Instead of going for high dose of a particular Statin, it is advisable to add another drug-Prof. Feroze Memon


 PHL 21st Annual Symposium

Instead of going for high dose of a particular
Statin, it is advisable to add another
drug - Prof. Feroze Memon

Hyper sitting syndrome is fast tracking
to graveyard - Prof. Ahmad Bilal

FAISALABAD: The second scientific session during the Pakistan Hypertension League’s 21st annual symposium on February 24th was jointly chaired by Prof. Naeem Aslam, Khalida Soomro, Abid Amin and Prof. Saulat Siddique. Dr. Abdur Rauf was the first speaker who talked about the use of salt. He pointed out that the processed food contains 77% of salt and our most salt intake is from processed food. One should avoid it. Increased use of salt increases mortality from cardiovascular diseases. Decrease in salt consumption will also decrease mortality from CVD. The children in particular should be advised to avoid junk food, he added.

Dr. Jalaluddin from Quetta talked about Pre-diabetes and dyslipidemias, estimation of the risks and therapeutic response. All pre-diabetics, he said, are likely to develop hypertension and diabetes. World Heart Federation has planned to reduce mortality from cardiovascular diseases by 25%. About 5-10% of diabetics become diabetic every year. Very few of them get Metformin as pre diabetics. Statins, he suggested, should be started early as it is the standard of care for dyslipidemias.

Dr. Shahbaz Sarwar highlighted tips in acute management of high blood pressure in patients with acute coronary syndrome. He said that it was important to go slow while reducing the blood pressure but do not abruptly lower the blood pressure. Beta blockers are quite safe and effective but if they fail to lower blood pressure, add calcium channel blockers. Loop diuretics should be preferred over thiazide. Dr. Kashif Hashmi discussed prevention and regression of end organ damage in pre-hypertension. It is relevant to nephrologists too. It is a great challenge to prevent organ damage for which one has to achieve the target blood pressure, he remarked.

Dr. Shahbaz Kureshi’s presentation on “I am intolerant to Statins: What do the guidelines say” was based on some case studies. He pointed out that the best documented treatment for cardiovascular diseases was with Statins and it shows the benefits of therapy. Poor compliance, low dose, moderate dose and non-adherence to Statin therapy have its own consequences. With the use of Statins, there is not much muscle pain and cramps. Unfortunately these days there is a campaign against Statins on the Net. Statins are generally well tolerated. Prof. Feroze Memon in his presentation highlighted that 10% reduction in cholesterol will lead to 50% reduction in mortality from heart diseases. He then gave details of IDEAL study conducted in thirteen centers in Pakistan using Ezitinibe and Atovastatin. There were two hundred forty patients of which 29 refused to participate hence they were excluded. The remaining 211 patients included 85 which were very high risk cases. There were no side effects of therapy. His conclusions were that instead of going for high dose of a particular Statin, it is advisable to add another drug.

Dr. Atif Khan gave details of a Hypertension prevalence survey which included 23,695 patients screened at various camps all over the country in urban and peripheral urban areas. The patients were between the ages of 18-70 years. About 66.7% were male and the rest female. The overall prevalence of hypertension in male was 45.3% and 43% in females. It also included newly diagnosed and pre-hypertension cases. The survey showed that the prevalence of hypertension was increasing. It was emphasized to organize counseling sessions for patients suffering from hypertension and ensure that their blood pressure is checked regularly. Doctor patient relationship also needs improvement.

Dr. Abbas Raza in his presentation on Cardiovascular effects of Antidiabetic Drugs said that there are about 1.8 million articles published annually of which 50% are read by authors and editors or reviewers only. Diabetes and cardiovascular diseases has close relationship. Treatment does reduce complications but does not prevent heart attacks. More than 20% of patients have diabetes and one third of them have coronary stenosis. He also referred to genetic predictors and said that Sitaglipton was no more dangerous than placebo. Glargin does not have a better outcome. New anti-diabetic medications reduce cardiovascular diseases risk and they show results. Referring to the LEADER trial he said that GLP-I results in 20% reduction in death due to cardiovascular diseases and there was 15% reduction in all-cause mortality. We now have anti diabetics which protect the heart. Liraglutide reduces weight, reduces blood pressure and it was now available in Pakistan. It stabilizes plaque in heart, reduces the size of infarct. All GLP-I, he further stated have variable effects.

