then discharged on 5 mg apixaban BID and 25 mg metoprolol prn for stroke prophylaxis given his CHA 2 DS 2 -VASc score of 4 (+ 2 for age ≥ 75, +1 for hypertension history, + 1 for prior MI). Echocardiogram was consistent with 60–65% left ventricular ejection fraction, mildly sclerotic aortic valve, and mild left ventricular hypertrophy. One year after his diagnosis of atrial fibrillation (year five), the patient returned to cardiology for follow up. The patient was still on metoprolol but reported that he discontinued apixaban himself shortly after starting it the previous year. He claimed he chose to stop the medication due to fear of bleeding risk in the case of falls while biking. Patient was counseled on his stroke risk and need to initiate anticoagulation, but he remained resistant. The patient’s poorly controlled lipid profile was also reviewed, yet he refused any lipid-lowering agents. About a year later (year six), the patient was started on 5 mg amlodipine QD but stopped metoprolol himself. His cholesterol and LDL remained elevated (Fig. 1). A month after his six year follow-up, the patient had a knee replacement and decreased his amlodipine dosage to 1.25 mg himself. Over his seventh and eighth year follow-ups, the patient's hypertension persisted and continued to take 1.25 mg of amlodipine QD despite advice from PCP to resume 5 mg. Table 1 Blood pressure and lab values over the patient's nine year management. Local laboratory normal reference ranges: LDL ≤ 99 mg/dL, cholesterol 120–200 mg/dL, triglycerides ≤ 149 mg/dL, HDL 40–60 mg/dL, VLDL ≤ 30 mg/dL. *Year 9’s blood pressure was upon presentation, but lab values were collected a day after treatment. Blood pressure (mmHg) LDL (mg/dL) Cholesterol, Total (mg/dL Triglycerides (mg/dL) HDL, Total (mg/dL) VLDL Calculated (mg/dL) Year 0 148/88 180 272 61 75 12 Year 1 154/84 180 257 74 62 15 Year 2 180/110 180 265 62 73 12 Year 3 169/80 154 248 81 78 16 Year 4 162/94 187 265 73 63 15 Year 5 138/80 204 269 90 47 18 Year 6 162/92 204 280 87 59 17 Year 7 131/75 195 266 71 57 14 Year 8 135/85 N/A N/A N/A N/A N/A Year 9* 191/92 124 191 60 55 12 Post-Op 138/88 67 138 52 61 10 Six months after his eighth year follow-up, patient presented to the ED for episodes of loss of motor control in his right arm lasting for 1 minute, having started a week prior. The patient denied pain, sensory deficits, slurred speech, or vision changes. The patient was only self-medicating with 81 mg of aspirin. Blood pressure on presentation was 191/92 mmHg. Computed Tomography Angiography (CTA) of the Head and Neck was obtained, revealing 90–95% stenosis of the left proximal internal carotid artery (ICA) stenosis with internal thrombus just proximal to the stenosis, moderate stenosis of the right distal ICA, diminutive appearance of left middle cerebral artery branches, and moderate to severe stenosis of the vertebral arteries (Fig. 1). Carotid Duplex demonstrated > 70% reduction in left ICA vessel lumen, causing low velocity blood flow. Echocardiogram revealed an ejection fraction of 55–60%. The patient was promptly treated with IV labetalol, 324 mg PO aspirin, 80 mg of atorvastatin, and 75 mg of clopidogrel. Given the degree of his carotid occlusion, the patient underwent a left carotid endarterectomy two days later, revealing a left carotid bifurcation with extensive plaque burden. The patient was discharged the next day on 81 mg of aspirin QD, 5 mg of apixaban BID, and 40 mg of atorvastatin QD. At the patient’s one week surgical post-op visit, his blood pressure remained high at 154/88 mmHg but is doing well with no recurrence of hemiparesis. [Insert Fig. 1] A month later, the patient’s atorvastatin was titrated down to 20 mg QD. The patient remains asymptomatic with significant improvement over his blood pressure, total cholesterol, and LDL levels (Table 1 ; Post-Op). During this follow up appointment, an emphasis was placed to review his medication compliance. Discussions were focused on medication education, providing explanations for how each medication will help him along with their associated side effects. Time was also spent reinforcing continued physical activity in a safe manner and talking about healthy diets that fit the requirements of an active runner. After noting his understanding of the importance of these medications in his health management, the patient did express a commitment to his medical regimen. He did not verbalize any concerns regarding ability to afford the cost of his medication regimen. The patient is still living a healthy lifestyle and will continue exercising every day. Discussion Medication noncompliance can be a difficult aspect of patient care, especially when attempting to manage chronic disease that has the potential to result in severe, oftentimes life-threatening, complications. This case report illustrates the unique challenge that noncompliance presents. Having already suffered a previous MI, this patient repeatedly denied and self-discontinued medications despite his consistently elevated laboratory values, most notably BP, LDL, and total cholesterol (Table 1 ). Though, it may be easy to place blame on a patient for disregarding medications that would improve their metabolic health and mitigate risk of adverse events, that is not the entire picture. Rather such situations are often multifactorial, as in the case of patients with a high level of physical fitness, and a clinician should implement multiple approaches that work with the patient towards improving their overall health. Several studies have identified numerous factors that predict nonadherence, including those related to physical health (poor physical and mental health, physical inactivity, BMI > 30, alcohol and cigarette use, etc.) as well as social risk factors (education, income, chronic stress, social support, etc.). It was further determined that those with 3–6 social risk factors had a 3.3 times increased risk of nonadherence compared to those without social risk factors. Other factors included stigma, cost, multiple prescribers, poor health literacy, and lack of trust, with cost proving to be one of the most common reasons for nonadherence. 12 , 13 More specifically, it has been observed that for every $ 10 out of pocket increase in monthly statin cost, the nonadherence rate rises by 7%. 14 Without taking into account the potentially aggravating side effect profile of statin therapy, this 7% rise seems significant. While physical risk factors are indirectly modifiable and preventable by encouraging lifestyle changes in patients, the social risk factors and host of other risk factors illustrate the socio-economic, cultural, and even logistical circumstances that play a more covert role in noncompliance. Despite having not completed any sort of social risk assessment for this patient, because of his commitment to an active lifestyle, it is suspected that there must be multiple social risk factors that have driven his noncompliance, including steady alcohol use and lack of health literacy regarding medications. Hence, it becomes evident that this phenomenon of noncompliance is incredibly complicated. The literature remains scarce regarding policy and effective strategies that can be enacted to improve compliance. However, as with nonadherence, there appears to be promise in the power of the physician-patient relationship. As with any relationship, the physician-patient relationship should be grounded in trust and effective communication. This becomes even more crucial in the setting of noncompliance. It has been documented that trust and whole-person knowledge are the two most important factors in promoting adherence, with adherence rates being 2.6 times higher in relationships characterized by high whole-person knowledge. 