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. Author manuscript; available in PMC: 2021 Jun 1.
Published in final edited form as: J Behav Med. 2020 Jan 29;43(3):402–410. doi: 10.1007/s10865-020-00139-0

Partner Presence in the Emergency Department and Adherence to Daily Cardiovascular Medications in Patients Evaluated for Acute Coronary Syndrome

Talea Cornelius 1, Jeffrey L Birk 1, Kyle Bourassa 2,3, Redeana C Umland 1, Ian M Kronish 1
PMCID: PMC7234891  NIHMSID: NIHMS1561798  PMID: 31997128

Abstract

Background.

Stressful health situations may compromise spouses’/partners’ ability to provide patients with support. We tested whether partner status/partner presence in the emergency department (ED) were associated with patients’ adherence to daily cardiovascular medications and whether effects differed by age/gender.

Methods.

Participants were 189 patients evaluated for acute coronary syndrome at an urban academic ED (MAge = 62.18; 57.1% male; 58.7% Hispanic). Participants self-reported partner status/partner presence. Medication adherence was measured using an electronic pillcap.

Results.

For male patients, having a partner was associated with increased adherence in the first month post-discharge, OR = 1.94, p < .001, but having a partner present in the ED was associated with lower adherence, OR = 0.33, p < .001. The opposite effect was evident for female patients.

Conclusions.

Partner status/partner presence in the ED are associated with medication adherence during the first month post discharge, with opposing effects for male and female patients.

Keywords: marriage, medication adherence, emergency department, acute coronary syndrome, social support

Having a spouse or partner has been associated with improved cardiovascular health (Kiecolt-Glaser & Newton, 2001; Kiecolt-Glaser & Wilson, 2017; Robles & Kiecolt-Glaser, 2003). One proposed mechanism to explain this association is that partners provide increased social support to their partners, which in turn, leads to improved adherence to cardioprotective medications (DiMatteo, 2004; Wu et al., 2012; Wu et al., 2008). A meta-analysis of 51 studies found that the odds of adhering to prescribed behaviors, including taking medications, were 1.27 times higher if married when compared to people who were not married (DiMatteo, 2004). However, marriage is not consistently associated with greater medication adherence (Cummings et al., 1982; Gazmararian et al., 2006; Rich et al., 1996; Trivedi et al., 2008; Wu et al., 2012). One possible explanation for the variable association between marital status and adherence is that social support from a partner is not always effective, and may even backfire under some circumstances—particularly during stressful situations when partners may not be well equipped to provide effective support (e.g., in the emergency department [ED]). The present study tested whether daily adherence to cardiovascular medications differed depending on partner status and partner presence during a stressful experience: ED evaluation for an acute coronary syndrome (ACS).

Although social support from a spouse or partner is widely considered beneficial for health, this is not always the case. Recent studies show that some attempts at social support from a spouse or partner can instead have a negative impact (e.g., can lead the support recipient to do the opposite of what is asked, such as skipping medications, or to experience feelings of inadequacy) (Craddock et al., 2015; Rafaeli & Gleason, 2009). Much of the previous literature studying the association of social support with health behaviors has focused on chronic disease management in stable patients. In acutely stressful situations, including ED evaluation for an ACS, support may be particularly ineffective. Acute coronary events can be distressful and traumatic for partners (e.g., worry about loss of joint income, fears related to the partner almost dying) (Coyne & Smith, 1991; Dalteg et al., 2011; Mahrer-Imhof et al., 2007; Olsen et al., 2009; Rafaeli & Gleason, 2009; Trump & Mendenhall, 2017; Vilchinsky, 2017), which may undermine partners’ ability to provide effective support during these times. Indeed, we have shown that patients who arrive in the ED with close others (e.g., a partner) perceive increased threat from the ED experience surrounding their evaluation for ACS than patients who arrive alone or with non-close others (e.g., a neighbor) (Cornelius, Meli, et al., 2019). In addition, negative forms of social support in the ED (e.g., companions who make patients feel anxious) contribute to the development of posttraumatic stress symptoms secondary to the ACS (Homma et al., 2016). Partners are also more likely to provide negative forms of support than non-close others (Cornelius, Derby, et al., 2019). In sum, it is possible that not all “support” provided by partners—such as joining the patient in the ED—are, in fact, beneficial to patients’ emotional health. Accordingly, it is plausible that partners may also have an adverse effect on patient health behaviors, particularly in the context of recent stressful health situations. This hypothesis has not yet been tested.