Prof. Saulat Siddique discussed the latest guidelines in hypertension patents with reduced Ejection Fraction. He suggested cutting down on fat. One of the studies which involved 7358 patients between the ages of 18-69 years showed that there was 52% reduction in heart failure, 38% reduction in fatal and non-fatal stroke. On the whole hypertension usually remains under treated. ACE Inhibitors should be the first choice followed by ARBs. As regards beta blockers, only selected ones should be used and all guidelines recommend that diuretics should always be added. He laid emphasis that we must prevent hypertension particularly the systolic high blood pressure. Prof.Tariq Waseem talked about obesity paradox. High BMI, he said, is a risk factor for many diseases.

Prof. Abdus Samad talked about strategies to boost blood pressure control. He stated that cholesterol, hypertension and diabetes were the main culprits for cardiovascular diseases. Sleepless nights, stressful days, atherosclerosis, sedentary life style, sugars, saturated fats, smoking is all very dangerous. Drug therapy for hypertension should include diuretics, beta blockers and low dose aspirin to begin with. Outcome is not good with polypill. It is seen that people with high income have more risk factors but less mortality but people with low income have high mortality. Patients might start taking poly pill to reduce high risk of coronary artery disease and stroke but we need better evidence as polypill was not ZAMZAM, Prof. Samad remarked.

Prof. Naeem Aslam spoke about diastolic heart failure and hypertensive heart disease. In such patients, sudden death, he stated, was most common. In most of the treatment guidelines there is no drug with proven benefits. Prof. Ahmed Bilal talked about Hyper sitting syndrome which is fast tracking to graveyard. He highlighted the beneficial effects of daily exercise and pointed out that one must take six thousand steps daily and ten thousand steps daily prevents heart attack. If the daily steps taken are more than eleven thousand, it further reduces the mortality. He also talked about metabolic obesity, weight reduction, avoiding exercise with full stomach. With daily exercise, more than two hundred genes are negatively affected. Lack of exercise, he opined, was the routine cause of chronic diseases.

Prof. Altaf Qadir discussed occupational stress and hypertension. He particularly highlighted the job related stress among doctors. They have more responsibilities and they think more about their job. He suggested planning time management. We usually do not treat stress until it becomes a serious disorder. SSRIs and SNRIs are quite useful in treatment of stress disorders. One must avoid benzodiazepines because of their dependency. He advocated relaxation exercises, improved time management, improving self-coping capabilities and strategies. Deep breathing, medications, music and self-talk are highly effective. One should develop some game plan, write down daily schedule, and plan your life, give time to yourself, your family and children. Identify negative thinking and spirits. Improve self-esteem and confidence. He also discussed human relationship on disease, effect of human relationship o heart diseases. If there is social community in the town, there will be no heart disease which was shown by RESETO story – an anatomy of Health.

Dr. Saima Dastgir highlighted the benefits of low blood pressure as it slows the heart rate and decrease emotional anger and frustration. Prof. Shabeen Naz Masood talked about Cardiac Remodeling in Gestational Hypertension and fetal outcome. She pointed out that small for date birth is associated with increased perinatal mortality. She advised that we must take care of the mother to take care of the future generations. Dr.Amir Hameed spoke about evolving role of ACEIs in hypertension and said that in case of too much salt intake, it won’t work but if diuretics are added, it will work better. ACE Inhibitors role in heart failure and atherosclerotic vascular diseases was also highlighted.

Prof. Haroon Babar in his presentation highlighted the evidence in favour of beta blockers and pointed out that Nebivolol is a different beta blocker and with its treatment, there is much better outcome in hypertension. It improves LV dysfunction, improves survival after MI, and lowers the risk of cardiovascular disease events. It can be safely used in pulmonary arterial hypertension.

During the discussion it was pointed out that ACE Inhibitors has a long history, they were compared against placebo but ARBs were compared with ACEIs. Judiciary and fighter pilots are known to be under too much stress. Time management offers lot of benefits. Psychiatrists are not taking Cognitive Behaviour Therapy seriously because they are more interested in prescribing drugs. Prayers offer lot of muscle relaxation. Blood pressure needs to be broken in different segments. Dr.Amar Hameed remarked that ACE Inhibitors are much cheaper. Prof. Hafeez Chaudhry remarked that it was very difficult to match the standards set by my predecessors but while organizing this symposium we all worked as a team. Hypertension is an increasing problem. Almost 52% of our population suffers and we need to make efforts to prevent high blood pressure and avoid known risk factors.

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