15 The research is robust in paralleling a similar idea that trust and continuity of care are significantly interrelated. 16 Interpersonal continuity has been found to be associated with significantly improved outcomes and lower costs, likely due to established provider-patient relations and high levels of trust. 17 Moreover, higher trust levels have been found to significantly increase the likelihood that patients partake in recommended behavior changes. 15 Additionally, nonadherence was increased when physicians did not give the patient adequate time, did not pay attention, or were unwilling to consider their lived experience. 18 Physicians must consider each patient’s unique set of experiences and circumstances. Although there are several unmodifiable risk factors that contribute to nonadherence, there are others that present an opportunity for healthcare professionals. In a recent meta-analysis, it was found that better communication regarding the disease itself and the medication were necessary. 19 Thus, part of the issue may be due to a mismatch in understanding, with one study suggesting that physician assessment of recall and comprehension at follow-ups improved glycemic control in those with diabetes. 20 Although physicians often reflexively note that treatments are discussed with and understood by patients, comprehension may not be adequate, as is suspected to be the case with this patient. Rather than speaking at the patient, making the dialogue interactive encourages the patient to be involved and feel like they have a say in their care, potentially facilitating health literacy. 21 Another study revealed that while 52% of patients would like the physician to make the final decision in care, 96% wanted to be included in the choices. 22 These aspects of care are expected to be incorporated into every patient interaction and should be reinforced with each visit to develop health literacy. This model of shared-decision making is gaining traction in the medical field. Some of the pillars of this model include asking open-ended questions, reaching a shared understanding of both the medical problem and what happens if it goes untreated, using ‘I’ statements, and enlisting social support from family. 23 Furthermore, medication-related burden, including adverse effects or the process of incorporating medicine into daily life, has been found to be central in patients' health and wellbeing and even their beliefs about medicine. 18 Synthesizing all of these findings illustrates a more comprehensive message in that lack of health literacy among patients and lack of empathy among physicians are two central facets of this complex issue. The time constraints of the current US healthcare system make it rather difficult to address these issues with patients, especially for those with chronic disease. One study calculated that to provide adequate recommended care to patients with the top 10 chronic diseases, it would require physicians 10.6 hours per day, which amounts to more than the workday itself. 24 Henceforth, this suggests a plausible reason as to why so many with chronic disease, including cardiovascular disease, are uncontrolled. Conclusion Despite all of these contributory factors, it is clear that the path forward in addressing noncompliance must be multifaceted. From the physician standpoint, building trust and lasting relationships with patients by listening to and engaging with their lived experiences, assessing their health literacy, and involving them in decision-making, seems to provide some semblance of an approach to tackling this issue. Future research should further investigate intervention techniques for noncompliant cardiology patients. Declarations Informed Consent This letter is to certify that written informed consent has been obtained for this case report. Consent was signed by the patient for publication of this case. The consent form includes use of their story, lab values, and CTA scans. In return, the patient will remain anonymous. Acknowledgements The authors would like to thank the patient for his willingness to share his story. Source of Funding This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors. Funding source was self. Disclosure No potential competing interest was reported by the author(s). Consent Written informed consent has been obtained for this case report. Consent was signed by the patient for publication of this case. The consent form includes use of their story, lab values, and CTA scans. References Ismail A, Ravipati S, Gonzalez-Hernandez D et al (2023) Carotid Artery Stenosis: A Look Into the Diagnostic and Management Strategies, and Related Complications. Cureus 15(5):e38794 Published 2023 May 9. 10.7759/cureus.38794 Johansson A, Acosta S (2020) Diet and Lifestyle as Risk Factors for Carotid Artery Disease: A Prospective Cohort Study. Cerebrovasc Dis 49(5):563–569. 10.1159/000510907 Dossabhoy S, Arya S (2021) Epidemiology of atherosclerotic carotid artery disease. Semin Vasc Surg 34(1):3–9. 10.1053/j.semvascsurg.2021.02.013 Qaja E (2024) Symptomatic carotid artery stenosis. StatPearls [Internet]. February 12, Accessed November 10, 2024. https://www.ncbi.nlm.nih.gov/books/NBK442025/ King A, Shipley M, Markus H, ACES Investigators (2013) The effect of medical treatments on stroke risk in asymptomatic carotid stenosis. Stroke 44(2):542–546. 10.1161/STROKEAHA.112.673608 Messas E, Goudot G, Halliday A et al (2020) Management of carotid stenosis for primary and secondary prevention of stroke: state-of-the-art 2020: a critical review. Eur Heart J Suppl 22(Suppl M):M35–M42 Published 2020 Dec 6. 10.1093/eurheartj/suaa162 Kengne AP, Brière JB, Zhu L et al (2024) Impact of poor medication adherence on clinical outcomes and health resource utilization in patients with hypertension and/or dyslipidemia: systematic review. Expert Rev Pharmacoecon Outcomes Res 24(1):143–154. 10.1080/14737167.2023.2266135 Kumbhani DJ, Steg PG, Cannon CP et al (2013) Adherence to secondary prevention medications and four-year outcomes in outpatients with atherosclerosis. Am J Med 126(8):693–700e1. 10.1016/j.amjmed.2013.01.033 Huizinga MM, Bleich SN, Beach MC, Clark JM, Cooper LA (2010) Disparity in physician perception of patients' adherence to medications by obesity status. Obes (Silver Spring) 18(10):1932–1937. 10.1038/oby.2010.35 Cutler RL, Fernandez-Llimos F, Frommer M, Benrimoj C, Garcia-Cardenas V (2018) Economic impact of medication non-adherence by disease groups: a systematic review. BMJ Open . ;8(1):e016982. Published 2018 Jan 21. 10.1136/bmjopen-2017-016982 Galea S, Maani N (2020) The cost of preventable disease in the USA. Lancet Public Health 5(10):e513–e514. 10.1016/S2468-2667(20)30204-8 Oates GR, Juarez LD, Hansen B, Kiefe CI, Shikany JM (2020) Social Risk Factors for Medication Nonadherence: Findings from the CARDIA Study. Am J Health Behav 44(2):232–243. 10.5993/AJHB.44.2.10 Rohatgi KW, Humble S, McQueen A et al (2021) Medication Adherence and Characteristics of Patients Who Spend Less on Basic Needs to Afford Medications. J Am Board Fam Med 34(3):561–570. 