All Acute Coronary Syndrome patients should be put on Dual Antiplatelet Therapy

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 An Update on Management of ACS

All Acute Coronary Syndrome patients
should be put on Dual Antiplatelet Therapy

They should be discharged on beta blockers, ACEIs, high dose Statin
and then adjust the dosage, do risk stratification-Dr. Atique Azam Mirza

KARACHI: All Acute Coronary Syndrome patients should be put on dual anti-platelet therapy. They should be discharged on beta blockers, Ace Inhibitors, high dose of Statins and then adjust their dosage besides doing risk stratification. This was stated by Dr. Atique Azam Mirza, Consultant Cardiologist and former President, Association of Pakistani Descent Cardiologists of North America (APCNA). He was making a presentation on An Update on Management of Acute Coronary Syndrome at a series of meetings held at Karachi, Lahore and Rawalpindi-Islamabad. These meetings were organized by PharmEvo as a part of their Continuing Medical Education programme for the healthcare professionals to build up their professional capacity. These meetings were very well attended by cardiologists and physicians. During his visit to Pakistan, Dr. Atique also participated in the CARDIO CON 2016 organized by Pakistan Cardiac Society at Faisalabad from November 25-27, 2016 and made numerous presentations in various sessions.


Dr. Atique Azam Mirza the Guest Speaker photographed along with Prof. Abdus Samad, Prof. M. Ishaq, Dr. Javed,
Prof. Mashoor Alam Shah, Dr. Abu Bakar Sheikh, Dr. Masood Jawaid, Syed Jamshed Ahmad COO PharmEvo
and some other senior executives of PharmEvo at the symposium organized at Karachi on November 23, 2016.

The meeting at Karachi on November 23, 2016 was chaired by Prof. Abdus Samad a well-known interventional cardiologists while members of the experts panel included Prof. Syed Nadeem Rizvi from NICVD, Prof. M. Ishaq from KIHD and Dr. Javed Majid Tai from AKU.

Speaking about the disease burden of Cardiovascular diseases, Dr. Atique Azam Mirza said that almost 17.1 Million deaths from cardiovascular diseases occur globally every year and 80% of them are in low and middle income countries. Most of these deaths are preventable with life style modification and risk stratification.  Almost 30-40% of deaths in Pakistan are due to cardiovascular diseases. According to reports almost 33% of people over the age of forty five years suffer from hypertension and 25% of people over the age forty five years have diabetes.  WE have about 14-21% smokers. There are 250/100,000 strokes and every year 3, 50,000 new cases of stroke are reported.


Prof. Nadeem Hayat Malik along with Prof. Zubair Akram, Brig. Afsar Raza,
Col. Imtiaz chairing the symposium at Lahore.

Speaking about the modifiable risk factors which can be controlled, he mentioned smoking, hypertension, dyslipidemias, diabetes and pre diabetes, over weight and obesity, physical inactivity, stress and behaviour, unhealthy diet and use of alcohol. ACS has a broad spectrum of clinical presentations covering STEMI, angina without evidence of myocardial infarction. MI occurs when the blood supply to the heart muscle is interrupted due to partial or complete occlusion or thrombosis of coronary artery with the result that some of the heart muscles get infracted. MI can be confirmed on ECG. He then also talked about signs and symptoms of ACS presentation in detail.

His presentation was mainly based on the American College of Cardiology/American Heart Association 2016 Guidelines on dual antiplatelet therapy in ACS. Acute coronary syndrome, Dr. Atique Azam Mirza stated starts with endothelial dysfunction leading to atherosclerosis, Ischaemic heart disease, angina pectoris, coronary thrombus, myocardial infarction, loss of muscle. Plaque rupture is the main reason. Atherosclerosis is a progressive disease which starts early in life. To begin with it is clinically silent then results in silent angina.  For managing ACS it is important to do proper assessment, risk and benefit assessment in view of the risk of bleeding due to dual antiplatelet therapy. Dual antiplatelet therapy should consist of Aspirin and Clopidogril. In patients with prior history of TIA or stroke, be careful and avoid prasugal. After stenting, patients should be put on dual antiplatelet therapy with Aspirin 75-100mg and Clopidogril and continue it for at least twelve months after stenting. In CABG, continue antiplatelet therapy for one to six months as it will improve the vein graft patency.


