Primary prevention is strategy of choice and population based prevention needs more emphasis-Dr. Abu Baker Sheikh


Cardiovascular Diseases

Primary prevention is strategy of choice
and population based prevention needs
more emphasis - Dr. Abu Baker Sheikh

Intravascular ultrasound is the diagnostic modality
of choice in women - Dr.Nusrat Ara Majeed

QUETTA: Dr. Abu Baker Sheikh from Aga Khan University Hospital Karachi was the first speaker in the second scientific session during the 5th Preventive Cardiology Conference held at Quetta recently. The topic of his presentation was Dos the preventive strategies work? This session was chaired by Prof. Munaf Tareen along with Dr. Baqi Durrani and Dr. Fawad Farooq from NICVD. Dr. Abu Baker Sheikh was of the view that patients like to live dangerously hence we should be aggressive in preventive strategies. There is no commercial reward in preventive cardiology and Drugs are not popular in certain segments of our society.

Continuing, Dr. Abu Baker Sheikh said that homosexuality is promoted in the West which leads to HIV. Preventive therapy is less expensive and less effective. Studies have revealed that in the West there has been decline in the prevalence of cardiovascular diseases with therapy as much as with preventive strategies. Diseases, he opined, should be treated therapeutically. Secondary prevention is more effective. Primary prevention is strategy of choice and population based prevention needs more emphasis.

Dr. Nusrat Ara Majeed from Rawalpindi-Islamabad was the next speaker who spoke about prevention of CAD in women. She pointed out that there are certain myths like only post menopausal women suffer from IHD and young women have only broken and bereaved heart. Intravascular ultrasound is the diagnostic modality of choice in women. Ladies may come with vague symptoms like feeling of tiredness, disturbed sleep, dry cough or pain in upper part of the abdomen. Other symptoms include headache, shortness of breath. Inflammation is primary suspect. Women have poor prognosis for various procedures. Anaemia and PCOS are the other risk factors. She concluded her presentation by stating that women’s heart is fragile, don’t ignore it and pay attention to symptoms.

Dr. Abu Baker Sheikh, Prof. Najmul Islam, Dr. Roohi Ilyas speaking at the preventive
cardiology conference while on extreme left Prof. Khalida Soomro is chairing the session.

Major Gen. Azhar Kiani from Rawalpindi Institute of Cardiology was the next speaker who talked about presence of risk factors in Pakistan. He pointed out that very few people have ideal cardiovascular health. We must reduce exposure to risk factors. He then gave the findings of a study which they had conducted at AFIC some years ago. It included forty thousand patients from all over the country and the study lasted for three years. Almost 57% of the study participants were from urban and 43% from rural areas. The common risk factors identified included diabetes mellitus, hypertension, obesity, and dyslipidaemias. Almost 35% of men and 27% of women had low HDL while 46.4% had low LDL in this study. Hypertension accounted for 18% while diabetes mellitus was seen in 11%.

Prof, Munaf Tareen in his concluding remarks said that certain areas in Baluchistan myocardial infarction was very high. Some tribe has different risk factors. Chest pain in women over the age of forty years should be taken seriously. Obesity is not common in Baluchistan. He further stated that we do get lot of patients from Afghanistan hence one should also be careful about rheumatic heart disease. Dr. Nusrat Ara Majeed opined that in women death due to IHD is more common than death due to breast cancer. Responding to a question Gen.Azhar Kiani said that cholesterol level was not very high in their patients who were having CAD. Dr. Abu Baker Sheikh said that in high risk countries like Pakistan, we have high risk behaviour. We need cool thinking. Do not get upset; do not be emotional and cool down. Young people have hot blood they should be advised to cool down to get beneficial outcome. He further stated that everyone should get his/her cholesterol and blood glucose checked after every six months. Dr. Fawad Farooq said that in cardiovascular diseases there is no cure but prevention is possible. Those with risk factors is a diseased person, we prevent events and not disease. Secondary prevention is intensive as compared to primary prevention which is less intensive, he remarked.

Third Session

The third scientific session was chaired by Dr. Nasir, Dr. Khalid Shah, Prof. Abdus Samad and Dr. Abu Baker Sheikh. Dr. Fawad Farooq from NICVD was the first speaker who talked about Update in hypertension management. He stated that only persistent raised blood pressure should be treated as hypertension because one can have sporadic increase in blood pressure. Tracing the history he said that it was the Framingham study which opened the way for treatment of hypertension as it became known that treatment reduces Myocardial Infarction and stroke besides kidney diseases. In 2011 NICE UK guidelines suggested that people with blood pressure measurement of 140/90 should be offered Ambulatory Blood Pressure Monitoring. He also referred to white coat and masked hypertension. The objective should be to achieve the target Blood Pressure. In stroke patients BP should not be lowered immediately as it will have more damage than offering any benefits. In JNC-8 there is no definition and no classification of hypertension. There are specific blood pressure goals. Different patients sub groups will have various blood pressure targets and goals. As regards drugs choice, one can opt for thiazide diuretics along with CCBs, ACEIs or ARBs. Those suffering from chronic kidney disease should be put on ACEIs but do not combine ACIs and ARBs.