Most previous studies of partners’ effects on patient outcomes have focused on psychological outcomes. Less research has explored the potential adverse impacts that partner presence might have during emergency health situations. This is a critical oversight, particularly when considering the effects of partner presence or negative forms of social support in the ED on patient distress (Cornelius, Derby, et al., 2019; Cornelius, Meli, et al., 2019). For example, it is possible that partners, distressed by the often chaotic and stressful ED environment, may also have difficulty recalling discharge instructions about medications or other behaviors. Suggestive of this dynamic (i.e., that partner support during ED encounters may not necessarily benefit patient health behaviors), we previously found no benefit of having a close other in the ED on patient perceptions of doctor-patient communication (Cornelius et al., 2018). Distressed partners may also be less effective in terms of providing practical support after the ED visit (e.g., picking up or organizing medications, providing medication reminders).

Given the mixed findings regarding the value of social support and partner presence in the ED during an accurately stressful events such as ACS, it is unclear whether partner status or presence might benefit—or perhaps harm—post-discharge health behaviors for patients that recently experienced an ACS. On one hand, partner-provided support could be beneficial for health behaviors (as suggested by research from primary care and oncology visits), despite any potentially negative impact on patient distress; on the other, it could be ineffective (or even detrimental) to patient mental health and health behaviors when provided in stress-inducing contexts. It is important that empirical research test these competing hypotheses.

To parse the aforementioned possibilities, the present study examined the association between partner status and partner presence in the ED in patients evaluated for an ACS with daily adherence to cardiovascular medication during the first month following hospital discharge. Because of the robust association of marriage with better health (Kiecolt-Glaser & Newton, 2001; Kiecolt-Glaser & Wilson, 2017; Robles & Kiecolt-Glaser, 2003) and our own research suggesting that the impact of partners in the ED is either null (Cornelius et al., 2018) or adverse (Cornelius, Derby, et al., 2019; Cornelius, Meli, et al., 2019), we tentatively hypothesized that day-to-day adherence to cardiovascular medications (known as implementation) (Vrijens et al., 2012) following ED evaluation for a suspected ACS would be highest for partnered patients who did not arrive in the ED with that spouse/partner, and lowest for those who arrived in the ED with a spouse/partner. We also explored effect modification by gender and age, as suggested by prior research (e.g., greater benefit of having a partner for men vs. women) (Kiecolt-Glaser & Newton, 2001; Kiecolt-Glaser & Wilson, 2017; Robles & Kiecolt-Glaser, 2003; Umberson, 1992).

Methods

The Reactions to Acute Care and Hospitalization (ReACH) observational cohort study examines the development and consequences of posttraumatic stress in patients evaluated for suspected ACS in the ED at an urban quaternary academic medical center (Birk et al., 2019). Participants for the present analysis were drawn from an ancillary study examining the impact of psychological and hospital environmental factors on medication adherence post-ACS. Research assistants identified potentially eligible patients using the electronic health record and approached them in the ED to confirm eligibility and gauge interest in participation. Participants interested in enrolling in the parent study completed informed consent and a brief interview in the ED. At discharge, patients enrolled in the ancillary medication adherence study were mailed an electronic bottle cap (eCAP). They were instructed to place one of their cardiovascular medications (preferentially aspirin if prescribed) in the eCAP bottle and to take this medication exclusively from the bottle for up to 6 months post-discharge. Participants were then provided stamped envelopes in which they would return the eCAP after completing the monitoring period. All study procedures were approved by the Columbia University Institutional Review Board.

Participants

Participants were English- and Spanish-speaking patients at least 18 years of age who presented to the ED with an admitting diagnosis of non-ST-elevation myocardial infarction (NSTEMI) or unstable angina (UA). Exclusion criteria for the parent study were: (1) terminal non-cardiovascular illness with life expectancy < 1 year; (2) severe mental illness; (3) significant cognitive impairment; (4) known active alcohol or substance use disorder; and (5) unavailability for follow-up. For the ancillary medication adherence study, additional exclusion criteria were: (6) not prescribed a cardiovascular medication at discharge; (7) unable to self-administer medications; and (8) concern that using the eCAP would disrupt their usual medication-taking behavior (e.g., patients who use only pillboxes).

Measures

The primary predictors of medication adherence were two dummy-coded variables: self-reported partner status and partner presence in the ED (no = 0; 1 = yes). These were structured such that any patient who reported a partner being present in the ED (dummy code = 1), they also had partner status coded as a 1.