10.3122/jabfm.2021.03.200361 Abbass I, Revere L, Mitchell J, Appari A, Medication, Nonadherence (2017) The Role of Cost, Community, and Individual Factors. Health Serv Res 52(4):1511–1533. 10.1111/1475-6773.12547 Safran DG, Taira DA, Rogers WH, Kosinski M, Ware JE, Tarlov AR (1998) Linking primary care performance to outcomes of care. J Fam Pract 47(3):213–220 Kordoutis P, Pizga A, Karatzanos E et al (2022) Psychosocial interventions to enhance treatment adherence to lifestyle changes in cardiovascular disease: A review of the literature 2011–2021. Eur J Environ Public Health 6(1). 10.21601/ejeph/11582 Saultz JW, Lochner J (2005) Interpersonal continuity of care and care outcomes: a critical review. Ann Fam Med 3(2):159–166. 10.1370/afm.285 Mohammed MA, Moles RJ, Chen TF (2016) Medication-related burden and patients' lived experience with medicine: a systematic review and metasynthesis of qualitative studies. BMJ Open 6(2):e010035 Published 2016 Feb 2. 10.1136/bmjopen-2015-010035 Dossabhoy S, Arya S (2021) Epidemiology of atherosclerotic carotid artery disease. Semin Vasc Surg 34(1):3–9. 10.1053/j.semvascsurg.2021.02.013 Schillinger D, Piette J, Grumbach K et al (2003) Closing the loop: physician communication with diabetic patients who have low health literacy. Arch Intern Med 163(1):83–90. 10.1001/archinte.163.1.83 De La Vega B, Chu C, Kressin N (2015) Patients’ feelings of being understood by their physician mediates the association between health beliefs and medication adherence. Abstract from the 38th Annual Meeting of the Society of General Internal Medicine. J GEN INTERN MED 30 (Suppl 2), 45–551 https://doi.org/10.1007/s11606-015-3271-0 Levinson W, Kao A, Kuby A, Thisted RA (2005) Not all patients want to participate in decision making. A national study of public preferences. J Gen Intern Med 20(6):531–535. 10.1111/j.1525-1497.2005.04101.x Kleinsinger F (2010) Working with the noncompliant patient. Perm J 14(1):54–60. 10.7812/TPP/09-064 Østbye T, Yarnall KS, Krause KM, Pollak KI, Gradison M, Michener JL (2005) Is there time for management of patients with chronic diseases in primary care? Ann Fam Med 3(3):209–214. 10.1370/afm.310 Additional Declarations The authors declare no competing interests. Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-7572283","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Case Report","associatedPublications":[],"authors":[{"id":512412107,"identity":"71bd9ff0-ff38-4378-b32b-1cdcaaee61ad","order_by":0,"name":"Nicholas Pfeifer","email":"","orcid":"","institution":"Creighton University School of Medicine","correspondingAuthor":false,"prefix":"","firstName":"Nicholas","middleName":"","lastName":"Pfeifer","suffix":""},{"id":512412108,"identity":"d7ed3beb-9b7b-4308-83ad-756519dcf67b","order_by":1,"name":"Kevin Hu","email":"","orcid":"","institution":"Creighton University School of Medicine","correspondingAuthor":false,"prefix":"","firstName":"Kevin","middleName":"","lastName":"Hu","suffix":""},{"id":512412109,"identity":"9b31ec89-1f36-4850-a593-c67f36973941","order_by":2,"name":"Eric Pedersen","email":"","orcid":"","institution":"Creighton University School of Medicine","correspondingAuthor":false,"prefix":"","firstName":"Eric","middleName":"","lastName":"Pedersen","suffix":""},{"id":512412110,"identity":"c5c82bd9-7d4f-4faf-8f34-20d254cf7f24","order_by":3,"name":"Michael Del Core","email":"","orcid":"","institution":"Creighton University School of Medicine","correspondingAuthor":false,"prefix":"","firstName":"Michael","middleName":"Del","lastName":"Core","suffix":""},{"id":512412111,"identity":"0fa970d1-b8c0-4835-8530-ae1fa686369e","order_by":4,"name":"Marco DiBlasi","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA8UlEQVRIiWNgGAWjYFCCxDaGBwwMPPwogjyEtCQA1Ug2EK8lgQ2khcHgALFadNuT2x4k1NTJGJ8//PgDY9sdOXPpBsYHb9twazE787DdIOHYYR6zG2lmEoxtz4wt5xxgNpyLT8uNxDaJBLYDQC0MZgyMbYcTN9xIYJPmJajlXx2Pcf/xz0CHHa4HamH/TVBLYhszjwFDjgHQYYcTDIC2MOPVAvJLYt9hHokbOWUSCeeeGW64kdgsOeccHi3H0589+PCtzp6///jmDx/K7sgb3Eg++OFNGW4tqCCB4QCQZGwgVj0YHCBJ9SgYBaNgFIwMAADFAVhJj8kxNAAAAABJRU5ErkJggg==","orcid":"https://orcid.org/0000-0001-7336-468X","institution":"Creighton University School of Medicine","correspondingAuthor":true,"prefix":"","firstName":"Marco","middleName":"","lastName":"DiBlasi","suffix":""}],"badges":[],"createdAt":"2025-09-09 09:45:19","currentVersionCode":1,"declarations":{"humanSubjects":true,"vertebrateSubjects":false,"conflictsOfInterestStatement":false,"humanSubjectEthicalGuidelines":true,"humanSubjectConsent":true,"humanSubjectClinicalTrial":false,"humanSubjectCaseReport":true,"vertebrateSubjectEthicalGuidelines":false},"doi":"10.21203/rs.3.rs-7572283/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-7572283/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":91078153,"identity":"f0383af9-3b45-4701-bd34-c18f3e654b9f","added_by":"auto","created_at":"2025-09-11 11:17:53","extension":"jpg","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":228503,"visible":true,"origin":"","legend":"\u003cp\u003eContrast enhanced CT angiography of the neck circulation demonstrates a 90% stenosis within the proximal Left internal carotid artery due to mixed, calcified, and non-calcified atherosclerotic plaque.\u003c/p\u003e","description":"","filename":"Figure1.jpg","url":"https://assets-eu.researchsquare.com/files/rs-7572283/v1/a088e84c7e0bbb3b28d08922.jpg"},{"id":91079805,"identity":"e99e1a7e-2ab0-4b5d-b3e5-db43caa18a9a","added_by":"auto","created_at":"2025-09-11 11:25:57","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":690521,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-7572283/v1/af023c97-83b6-41ff-b788-929a3f867a80.pdf"}],"financialInterests":"The authors declare no competing interests.","formattedTitle":"\u003cp\u003eUnraveling the Impact of Medication Noncompliance in a Physically Active 76-Year-Old with Severe Carotid Artery Stenosis: A Case Report; From Atrial Fibrillation to Stroke and Carotid Endarterectomy\u003c/p\u003e","fulltext":[{"header":"Key Clinical Message","content":"\u003cp\u003eMedication noncompliance in cardiovascular disease can lead to severe complications despite a patient\u0026rsquo;s perceived wellness. This case underscores the critical need for effective clinician-patient communication and targeted education to improve adherence and prevent life-threatening events like stroke.\u003c/p\u003e"},{"header":"Introduction","content":"\u003cp\u003eAtherosclerosis of the carotid artery is associated with a number of prominent risk factors, including age, hypertension, hyperlipidemia, diabetes, obesity, unhealthy diet, and family history.\u003csup\u003e\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e\u003c/sup\u003e Although the prevalence of carotid artery stenosis is relatively low at 3\u0026ndash;5%, it is anticipated this will become more problematic due to increasingly unhealthy eating habits and sedentary lifestyle within the general population.\u003csup\u003e\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e\u003c/sup\u003e A particularly concerning complication of carotid stenosis is ischemic stroke, with studies finding that 33% of all strokes result from cervical carotid artery disease.