Clinical Proceedings of Pakistan Hypertension League 18th annual symposium


Clinical Proceedings of Pakistan
Hypertension League 18th annual symposium

RAWALPINDI: The formal inauguration of 18th annual symposium of Pakistan Hypertension League, on August 14th, was followed by a number of interesting presentations by various speakers. Prof.Shahbaz Kureshi talked about resistant hypertension.  He pointed out that these are poorly controlled hypertensive patients due to suboptimal therapy. He emphasized the importance of ensuring optimal drug therapy. These patients also suffer from obstructive sleep apnea. Ambulatory blood pressure monitoring is suggested for patients suffering from resistant hypertension.  If they are well controlled, less number of patients will then require interventional procedures. He also laid emphasis on life style modifications.

Prof. Saeed Ahmad Sangi from SMBBMU Larkana talked about DASH Diet Plan. The objective, he said, should always be control of blood pressure which can be achieved by taking care of the known risk factors including weight loss, salt reduction. If the diet contains low magnesium, it will increase blood pressure, he added.

Prof. Abdus Samad from Karachi spoke about hypertension and heart failure. He pointed out that LVH patients will develop heart failure. He referred to the four cities study which they had conducted many years ago which enrolled 2,256 patients between 51-60 years of age. It showed that 30-39% of them did suffer from heart failure.  Thiazide diuretics are better in heart failure while beta blockers and alpha blockers are not recommended in these patients. Use of ARBs and ACE Inhibitors reduce mortality.

Col. Amjad from AFIC pointed out that stenting does reduce blood pressure and it becomes easier to control blood pressure. Patients with coarction of aorta, he said, should be put on 150mg of
Aspirin daily. Dr. Masood Ahmad from Lahore spoke about endovascular management of renovascular hypertension. Brig. Sohail Aziz spoke abut atrial fibrillation which is most common after stroke. With proper follow up this needs to be protected.

Maj. Gen. M.H.Nuri discussed renal artery stenosis and described the management of twelve cases during the last five years. This included five diabetics and seven non-diabetics. Renal artery stenting was successful in all the cases.  This is one of the sub-specialties which one can take up.  Four of our patients, he said complained of abdominal pain, one had excessive bleeding and one patient complained of nausea and vomiting.

On second day of the conference, Prof.M. Ishaq was the first speaker who gave an overview of Hypertension and dedicated this lecture to late Dr.Maqool H.Jafary. He discussed at length awareness, diagnosis, overall risk assessment, treatment and control. Hypertension, he said, was more common in Pakistan in Urban areas than rural areas. It is estimated that about 12.2% of children also suffer from hypertension. Salt reduction, he opined, can reduce the prevalence of hypertension.
With the rise in blood pressure, cardiovascular mortality also increases. Life style modification, control of diabetes, hypertension is important. Lack of physician’s education and motivation is another issue. His plea to the physicians was to adhere to the guidelines on control and treatment of hypertension.

Dr. Sajid Ahmad spoke about risk factors for hypertensive urgency in Pakistan. This study included 52 patients of which 77% were male and 60% were obese. Compliance with drug therapy was less than 40% and 20% were vegetarian.  Non compliance with therapy, he opined, was very high. These people also suffer from stress. Dr. Azizur Rehman’s presentation was on isolated systolic hypertension. ISH, he felt, is more likely to be untreated. ISH and untreated hypertension is very high in elderly. It is not easy to convince asymptomatic patients that they need treatment. One of the studies has reported 42% reduction in stroke and 52% reduction in vascular dementia if treated properly.  All drugs are effective but CCBs and diuretics should be preferred in elderly.  Patients should be advised to adhere to treatment.  Majority of the elderly suffer from isolated systolic hypertension. Myocardial infarction, stroke, chronic kidney disease is very high in these patients. For these patients thiazides and Amlodipine should be preferred.

Participating in the discussion Prof.Shahbaz Kureshi said that most of the elderly are already taking NSAIDs hence it is difficult to control hypertension in these patients. Summing up the presentations Dr. Shaukat Malik remarked that proper diagnosis should be made before naming any one to be suffering from hypertension and then giving him a life sentence since treatment for hypertension has to be life long. Preventon should be given due importance. Large family size was another risk factor for hypertension.