Prof. Khalida Soomro discussed prevention of cardiovascular diseases in women and emphasized the fact that we need gender specific guidelines for various reasons. Aspirin can be useful for women over sixty five years of age and they can take 100mg on alternate days. Much of the cardiovascular diseases in women, she opined, are preventable.

Dr. Jalaluddin Achakzai talked about obesity-a new name for an old Sin. He pointed out that genetics and behavioural factors play an important role in obesity. It was in American Medical Associaton 2013 guidelines when obesity was declared a disease for the first time. Obesity is increasing all over the world. Obese people have more chances of developing diabetes. He suggested that obesity and hypertension clinics should be established in every major hospital.

While time management was strict for others, the organizers did not abide by the allotted time and the chairpersons were also magnanimous enough to keep quiet and did not ring the bell. However, in his concluding remarks Prof. Samad did narrate a story with the take home message that if the speakers go on and on, the audience has the right to leave. One does not know if the message was understood by those for whom it was meant. During the discussion it was also pointed out that some people are prone to obesity because of certain genes. Use of anti obesity drugs can lead to malabsorption of certain vitamins hence anti obesity drugs should not be taken for long time. Target the BP one wishes to treat. There are pharmacological guidelines in the JNC-8. Calcium antagonists, Prof. Samad stated can control blood pressure in most of the patients. One should never combine ACEIs with ARBs as it can lead to hyperkalemia which is a very fatal condition. One can use up to four drugs in combination therapy. JNC-8 is the continuation of JNC-7 One should not give ACEIs in pregnancy. Methyldopa is the safest drug in pregnancy. One should use optimal dose of methyldopa. Blood pressure should be treated aggressively in pregnancy. IV nitrates can be used to control BP in emergency, he added.

Fourth Session

Dr. Nusrat Ara Majeed along with Dr.Abdul Wahid from Afghanistan chaired this session. Prof. Abdus Samad was the first speaker who gave a detailed account of Million Heart Programme in USA and the lessons for Pakistan it offers. Speaking about the etiological factors he mentioned 9S which are Smoking, Statins, Sugar, Salt, Soda, Sedentary life style, stressful days, sleepless nights. Added to this are the emotional factors. United States through their Million Heart Programme wish to prevent One Million Heart Attacks and stroke in five years. Giving further details as to how they are going to achieve that Prof. Samad said that at present only 47% of people with increased risk of cardiovascular disease are taking Aspirin and they intend to increase it to 65% in the next five years. At present only 46% Americans have their blood pressure controlled and they wish to increase this figure to 65%. Again only 33% Americans have their cholesterol controlled and it will be increased to 66%. Currently only 23% patients in USA get advice on cessation of smoking and it will be increased. All these interventions, they hope, will result in reducing the heart attacks by one million in the next five years.

The 11S which Prof. Samad mentioned for treatment include Salicylic Acid, Statins, and Seventeen KMs of walk per week, Salt reduction, Salad, sweet peanuts, sleep for seven hours daily and Smile all day. Every body managing cardiovascular diseases and treating hypertension must be familiar with Risk Assessment Working Group (RAWG) and FHS which stands for Framingham Heart Study. They should also be familiar with CHS and AIRC besides CARDIA i.e. Coronary Risk Development in Young Adults. There are high, moderate and low intensity Statins groups and the dose of Statins is different for all groups. Talking about the safety and efficacy of regular use of low dose Aspirin Prof. Samad said that it can reduce 1.4 million deaths and the amount needed for their normal burial will be over seven billion rupees.

Dr. Hazrat Ali Khan talked about Stress as a risk factor for coronary heart disease and how to prevent it. He was of the view that we should be familiar with the stress management strategies in daily professional life. It can be by sharing one’s feelings as bottled up emotions can increase frustration and stress. He also referred to various relaxation techniques, good sleep, exercise, proper diet and positive thinking. Antidepressants are also used to treat stress but some of these patients can develop hypertension. Hence one should always use safe antidepressants in cardiac patients. TCS, SSRIs are quite good and useful drugs. During the discussions it was stated that one should not take Paracetamol quite frequently to treat headache as it has serious side effects. For the use of Statins, one should get the baseline investigations and then repeat it after two weeks. Then there is no need to repeat the laboratory investigations too frequently.

In her concluding remarks, Dr. Nusrat Ara Majeed laid stress in moderation in every thing, healthy diet, refraining from smoking, no alcohol, use of vegetables and fruits. Healthy diet coupled with life style modifications, she opined, will be helpful in reducing and preventing the cardiovascular diseases.