Cardiovascular medication adherence was measured electronically using eCAP devices (Information Mediary Corp, Ottawa, Canada), which are electronic pill bottle caps that fit on standard pill bottles and record the date and time of each pill bottle opening. Participants were considered adherent on any given day if the eCAP was opened the same number of times as prescribed (i.e., correct dosing adherence). Thus, if a participant was prescribed aspirin once per day and the eCAP recorded one opening, they were considered “adherent” to their cardiovascular medication for that day. Adherence proximal to discharge (i.e., during the first month post-discharge) was of primary interest.

Covariates included demographic and medical characteristics. Participants self-reported gender and ethnicity, and age was recorded from patient medical charts. Medical characteristics extracted via chart review included ACS status (a board-certified cardiologist and a research nurse reviewed hospital records to determine whether the index event was a true ACS) and comorbidity, assessed using the Charlson comorbidity index, a weighted risk-score predicting one-year mortality based on the presence of 19 comorbid medical conditions (Charlson et al., 1994). These covariates were selected a priori based on their association with medication adherence and accompaniment in other studies, for consistency with the parent study planned analysis (Birk et al., 2019), and because accompanied patients are more likely to be sicker (captured by the Charlson comorbidity index), older, and female, compared to those who are not accompanied (Laidsaar-Powell et al., 2013; Wolff & Roter, 2011). In addition to these planned covariates, dosing frequency (i.e., number of times per day the monitored medication was prescribed) was also included. Whether the participant arrived in the ED alone was also included as a control variable (v., e.g., with a friend, neighbor, or other relative).

Data Analysis Strategy

In models assessing correlates of medication adherence, adherence data were modeled as total days adherent, accounting for number of days monitored (count/days; i.e., as a rate) using PROC GENMOD in SAS v. 9.4. In the first model, unadjusted effects of month since discharge and partner status and presence were entered as predictors of adherence to daily cardiovascular medications during the first month post-discharge. Next, covariates were added to the model. Finally, interactions were specified to test whether associations between the categorical partner presence variable and medication adherence differed by month, age, or gender.

Although we expected that partner presence in the ED would be most likely to impact those observations most proximal in time to the ED evaluation (i.e., the first month post-discharge), we additionally conducted sensitivity analyses examining adherence over the first two and three months post-discharge. Because this introduced interdependence due to multiple months observed for each individual, errors were specified as correlated using the REPEATED command and an unstructured matrix.

Results

Of the N = 189 participants, 184 also had adherence data in the second month post-discharge, and 135 in the third month. Mean age was 62.18 years (SD = 12.79), 57.1% were men, and 58.7% were Hispanic. Mean Charlson comorbidity score was 2.13 (SD = 1.91), and 40.74% had a confirmed ACS as the index event. Half (49.74%) had a spouse or partner, of whom approximately half (46.81%) had partners that were present in the ED.

The most common medication type used in the eCAP device was aspirin (62.43%). Nearly all participants had been instructed to take their medication once per day (90.48%), and mean adherence was 71.20% (SD = 32.15). Male participants were more likely to have a partner (present in the ED or not) than female participants. Table 1 presents demographic and medical characteristics overall and stratified by partner status and partner presence.

Table 1.

Demographics

Overall
(N = 189)		 No Partner
(n = 95)		 Partner Not
Present
(n = 50)		 Partner Present
(n = 44)
M (SD) or N (%) M (SD) or N (%) M (SD) or N (%) M (SD) or N (%) p-value
Age 62.18 (2.13) 61.44 (13.37) 61.48 (12.31) 64.56 (12.01) 0.37
Charlson 2.13 (1.91) 2.09 (1.89) 2.18 (1.86) 2.14 (2.06) 0.97
Male 108 (57.14%) 39 (41.05%) 38 (76.00%) 31 (70.45%) < 0.001
Hispanic 111 (58.73%) 56 (58.95%) 30 (60.00%) 25 (56.82%) 0.95
Confirmed ACS 77 (40.74%) 32 (33.68%) 23 (46.00%) 22 (50.00%) 0.13
Aspirin in eCAP 118 (62.43%) 59 (62.11%) 32 (64.00%) 27 (61.36%) 0.96
Dosing more than Once/Day 18 (9.52%) 10 (10.53%) 4 (8.00%) 4 (9.09%) 0.88
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Unadjusted Models

In the model including only partner status and partner presence, having a partner was not associated with daily adherence to cardiovascular medications in the first month post-hospital discharge compared to not having a partner, OR = 1.12, 95% CI 0.94, 1.33, p = .23. However, of those with a partner, if that partner was present in the ED, the odds of adherence were significantly lower (v. when that partner was not present), OR = 0.66, 95% CI 0.54, 0.80, p < .001.