\u003csup\u003e\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e\u003c/sup\u003e Recommended pharmacologic management of atherosclerotic disease, including for those with asymptomatic carotid stenosis, consists of statins, antihypertensives, antiplatelets, statins, and lifestyle interventions, with antiplatelets and antihypertensives being associated with lower risk of any stroke or cardiovascular death.\u003csup\u003e\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e\u003c/sup\u003e However, if the patient is symptomatic (i.e. recent TIA or stroke) or if the stenosis is measured\u0026thinsp;\u0026gt;\u0026thinsp;50%, revascularization via carotid endarterectomy is indicated.\u003csup\u003e\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e\u003cp\u003eRegarding pharmacologic treatment, noncompliance and nonadherence are serious multifaceted risks to effective management. It is well documented that, in patients with risk factors or known atherosclerosis, outcomes are significantly worse in those that are noncompliant or nonadherent, including more hospitalizations with longer stays and increased cardiovascular events and mortality.\u003csup\u003e\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e\u003c/sup\u003e In seemingly healthy, active patients, adherence may be overlooked or even expected when compared to those with higher BMI, who are perceived to be less compliant.\u003csup\u003e\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e\u003cp\u003eIn 2003, the WHO determined that adherence levels among those with chronic diseases in developed nations averaged about 50%. More specifically, preventable disease accounted for 27% of all US healthcare expenditure in 2016, and it has been estimated that the cost of nonadherence per person ranges from approximately \u003cspan\u003e$\u003c/span\u003e5,000-\u003cspan\u003e$\u003c/span\u003e50,000.\u003csup\u003e\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e, \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e\u003cp\u003eThis case presents what may seem like nothing more than another account of chronic cardiovascular disease. However, it is the interplay of factors, including past medical history, lifestyle, and medication noncompliance, that make this case both intriguing and significant in terms of management of atherosclerotic disease and, more importantly, addressing noncompliance.\u003c/p\u003e"},{"header":"Case History","content":"\u003cp\u003eA 76 year-old male presented to the cardiology clinic with complaints of an irregular, paroxysmal heart rate. His intermittent palpitations had been occurring infrequently for about a year. The patient denied any dyspnea or anginal symptoms. He had documented hypertension, hypercholesterolemia, and hyperlipidemia in previous blood work. The patient had a history of proximal left anterior descending coronary artery myocardial infarction (MI) with stent placement 10 years ago. The patient verbalized that this MI event was very mild, happened while he was running, and had no associated chest pain throughout the incident. He was a former smoker, having smoked for five years about 55 years ago. The patient also reported drinking two to three alcoholic beverages a day and not sticking to any diet plans. The patient had an extensive family history of coronary artery disease (CAD), consisting of both his father and brother having MIs in their 40-50s while his second brother had a coronary artery stent placed for CAD. Despite his history, the patient still regards himself as very healthy. On examination, the patient\u0026rsquo;s blood pressure was 148/88 mmHg, had normal S1 and S2 heart sounds on auscultation, and had a BMI of 21.2 kg/m. Review of an echocardiogram three years prior was within normal limits. The patient was previously started on 5 mg Nebivolol and 81 mg Aspirin; however, he was no longer on these medications.\u003c/p\u003e\u003cp\u003eDuring this visit, the patient recounted his own physically active lifestyle, discussing his life as an avid runner. He noted spending 3\u0026ndash;4 years in the Marine Corp in his twenties, and afterwards had begun running marathons every year, stating that 10 years ago he was placing in the top of his age bracket in his races. Currently, he works out at the gym four days a week, incorporating track runs, swimming, and biking into his routine. The patient referenced his physical shape being the reason why he does not need medications. A 48-hour Holter monitor was performed, which demonstrated normal sinus rhythm with no arrhythmia.\u003c/p\u003e\u003cp\u003eOver the course of the next five years, the patient would follow up annually with either his primary care physician (PCP) or cardiologist. Four out of the five of these visits, his blood pressure was significantly elevated (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). The first year after presentation, the patient had no changes in symptoms, had an electrocardiogram (ECG) that only showed sinus bradycardia, and still a significantly elevated lipid profile. 5 mg of Amlodipine was recommended, but the patient did not start it. On year two of management, the patient was advised to start lisinopril and a PCSK-9 inhibitor, yet he declined treatment despite being counseled on the cardiovascular risks of not controlling his hypertension and hyperlipidemia. At his third year follow-up, the patient again was recommended lisinopril, but he declined. Four years after his initial visit, his blood pressure was significantly elevated again to 162/94 mmHg.\u003c/p\u003e\u003cp\u003eOne month after his four year follow-up, the patient presented to the emergency department for an irregular heartbeat that lasted over an hour. He reported earlier in the week, his smart watch detected atrial fibrillation. The patient had no associated chest pain, dyspnea, or light headedness. The patient\u0026rsquo;s blood pressure was 174/103 mmHg, his heart rate was 121 beats per minute, and his ECG confirmed atrial fibrillation with rapid ventricular response with premature ventricular complexes. The patient had unremarkable troponin, B-Type natriuretic peptide, and basic metabolic panel. His cholesterol and LDL were elevated to 265 mg/dL and 187 mg/dL, respectively. Chest X-ray showed no acute abnormality. The patient was treated with IV diltiazem to achieve heart control and then discharged on 5 mg apixaban BID and 25 mg metoprolol prn for stroke prophylaxis given his CHA\u003csub\u003e2\u003c/sub\u003eDS\u003csub\u003e2\u003c/sub\u003e-VASc score of 4 (+\u0026thinsp;2 for age\u0026thinsp;\u0026ge;\u0026thinsp;75, +1 for hypertension history, +\u0026thinsp;1 for prior MI). Echocardiogram was consistent with 60\u0026ndash;65% left ventricular ejection fraction, mildly sclerotic aortic valve, and mild left ventricular hypertrophy.\u003c/p\u003e\u003cp\u003eOne year after his diagnosis of atrial fibrillation (year five), the patient returned to cardiology for follow up. The patient was still on metoprolol but reported that he discontinued apixaban himself shortly after starting it the previous year. He claimed he chose to stop the medication due to fear of bleeding risk in the case of falls while biking. Patient was counseled on his stroke risk and need to initiate anticoagulation, but he remained resistant. The patient\u0026rsquo;s poorly controlled lipid profile was also reviewed, yet he refused any lipid-lowering agents.\u003c/p\u003e\u003cp\u003eAbout a year later (year six), the patient was started on 5 mg amlodipine QD but stopped metoprolol himself. His cholesterol and LDL remained elevated (Fig.