Survivors of myocardial infarction are at risk of recurrent events and have an annual death rate of 5%. Advances in treatment and, in particular, the interventional management of myocardial infarction have seen important mortality gains over recent decades, yet cardiovascular diseases remain the biggest killer in many European countries. Change in lifestyle and adherence to medication to prevent further events are key to the recurrence of future events following myocardial infarction, but adherence to medication for the secondary prevention of cardiovascular disease is a profound problem. This article outlines a growing evidence base about the complex nature of adherence as a psychological phenomenon that is influenced by the nature of the event itself, illness perception and factors related to medication beliefs that cannot be addressed simply through a combination of educational approaches. A whole-systems approach is advocated, starting with the education of health professionals to understand the psychology of adherence, and to react comfortably to patients decisions about medication, with a pivotal role for follow-up in secondary care and cardiac rehabilitation.