Today we can predict, prevent, postpone and treat CVD-Prof. Sheharyar Sheikh


 Clinical Proceedings of CARDIO CON 2016-I

Today we can predict, prevent, postpone
and treat CVD-Prof. Sheharyar Sheikh

Cholesterol is a problem and LDL-C reduction of 50%
or more is important-Prof. Abdus Samad

 In acute illness, endocrine management will determine
outcome of the disease-Prof. A. H. Amar

FAISALABAD: Cardiovascular diseases account for 31% of global death annually. Non communicable diseases were not included in MDGs and it looks that by 2025 we will have 25% world mortality due to cardiovascular diseases. Inter Heart Study had emphasized the importance of  modifiable risk factors like smoking, diabetes mellitus, and cholesterol and it has been proved beyond any doubt that prevention works. This was stated by Prof. Sheharyar A. Sheikh while making a presentation on How to Manage rapidly increasing burden of cardiovascular diseases at the recently held CARDICON 2016 organized by Pakistan Cardiac Society here from November 25-27, 2016. This session was chaired by Dr. Ehsanul Ul Haque one of the senior most cardiac physicians in the city along with others.

Prof. Sheharyar Sheikh

Continuing Prof. Sheharyar Sheikh said that a community study has showed that there was 50% reduction in mortality by modifiable risk factors. The real benefit is lost when we go to the community and patients go to the GPs. PURE study showed that how to implement the knowledge, guidelines we know is the real CME. Today we can predict, prevent, postpone and treat CVD. We need to protect the general population, start preventive programme for those at risk, and postpone the disease by treating those with cardiovascular disease. The population approach to prevent cardiovascular disease was through healthy diet, physical activity, elimination of tobacco use.

Prof. Sheharyar Sheikh further stated that 35 million people each year suffer from acute coronary syndrome and 50% will be those who already have a disease. Referring to working in resource poor setting in Pakistan, Prof. Sheharyar Sheikh said that we have seen unbalanced development of high tech, high cost treatment. We need to look at low cost treatment. It is unfortunate that no cardiac institute in Pakistan has a prevention of cardiovascular disease programme. He suggested that we can use the Lady Health Workers in the primary prevention of cardiac care. We need to think about it. We can have smart phone APP for cardiology. We need to have a National Action Plan on cardiovascular diseases which should include all the stake holders like physicians, policy makers, public, and media. As regards cholesterol levels in Pakistan, something like 70-90 is good enough and we do not need to have less than 70. Some patients have very high HDL. Prof. Samad said that European Society says less is better but US recommends more than 50% reduction. Cholesterol, he said, was a big problem in Pakistan, hence we should all opt for 50% reduction. American Guidelines on Cholesterol are better than European. Prof. Samad also recalled that Col. Ashiq Hussain was very much interested in preventive cardiology and until retirement he used to do regular educaiotn and teaching sessions for patients at AFIC. Gen. Ashur Khan remarked that at present Col.Ashiq Hussain is affiliated with a private medical college at Mirpur in Azad Kashmir and was doing lot of work in the field of preventive cardiology there. PANAH an NGO was also working for prevention of cardiac diseases where in Gen.M.R.Keyani and Dr. Abdul Qayum Awan and others are very active.

Earlier Dr. Atique Azam Mirza from USA was the first speaker who talked about ECG Basic Review, Axis and Vector determination, Rate and Rhythm followed by interactive case presentations.  Dr. Willen, he said, was the one who invented ECG and also got Nobel Prize for this invention. Basics of ECG have remained the same and it has not changed much over the years. He then discussed in detail cardiac cycle and ECG, coronary artery system, approach to read ECG, pattern of reading ECG so that one does not miss anything. Rate and Rhythm in p waves are present. He also spoke about plane axis determination. He then presented two case histories and discussed the interpretation of their ECGs. One of them was sinus arrest or severe sinus bradycardia. He pointed out that VA conduction does not mean AV block.

Dr. Fawad Farooq from NICVD was the next speaker who talked about Chamber Hypertrophy. He discussed in detail the ECG for rhythm assessment, effect of disease, injury on heart function, electrolyte and other disturbances. His advice was that one must be competent in ECG reading. He also talked about atrial enlargement, left atrial enlargement, and bi-atrial enlargement, voltage changes due to LVH, LVH pattern, RVH ECG and Bi-ventricular hypertrophy. Chamber enlargement and ECG assessment is helpful in evaluating  cardiac and non-cardiac  disease and heart function but one must be careful about over diagnosing LVH , he added. He also disclosed that they at NICVD Karachi were performing between 15-20 primary angioplasties daily.