\u0026nbsp;1). A month after his six year follow-up, the patient had a knee replacement and decreased his amlodipine dosage to 1.25 mg himself. Over his seventh and eighth year follow-ups, the patient's hypertension persisted and continued to take 1.25 mg of amlodipine QD despite advice from PCP to resume 5 mg.\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eBlood pressure and lab values over the patient's nine year management. Local laboratory normal reference ranges: LDL\u0026thinsp;\u0026le;\u0026thinsp;99 mg/dL, cholesterol 120\u0026ndash;200 mg/dL, triglycerides\u0026thinsp;\u0026le;\u0026thinsp;149 mg/dL, HDL 40\u0026ndash;60 mg/dL, VLDL\u0026thinsp;\u0026le;\u0026thinsp;30 mg/dL. *Year 9\u0026rsquo;s blood pressure was upon presentation, but lab values were collected a day after treatment.\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"7\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eBlood pressure (mmHg)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eLDL (mg/dL)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003eCholesterol, Total (mg/dL\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c5\"\u003e\u003cp\u003eTriglycerides (mg/dL)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c6\"\u003e\u003cp\u003eHDL, Total (mg/dL)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c7\"\u003e\u003cp\u003eVLDL Calculated (mg/dL)\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eYear 0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e148/88\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e180\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e272\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e61\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e75\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e12\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eYear 1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e154/84\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e180\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e257\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e74\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e62\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e15\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eYear 2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e180/110\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e180\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e265\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e62\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e73\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e12\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eYear 3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e169/80\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e154\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e248\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e81\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e78\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e16\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eYear 4\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e162/94\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e187\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e265\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e73\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e63\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e15\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eYear 5\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e138/80\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e204\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e269\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e90\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e47\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e18\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eYear 6\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e162/92\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e204\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e280\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e87\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e59\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e17\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eYear 7\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e131/75\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e195\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e266\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e71\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e57\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e14\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eYear 8\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e135/85\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eN/A\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eN/A\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003eN/A\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003eN/A\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003eN/A\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eYear 9*\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e191/92\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e124\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e191\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e60\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e55\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e12\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003ePost-Op\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e138/88\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e67\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e138\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e52\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e61\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e10\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003eSix months after his eighth year follow-up, patient presented to the ED for episodes of loss of motor control in his right arm lasting for 1 minute, having started a week prior. The patient denied pain, sensory deficits, slurred speech, or vision changes. The patient was only self-medicating with 81 mg of aspirin. Blood pressure on presentation was 191/92 mmHg. Computed Tomography Angiography (CTA) of the Head and Neck was obtained, revealing 90\u0026ndash;95% stenosis of the left proximal internal carotid artery (ICA) stenosis with internal thrombus just proximal to the stenosis, moderate stenosis of the right distal ICA, diminutive appearance of left middle cerebral artery branches, and moderate to severe stenosis of the vertebral arteries (Fig.\u0026nbsp;1). Carotid Duplex demonstrated\u0026thinsp;\u0026gt;\u0026thinsp;70% reduction in left ICA vessel lumen, causing low velocity blood flow. Echocardiogram revealed an ejection fraction of 55\u0026ndash;60%. The patient was promptly treated with IV labetalol, 324 mg PO aspirin, 80 mg of atorvastatin, and 75 mg of clopidogrel. Given the degree of his carotid occlusion, the patient underwent a left carotid endarterectomy two days later, revealing a left carotid bifurcation with extensive plaque burden. The patient was discharged the next day on 81 mg of aspirin QD, 5 mg of apixaban BID, and 40 mg of atorvastatin QD. At the patient\u0026rsquo;s one week surgical post-op visit, his blood pressure remained high at 154/88 mmHg but is doing well with no recurrence of hemiparesis.