Heart Team should examine every patient before recommending for interventional procedures or CABG-Maj. Gen. Sohail Aziz

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 CARDIOCON 2018 Proceedings

Heart Team should examine every patient
before recommending for interventional
procedures or CABG- Maj. Gen. Sohail Aziz

Now patients with CAD are managed better, they
live longer with the result that the heart failure
patients are increasing-Prof. Shahbaz Kureshi

MULTAN: The first scientific session during the CARDIOCON 2018 held at Nishtar Medical University from November 23-25th 2018 was moderated by Dr. Bilal S.Mohydin from PIC Lahore. Dr. Azfar Zaman was the first speaker who talked about mechanical support for high risk PCI: How good is the evidence. He pointed out there is consensus on using it in selected patients.

Maj. Gen. Sohail Aziz from AFIC Rawalpindi discussed distal bifurcation left main stem stenting-different techniques. He opined that one must opt for tailor made treatment for every patient. It is essential that the heart team examines every patient and the surgeons should also bring their patient to the heart team as we the cardiologist do. Do not confuse the patient. Physicians and surgeons should interact with each other. If people do not want surgery, we can avoid it. We must know what physicians and surgeons are able to do. No treatment is forever. He then discussed in detail the crush technique, mini crush, DK crush. In some cases ten to twelve balloons may be needed for DK. Hence, be careful, he remarked.

Maj. Gen. Nuri from Tahir Heart Institute was the next speaker who talked about two simple intervention techniques in challenging PCIs. He then presented his experience with mitra clip and also discussed results of mitral FR. For heart failure first medical treatment should be tried and then mitra clip should be given a chance. This new technique can be used effectively in heart failure patients. It is particularly useful in those patient who refuse surgery. We have to consider all options available. Responding to a question Gen. Nuri said that this clip costs about fifty lac rupees. Cost is very high and it is also imaging dependent. One needs to perform at least ten to twelve procedures to learn this. Usually it requires about twenty procedures to train someone, he added.

Dr. Fawad Farooq from NICVD spoke about managing ACS in emergency room- a case based approach. He also discussed ACS algorithm. History is the main guide and CT Angio is a good test, he remarked.

Hypertension Session

The next session was devoted to management of hypertension which was moderated by Dr. Kashif Ali Hashmi. Prof. Ishaq was the first speaker who opined that blood pressure of less than 120/80 is considered ideal but a BP of more than 130/80 is hypertension. He then quoted Dr. Ian who had once said that Life of Heart is knowledge and Death of Heart is ignorance.

Prof. Fasih Hashmi in his presentation on when to refer patient with hypertension for hospital based care said that timely referral will save the patient from organ damage. He then spoke about emergency care and urgency in care. A BP of more than 220/120 is urgency. Acute ischemic stroke with target organ damage is an emergency. It is always advisable to opt for gradual reduction in blood pressure, he added.

Prof. Saulat Siddique from Lahore gave a comparison of Hypertension Guidelines prepared by Pakistan Hypertension League and European Society of Hypertension. It was unfortunate that very few have read the guidelines prepared by Pakistan Hypertension League which, he stated, are very informative and useful in managing high blood pressure.

Prof. Amir Hamid Khan discussed how to diagnose hypertension in 2018. The numbers are constantly changing. Dr. Bilal Mohydin spoke about management of resistant hypertension. He emphasized the importance of using proper dose of drugs and it was also important for the patients to do regular exercise to lose weight. During the discussion the importance of proper blood pressure measurement, making sure that the BP apparatus is calibrated and taking more than three BP measurements at rest on different occasions was emphasized before a patient is labelled hypertensive and subjected to lifelong treatment.

In another session Prof. Hafeezullah Khan from Peshawar discussed how to Publish and not Perish. His advice was to be careful while choosing a topic, prepare well, be concise and be precise. Carefully read instructions for authors of the journal to which you wish to submit your manuscript. Follow the IMRAD formula. Text should be concise, specific and informative. Remember most people read abstract hence it must give the whole information and contain the message you wish to convey to the readers.

Explain in detail when, where and how the study was conducted. Study design, sample size, sampling techniques, interventions, data collection and interpretation, analysis, study outcome were also discussed in detail. Conclusions should be based on study findings and it must have a message, he added.

Prof. Azfar’s presentation was on Ticagrelor in Acute Coronary Syndrome. He opined that in acute conditions it is very good as it has quick effect. It leads to reduction in MI and stroke. It can be used in dual antiplatelet therapy and 60g BID can be continued for six to twelve months. If there is no bleeding in the first year, one can continue DAPT. When added to Aspirin it is very effective in all cases of ACS, he added.

Dr. Javed Iqbal discussed why most of the papers get rejected by the journal editors and highlighted some of the reasons which results in such a decision. Prof.Azhar Farooqui spoke about cardiology in Pakistan and gave a historical background to studies done in Mayo Hospital, formation of Pakistan Cardiac Society by late Col.M.H. Shah and his colleagues. Prof. Abid Amin Khan’s presentation was on AOACS in Valvular Atrial Fibrillation.

Heart Failure Therapy

Prof. Shahbaz Kureshi from Islamabad made a presentation on State of the Art in Heart Failure Therapy. He discussed the usefulness of sodium restriction, safety and efficacy of digitalis, diuretics, Ace Inhibitors, Beta Blockers. It was in the Year 2000 that the device era started with the availability of ICDs followed by CRTs and LVAD. During the last thirty years heart failure management has made tremendous progress, he added. Now patients with CAD are managed better, they live longer with the result that the heart failure patients are increasing. While on one hand coronary disease has reduced, heart failure has increased. He then discussed in detail the therapy of heart failure with reduced ejection fraction. Heart failure he further stated is a member of the diseases which leads to heart failure. Hence it is important to know when to go to war and for this one has to understand the enemy. Our problem is that we do not know the enemy.

Continuing Prof.Shahbaz Kureshi said that neuro humeral activation has gone wrong. Dose of ACE Inhibitors, ARBs for managing heart failure has to be appropriate. It is advisable to start with a small dose and then gradually increase it to a level which the patient can tolerate. The golden principle is start low, go slow and aim high. Use of ACEIs may result in angioedema, cough and hyperkalemia are the other side effects. Studies have shown that Metaprolol reduce mortality in heart failure. He then described how Aldosterone Antagonists work in heart failure. He also shared the results of Valsartan-Sacubitril trial. He also discussed the contraindications for the use of this combination, its titration and necessary precautions. It is essential to discontinue ACE Inhibitors at least thirty six hours before the start of this Valsartan-Sacubitril combination. Do not combine it with ACEIs or ARBs. Do not use this drug in sleep apnea and diabetics. Diuretics are recommended in congested patients to alleviate the signs and symptoms, Prof. Shahbaz Kureshi concluded.

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