Whenever a new drug is introduced, try to understand how it works before prescribing it to patients-Yousuf Hassan


 Proceedings of Cardiology Update Symposium organized by PIMS

Whenever a new drug is introduced,
try to understand how it works before
prescribing it to patients-Yousuf Hassan

CBI blockade reduces multiple cardio
metabolic risk factors - Prof. Javed Akram

BHURBAN: The first scientific session during the Cardiology Update Symposium organized by Pakistan Institute of Medical Sciences in collaboration with Pakistan Cardiac Society here at Bhurban from June 29th to July 1st was jointly chaired by Prof. Naeem Aslam, Prof. Saulat Siddique, Dr. Shaukat Malik, Prof. Javed Akram and Prof. Feroze Memon. Dr. Fazal was the moderator of the session.

 Dr. Yousuf Hassan was the first speaker who talked about Managing Heart Failure in 2018. He pointed out that studies had shown that Enalapril reduced mortality by 24-40% in congestive heart failure. Carvidolol also had a positive impact in mortality reduction but all beta blockers are not the same. Neprilysine inhibitors also reduce mortality and improve symptoms in heart failure.

Dr. Akhter Ali Bandeshah Convener Cardiology Update Symposium 2018 organized by PIMS
at Bhurban recently presenting a memento to Prof. Naeem Aslam President
Pakistan Cardiac Society at one of the Scientific Sessions.

Nesiritide Peptide was also tried in congestive heart failure but it did not show any mortality benefits. He was of the view that if mortality is higher than expected, we may be doing something wrong as it had 17% mortality as compared to the expected 14%. Patients in NYHA class four has the highest mortality which is above 40% without treatment but with treatment it is 24%. Nesiritide did not work as placebo group had a mortality of 19% as compared to the treated group which had 17%. Treatment, he further stated, is more effective in seriously sick patients. He advised the participants that whenever a new drug is introduced, try to understand how it works before you start prescribing it to the patients. ARBs should not be used as first line drugs in heart failure.

Prof. Javed Akram talked about Pathogenic Pathways of Cardio Metabolic Syndrome. This, he said, starts with insulin resistance and after the age of seventy years we all develop insulin resistance. We see an epidemic of PCOs in young girls. Milk may have some role in it and we are currently looking at it. He then described how the endocannulinoid system works. CBI blockade reduces multiple cardio metabolic risk factors. Hypertension comes with many other baggage, he added.

Dr. Shahbaz Kureshi highlighted the evolving role of ARBs beyond hypertension. He opined that MRFIT study had shown the problems associated with Office Blood Pressure measurement. ABPM is the best. He also referred to the JNC-8 blood pressure classifications and said that 120/80 is now considered normal BP. Blood Pressure of 120-139 Systolic and 80-89 DBP is known as pre hypertension stage. One drug is often not adequate to control blood pressure and one needs at least two to three drugs to control BP. Combination of low dose of all drugs is preferred. Other measures which help include life style modification, low sodium consumption, low fat, and physical activity at least forty five minutes a day. Beta Blockers, ACEIs, Diuretics, ARBs, CCBs, BBs are all effective. He however, opined that one should avoid combination of ARBs with ACEIs. All drugs used should have at least twenty four hours effect. In HOPE study 30% patients reported side effect of cough. Ramipril reduces the risk of cardiovascular events in broad sections of high risk patients. The use of ACEIs is limited due to intolerance.

Dr. Jalaluddin Achakzai discussed the role of ARNIs in management of heart failure. This, he said, is a combination of Sacubitril and Valsartan. It is reported to result in 20% relative risk reduction besides 16% all-cause mortality reduction. With the use of this combination there is significant reduction in hospitalization. There is a consensus between United States and Europe in their Guidelines on management of Heart Failure. It is class one recommendation. ARNI improve heart failure symptoms.

Prof. Masood spoke about the role of MRAs in Heart Failure. RALES study trial, he said, showed mortality benefits with 25mg.There was a significant advantage in the treatment arm. There was 30% risk reduction in overall mortality and 35% reduction in repeat hospitalization, hence it became a cornerstone of therapy.

