For secondary prevention of heart disease take Aspirin for life, for primary prevention weigh benefit vs. risks-Prof. Shahbaz Kureshi


 Aspirin Session at Cardiology Update Symposium by PIMS

For secondary prevention of heart disease take
Aspirin for life, for primary prevention weigh
benefit vs. risks - Prof. Shahbaz Kureshi

While prescribing Aspirin, do not think about single disease
and life time risk calculation should be preferred-Prof. Samad

We cannot prevent CAD or IHD but we can
prevent the events-Dr. Fawad Farooq

BHURBAN: Pakistan Aspirin Foundation organized a scientific session on July 1st 2018 during the Cardiology Update Symposium organized by Pakistan Institute of Medical Sciences, held here from June 29th to July 1st 2018. This academic activity was a part of the CME programme being continued by PAF to educate the healthcare professionals about the use of Low Dose Aspirin therapy in its well established indications. This session was jointly chaired by eminent cardiologists of the country which included Prof. Abdus Samad from Karachi, Prof. Shahryar Sheikh from Lahore, Dr. Shaukat Malik from Islamabad, Prof. Naeem Aslam President of Pakistan Cardiac Society from Faisalabad and Prof. Feroze Memon from Hyderabad. Prof. Shahbaz Kureshi another noted cardiologist from Islamabad and Dr. Fawad Farooq from NICVD Karachi were the guest speakers during the session which was well attended by cardiologists participating in the Cardiology Update symposium. This session was moderated by Dr. Asad Riaz Kitchlew.

Prof. Shahbaz Kureshi 

Prof. Shahbaz Kureshi in his presentation on Aspirin for Life concluded that for secondary prevention of heart disease, one should take Aspirin for life but for primary prevention one has to weigh the benefit vs. risk. We can use low dose aspirin therapy in high ischemic risk patients and Proton Pump Inhibitors (PPIs) can be combined to oversee the risk of adverse reactions. Aspirin, he further stated, is not only very economically priced anti-platelet agent but it is also safe, effective and continues to show us wonders as a lifesaving drug.

Aspirin, Dr. Shahbaz Kureshi stated was used four hundred years ago as an analgesic for treatment of fever in 1897. It was in 1967 that its antiplatelet properties were discovered. It has effects on many vessels not only coronaries. It is also known that almost 25% of CAD patients have disease in other arterial arteries as well. He then discussed in detail the platelet activation, aggregation, benefits of Aspirin in cardiovascular diseases saying that now we have robust data. There is no doubt about its safety and efficacy in secondary prevention after previous MI, Acute MI, prior Stroke and TIAs. The dosage of Aspirin 75-325mg is used in various conditions. Low dose of 75-100mg which is usually used in cardiovascular diseases is quite safe, there is less chance of GI bleeding. Even at present there are numerous trials being conducted in which Aspirin is being used in a dose of 75, 81 and 325mg daily. In one of the trials related to ACP Receptor antagonists (clopidogrel), it was shown that re-hospitalization with these drugs reduced better as compared to Aspirin. However, the use of Aspirin in a dose of 75-100mg has to be continued indefinitely but if it is contra indicated, one can use Clopidogrel.

Prof. Abdus Samad

In the Physicians Health Study which enrolled 22071 physicians, Aspirin 325mg was used on alternate days and this resulted in 45% reduction in Myocardial Infarction. Bleeding risk requires individualized assessment. This risk may vary from patient to patient. In the Women Health Study group, low dose Aspirin therapy for primary prevention, the results were not very impressive but there was some definite benefit in stroke in elderly women sixty years of age and above. Over forty thousand healthy women participated in this study which showed that use of Aspirin did lower the risk of stroke.

Continuing Dr. Shahbaz Kureshi said that American Diabetic Association recommends low dose 75-162mg daily for secondary prevention in diabetes and those with history of ASCVD. The same dose can be considered for primary prevention in Type-1 and Type-2 diabetes as it is a risk factor for cardiovascular diseases along with hypertension, smoking and dyslipidemias. However, in case of low risk of cardiovascular disease, one should not use Aspirin. Diabetes is a risk factor and in men, the risk of MI is reduced significantly with the use of low dose Aspirin but one has to be careful about the GI symptoms. One can also use PPIs to control the adverse effects of Aspirin. Use of low dose Aspirin is recommended in high risk profile patients. Referring to the COMPASS study which enrolled 27,000 patients, Dr. Shahbaz Kureshi said that it showed reduction in GI cancer and colorectal cancer in particular. He also referred to the Aspirin resistance which is reported to be 1-2% but in some cases the patients may not be taking Aspirin, hence one has to check with the compliance and then there are some non-responders to any drug as, he added.