In the second session Prof. Shahbaz Kureshi in his presentation pointed out that ARBs were not inferior to ACE Inhibitors. We cannot compare old drugs with new drugs in a trial comparison. ARBs were not tested in the same population.ACE Inhibitors have shown their effects. They are safe and effective though ARBs are slightly better. Prof. Abdus Samad participating in the debate said that Capoten was the first drug in this class and we were part of the seven country study which showed that it was very effective. Used along with a small dose of diuretics, it was very effective. However, it was advised that pregnant women should not be given this drug because of the likely risk of congenital malformations. The current trend is for use of ACE Inhibitors but ARBs are preferred due to cough though they can also produce cough. Ladies of child bearing age should avoid ARBs and ACE Inhibitors.  Patients with MI and heart failure should be put on long acting ACE Inhibitors since cough is much less. He further opined that ACE Inhibitors and ARBs should not be combined.  Spirolactone should not be added in patients who suffer from diabetes. Those patients, who complain of persistent cough, do not prescribe ACE Inhibitors but those who have rare cough can be put on ACE Inhibitors.

Dr. Abu Bakar in his presentation asked is definition of hypertension still relevant. Most patients, he said, have co morbidities and they do not suffer from hypertension alone. We need to define goals for co-morbid. High blood pressure is a multifactorial disease. We should focus on treatment and we should convince our patients to achieve the targeted blood pressure goal.

In the third session Prof. Khalida Soomro in her presentation stated that dietary sugar could also increase blood pressure, hence it can be a risk factor for hypertension. We use diet every day which contains lot of sugar. It leads to obesity and other problems. Sugar has calories but no nutrition, she remarked. The next speaker talked about ethnic differences in hypertension management and poor compliance. Life style modifications are often ignored; rapid change in medications was yet another issue. Speaking about Hypertension and Kidney Prof. Mansoor Ahmad said that when urinary output goes up, blood pressure also goes up. He discussed in detail pressure diuresis, renal hypertension. Diabetes mellitus, he said, was the major cause of chronic kidney disease followed by hypertension. CKD is also a cause of secondary hypertension. In CKD patients first prescribe ACE Inhibitors but if they cannot tolerate it, then go for ARBs, The target blood pressure in these patients should be 130/80 and all efforts should be made to achieve that.

Dr. Faraz Farooq Memon in his presentation said that Blood Pressure should be checked after three to five minutes rest and one should always take two readings. Check BP in both arms and take the higher figures. He also discussed treatment strategies in nephro pathology and said that do not use ACE Inhibitors and ARBs together. Treatment of resistant hypertension was also discussed. Prof. Ejaz Ahmad Vohra in his concluding remarks said that small group discussions are much better. We need to invite psychiatrists, ENT surgeons and orthopaedic surgeons to such meetings as well. ABPM is recommended by NICE guidelines before starting treatment.

In the next session Dr.A.Rashid Khan from Karachi in his presentation discussed how to improve compliance in hypertension patients. Those patients suffering from hypertension will later develop diabetes as well. They are 2.5% more likely to develop diabetes in five years. Hypertension leads to stroke, heart failure, myocardial infarction, end stage renal disease and retinopathy. Home BP measurement can help in control of blood pressure. He laid emphasis on comprehensive diagnosis and reducing the need for medications. He also emphasized on diet modification, exercise, compliance with hypertension medications making a deal with the patient through health education.

Dr.Abu Bakar Sheikh discussed hypertension and atrial fibrillation.  AF, he said, increases the risk of heart failure and it also increases hospitalization by 23%.  AF is now spreading. RAAS blockade helps in reversal and in remodeling. Increasing age and uncontrolled hypertension is also a risk. Dr. Jawaid Akbar Sial presented a study which included one hundred  five patients. This study was done at Larkana. This included 49 known hypertensive’s with uncontrolled blood pressure. Prevalence of hypertension in the area, he said, was quite high. Awareness is lacking. Control of blood pressure is poor despite treatment.

Dr. S.A.Raza Kazmi made a presentation on Epigenetic and hypertension- the emerging challenges. Referring to the use of Statins, he said, now more and more molecules are being developed. Many new anti cancer drugs are also being studied. Studies have shown that DD genotype of ACE gene is higher in metabolic syndrome patients.  Dr. Farooq Fawad talked about Diet and Exercise- a big waste of time. His advice was that one should keep a balance between diet intake and exercise. It is advisable to find a balance between food and physical activity. Dr. Nusrat Ara Majid speaking on History to hyperlipidemia said that Statins are helpful in reducing blood pressure. Dr. Imran Saeed talked about smoking trend in medical students. It was pointed out that Sheesha smoke was increasing rapidly. Apart from smoking, psychotropics were also being used by the students. He laid emphasis on a multidisciplinary approach to quit smoking through education.

