Always consider Risk Benefits ratio,
careful selection of patients remains important
Low Dose Aspirin results in 62% reduction in pre-eclampsia
in high risk pregnant women – Tayyiba Wasim
Aspirin Session at PHL Conference at Lahore
LAHORE: Prof. Javed Akram an eminent physician, former President of Pakistan Society of Internal Medicine and former Vice Chancellor of University of Health Sciences chaired the Aspirin Update Session at the recently concluded conference of Pakistan Hypertension League held here from September 19th to 21st 2025. Other members of the Experts Panel included Prof. Feroz Memon current President of Pakistan Aspirin Foundation, Prof. Akbar Chaudhry former President of Pakistan Aspirin Foundation currently affiliated with Superior University/Azra Naheed Medical College, Prof. M. Ishaq another former President of Pakistan Aspirin Foundation, Prof. Mansoor Ahmed noted cardiologist and President-elect of PAF.
Prof. Javed Akram (second from right) along with Prof. Feroz Memon President Pakistan Aspirin Foundation chairing the Aspirin Update session at the PHL conference held at Lahore recently. Members of the Experts Panel siting on the dais from (L to R) are Prof, Mansoor Ahmad President-elect of Pakistan Aspirin Foundation, Prof. M. Akbar Chaudhry and Prof. M. Ishaq former Presidents of PAF.
Prof. Fawad Farooq Prof. of Cardiology at NICVD was the first speaker who talked about “Aspirin a Wonder Drug”. In his presentation he highlighted the Evidence Based Innovative use for high risk young, poorly controlled patients. He pointed out that we should not deprive high risk patients with poorly controlled blood pressure the benefits of low dose aspirin therapy. Majority of our population is younger and also suffer from many diseases. While use of Aspirin in secondary prevention is well established, there is some controversy as regards its use in primary prevention. In high risk young people with poorly controlled hypertension it is lifesaving. However, he emphasized that careful selection of patients is extremely important. One must always weigh the risk benefits ratio.
Promoting the use of Low Dose Aspirin Therapy is important in a country like Pakistan because of high burden of ASCVD, Diabetes Mellitus, hypertension and late presentation which is common. There are adherence gaps and underuse of proven therapies in secondary prevention. After new trials, there are some concerns as regards its role in primary prevention but it needs targeted use. Finally, we have resource constraints, hence must prioritize high value low cost interventions.
Some of the eminent medical personalities who attended the Aspirin Update Session during the PHL conference held at Lahore photographed with the chief guest Prof. Javed Akram and Members of the Experts Panel.
Aspirin Prof. Fawad Farooq said is unequivocally beneficial in secondary prevention of ASCVD i.e. chronic coronary disease, prior to myocardial infarction, PCI as well as in Coronary Artery Bypass Graft Surgery, in established atherosclerotic stroke, TIAs, in Acute Coronary Syndrome. One should use immediately chewable Aspirin unless contraindicated. At times we combine it with Clopidogrel as Dual Antiplatelet Therapy in acute conditions. The duration may vary and it has to be individualized. We must start using low dose aspirin therapy before an event takes place or prevent that event taking place. Once an event occurs, it becomes essential to use Aspirin therapy. Hence it is always advisable to individualize high risk patients.
As regards secondary prevention in ACS, antiplatelet benefits are robust. Antiplatelet Trialists Collaboration showed it reduced serious vascular events. CURE ad PLATO showed that DAPT in ACS reduces ischemic events as against Aspirin alone. However, one should be careful to balance bleeding risk, tailor DAPT duration in patients who have had stenting, have history of prior bleed and age factor is also important. Speaking about Thrombus formation he said endothelial damage results in plaque rupture. Describing the sequence of platelet related events he said first adhesion takes place followed by activation of antiplatelet and then the process of aggregation takes place which triggers the clotting mechanism.
Some of the distinguished cardiologists who were present during the Aspirin Update Session photographed during the recently held PHL Conference at Lahore.
Speaking about the use of Aspirin in primary prevention Prof. Fawad Farooq said, modern Randomized Controlled Trials (RCTs) have shown that there is small absolute benefit but increase in bleeding. ASCEND trial in 2018 showed that in diabetics without cardiovascular disease, there were fewer events but major bleeds. ARRIVE Trial 1n 2018 also showed that in patients with moderate risk, it had neutral efficacy but increased bleeding. ASPREE trial again in 2018 showed that in older adults there were no cardiovascular benefits but increased bleeding. Hence, the message is that Aspirin should be reserved for selected very high risk patients after shared decision making. As such we cannot say that in primary prevention Aspirin has no role which is not true.
In Non-cardio metabolic TIAs, minor ischemic stroke early short course of dual antiplatelet therapy for two to three months reduces the chances of recurrence. Then one can use single antiplatelet Aspirin or Clopidogrel. However, avoid Aspirin for primary prevention of stroke in low risk patients. One should use low dose aspirin 75-100mg when indicated. Avoid it in active bleeding and those with NSAID allergy, severe thrombocytopenia. For GI protection, assess risk, prior history of ulcer bleed, use of steroids and do prescribe PPIs if there is a high risk of GI. Consider H. Pylori test and if positive do treat it. Counsel patient on warning signs i.e. melena, hematemesis and easy bruising.
