Regular use of Low Dose Aspirin therapy significantly reduces morbidity and mortality besides stroke and other cardiovascular events - Prof. Akbar Chaudhry

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Prevention of Cardiovascular Diseases

Regular use of Low Dose Aspirin therapy

significantly reduces morbidity and mortality
besides stroke and other cardiovascular
events - Prof. Akbar Chaudhry

Those individuals with over 10% absolute risk
over ten years must be given Aspirin Therapy

25-41% of women in Baluchistan suffer from high blood pressure
and stress ECG is recommended when history is suggestive
of myocardial ischemia - Prof. Munaf Tareen

QUETTA: Cardiovascular Diseases are the No. 1 cause of mortality and a real threat to urban health. According to WHO low and middle income countries will have more cardiovascular diseases and mortality in the years to come. As per various studies, cardiac diseases are more prevalent in urban areas as compared to rural areas and Coronary Artery Diseases has now become an epidemic in Pakistan. This was stated by Prof. M. Akbar Chaudhry Principal of Azra Naheed Medical College Lahore and former President of Pakistan Aspirin Foundation. He was speaking at the 5th Preventive Cardiology Conference recently held at Quetta. This session was chaired by Maj. Gen. Azhar Kiani, Prof. Khalida Soomro and Dr. Haqdad Tareen.

  

Maj. Gen. Azhar Kiani, Prof. Munaf Tareen, Prof. M. Akbar Chaudhry, Dr. Haqdad Khan Tareen
and Dr.Jalaluddin Achakzai speaking at the preventive cardiology conference held
at Quetta on August 9-10th 2014

Continuing Prof. Akbar Chaudhry said that about 18% of Pakistan’s adult population suffers from hypertension and the number of people with diabetes were between six to nine million or may be more. Other risk factors for cardiovascular diseases include dyslipidaemias, obesity, metabolic syndrome and smoking. Smoking cessation, physical activity, diet therapy, weight control, blood pressure control, lipid control, diet control besides Aspirin therapy are some of the treatment strategies. Aspirin is the life saving miracle drug and almost 37.6% of Aspirin is used in the treatment of cardiovascular diseases. He also highlighted the well established indications for Aspirin therapy and pointed out that it was poor man’s streptokinase which is easily available everywhere in the country and can also be easily administered. Regular use of low dose Aspirin therapy reduces non-fatal myocardial infarction by 32% besides non-fatal stroke. It will also avoid MI and stroke in thirty to forty patients out of one thousand patients. As regards primary prevention, it will reduce one third first MI besides one eighth of all vascular events.

Numerous studies have confirmed that regular use of low dose Aspirin therapy reduces myocardial infarction by 33%, stroke by 25% and other cardiovascular events by 17%. In secondary prevention it reduces stable angina by 46%. Despite all these benefits, safety and efficacy of low dose aspirin therapy, it remains under used. Giving details of Aspirin Awareness and Usage Study(AAUS) conducted by Pakistan Aspirin Foundation about ten years ago at seventeen Coronary Care Unites all over Pakistan in which over fourteen hundred ACS patients were enrolled, Prof. Akbar Chaudhry said that only 16% of the patients got Aspirin at home when they suffered chest pain. About 20% of the patients were given Aspirin by the GPs and Family Physicians, 60% patients got Aspirin in Emergency Room and 71% patients were given Aspirin in the Wards. What was more surprising was the fact that only 50% of these patients were prescribed Aspirin on discharge. That is why Pakistan Aspirin Foundation started a CME programme to create awareness about the safety and efficacy of low dose aspirin among public as well as healthcare professionals. These meetings have been organized all over the country even in the small towns and cities with the result that now the use of Aspirin has increased though it is still not what is desirable. It is evident from the fact that a recent study showed that 31% of patients were taking Aspirin for primary prevention, 43% were taking Aspirin along with Clopidogrel. If need be Aspirin can be stopped five days before elective surgery but in emergency surgery, there is no problem as regards Aspirin therapy.

Apart from cardiovascular diseases, new and emerging indications for Aspirin therapy include colorectal cancer, gastric and esophageal cancer, prostate cancer, pre eclampsia, DVD, pulmonary embolism besides Alzheimer’s disease. He concluded his presentation by stating that low dose aspirin therapy is very safe and effective which significantly reduces morbidity and mortality. In high risk cases, clopidogrel can be added. In high risk individuals, Statins can also be added for primary prevention. He suggested to the healthcare professionals to keep soluble Aspirin with them all the time, in their offices, clinics and while travelling as it may be needed and prove life saving in someone needs it.