Covariate-adjusted Models

After adjustment for covariates, having a partner was associated with increased odds of adherence to cardiovascular medications in the first month post-hospital discharge (v. not having a partner), OR = 1.25, 95% CI 1.04, 1.51, p = .019. For those with a partner, however, having a partner that was present in the ED remained associated with a significantly lower odds of adherence (v. when that partner was not present), OR = 0.61, 95% CI 0.48, 0.78, p < .001 (see Figure 1). Converting these odds to probabilities indicated that individuals with no partner had ~70% probability of adhering to medications each day (i.e., took medications as prescribed on ~4.9 of 7 days), those with a partner who was not present in the ED had ~74% probability of adhering (~5.2 of 7 days), and those with a partner who was present in the ED had ~64% probability of adhering (~4.5 of 7 days).

Figure 1.

Figure 1.

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Partner status and partner presence predicting odds of electronically monitored adherence to daily cardiovascular medication in the first month post-hospital discharge.

Note. Error bars represent 95% Confidence Intervals.

The impact of partner status and partner presence in the ED each differed by gender (interaction ps < .001). For female participants, having a partner was associated with lower odds of adherence (v. not having a partner), OR = 0.45, 95% CI 0.33, 0.61, p < .001, but, of those with a partner, partner presence in the ED was associated with higher odds of adherence (v. when that partner was not present), OR = 2.74, 95% CI 1.81, 4.17, p < .001. Conversely, for male participants, having a partner was associated with higher odds of adherence (v. not having a partner), OR = 1.94, 95% CI 1.53, 2.46, p < .001, and partner presence was associated with lower odds of adherence (v. when that partner was not present), OR = 0.33, 95% CI 0.25, 0.43, p < .001 (see Figure 2).

Figure 2.

Figure 2.

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Interaction between gender, partner status, and partner presence predicting odds of electronically monitored adherence to daily cardiovascular medication in the first month post-hospital discharge.

Note. Error bars represent 95% Confidence Intervals.

The impact of partner status and partner presence in the ED also differed by age (interaction ps < .001 and .058, respectively). For younger participants (−1 SD, 49.39 years old), having a partner was associated with higher odds of adherence (v. not having a partner), OR = 6.07, 95% CI 1.28, 28.80, p = .02, but having a partner present in the ED was not associated with adherence (v. when that partner was not present), p = .22. For older participants (+1 SD, 74.97 years old), having a partner was associated with lower odds of adherence (v. not having a partner), OR = 0.70, 95% CI 0.53, 0.91, p = .008, and having a partner present in the ED was associated with lower odds of adherence (v. when that partner was not present), OR = 0.52, 95% CI 0.39, 0.71, p < .001 (see Figure 3).

Figure 3.

Figure 3.

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Interaction between age, partner status, and partner presence predicting odds of electronically monitored adherence to daily cardiovascular medication in the first month post-hospital discharge.

Note. Error bars represent 95% Confidence Intervals.

Sensitivity Analyses

When including data for the first two months after hospital discharge in covariate-adjusted analysis, having a partner that was not present in the ED was associated with increased odds of adherence to cardiovascular medications (v. not having a partner), OR = 1.86, 95% CI 1.02, 3.36, p = .041, and having a partner present in the ED was associated with a marginally lower odds of adherence (v. when that partner was not present), OR = 0.47, 95% CI 0.21, 1.07, p = .073 (interactions of partner status and partner presence in the ED with month were not significant, ps = .27 and .87, respectively). When including three months of data, the effect of partner status on adherence remained robust, OR = 2.00, 95% CI 1.14, 3.50, p = .012, and, although the coefficient remained similar in magnitude, the impact of partner presence in the ED was no longer significant, OR = 0.55, 95% CI 0.25, 1.22, p = .14 (interactions with month were not significant, ps = .49 and .22, respectively).