Prof. Zahid Jamal’s presentation was on ST Elevation Myocardial Infarction which was also followed by interactive session.  He discussed the evaluation of MI and assessment of prognosis with ECG evidence. Speaking about progression of wave changes and ST segment changes, he said that it takes place within hours of onset of symptoms. T wave becomes broad and ST segment elevates. He then talked about St Segment depression. Right ventricular MI is only seen with right coronary occlusion. Anterior MI and high lateral MI were also discussed.

Dr. Maria Viqar from USA spoke about Brady Arrhythmias, conduction blocks. She discussed at length symptoms of bradycardia and classification of bradyarrythmias. Some of the causes include use of beta blockers, calcium channel blockers, eye surgery and meningitis etc.  Glaucoma patient on beta blockers, elderly patient on digoxin can also suffer from this. It occurs more commonly during anterior MI. Treatment is essential if the patient has severe symptoms. She also talked about sinus arrest. The causes can be acute MI, digital toxicity etc.  AV block also occurs. Sick Sinus Syndrome is a serious nodal abnormality. She also talked about problems with impulse conduction.  She concluded her presentation by stating that if one does not know ECG, it means he or she does not know anything about cardiology. Summing up the session Dr. Ehsan Ul Haque said that we have seen normal and abnormal ECG, sometimes we do recognize but at times, one tends to make some mistake. I myself have learnt a lot from this interactive session. As far as abnormalities are concerned, at times abnormality, conduction defects are over cited by us, he added.

The next concurrent session was organized in collaboration with Pakistan Cholesterol Awareness Society and PCS Council of Preventive Cardiology. Prof. A. H. Amar a noted endocrinologist from Peshawar was the first speaker who talked about Management of Endocrine Diseases in Cardiovascular setting. He talked about stress hyperglycemia and said that illness leads to stress and it then leads to hyperglycemia during MI. During critical care the only intervention is through insulin infusion to prevent hypoglycemia. Speaking about indications for IV insulin therapy he mentioned DKA, critical care illness, post cardiac surgery. In these patients one should do hourly bedside monitoring and every two hour if the patient is stable. Potassium should also be monitored. In some cases simple blood glucose monitoring may not be enough and one needs to do venous monitoring. He also laid emphasis on bedside glucose monitoring in these critically ill patients. In Type-I When the patient starts eating and blood glucose levels are stable, subcutaneous insulin therapy can be started. There are increased chances of hypoglycemia in advanced age, in case of decreased oral intake, liver disease, chronic renal disease and when there is lack of coordination from diet.

Talking about Insulin delivery modes, he referred to CGMS glucose monitoring system. It is a bit tedious to use, needs careful monitoring. Hypoglycemia is common in critical illness. Intensive blood glucose monitoring results in significant reduction in morbidity and mortality. In these patients blood glucose levels of   140-180 are considered good enough. His other presentation was on Thyroid supplementation in critical care patients. In acute illness, endocrine management will determine outcome of the disease.

Prof.Abdus Samad from Karachi speaking about what should be the level of LDL in pregnancy, primary prevention and secondary prevention referred to Leibowitz and Bangalore recommendations. He also referred to the Four City study conducted in 1990 involving 1538 patients of which 638 were female and said that at that time it showed that cholesterol was not a problem in Pakistani population. He then referred to a study conducted at NICVD which included one thousand angiographies which showed that we had disease at a very young age and left main disease was the same. He also referred to life expectancy and quality of life which was important. He then referred to the ACC-AHA Guidelines which showed that Statins are good and beneficial. Statin intensity, he said, has generated lot of discussion.

Continuing Prof. Samad said that Leibowitz in another Meta-Analysis in 2016 which included 31,639 patients with six to seven years follow up and their mean duration of disease was 6.6 years showed best results with LDL lowering. CAD, he said, was a multifactorial disease. Taking global view of the disease, LDL-C, he said, was the most modifiable risk factor and one should aim for LDL-C of 70-100.

On the other hand Bangalore published a study in 2016 “Cholesterol Guidelines Re-visited” using Atorva 80mg-200mg. There was more than 50% reduction in 4538 patients and less than 50% in 494 patients. He showed that when doctors are treating these patients aggressively intervention is better. In stroke heart rate is more than double, hence LDL-C reduction of more than 51% is excellent. Prof. Samad further stated that LDL-C reduction of 50% or more is very important. Atherosclerotic CVA is treated with Statin. He showed that with 70-90mg one gets best results. Saleem Yusuf in his study showed that Statins help you if LDL is normal. But there is a risk of new onset diabetes mellitus of 3.9% with the use of Statins.

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