Prof. Jamal Zafar from PIMS Islamabad gave an update in management of diabetes mellitus. Age, body weight, complications and disease duration, he said, were all very important.  Metformin is the first line drug but one must aim at individualization of therapy for people with diabetes. He also referred to Self Monitoring of Blood Glucose Guidelines which provides lot of useful information. Prof. Ali Jawa also from PIMS highlighted the standard care as advocated by the International Diabetes Federation.  He referred to reduced care, limited care and comprehensive care in detail. He opined that we should aim at providing evidence based care which requires lot of resources. In limited care, he referred to screening camps, laboratory tests, annual surveillance, and education to the patient. It is team which makes assessment with the use of low cost technology. He also talked about psychological care, signs of cognitive emotional behavioral social problems, life style management, training of nurses, paramedics who can talk to the patients which will reduce your emergency intake. Introduce physical activity, use less expensive insulin preparations. He also talked about eye screening, use of ACE inhibitors, protein urea and foot care. Look for nerve damage in these patients.  Now we have the facilities and we can do everything for these patients in Pakistan, he remarked.

Dr.Abid Ameen from Quetta spoke about chronic kidney disease. He discussed in detail heart failure, treatment of LVH, stroke and said that cardiovascular disease demand aggressive therapy. We should aim at 130/80 blood pressure and   120-135/79 with protein urea.

In his concluding remarks Prof. Samad said that as regards life style modification, it is difficult to ask patient for walk due to various factors. Gene therapy offers lot of promise. All ethnic groups in Pakistan have the same genetics but Memon genetics were a bit different. 

On last day of the symposium, Brig.  Imran Fazal presented challenging clinical scenarios in hypertension which was followed by Brig. Qaiser Khan who spoke on drug choice in treatment of hypertension. He emphasized the importance of taking life partner into confidence. One should talk to the family; consider environmental problems like broken family, problems with children, eating habits because drugs alone will not work. Take the high blood pressure in elderly patients. He also referred to white coat hypertension and masked hypertension. All drugs, he further stated, are not equally effective. Aim should be to reduce morbidity and mortality. Drugs should be chosen keeping in view the financial position of the patient. Patients with LVH should be prescribed ACE Inhibitors, CCBs and ARBs. Those suffering from heart failure should be put on beta blockers, diuretics, ACE Inhibitors and ARBs. Those suffering from PAD should be prescribed ACE Inhibitors and CCBs. To prevent AF, use ARBs and ACE inhibitors.  Patients with diabetes who also suffer from hypertension should be put on ACE Inhibitors and ARBs. Treatment strategy in special conditions needs close monitoring. Elderly patients are very sensitive to certain drugs; hence one should be careful of postural hypertension. In pregnant women he suggested the use of methyldopa and nifidipine. In diabetics one should consider treatment a bit earlier. In certain patients ACE Inhibitors may be contra indicated or sometimes it has to be combined with other medications. In pregnancy it is better to use combination therapy.   Dr.Fawad Farooq remarked that do not use ARBs and ACE Inhibitors in women in child bearing age.

Dr. Shahbaz Sarwar from Lahore spoke about imaging in hypertension and echocardiography. In LVH echocardiography is very useful. LVH regression can occur with drugs. Prof.Samad remarked that control of blood pressure does not mean reversal of LVH. Heart failure is a clinical diagnosis and one can confirm it on Echo.

Dr. Bilal Mohyuddin from PIC Lahore strongly presented the case of beta blockers which he opined will remain a useful drug in management of hypertension. He was of the view that we need to re-examine clinical evidence for beta blockers in hypertension. BBs can be considered as vasodilator drugs.  It is essential because of secondary preventon as well. Beta Blockers, Dr. Bilal Mohyuddin said is ideal in ischaemic heart disease, Myocardial infarction, silent ischaemia, tachycardia and SVT.  Some of the side effects include smooth muscle spasm but beta blockers are extremely cost effective. However, he hastened to add that all beta blockers are not the same. Atenolol is a good choice. Life style modifications diet and exercise all needs to be taken care of.

Prof. Abdus Samad remarked that beta blockers are not the first choice in hypertension. There are many guidelines. Sexual dysfunction is an important side effect of beta blockers; hence one should always avoid prescribing it to young male patients. Dr. Bilal Mohyuddin showed a slide with diuretics having 26% erectile dysfunction whereas in case of beta blockers it was just   11%.  Dr. Abu Bakar said that in case of co morbid, beta blockers should be used. However, we must use them judiciously and selectively if there are no contra indications. In MI, heart failure, post MI, beta blockers have a place. Beta Blockers are also more useful in women when used in combination with diuretics. Dr. Masood Ahmad from Lahore discussed the current Statin therapy guidelines.

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