Discussion

The current study tested the association of partner status and partner presence in the ED with adherence to daily cardiovascular medications during the first month post-discharge in a sample of 189 patients evaluated for suspected ACS. As hypothesized, and in line with research suggesting that having a spouse or partner is beneficial for health behaviors (DiMatteo, 2004) and cardiovascular health more broadly (Kiecolt-Glaser & Newton, 2001; Kiecolt-Glaser & Wilson, 2017; Robles & Kiecolt-Glaser, 2003), having a partner was associated with better medication adherence. If a partner was present in the ED, however, odds of adherence were lower than if a partner was not present in the ED. These effects were moderated by both gender and age, suggesting important sources of heterogeneity in the impact of social relationships on health.

Why might partner presence in the ED predict poorer day-to-day adherence to cardiovascular medication following discharge? Although we do not have the ability to examine couple-level dynamics within this study, it is possible that the often chaotic and stressful ED environment impaired partners’ ability to support their partner or increased their use of controlling behaviors, each of which could reduce later patient adherence. Indeed, patients who report that their support partner makes them anxious in the ED have higher levels of distress (Cornelius, Meli, et al., 2019), which could undermine adherence early post-hospital discharge. The time immediately following an ACS is already distressing for patients and partners alike, with substantial disruptions to roles within the couple and to daily routine (Dalteg et al., 2011; Goldsmith et al., 2006; Pretter et al., 2014; Stewart et al., 2000). If partners, too, experience additional distress due to the ED experience (Edmondson et al., 2013), they may have fewer psychological resources to support their partners. More broadly, marital distress—which could be compounded in the ED (e.g., stress contagion) (Gump & Kulik, 1997)—is associated with lower levels of adherence following ACS (DiMatteo, 2004). Distressed partners may also use more controlling tactics in an attempt to influence patients’ medication adherence behaviors post-discharge (e.g., criticizing missed medication days, bargaining). Critically, more controlling forms of influence are associated with lower levels of adherence to chronic disease self-management (Stephens et al., 2013; Stephens et al., 2010), as these techniques are often ineffective or can even lead to “backfiring” behaviors (e.g., doing the opposite of what is asked) (Craddock et al., 2015). Future studies should collect dyadic data to test these possible mechanisms, particularly given increasing focus on couple-targeted interventions to improve patient health (Helgeson et al., 2018; Lewis et al., 2006; Martire & Helgeson, 2017; Martire et al., 2010). For example, there may be ways to reduce anxiety and bolster positive forms of social support in partners who come to the ED with patients in order to improve patient adherence early post-discharge.

The impact of partner status and partner presence in the ED on adherence was moderated by patient gender and age. For women, having a partner was associated with lower adherence, but adherence was higher if that partner was present in the ED; the opposite was true for men (i.e., having a partner was associated with higher levels of adherence, but lower adherence if that partner was present). These differences may be due to gender role expectations of support and coping or to different partner behaviors in the ED. First, female partners may be more distressed by the ED experience than male partners. One study in cancer patients showed that female partners are as distressed as female patients, whereas male partners are less distressed than male patients (Hagedoorn et al., 2000). Female partners may also provide more emotion-focused support than men, who tend to use problem-focused coping techniques (Matud, 2004; Ptacek et al., 1992), and there is a trend for practical support to be more strongly associated with adherence than emotional support (DiMatteo, 2004). If female partners are distressed by the ED experience, then counter-productive emotion-focused support and coping techniques may predominate; conversely, if male partners turn to problem-focused strategies, then any benefit to patient adherence could be increased. Women are also more likely to try to influence their partner’s health behaviors than men (August & Sorkin, 2010), and—if distressed by the ED experience—might use more ineffective (i.e., controlling) techniques. Male partners may also be more likely to actively engage others in their recovery (Kristofferzon et al., 2003). Men whose partners are not present in the ED may enlist their partners in their recovery to an extent that is beneficial, whereas those who have a partner in the ED may have less control over partner involvement. These possibilities are highly speculative and should be explored in future research.

It is similarly unclear which processes may be in play when considering age-related differences. There was evidence that having a partner benefitted adherence for younger patients, and there was no detriment when the partner was present. Conversely, for older patients, there was a negative impact of a partner and of partner presence on adherence. Some research on martial quality over the life course suggests that negative aspects of partnerships have a negative health impact for older, but not younger, couples (Umberson et al., 2006). Finally, it is important to note that these effects seem to be the most pronounced when proximal in time to the ED experience. Although the positive main effect of partner status on adherence persisted when including observations two and three months post discharge, the association between partner presence in the ED and adherence became less reliable. This is not unexpected, given that partner status is an ostensible constant, but the effect of partner presence in the ED on adherence should be most pronounced in the days closest to this event. It is also important to note that the odds ratio for the association of partner presence with adherence remained of similar magnitude when examining one, two, and three months of data (0.61, 0.47, and 0.55, respectively) and fewer patients had adherence data at three months, so this result is somewhat inconclusive. Furthermore, even if this association may attenuate somewhat over time, medication adherence in the first month post-discharge is a critical determinant of patient prognosis (DiMatteo, 2004; Jackevicius et al., 2008).

