Low Dose Aspirin therapy can be used for primary prevention in high risk patients-Prof.Ejaz Ahmad Vohra

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 Symposium on Cardiovascular Diseases at Quetta
Low Dose Aspirin therapy can be used for
primary prevention in high risk patients-
Prof.Ejaz Ahmad Vohra
PPIs can be added to reduce the chances
of GI bleeding & Dyspepsia
Nebivolol 5mg daily is an ideal antihypertensive which
reduces LVH, end organ damage - Prof. Abid Amin

QUETTA: While the safety and efficacy of regular use of Low Dose Aspirin therapy is well established in secondary prevention, it can also be used safely for primary prevention of cardiovascular diseases in high risk patients. Since patients in Pakistan and other low income countries use lot of carbohydrates, do not use Statins, the prevalence of hypertension, diabetes mellitus, smoking is increasing, it is much better strategy to go for preventive measures otherwise Myocardial Infarction and Stroke can make the life of the patients miserable. This was stated by Prof. Ejaz Ahmad Vohra an eminent physician, former President of Pakistan Aspirin Foundation, Director Postgraduate Studies Clinical and Prof. of Medicine at Ziauddin University Karachi. He was speaking at a symposium on Cardiovascular Diseases organized by Pakistan Aspirin Foundation in collaboration with Pakistan Hypertension League held here on August 24, 2019. Prof. Abid Amin a noted cardiologist was the other speaker and local organizer and it was attended by a select group of physicians, cardiologists besides a large number of family physicians.

Prof. Ejaz Ahmad Vohra in his presentation “Medical Uses of Aspirin: An Update in the 21st century” pointed out that with the use of Aspirin reduction in cardiovascular diseases is well-established but more recently there have been some studies about its use in primary prevention which has raised lot of discussion among the healthcare professionals. While in low risk cases, there is no need to use Aspirin for primary prevention but in high risk cases, regular use of Low Dose Aspirin therapy still has a role. The treating physicians should take the patient into confidence and discuss with them the benefits and risks in detail, he remarked.


Prof. Ejaz Ahmad Vohra, Prof. Abid Amin, Dr. Haqdad Khan, Dr. Asif Tabba, Mr. Shaukat Ali Jawaid,
Mr. Kashif Riaz from Atco alongwith other senior physicians photographed during the
symposium on cardiovascular diseases held at Quetta recently.

Speaking about the established uses of Aspirin, he mentioned its use in emergency situations like acute myocardial infarction, Acute Coronary Syndrome, prevention and treatment of preeclampsia, colorectal and other cancers and it can also be combined with many other agents. Apart from patients with AMI, it is being used in unstable angina, patients with acute occlusive stroke, patients with stable Cardiovascular diseases, ischemic heart disease, patients who have undergone revascularization with coronary artery bypass graft surgery, stable peripheral artery diseases or carotid artery disease besides patients who have undergone coronary stenting. If Aspirin is added to streptokinase it reduces mortality by 40%. In secondary prevention if combined with Clopidogrel it reduces vascular mortality by 8.7%. It can also be combined with Ticagrelor and Rivaroxaban but there is an increased risk of bleeding.

Continuing Prof.Ejaz Ahmad Vohra said that in United States Aspirin is now being used by 90% of patients for prevention of heart attacks. Studies have also shown that it reduces the chances of heart attack and stroke in both men as well as women. There is a small risk of increase in intra cerebral hemorrhage hence one should balance the risk against the benefits in such patients. Most common use of Aspirin in stroke is for acute cases, acute TIAs and minor stroke. Most of the guidelines recommend use of Aspirin for acute ischemic stroke. Its effects in TIA and minor stroke are probably larger and more beneficial than in higher risk events. When combined with clopidogrel, it is more effective in preventing stroke after TIA compared to the use of Aspirin alone. However, Aspirin is highly effective for secondary prevention of TIA and minor stroke, he added.

Speaking about the use of Aspirin in pregnancy and cancers, Prof. Ejaz Ahmad Vohra said that it is drug of choice for prevention of pre-eclampsia. Meta-analysis have showed that women at risk of pre-eclampsia gestation hypertension or fetal growth restrictions, it has relative risk reduction of 0.90 CL 95%. It is also effective in various types of cancer but greatest effect was seen in those patient who were taking it for at least five years. It reduces mortality in colorectal cancer, esophageal cancer, gastric cancer, lung cancer and prostate cancer besides breast cancer. Daily aspirin therapy may also be associated with a reduced risk of HBV-related HCC. American College of Cardiology and American Heart Association Guidelines for the year 2019 both recommend low dose aspirin (75-100mg) in primary prevention of ASCVD among selected adult of 40-70 years of age who are at higher ASCVD risk but not increased risk of bleeding. However, it should not be administered on a routine basis for primary prevention of ASCVD in adults less than 70 years of age. Aspirin should not be administered for primary prevention in adults who are at increased risk of bleeding.


