ACE Inhibitors improve survival, reduce second heart attack and DM complications- Dr. Basheer Haneef


 PHL Annual Symposium at Hyderabad
ACE Inhibitors improve survival, reduce
second heart attack and DM
complications - Dr. Basheer Haneef
ARBs have shown significant reduction in morbidity
and mortality - Dr. Shahbaz Kureshi

HYDERABAD: Hypertension is a preventable disease and one third of world mortality is due to cardiovascular diseases. In Pakistan prevalence of hypertension is 12.2% among children between 5-14 years of age while overall prevalence of hypertension is about 18% in adult population. About 25% of women in Asia are obese. This was stated by Prof. M. Ishaq President of Pakistan Hypertension League while speaking on Hypertension- a preventable disease in the first scientific session of the 16th annual symposium of PHL held here from February 8-10th 2013.
Prof. Ishaq highlighted the importance of early detection, control and preventive measures for all the common chronic illnesses. Prof. Waris Qidwai from AKU in his presentation on complications of anti-hypertensives at community physicians level pointed out that blood pressure control is important. Now effective anti-hypertensive drugs are available but patients must take drugs regularly. Often there is problem with compliance with therapy. Usually it is seen that only 50% of the hypertension patients are taking drugs and only 50% of them are under control. He stressed the importance of health awareness programmes at community level.

Prof. S.M. Rab former President CPSP along with Prof.M. Ishaq and
Prof. Feroze Memon chairing one of the sessions during
PHL annual symposium.

Dr. Abdul Rauf Sheikh from Hyderabad talked about water therapy to reduce hypertension.Dr. Ismail from Islamabad spoke on molecular and genetic analysis of hyper homocysteinemia with hypertension. He pointed out that there are more than ten thousand genetic disorders of which hypertension is one of them. He then spoke about gene therapy and presented work related to GNB3.
Dr. Basheer Haneef from Taba Heart Institute discussed blood pressure variability: a new paradigm for the management of hypertension. He pointed out that there are several factors responsible for this variability which includes behavioural and emotional factors. Short term and long term variability is related to cardiovascular damage, increased mortality. Long term variability is related to high mortalty and target organ damage. There are implications for treatment; hence one should avoid those drugs which increase blood pressure variability.

Prof. Hafeez Chaudhry along with Prof. Mansoor Ahmad and
Prof. Feroze Memon chairing one of the sessions during the
PHL annual symposium at Hyderabad.

Dr. Aysha Almas from AKU spoke about association of depression and anxiety with uncontrolled hypertension at two tertiary care centers in Karachi. She pointed out that it is a seriousproblem which is seen much more common in Urdu speaking and Pathan population which have more uncontrolled hypertension. Smoking and no formal education were seen as other important risk factors, she added. Prof. Khan Shah Zaman Khan Executive Director NICVD talked about renal denervation in resistant hypertension.

Ms. Mehtab Akbar Raashdi was the chief guest at the Pakistan Hypertension
League annual symposium held at Hyderabad. Picture shows her presenting
a mementoe to Dr. Fazalur Rehman Memon. Also seen in the picture from
(L to R) are Prof. Hafeez Chaudhry, Prof. Feroze Memon and Prof.M. Ishaq.