Dr.Amir Hameed’s presentation was on Systemic Arterial Hypertension. He pointed out that we have seen that the blood pressure pre clinic check up by nurses is wrong. There was a difference of 20mmHg in blood pressure taken by the nurses and physicians in office. Clinical values were wrong and in the developed world in such cases 40% of patients might go to litigation. 30% have wrong blood pressure in clinics. It increases cost of treatment and un-necessary treatment. There is 80% chance of wrong reading with one measurement. It is advisable to take post clinic blood pressure after fifteen to twenty minutes. He suggested that let us re-think about the blood pressure measurement strategies. He laid emphasis on cost effective treatment and opined that ABPM has the best reading.

Dr. Bilal Mohyuddin spoke about Hypertension emergencies. It was stated that as per ACOG a BP measurement of 160/110 during pregnancy is an emergency. Do not use ARBs or ACEIs. There should be no crisis situation, there is no need for hospitalization. Gradually reduce the blood pressure within 24-48 hours. He laid stress on CME for health providers and careful appropriate use of rapid IV medications.

Brig. Azmat Hayat’s presentation was on implantable cardiac devices which cannot be manually removed. In United States there is 60% exploration due to infections. He then discussed the management of device removal. The patient suffers from chronic pain. Fibrozed devices will not come out easily. At times it cannot be taken out. He also demonstrated the Lead Explant simple procedure in detail.

Prof. Naeem Aslam highlighted the challenges in preventive cardiology. World Heart Federation, he stated, opines that one can prevent 80% deaths from heart diseases but the reasons for high mortality are failure to control blood pressure and the GPs, patients do not follow the guidelines. In Pakistan almost all the state of the art cardiac care institutions, have no preventive programme. No attention is paid to secondary prevention but all emphasis is on primary PCI. Prevention, he said, is the key but we have lack of awareness, lack of political will. We must tell patients to improve their physical activity. Media as well as the services of religious leaders can be used to impart health education to the public, he added.

Brig. Qaiser Khan made his presentation on pharmacological management of ischemic heart disease in an era of cardiac interventions. He asked is there anything more than symptom relief? At times stable plaques do more harm. He then discussed the management of these patients based on risk stratification. PCI in stable CAD, he said, can do more harm. It only provides symptoms relief with no survival benefits.

Prof. Saulat Siddique discussed Update on treatment of hypertension and referred to JNC-1 Guidelines in 1977 and compared it with JNC-8 Guidelines and PHL guidelines. JNC-1, he remarked, had stated that a blood pressure of 160-95 should not be treated. Late Dr. Maqbool H. Jafary and Dr. Aamir Hameed has done lot of work on preparing the PHL Guidelines. Home blood pressure monitoring, he opined, was the way to go. ABPM is not patient friendly and it has its own limitations. PHL, he said, has recommended a target of 150/90 BP for elderly people. First target is 140/90 and the second target should be 130/80. Aspirin should be prescribed to high risk CVD patients and not everyone. During first trimester of pregnancy, anxiolytics should be preferred as first line of therapy.

Prof. Masood Sadiq discussed pregnancy and congenital heart disease. He stated that they see congenital heart diseases in 5-8% of the population. It can be corrected but not controlled. Almost 85% of CHD babies born now survive to adulthood, he said. Congenital heart disease is increasing. He also discussed the maternal cardiac lesions and the risk of ASD. Some diseases need management of large left to right shunt for mild, moderate to severe pulmonary stenosis. He also referred to CHD fetus recurrence. He suggested pre-conception counselling about maternal and fetal risk. He then mentioned about the importance of evaluation of cardiac states, care during pregnancy, peri partum care. The treating physician must sit with female, talk to Paediatric cardiologist and gynecologist as to what is going to happen to the mother. When pregnancy is contra indicated, tell the parents of those girls. ACEIs and statins are safe to give in pregnancy but make sure to involve the whole family in treatment plan. Do talk to the in-laws of the girls as well. In case of symptoms of decompensation, fetal echocardiography is a must at 14-16 weeks of gestation. Most of the time one goes for vaginal delivery and there is no need of cesarean section. ARBs, ACEIs are contra indicated in heart failure in pregnancy. In case of ASD many patients can go through the pregnancy. They can go for repair of VSD after pregnancy. In case of untreated Tetralogy of Fallout, do not let the patient become pregnant. Correct TOF first and then they can go for pregnancy.

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