There are a number of important limitations to this early-stage research examining the association between partner status, partner presence in the ED, and health behaviors. Results may not generalize to other populations, such as suburban or rural samples, or to other types of medical events (e.g., stroke) or medical encounters (e.g., primary care). It is also important to note that, even though all patients were evaluated for suspected ACS, not all patients had a confirmed ACS. Accordingly, we included ACS status as a covariate. Of note, our prior research shows that psychological distress does not differ between patients who rule in v. rule out for a ACS (Kronish et al., 2018). Similarly, it is possible that the perceived or actual severity of the medical event influences whether a partner is present in the ED, which could confound results. In addition, research on other medical encounters (e.g., primary care visits, cancer appointments) indicates that older and sicker patients are more likely to be accompanied (Laidsaar-Powell et al., 2013; Wolff & Roter, 2011). To guard against these possibilities, we adjusted for number of comorbidities, whether the patient had a confirmed ACS, and medication dosing frequency. We also did not find differences in Charlson comorbidity score or ACS status across the three groups (i.e., no partner, partner not present, partner present). Although the eCAP objectively measures the behavior of opening bottles, it is possible that medications were not actually ingested. eCAP also only measures adherence to one medication, and it is not clear whether this represents adherence to the full medication regimen. Furthermore, it is possible that the findings may have been influenced by residual confounding concerning unmeasured aspects of medication regimen complexity, although we did adjust for dosing frequency of the monitored medication. Future research should explore whether the effects observed in the present study are best accounted for by partner characteristics, patient characteristics, relationship characteristics, characteristics of the ED experience, or some combination of these factors. For example, it is possible that partners who attend participants’ ED visits are also more likely to engage in controlling behaviors related to other recommended health behaviors (e.g., diet, exercise, smoking cessation) irrespective of the acute cardiovascular event, such that the partner’s presence in the ED reflects qualities of the relationship more than being a causal factor in and of itself. Unfortunately, we did not assess these factors (e.g., relationship quality was not measured). Nevertheless, the apparently greater reliability of the effect of partner presence at more proximal times suggests that association between partner presence in the ED and adherence is more than just a relationship or partner characteristic. Future research should additionally explore the impact of partner presence and partner status on other types of adherence behaviors (e.g., initiation, persistence), and should consider the impact of other types of relationships (e.g., live-in companion, child) on medication-taking behavior.

Conclusion

The association between having a partner and adherence to medications is unclear, and disparate lines of work suggest potentially positive, null, or even detrimental effects of partner status on health behaviors. In the present study, results suggested a paradoxical effect of partners on medication adherence: for male patients, being in a relationship predicted greater adherence to cardiovascular medications in the first month post-hospital discharge following ED evaluation for a suspected ACS, but only if that partner was not present in the ED. Conversely, for female patients, partner presence in the ED was beneficial. Future studies should investigate potential mechanisms of these effects, including characteristics of the patient, partner, relationship, and ED environment, to inform ED policy, as well as couple-targeted intervention research to improve medication adherence.

Acknowledgments

Funding: This work was supported by National Heart, Lung, and Blood Institute (NHLBI) grants to Dr. Edmondson [grant numbers R01HL117832, R01HL128310] and Dr. Kronish [R01HL123368]. The content is solely the responsibility of the authors and does not necessarily represent the official view of the National Institutes of Health. The funding body had no role in the design of the study, collection and interpretation of data, or in writing this manuscript. The views expressed in this article are those of the authors and do not necessarily reflect the position or policy of the VA or the United States Government. The third author received support from a National Institute on Aging Training Grant [grant number T32-AG000029].

Footnotes

Ethical Adherence: All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards.

Procedures were approved by institutional review boards at Columbia University Medical Center.

Informed Consent: Informed consent was obtained from all individual participants included in the study.

Conflicts of Interest: The authors declare that they have no conflicts of interest.

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