Low Dose Aspirin is currently cornerstone of antithrombotic component for secondary prevention of CVD-Prof. Ejaz Ahmad Vohra


 Seminar on Medical Uses of Aspirin

Low Dose Aspirin is currently cornerstone
of antithrombotic component for secondary
prevention of CVD-Prof. Ejaz Ahmad Vohra

Aspirin, BP Control, Cholesterol management and smoking cessation
figure prominently in Million Hearts Programme of USA-Prof. Samad

IHD cannot be prevented but we can reduce
atherothrombotic events with Aspirin - Fawad Farooq

KARACHI: Low dose aspirin is currently the cornerstone of the antithrombotic component of secondary prevention of cardiovascular diseases.  New research studies underway are investigating the best way to use aspirin as well as new approaches for antithrombotic therapy for secondary prevention. This was stated by Prof. Ejaz Ahmad Vohra, an eminent physician from Ziauddin Medical University. He was speaking on Aspirin in the 21st Century highlighting its safety and efficacy in a wide range of medical disorders from cardiovascular diseases to stroke, diabetes, cancer prevention, in pregnancy and HIV. The seminar was organized by Pakistan Aspirin Foundation as a part of its CME programme on May 10th 2016. It was chaired by Prof.Abdul Samad another eminent cardiologist of the country. Dr. Fawad Farooq Assistant Prof. from NICVD was the other speaker who talked about Aspirin in secondary prevention of IHD. The members of the expert’s panel included Prof. Mansoor Ahmad from KIHD, Prof. Zaman Sheikh from SSIMS, and Prof. Wasim Akhtar from Abbasi Shaheed Hospital KMDC, Karachi.

In his presentation Prof. Ejaz Ahmad Vohra discussed in detail the role of aspirin beyond Cox-inhibition, its adverse effects, economics of Aspirin use, and its established uses for the treatment of Acute Coronary Syndrome besides benefits of Aspirin maintenance therapy during the first year.He also highlighted efficacy of aspirin in prevention of recurrent stroke. Referring to various studies Prof. Ejaz Ahmad Vohra opined that more data is needed on primary prevention in people at high risk of cardiovascular diseases. US Task Force on Preventive Services has recently recommended theuse of Aspirin for primary prevention of cardiovascular diseases and colorectal cancer as a preventive medication in those who are at high risk and have no risk of bleeding. 

 Prof. Abdus Samad chairing the seminar on Medial Uses of Aspirin organized by Pakistan Aspirin Foundation at Karachi on May 10th. Also sitting on the dais from (L to R) are Dr. Wasim Akhtar, Prof. Mansoor Ahmad, 
Prof. Zaman Sheikh, Prof. Ejaz Ahmad Vohra (speaker) and Dr. Fawad Farooq the other speaker.

Speaking about the use of Aspirin in Neurology, Prof. Ejaz Vohra said that most common use of Aspirin is in acute stroke, acute TIA and minor stroke. Studies have confirmed that it reduces the early recurrence of second stroke by 30-40%. Various Guidelines have recommended Aspirin for acute Ischaemic strokes. However, it may be noted that there could be an increased risk of intracereberal haemorrhage, hence one needs to balance risk against its benefits, he added. Continuing he further stated that effects of aspirin in TIA and minor stroke are probably larger and more beneficial than in higher risk events. Combination of Aspirin and clopidogril is more effective in preventing stroke after TIA compared to aspirin alone. However, it is highly effective for secondary prevention of TIA and Minor strokes when given alone.

For long term prevention of stroke, aspirin monotherapy was an option. Initial benefits of aspirin are maintained while other antiplatelet drugs like clopidogril are also effective and combination therapy is recommended for prevention of stroke. Various trials has shown safety and efficacy of aspirin long term use in primary prevention of stroke. Its effects in cerebral aneurysm, migraine, depression and cerebral tumors are being investigated. In acute chest pain, it is advised to use aspirin formulation with faster onset of action like soluble aspirin. Long term use of NSAIDS, Prof. Ejaz Ahmad Vohra stated is well known to increase the risk of serious GI events such as perforation, ulcer and bleed. Speaking aboutthe use of Aspirin in diabetes, he said that ADA, AHA and American College of Cardiology Foundation have provided additional information for the use of aspirin in diabetes. In their joint statement they have said that aspirin in low dose is reasonable for adults suffering from diabetes who are at increased risk of cardiovascular diseases, with no previous history of CVD and who are not at increased risk of bleeding. Aspirin is also recommended for those who have intermediate risk of developing cardiovascular disease. The recommended dose of Aspirin is between 75-162mg daily.

Long term use of low dose Aspirin has alsodemonstrated reduction in cancer incidence and mortality with aspirin in colorectal cancer, esophageal cancer, gastric cancer, lung cancer, prostate cancer and breast cancer. Now there is increasing evidence that aspirin has anticancer effect possibly mediated through platelets. With the every passing day, there is an increase in emerging indication for the use of aspirin and now short term effects of Aspirin in people with HIV have also been reported. It is said that low dose aspirin may have a therapeutic role in alternating immune activation and inflammation. Aspirin is also a drug of choice in prevention of Pre-eclampsia, he added.