In Pakistan one should always target the right patients for low dose aspirin therapy, go for risk based primary prevention, go for Polypill approach. Use lady health workers, community, pharmacists for refill support and ensure regular glucose blood pressure checking. Promoting the use of Low Dose Aspirin Therapy is important in a country like Pakistan because of high burden of ASCVD, Diabetes Mellitus, hypertension and late presentation is common. There are adherence gaps and underuse of proven therapies in secondary prevention. After new trials, there are some concerns as regards its role in primary prevention but it needs targeted use. Finally, we have resource constraints, hence must prioritize high value low cost interventions. In patients suffering with established ASCVD, Aspirin remains cornerstone of secondary prevention. In pregnancy, low dose aspirin for preeclampsia prevention in high risk women is recommended. In chronic kidney disease if patient has high risk of bleeding, Aspirin should be used only for secondary prevention but avoid its use in primary prevention unless there are some compelling reasons. In elderly and frail patients, one must reassess indications regularly and DE-prescribe aspirin for primary prevention.
Describing management of a few cases Prof. Fawad Farooq said that in a fifty-five years old male post STEMI on DAPT with dyspepsia add PPI, reinforce adherence, review DAPT duration at six and twelve months. In a forty years old female who is diabetic and obese with no CVD but BP of 170/95 and dyslipidemia with noncompliance, focus on BP, Statins and weight reduction first. Use Aspirin only if very high ASCVD risk after discussion. In a sixty-two years old male with minor ischemic stroke five days ago, initiate short Couse DAPT if not bleeding then de-escalate to single antiplatelet.
He concluded his presentation by stating that in secondary prevention Aspirin saves lives, is beneficial in prevention and in ACS make it universal unless contraindicated. For primary prevention its selective use only is permitted considering risk/benefits, prioritize blood pressure, Statins and life style modifications.
Aspirin in Gynaecology
Prof. Tayyiba Wasim an eminent obstetrician & gynecologists Principal of Allama Iqbal Medical College discussed the role of Aspirin in Obstetrics & Gynecology. She pointed out that low dose aspirin (75-150mg) is widely used in obstetrics & gynecology. There were some initial concerns about its teratogenic effects but research showed its safety and efficacy with low dose therapy. Later large trials demonstrated benefits in preventing pre-eclampsia and various guidelines endorse its use high risk pregnancies. Aspirin ,she said, is rapidly absorbed in GI tract, its half-life is twenty mints, it is metabolized in the liver and excreted by kidneys and crosses placenta readily.
In high risk women prevention of pre-eclampsia is important. The ASPRE randomized trial showed that Aspirin 150mg daily initiated between 11-14 weeks continued till 36th week of pregnancy, there was 62% relative reduction in pre-term pre-eclampsia. Systematic Reviews and Meta-Analysis also showed that it results in moderate but consistent reduction in pre-eclampsia. Serious risks include chronic hypertension, diabetes mellitus, auto immune disorders, renal diseases, multiple pregnancy and previous pregnancy with pre-eclampsia or intrauterine growth restriction. American College of Obstetricians & Gynecologists, WHO, NICE Guidelines all recommend use of low dose aspirin (81-150mg) for women at high risk of pre-eclampsia. They advise its use starting from 12th week of gestation and continue it until delivery.
WHO advocate use of Aspirin plus calcium supplements which are beneficial in high risk population. Pregnant women at high risk of pre-eclampsia should take 75-150mg of Aspirin daily from twelve weeks of pregnancy until the birth of the baby. Meta-analysis also shows 18% reduction in Intra-Uterine- Growth-Restrictions and small for gestational age babies. Aspirin is also beneficial in Antiphospholipid syndrome and in recurrent pregnancy loss. Aspirin combined with LMWH is associated with higher live birth rate compared with Aspirin alone.
High dose Aspirin in pregnancy is associated with fetal risks, premature closure of ductus arteriosus. Talking about contraindications for the use of Aspirin therapy she mentioned Aspirin hypersensitivity, bleeding disorders and active peptic ulcer disease. Studies have also showed efficacy of Aspirin in Ovarian Cancer prevention, Endometrial Cancer Prevention. She concluded her presentation with a message that “Develop a passion for learning, if you do, you will never cease to grow.”
Prof. Feroz Memon in his remakes stated that Aspirin remains a wonder drug in high risk patients poorly controlled. It should be used in people after forty years. Prof. M. Ishaq pointed out that Aspirin has well established role in secondary prevention but in primary prevention we need to weigh the risk benefit ratio. It is a cost effective therapy, safe and effective easily available everywhere. In case of DAP there are some reports of minor bleed, risks are there but it should be monitored and before starting aspirin therapy proper risk assessment should be undertaken. Prof. M. Akbar Chaudhry remarked that Aspirin offers many benefits in CVD prevention, ACS, and as highlighted it has benefits in prevention of pre-eclampsia and many cancers and other medical disorders. As regards primary prevention one has To be a bit cautious. If risk is 15% or more, it is a must for primary prevention. However, elderly patients must have their hemoglobin checked after every six months. Prof. Mansoor Ahmad remarked that Aspirin is a cost effective antiplatelet therapy which offers numerous benefits in carefully selected patients. Aspirin is here to stay, he added.
Prof. Javed Akram in his concluding remarks reiterated that risk stratification is very important. Aspirin has some indications in primary prevention as well. We should not deprive our patients the benefits of low dose aspirin therapy. As regards primary prevention, Aspirin is not out yet. He also referred to the A4P study which was planned some years ago but could not be initiated due to COVID. It will enroll thousands of patients to generate local data, he added.