Prof. Ejaz Ahmad Vohra and Prof. Abid Amin speaking at a symposium on Cardiovascular Diseases
organized by Pakistan Aspirin Foundation in collaboration with Pakistan Hypertension League at Quetta
on August 24th 2019 at Quetta.

He also referred to various trials of Aspirin in primary prevention in cardiovascular diseases. Both AHA and ADA recommend use of aspirin for diabetes patients who have a ten years cardiovascular disease risk of at least 10% but not at risk of increased bleeding. However, there were some limitations of these Trials in primary prevention. It included compliance with random assignment was relatively poor resulting in substantial crossover, population studies had CV events lower than anticipated which leaves the questions unanswered whether aspirin might have benefitted in higher risk younger population. Again only a small number of patients were on PPI which might have cut down aspirin induced dyspepsia and GI bleeding. There was no information regarding the use of NSAIDs in these patients. Median follow up was too short. Moreover improved control of CV risk factors including smoking, hypertension and hyperlipidemia compared to early trials may be the reason aspirin is not needed for primary prevention. Above all the ASCEND trial had only 17% patients with high risk and observed events for lower than expected. On the contrary patients in Pakistan, Prof. Ejaz Ahmad Vohra reiterated are high risk, the use of Statins is very poor, they are obese, overweight, there is increase in smoking and the non-compliance with drug therapy is very common. Hence, in such circumstances, the use of Aspirin for primary prevention in carefully selected high risk patients can be beneficial. It is thus better to prevent the disease. It also results in 40% reduction in Venous Thrombo Embolism (VTE).

He concluded his presentation by stating that in places of the world where CVD risk is increasing, where other preventive strategies such as Statins are less available, Aspirin as a low cost intervention may have a more important role to play. The benefits of Aspirin in secondary prevention significantly outweigh the risks.

Management of Hypertension

Prof. Abid Amin in his presentation on “New trends in management of Hypertension” said that by 2025 it is expected that there will be a 60% increase in hypertensives. As per National Health Survey done some year ago, in Pakistan 18% of our adult population suffer from hypertension, 50% are diagnosed and only 50% of them are treated while just about 12.5% patients have their blood pressure under control. Hypertension accounts for 7.6 Million global mortality. As regards complications of hypertension, it can affect all body organs. A 20/10mmhg increase in blood pressure results in 20% increase in mortality while a mere 2mmhg reduction in blood pressure leads to 7-10% reduction in mortality.

JNC-8 Guidelines on management of hypertension, Dr. Abid Amin said recommend the following:
• Heart Failure ACEIs, ARBs, Diuretics, Spirolactone
• Post MI, CAD BBs are indicated
• Recurrent Stroke ACEIs and Diuretics
• CKD ACEIs and ARBs

In endothelial dysfunction Nebivolol, he stated, was the most effective and safe beta blocker. It is a third generation beta blockers. The recommended dosage is 5mg daily and one can up to ten mg. There is no sleep disturbance and it has a bioavailability of 96%. Giving details of the ENECA trail which enrolled two hundred sixty patients, he pointed out that there was 80% increase in LVEF, survival rate also improved. It also reduced mortality by 38% as compared to 34% mortality reduction with other Beta Blockers. The adverse effects noted were also 21% as compared to 15% in the placebo group.

In yet another trial 6376 patients with atrial hypertension were enrolled. After six weeks therapy, erectile function of the patients improved and their sexual activity also improved. TGs were reduced, new onset of diabetes also reduced by 1.8%. The dosage of Nebivolol for angina and hypertension is 5mg daily. He concluded his presentation by stating that Nebivolol is an ideal antihypertensive agent which reduces LVH, end organ damage, it is a high potency selective beta blocker which is preferred in the management of hypertension.

Discussion

During the discussion it was pointed out that Asian population use lot of carbohydrates. The patients should be advised to increase the use of protein and reduce carbohydrates. Our patients also have much more risk factors as compared to the patient population in the West, hence we need to keep these things in mind while treating our patients. Aspirin may not be used for primary prevention in patients with diabetes but we must remember that most of our patients are not on Statins which increases their risk factors. Prof. Ejaz Ahmad Vohra remarked that once stroke or myocardial infarction occurs, it is a disaster, hence prevention is always better and preventive strategies should be given preference. If there are concerns for safety and to take care of risk of GI bleedings, one should use PPIs but in low risk patients, there is no need to use Aspirin for primary prevention. Dr. Asif Tabba pointed out about the possibility of bleeding from other sources like Hemorrhoids etc. Responding to this, it was stated that one has to take care of all these aspects while initiating low dose aspirin therapy.

Earlier Mr.Shaukat Ali Jawaid Secretary Pakistan Aspirin Foundation welcomed the guest speakers Prof. Ejaz Ahmad Vohra and Prof.Abid Amin besides participants. Such meetings, he stated, are part of the CME activities we organized to create awareness and promote the use of Aspirin in its well established indications.

The meeting was sponsored by M/s Atco Laboratories. Mr. Kashif Riaz Business Unit Head from Atco Laboratories also thanked the speakers and the participants to grace the occasion with their presence.