\u003c/p\u003e\u003cp\u003e[Insert Fig.\u0026nbsp;1]\u003c/p\u003e\u003cp\u003eA month later, the patient\u0026rsquo;s atorvastatin was titrated down to 20 mg QD. The patient remains asymptomatic with significant improvement over his blood pressure, total cholesterol, and LDL levels (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e; Post-Op). During this follow up appointment, an emphasis was placed to review his medication compliance. Discussions were focused on medication education, providing explanations for how each medication will help him along with their associated side effects. Time was also spent reinforcing continued physical activity in a safe manner and talking about healthy diets that fit the requirements of an active runner. After noting his understanding of the importance of these medications in his health management, the patient did express a commitment to his medical regimen. He did not verbalize any concerns regarding ability to afford the cost of his medication regimen. The patient is still living a healthy lifestyle and will continue exercising every day.\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eMedication noncompliance can be a difficult aspect of patient care, especially when attempting to manage chronic disease that has the potential to result in severe, oftentimes life-threatening, complications. This case report illustrates the unique challenge that noncompliance presents. Having already suffered a previous MI, this patient repeatedly denied and self-discontinued medications despite his consistently elevated laboratory values, most notably BP, LDL, and total cholesterol (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). Though, it may be easy to place blame on a patient for disregarding medications that would improve their metabolic health and mitigate risk of adverse events, that is not the entire picture. Rather such situations are often multifactorial, as in the case of patients with a high level of physical fitness, and a clinician should implement multiple approaches that work with the patient towards improving their overall health.\u003c/p\u003e\u003cp\u003eSeveral studies have identified numerous factors that predict nonadherence, including those related to physical health (poor physical and mental health, physical inactivity, BMI\u0026thinsp;\u0026gt;\u0026thinsp;30, alcohol and cigarette use, etc.) as well as social risk factors (education, income, chronic stress, social support, etc.). It was further determined that those with 3\u0026ndash;6 social risk factors had a 3.3 times increased risk of nonadherence compared to those without social risk factors. Other factors included stigma, cost, multiple prescribers, poor health literacy, and lack of trust, with cost proving to be one of the most common reasons for nonadherence.\u003csup\u003e\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e,\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e\u003c/sup\u003e More specifically, it has been observed that for every \u003cspan\u003e$\u003c/span\u003e10 out of pocket increase in monthly statin cost, the nonadherence rate rises by 7%.\u003csup\u003e14\u003c/sup\u003e Without taking into account the potentially aggravating side effect profile of statin therapy, this 7% rise seems significant.\u003c/p\u003e\u003cp\u003eWhile physical risk factors are indirectly modifiable and preventable by encouraging lifestyle changes in patients, the social risk factors and host of other risk factors illustrate the socio-economic, cultural, and even logistical circumstances that play a more covert role in noncompliance. Despite having not completed any sort of social risk assessment for this patient, because of his commitment to an active lifestyle, it is suspected that there must be multiple social risk factors that have driven his noncompliance, including steady alcohol use and lack of health literacy regarding medications. Hence, it becomes evident that this phenomenon of noncompliance is incredibly complicated. The literature remains scarce regarding policy and effective strategies that can be enacted to improve compliance. However, as with nonadherence, there appears to be promise in the power of the physician-patient relationship.\u003c/p\u003e\u003cp\u003eAs with any relationship, the physician-patient relationship should be grounded in trust and effective communication. This becomes even more crucial in the setting of noncompliance. It has been documented that trust and whole-person knowledge are the two most important factors in promoting adherence, with adherence rates being 2.6 times higher in relationships characterized by high whole-person knowledge.\u003csup\u003e\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e\u003c/sup\u003e The research is robust in paralleling a similar idea that trust and continuity of care are significantly interrelated.\u003csup\u003e\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e\u003c/sup\u003e Interpersonal continuity has been found to be associated with significantly improved outcomes and lower costs, likely due to established provider-patient relations and high levels of trust.\u003csup\u003e\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e\u003c/sup\u003e Moreover, higher trust levels have been found to significantly increase the likelihood that patients partake in recommended behavior changes.\u003csup\u003e\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e\u003c/sup\u003e Additionally, nonadherence was increased when physicians did not give the patient adequate time, did not pay attention, or were unwilling to consider their lived experience.\u003csup\u003e\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e\u003cp\u003ePhysicians must consider each patient\u0026rsquo;s unique set of experiences and circumstances. Although there are several unmodifiable risk factors that contribute to nonadherence, there are others that present an opportunity for healthcare professionals. In a recent meta-analysis, it was found that better communication regarding the disease itself and the medication were necessary.\u003csup\u003e\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e\u003cp\u003eThus, part of the issue may be due to a mismatch in understanding, with one study suggesting that physician assessment of recall and comprehension at follow-ups improved glycemic control in those with diabetes.\u003csup\u003e\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e\u003c/sup\u003e Although physicians often reflexively note that treatments are discussed with and understood by patients, comprehension may not be adequate, as is suspected to be the case with this patient. Rather than speaking at the patient, making the dialogue interactive encourages the patient to be involved and feel like they have a say in their care, potentially facilitating health literacy.\u003csup\u003e\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e\u003c/sup\u003e Another study revealed that while 52% of patients would like the physician to make the final decision in care, 96% wanted to be included in the choices.\u003csup\u003e\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e\u003c/sup\u003e These aspects of care are expected to be incorporated into every patient interaction and should be reinforced with each visit to develop health literacy.