Beta Blockers- a viable option in Hypertension

The next session was devoted to debate on Beta Blockers: Still a viable option for hypertension. Speaking on the topic Dr. Syed Imran Ahmad from Ziauddin University said that the goal of treatment is to reduce blood pressure by whatever means it is possible. One should opt for the most cost effective method as hypertension control will help reduce premature cardiovascular disease morbidity and mortality.Tracing the history he said that the first beta blocker was introduced in 1948 and Propranolol was introduced in 1963. Then we had the first generation, second generation and third generation beta blockers followed by cardio selective beta blockers. It is NICE guidelines which has demoted beta blockers while JNC VII guidelines report 38% reduction in heart failure with blood pressure control using beta blockers. NICE guidelines regarding beta blockers were atenolol related. Safety and efficacy of beta blockers in heart failure has been very well documented. New beta blockers also reduce the risk of stroke by 25%. In any patient with any cardiac condition, beta blockers are the first line of drug even as per European Society of Cardiology, he added.
Prof. Khawar Kazmi from AKU in his response said that hypertension is not the only cardiac condition. He discussed the mode of action of beta blockers and pointed out that in heart failure, beta blockers are no problem. Beta blockers have been in the market for the last three decades but they have had no impact on morbidity and mortality. Beta blockers do reduce blood pressure but there is more new onset of diabetes with beta blockers hence they are causing harm. New beta blockers may have a role in hypertension. When patients have hypertension with complication use beta blockers but before they develop any cardiac condition. Dr. Syed Imran Ahmad remarked that hypertension is a risk factor for heart failure.
Prof. Azhar MA Farooqui saidthat beta blockers are a useful group of drugs. New beta blockers still have no long term morbidity and mortality data. In heart failure, there is no question beta blockers are good drugs to use. In early primary myocardial infarction, they are necessary group of medications. However, he cautioned the participants that do not get carried away by improvised data presented by the Pharma industry. Prof. S.H.Shafqat remarked that beta blockers do not produce impotence. Dr. Abu Bakar Sheikh opined that hypertension is a multifactorial disease and it is not desirable to exclude any group of drugs.
Prof. Azhar M.A. Farooqui along with Prof, Saulat Siddique from Sheikh Zayed Hospital Lahore chaired the next session. Dr. Wajiha Inam from Cardiff UK was the first speaker who talked about NICEguidelines in the management of primary hypertension in adults. In UK we have elderly population and incidence of stroke is quite high. She emphasized the importance of measuring blood pressure in both the arms and the use of right cuff size besides assessing target organ damage.

Convincing data about ACE Inhibitors and ARBs

It was followed by a debate on usefulness and efficacy of ACE Inhibitors vs. ARBs. Dr. Basheer Haneef from Taba Heart Institute in his presentation said that ACE Inhibitors improve survival and they are the fourth largest prescribed drug which reduces second heart attack as well as diabetes mellitus. They also reduce diabetes mellitus complications. They are indicated in early complications. ACE Inhibitors also reduce post MI mortality. ARBs should be used only if ACE Inhibitors are not tolerated. ACE Inhibitors reduce LVH they are also useful in hypertension patients with chronic kidney disease. ARBs have no evidence that they are better than ACE Inhibitors in any condition. There are many studies which show that ACE Inhibitors reduce morbidity and mortality. Both ACEIs and ARBs are well tolerated. One has to monitor patients in both the cases. Some studies show that ARBs may increase the risk of cancer. One can continue ACE Inhibitors indefinitely. Do not prescribe ARBs routinely. Many trials have showed that ARBs are much less effective than ACE Inhibitors, he remarked.
Dr. Shahbaz Kureshi from Islamabad in his response said that in cardiovascular prevention the choice is ARBs since complications is a major problem. ACE Inhibitors are effective in primary and secondary prevention. ARBs data is also convincing. ARBs have also shown significant reduction in morbidity and mortality.
In the next session Dr. Sultana Habib talked about hypertension in special conditions while Prof. Zaman Sheikh discussed cardiovascularrisk and microalbumnuria prevalence inType2 diabetes mellitus patients’ in OPD setting and presented highlights from the CAMPAIGN study. This study included fifteen hundred patients and lasted for three months. About 55.6% of patients had microalbumnuria. The risk factors included total cholesterol and uncontrolled high blood pressure which are both preventable. ACE Inhibitors were the first drugs used, CCBs were the second and ARBs were the fourth drug used. Type2 diabetes mellitus, he said has increased risk of cardiovascular diseases. Cut off values for blood pressure in diabetics should be 130/80 and 125/75 in those patients’ who are suffering from hypertension but also have developed complications.
Prof. Saulat Siddique from Lahore discussed how to manage incidental hypertension while Prof. S.H. Shafqat in his talk opined that diabetes and hypertension were manifestations of affluence since we are working against nature. He advised adopting simple life style, using natural healthy diet, good sleep and avoiding all sort of stresses to live normal healthy life. Prof. Amber Malik from Shaikh Zayed Hospital Lahore discussed case series of Takayasu disease in hypertension. It is seen in young people particularly women and was an uncommon disease. It is of uncertain origin, signs and symptoms include arthralgia, malaise, weight loss, headache, visual disturbances and fever. She then discussed the management of a few cases.

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