Dr. Fawad Farooq in his presentation described three case histories of patients and how lipid deposition, inflammation and thrombosis takes place. Discussing the process of thrombus formation Dr. Fawad Farooq said that itstarts with endothelial damage or plaque rupture which is followed by adhesion, activation and aggregation of platelets which eventuallytriggers clotting mechanism.  The various antiplatelet agents available include Aspirin, P2Y12inhibitors like Ticlopidines, Clopidogril, Prasugrel, Ticagrilor, Dipyridamole, Cilostazol, GP 11b IIIa inhibitors. He pointed out that we cannot prevent IHD which is an atherosclerosis process which starts much early in adult life but we can reduce the atherothrombotic events with the use of Aspirin.

Group photograph taken at the seminar on Medical Uses of Aspirin held at Karachi on May 10th shows
from (L to R) Mr. Farhan, Shaukat Ali Jawaid, Dr. Waseem Akhtar, Prof.Mansoor Ahmad, Prof. Zaman
Sheikh, Prof. Abdus Samad, Prof. Ejaz Ahmad Vohra, Mr. Akhtar and Mr. Kashif Riaz
from Atco Laboratories sponsors of  the meeting.

Aspirin can be used 75-162 mg daily in case of known cardiovascular diseases or NSTE-Acute coronary syndrome, following PCI oras Fibrinolytic therapy for a STEMI. Its clinical uses include secondary prevention of stableIHD, NSTEMI/Unstable Angina, STEMI as well as Peri-PCI procedures like stenting.

Various guidelines suggest that in acute coronary syndrome dual antiplatelet therapy can be used for a year. Then clopidogril can be stopped while one can continue with low dose aspirin therapy. He concluded his presentation by stating that atherosclerosis is a process which starts very early in life. Atherothrombosis leads to major vascular events at any stage of atherosclerotic process. Platelets play a key role in atherothrombotic process to prevent events.

During the discussion Prof. Zaman Sheikh pointed out that during Ramzan one should take Aspirin after Iftar while all other anti-diabetic medications including insulin dosage will have to be adjusted accordingly after consultation with the treating physician. Prof. Wasim Akhtar opined that since the prevalence of diabetes and hypertension is very high in Pakistan, it is advisable to use low dose aspirin therapy which has shown to reduce morbidity and mortality in various diseases significantly. Prof. Mansoor Ahmad opined that use of Aspirin in ACS, in acute myocardial infarction and prevention of stroke have all been adequately highlighted by the speakers. One of the participants said that one of the gastroenterologist told him that he was seeing more cases of gastric ulcer and 30% of them were related to use of Aspirin. At this Prof. Abdus Samad remarked that anecdotal evidence has no value in the present era of evidence based medicine. All these things have got to be documented and reported. He further stated that we in Indo-Pakistan use lot of spicy foods and if a study is conducted to find out gastric ulcer among those who are taking low dose aspirin and those who are not, it is quite likely that those not on aspirin therapy will have more gastric ulcer. Hence we need to change our dietary habits, life style modificationis extremely important in prevention of cardiovascular diseases, diabetes and numerous other diseases. Mr. Shaukat Ali Jawaid General Secretary of Pakistan Aspirin Foundation remarked that they had looked at all the data related to Aspirin until 2014 before finalizing the Guidelines. All the recommendations in this document are properly referenced. He further stated that we are extremely grateful to Atco Laboratories who are sponsoring our CME activities for the last many years but keeping up the professional ethics, we do not patronize any company or promote any particular brand name of Aspirin. It was up to the physicians to use whichever aspirin preparation they want to use.

Summing up the discussion Prof. Abdus Samad referred to the Million Hearts Programme of United States of America. Adopting the preventive strategy which consists of life style modification, use of drugs, interventions, surgery and genetic intervention, they wish to save millions of heart attacks by 2025. This programme lays special emphasis on ABCS which stands for use of Aspirin when appropriate, Blood Pressure Control, Cholesterol Management and Smoking Cessation. US Preventive Services Task Force has also recommended initiation of low dose aspirin therapy in individuals over the age of fifty years with moderate risk. Those who have a relative risk of developing cardiovascular disease of more than 10% must be put on low dose aspirin therapy. However, in elderly over the age of seventy years there was not sufficient evidence. Since in Pakistan life expectancy is ten years less, hence we in Pakistan recommend the use of Aspirin therapy in individuals over the age of forty years who are at risk of developing cardiovascular disease. Speaking in a lighter vein Prof. Samad remarked that it is not difficult to remember 10% in Pakistan. We should be happy as we have only seen PANAMA leaks, had there been PAJAMA leaks, it would have proved to be a far serious situation, he remarked.