\u003c/p\u003e\u003cp\u003eThis model of shared-decision making is gaining traction in the medical field. Some of the pillars of this model include asking open-ended questions, reaching a shared understanding of both the medical problem and what happens if it goes untreated, using \u0026lsquo;I\u0026rsquo; statements, and enlisting social support from family.\u003csup\u003e\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e\u003c/sup\u003e Furthermore, medication-related burden, including adverse effects or the process of incorporating medicine into daily life, has been found to be central in patients' health and wellbeing and even their beliefs about medicine.\u003csup\u003e\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e\u003cp\u003eSynthesizing all of these findings illustrates a more comprehensive message in that lack of health literacy among patients and lack of empathy among physicians are two central facets of this complex issue. The time constraints of the current US healthcare system make it rather difficult to address these issues with patients, especially for those with chronic disease. One study calculated that to provide adequate recommended care to patients with the top 10 chronic diseases, it would require physicians 10.6 hours per day, which amounts to more than the workday itself.\u003csup\u003e\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e\u003c/sup\u003e Henceforth, this suggests a plausible reason as to why so many with chronic disease, including cardiovascular disease, are uncontrolled.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eDespite all of these contributory factors, it is clear that the path forward in addressing noncompliance must be multifaceted. From the physician standpoint, building trust and lasting relationships with patients by listening to and engaging with their lived experiences, assessing their health literacy, and involving them in decision-making, seems to provide some semblance of an approach to tackling this issue. Future research should further investigate intervention techniques for noncompliant cardiology patients.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eInformed Consent\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis letter is to certify that written informed consent has been obtained for this case report.\u003c/p\u003e\n\u003cp\u003eConsent was signed by the patient for publication of this case. The consent form includes use of their story, lab values, and CTA scans. In return, the patient will remain anonymous.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors would like to thank the patient for his willingness to share his story.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eSource of Funding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors. Funding source was self.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eDisclosure\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNo potential competing interest was reported by the author(s).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWritten informed consent has been obtained for this case report. Consent was signed by the patient for publication of this case. The consent form includes use of their story, lab values, and CTA scans.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eIsmail A, Ravipati S, Gonzalez-Hernandez D et al (2023) Carotid Artery Stenosis: A Look Into the Diagnostic and Management Strategies, and Related Complications. Cureus 15(5):e38794 Published 2023 May 9. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.7759/cureus.38794\u003c/span\u003e\u003cspan address=\"10.7759/cureus.38794\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eJohansson A, Acosta S (2020) Diet and Lifestyle as Risk Factors for Carotid Artery Disease: A Prospective Cohort Study. Cerebrovasc Dis 49(5):563\u0026ndash;569. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1159/000510907\u003c/span\u003e\u003cspan address=\"10.1159/000510907\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eDossabhoy S, Arya S (2021) Epidemiology of atherosclerotic carotid artery disease. Semin Vasc Surg 34(1):3\u0026ndash;9. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1053/j.semvascsurg.2021.02.013\u003c/span\u003e\u003cspan address=\"10.1053/j.semvascsurg.2021.02.013\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eQaja E (2024) Symptomatic carotid artery stenosis. StatPearls [Internet]. February 12, Accessed November 10, 2024. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://www.ncbi.nlm.nih.gov/books/NBK442025/\u003c/span\u003e\u003cspan address=\"https://www.ncbi.nlm.nih.gov/books/NBK442025/\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eKing A, Shipley M, Markus H, ACES Investigators (2013) The effect of medical treatments on stroke risk in asymptomatic carotid stenosis. Stroke 44(2):542\u0026ndash;546. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1161/STROKEAHA.112.673608\u003c/span\u003e\u003cspan address=\"10.1161/STROKEAHA.112.673608\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eMessas E, Goudot G, Halliday A et al (2020) Management of carotid stenosis for primary and secondary prevention of stroke: state-of-the-art 2020: a critical review. Eur Heart J Suppl 22(Suppl M):M35\u0026ndash;M42 Published 2020 Dec 6. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1093/eurheartj/suaa162\u003c/span\u003e\u003cspan address=\"10.1093/eurheartj/suaa162\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eKengne AP, Bri\u0026egrave;re JB, Zhu L et al (2024) Impact of poor medication adherence on clinical outcomes and health resource utilization in patients with hypertension and/or dyslipidemia: systematic review. Expert Rev Pharmacoecon Outcomes Res 24(1):143\u0026ndash;154. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1080/14737167.2023.2266135\u003c/span\u003e\u003cspan address=\"10.1080/14737167.2023.2266135\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eKumbhani DJ, Steg PG, Cannon CP et al (2013) Adherence to secondary prevention medications and four-year outcomes in outpatients with atherosclerosis. Am J Med 126(8):693\u0026ndash;700e1. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1016/j.amjmed.2013.01.033\u003c/span\u003e\u003cspan address=\"10.1016/j.amjmed.2013.01.033\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eHuizinga MM, Bleich SN, Beach MC, Clark JM, Cooper LA (2010) Disparity in physician perception of patients' adherence to medications by obesity status. Obes (Silver Spring) 18(10):1932\u0026ndash;1937. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1038/oby.2010.35\u003c/span\u003e\u003cspan address=\"10.1038/oby.2010.35\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eCutler RL, Fernandez-Llimos F, Frommer M, Benrimoj C, Garcia-Cardenas V (2018) Economic impact of medication non-adherence by disease groups: a systematic review. \u003cem\u003eBMJ Open\u003c/em\u003e. ;8(1):e016982. Published 2018 Jan 21. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1136/bmjopen-2017-016982\u003c/span\u003e\u003cspan address=\"10.1136/bmjopen-2017-016982\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eGalea S, Maani N (2020) The cost of preventable disease in the USA. Lancet Public Health 5(10):e513\u0026ndash;e514. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1016/S2468-2667(20)30204-8\u003c/span\u003e\u003cspan address=\"10.1016/S2468-2667(20)30204-8\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eOates GR, Juarez LD, Hansen B, Kiefe CI, Shikany JM (2020) Social Risk Factors for Medication Nonadherence: Findings from the CARDIA Study. Am J Health Behav 44(2):232\u0026ndash;243. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.5993/AJHB.44.2.10\u003c/span\u003e\u003cspan address=\"10.5993/AJHB.44.2.10\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eRohatgi KW, Humble S, McQueen A et al (2021) Medication Adherence and Characteristics of Patients Who Spend Less on Basic Needs to Afford Medications. J Am Board Fam Med 34(3):561\u0026ndash;570. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.3122/jabfm.2021.03.200361\u003c/span\u003e\u003cspan address=\"10.3122/jabfm.2021.03.200361\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eAbbass I, Revere L, Mitchell J, Appari A, Medication, Nonadherence (2017) The Role of Cost, Community, and Individual Factors. Health Serv Res 52(4):1511\u0026ndash;1533. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1111/1475-6773.12547\u003c/span\u003e\u003cspan address=\"10.1111/1475-6773.12547\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eSafran DG, Taira DA, Rogers WH, Kosinski M, Ware JE, Tarlov AR (1998) Linking primary care performance to outcomes of care. J Fam Pract 47(3):213\u0026ndash;220\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eKordoutis P, Pizga A, Karatzanos E et al (2022) Psychosocial interventions to enhance treatment adherence to lifestyle changes in cardiovascular disease: A review of the literature 2011\u0026ndash;2021. Eur J Environ Public Health 6(1). \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.21601/ejeph/11582\u003c/span\u003e\u003cspan address=\"10.21601/ejeph/11582\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eSaultz JW, Lochner J (2005) Interpersonal continuity of care and care outcomes: a critical review. Ann Fam Med 3(2):159\u0026ndash;166. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1370/afm.285\u003c/span\u003e\u003cspan address=\"10.1370/afm.285\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eMohammed MA, Moles RJ, Chen TF (2016) Medication-related burden and patients' lived experience with medicine: a systematic review and metasynthesis of qualitative studies. BMJ Open 6(2):e010035 Published 2016 Feb 2. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1136/bmjopen-2015-010035\u003c/span\u003e\u003cspan address=\"10.1136/bmjopen-2015-010035\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eDossabhoy S, Arya S (2021) Epidemiology of atherosclerotic carotid artery disease. Semin Vasc Surg 34(1):3\u0026ndash;9. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1053/j.semvascsurg.2021.02.013\u003c/span\u003e\u003cspan address=\"10.1053/j.semvascsurg.2021.02.013\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eSchillinger D, Piette J, Grumbach K et al (2003) Closing the loop: physician communication with diabetic patients who have low health literacy. Arch Intern Med 163(1):83\u0026ndash;90. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1001/archinte.163.1.83\u003c/span\u003e\u003cspan address=\"10.1001/archinte.163.1.83\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eDe La Vega B, Chu C, Kressin N (2015) Patients\u0026rsquo; feelings of being understood by their physician mediates the association between health beliefs and medication adherence. Abstract from the 38th Annual Meeting of the Society of General Internal Medicine. \u003cem\u003eJ GEN INTERN MED\u003c/em\u003e 30 (Suppl 2), 45\u0026ndash;551 \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1007/s11606-015-3271-0\u003c/span\u003e\u003cspan address=\"10.1007/s11606-015-3271-0\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eLevinson W, Kao A, Kuby A, Thisted RA (2005) Not all patients want to participate in decision making. A national study of public preferences. J Gen Intern Med 20(6):531\u0026ndash;535. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1111/j.1525-1497.2005.04101.x\u003c/span\u003e\u003cspan address=\"10.1111/j.1525-1497.2005.04101.x\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eKleinsinger F (2010) Working with the noncompliant patient. Perm J 14(1):54\u0026ndash;60. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.7812/TPP/09-064\u003c/span\u003e\u003cspan address=\"10.7812/TPP/09-064\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003e\u0026Oslash;stbye T, Yarnall KS, Krause KM, Pollak KI, Gradison M, Michener JL (2005) Is there time for management of patients with chronic diseases in primary care? Ann Fam Med 3(3):209\u0026ndash;214. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1370/afm.310\u003c/span\u003e\u003cspan address=\"10.1370/afm.310\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":true,"hideJournal":true,"highlight":"","institution":"Creighton University School of Medicine","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Carotid Stenosis, Medication Noncompliance, Stroke, Radiology, Health Literacy","lastPublishedDoi":"10.21203/rs.3.rs-7572283/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-7572283/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003eCardiovascular disease remains the leading cause of morbidity and mortality worldwide despite significant progress in medication management. Medication noncompliance continues to pose a persistent challenge in achieving the best outcomes for patients. This report follows a 76-year-old male with cardiovascular disease for nine years. Despite his history and current symptoms, the patient consistently refused recommended medical therapies, attributing his health to his advanced fitness regimen and minimizing the need for any pharmacological intervention. Over time, his blood pressure and lipid levels remained poorly controlled, culminating in episodes of atrial fibrillation, significant carotid artery stenosis, and eventually a stroke requiring emergent carotid endarterectomy. Through educationally focused discussions regarding his medication compliance, the patient achieved significant control over his lab values. This case highlights the profound consequences of medication noncompliance as well as thoroughly reviews current literature to characterize various gaps in clinician-patient communication and how to improve interventional strategies.\u003c/p\u003e","manuscriptTitle":"Unraveling the Impact of Medication Noncompliance in a Physically Active 76-Year-Old with Severe Carotid Artery Stenosis: A Case Report; From Atrial Fibrillation to Stroke and Carotid Endarterectomy","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-09-11 11:17:48","doi":"10.21203/rs.3.rs-7572283/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"bf3154fe-b9ed-49e2-ad1d-20b1ef859690","owner":[],"postedDate":"September 11th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[{"id":54425097,"name":"Cardiac \u0026 Cardiovascular Systems"}],"tags":[],"updatedAt":"2025-09-11T11:17:48+00:00","versionOfRecord":[],"versionCreatedAt":"2025-09-11 11:17:48","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-7572283","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-7572283","identity":"rs-7572283","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}