Earlier Prof. Munaf Tareen spoke about management of hypertension and pointed out that Blood Pressure control is not good even in countries like Australia and United States where only 24% and 35% patient respectively suffering from hypertension have controlled their BP. In Pakistan only 12.5% of patients with hypertension are reported to have BP control. About 25-41% of women in Baluchistan suffer from high blood pressure. It is important that one must confirm the diagnosis before starting treatment. One has to assess the risk factors, organ damage, look at the concomitant clinical conditions. BP measurement of 120/80 is considered optimal normal while a blood pressure of 140/90 will require treatment. BP measurement of 140/90 will be considered as isolated systolic hypertension. It is important that the patient has rest for two to five minutes before taking blood pressure and one must have at least two readings with five minutes interval. Stress ECG is recommended when history is suggestive of myocardial ischemia.

Speaking about the pharmacological treatment of hypertension, Prof. Munaf Tareen said that diuretics, beta blockers, Calcium Channel Blockers, ACE Inhibitors and ARBs all are effective. BP in some patients can be controlled with monotherapy but some patients will require combination therapy of two, three or even four drugs. He then discussed the treatment strategies in women and patients with diabetes. During the first week of stroke it is advisable that one should not use any antihypertensive drug. In patients with low and moderate risk, Aspirin therapy is not recommended but those who have had previous cardiovascular events must be put on low dose Aspirin therapy, he remarked.

Prof. Najmul Islam from Aga Khan University talked about diabetes as a risk factor for cardiovascular diseases. He referred to MRFIT Trial and Haffner Study and highlighted the fact that patients with type 2 diabetes suffer from cardiovascular events. People with diabetes have high chance of getting myocardial infarction. Studies have shown that cardiovascular diseases account for 46% deaths in people with diabetes. People with diabetes should be put on Statins to prevent cardiovascular diseases. Speaking about control of glycaemic Prof. Najmul Islam said that all patients with diabetes over the age of forty years should be put on Statins. Aspirin is also more effective in patients with diabetes. He advised the healthcare professionals to use 75-162 mg of Aspirin for primary prevention in Type 1 and Type 2 diabetes. People with diabetes, Prof. Najmul Islam opined have 2-4% more risk of cardiovascular diseases hence it is important that one must try for optimal blood pressure control. Diabetes is considered as stage-I heart failure.

During the discussion it was clarified that in case of minor surgery or during PCI one does not need to stop Aspirin. In case of major elective surgery, if need be one can stop Aspirin for few days and start it two to three days after surgery. However, in case of road traffic accident when there is an emergency, one can go ahead and perform surgery even if the patient has been on Aspirin therapy. In case of PCI, one can stop clopidogrel. Stop it for five days and start it three days after surgery. Gen. Azhar Kiani opined that do not stop Aspirin if it is not required. Even in CABG do not stop Aspirin therapy as its benefits are much more as compared to the risk of bleeding. Responding to a question regarding the use of weekly Aspirin, it was stated that there is no data supporting it.

Participating in the discussion Prof. Samad said that one should stop antiplatelet therapy including use of Aspirin only in intracranial procedures. Otherwise it should not be stopped during surgery. If the bleeding does not stop even after two hours, one must go back, open the chest and seal the bleeding vessel. Dr. Abu Baker Sheikh said that Aspirin can cause oozing of blood from incisions. Patients should be counseled to stop smoking and they should be put on Aspirin therapy. Dr.Daud Shah said that we use Aspirin and Clopidogrel until at the time of surgery. We monitor the platelet count and if it is more than one lac, we do not stop Aspirin. Re-opening is very rare. It is desirable that antiplatelet is continued till the night prior to surgery. Prof. Samad suggested additional 325mg of Aspirin at night to avoid graft closure. In patients who have had drug eluting stents, Aspirin should never be stopped because stent thrombosis is a real problem in PCI. Dr. Haqdad Tareen said that Aspirin was an old drug being used for over hundred years. If you go for surgery prior to screening test and if the platelet count is more than 100,000, do not worry. In parnasal sinuses, optic surgery and intracranial procedures one needs to stop Aspirin therapy.