Maj. Gen. Hamid Shafique along with Dr. Saeedullah Shah, Prof. Iqbal Saifullah
and Dr. Syed Mumtaz Ali Shah chairing the symposium held at Islamabad.

In stable Ischaemic Heart Disease clopidogril should be continued at least for one month. After Drug Eluting Stents, dual antiplatelet therapy should be continued for at least six months. It is advisable to continue Aspirin 75mg for lifelong in case of stable IHD and DES stenting. Non-cardiac surgery should be delayed for at least thirty days after BMS implantation. Non-cardiac surgery should be avoided unless there is a life and death situation. After three to six months, one should weigh the risk and benefit ration but after six months one can undertake non-cardiac surgery. There is strong evidence that Aspirin is extremely useful in secondary prevention of Acute MI, CVA, and Post MI.  Aspirin is highly beneficial in cardiovascular diseases. Studies have shown that high dose of Aspirin does not improve efficacy, hence one should continue with 75-100mg of Aspirin.

Dual antiplatelet therapy is most efficacious in NSTE and ACS. It produces greater benefits when used for more than one year were shown in the CREDO trial. He further stated that lower the LDL, the better. High dose of Statin is also better. However, he cautioned that Statins does cause memory deficit and insipideous diabetes. Compliance is linked with dosage and in case of once daily dosing, the compliance is much better. That is why combinations are used but non-compliance could prove costly. Dr. Atique Azam Mirza concluded his presentation by laying emphasis on preventive medicine saying that it is doable but it has no incentives. He also disclosed that the honorarium he has received from PharmEvo for making these presentations in Pakistan will be used for Pace Makers Bank established by Association of Pakistani Cardiologists of North America and so far we have provided six hundred pace makers, he added.


Dr. Atique Azam Mirza photographed along; with the Chairman and Members of the Expert Panel and some 
senior Executives of PharmEvo at the symposium on Management of ACS held at Islamabad recently.

Participating in the discussion Prof. M. Ishaq said that we should stick to our own Guidelines which give details about what to do after intervention, in case of Drug Eluting Stents and BMS implantation. While using dual antiplatelet therapy, it is important to closely monitor the risk of bleeding. Summing up the presentation Prof. Abdus Samad thanked the guest speaker Dr. Atique Azam Mirza stating that presenting Guidelines with too much repetition in various conditions is not an easy task but the speaker has done exceptionally well covering the whole spectrum of how and for how long one should use  dual antiplatelet therapy (DAPT) in acute coronary syndromes, duration of DAPT in patients with ACS treated with PCI, in patients undergoing CABG, in patients with stable IHD, Stable Ischaemic Heart Disease, in patients with STEMI  treated with  Fibrinolytic Therapy besides non-cardiac surgery after BMS, DES implantation and CABG. We have much younger patients as compared to the developed world. We have more clot than atheroma. Hence treatment of clot is very important as it leads to acute events. He also advised checking the hemoglobin level of patients on antiplatelet therapy regularly in view of the risk of bleeding.

Meetings at Lahore and Islamabad

According to another report, the meeting at Lahore was chaired by Prof. Nadeem Hayat Malik while the panel of experts included Prof. Zubair Akram, Brig. Afsar Raza and Col. Imtiaz. Maj. Gen. Hamid Shafique chaired the meeting held at Islamabad. Here the panelists included Dr. Saeedullah Shah, Prof. Iqbal Saifullah and Dr.Syed Mumtaz Ali Shah. Presentation by the guest speaker Dr. Atique Azam Mirza was followed by lively discussion. Earlier Dr. Masood Jawaid Director Medical Affairs at PharmEvo in his welcome address as all the places first highlighted the academic activities of Clinician established by PharmEvo, achievements and accomplishments of Health RAB another entity established by PharmEvo to promote research culture, setting up of Learning Resource Centers and Clinical Research Cells at various medical institutions to provide help, guidance and assistance to young researchers besides speaking about other initiatives taken by PharmEvo as Corporate Social Responsibility. He also introduced the Guest Speaker Dr, Atique Azam Mirza.