Aspirin in Primary Prevention of CAD

Dr. Fawad Farooq from NICV Karachi talked about the use of Aspirin in primary prevention of cardiovascular diseases and pointed out that we cannot prevent CAD or IHD but we can prevent the events and reduce athero-thrombosis. Aspirin does help in preventing events. Treatment strategy has to take into account the future plan. We need to see in which patient’s one can use Aspirin for primary prevention of coronary artery disease. He also discussed the rationale for using antiplatelet.

Dr. Shaukat Malik

Continuing Dr. Fawad Farooq said that one has to assess the cardiovascular risk and bleeding while deciding which patients should be put on Aspirin therapy as one can have thrombosis at any time. He then showed the adhesions, activation and aggregation of platelets, thrombus formation which is followed by ischemic stroke. Compliance with Aspirin therapy, he reiterated was very important. In high risk population use of Aspirin therapy has more benefits but do not use it if there is a risk of bleeding even in low risk patients. He also referred to the risk calculation which is quite easy which takes into account multiple risk factors like sex, age, race, HDL, Cholesterol, systolic blood pressure, treatment of high blood pressure, diabetes mellitus, smoking etc. If ten years relative risk is less than 3% do not use Aspirin but if it is between 7.5 to 10%, put these patients on low dose Aspirin therapy. However, in case of moderate risk, discuss with the patient. Low HDL is also a risk factor. Identifying and treating significant risk factor was not enough to reduce the risk but continuous risk assessment is recommended, he remarked.

During the discussion it was pointed out that all young people are smokes hence should all of them be put on low dose Aspirin Therapy? Prof. Samad responded by stating that for smoking and primary prevention we need evidence. Replying to yet another question it was stated that all patients with diabetes are high risk patients hence they are candidates for Aspirin therapy. In diabetics with low risk, calculate the risk and then make a decision. For prevention of stroke combination of Aspirin and Clopidogrel is recommended. All neurologists use dual antiplatelet therapy for secondary prevention of stroke. It was also pointed out that for the use of Dual Antiplatelet Therapy, there are scientific indications. After the age of eighty years, do not use Aspirin as bleeding risk is very high. Similarity do not use combination of DAPT in these patients as well. Risk profile, Prof. Shahryar Sheikh remarked takes care of the age. For secondary prevention of CAD Yes one can use Aspirin but for primary prevention, only use it in high risk cases. Male have a high risk since they go out, suffer from more stress and strains of all sort as compared to the female. Counselling of the patient is therefore important.

Prof. Shahryar Sheikh

Dr. Shaukat Malik laid emphasis on educating the patient and insist upon them to take Aspirin regularly, do not stop it. GPs also needs to be educated. Gastroenterologists are afraid of using Aspirin but one can use it at the right time.

Summing up the discussion Prof. Abdus Samad stated that for prevention one has to make individual strategy and population based strategy. When patient comes to your clinic he or she has some problem. It is only a very small population which come to consult the doctors, hence for overall prevention, we have to chalk out a population based strategy. Risk calculation is a professional strategy. He further stated that one should never take things lightly. Do not think of single disease. Aspirin is used for many disorders. If a pregnant women comes to you, you have to take care of her as well as her baby. Take careful history and during physical examination, be careful if the patient’s colour is looking white or fair, there could be some bleeding and the patient may be suffering from anaemia due to repeated blood loss. He concluded his remarks by commending the organizers of the session for keeping up the professional ethics as no drug or company banner was on display in the meeting hall where as in the main meeting hall, there were drug banners all around which should not be there. At this Dr. Akhtar Ali Bandeshah Convener of the symposium who was present among the audience stated that they have noted it and in future, take care of such issues.

Earlier Mr. Shaukat Ali Jawaid General Secretary of Pakistan Aspirin Foundation welcomed the participants, the guest speakers and the Panel of Experts and thanked them for gracing the occasion with their presence. We in Pakistan Aspirin Foundation from its very inception, he stated, have always upheld the professional ethics. We are extremely grateful to M/s Atco Laboratories and Mr. Kashif Riaz their Business Unit Head for sponsoring these CME meetings and other academic activities for the last many years but we do not patronize and promote any particular company or brand name of Aspirin, he remarked.

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