Speakers highlight the use of Statins, Aspirin therapy in reducing morbidity and mortality in CVD


 Cardiology Update Symposium at Isra University Hyderabad

Speakers highlight the use of Statins, Aspirin
therapy in reducing morbidity and mortality in CVD

Use of Statins reduce CVD events, stroke, DVT and
pulmonary embolism- Prof. Ejaz Vohra

Those patients who have more than two risk factors, they are candidates
for Aspirin therapy for primary prevention of CVD-Fawad Farooq

HYDERABAD: Department of Cardiology at Isra University Hyderabad organized a session on Cardiology Update on January 21, 2016. Prof. Feroze Memon was the convener of the symposium. Dr. Syed Ali Raza from Zia Uddin University Karachi was the first speaker who talked about Systemic Hypertension. He pointed out that lot of changes have occurred in the measurement of blood pressure. It is important to decide what level of control we wish to achieve.  Poor medication adherence is a problem. Isolated systolic hypertension remains the main problem which contributes more to morbidity and mortality. He also referred to office blood pressure measurement and white coat hypertension. If the patients have stress at home, their blood pressure may be normal at office and similarly some patient’s blood pressure rises when they enter a doctor’s clinic.  That is why it is suggested that let the patient take rest for at least five minutes before taking the blood pressure.

Prof. A.G. Qazi along with Prof. Feroze Memon presenting a mementoe
to Prof. Ejaz Ahmad Vohra at the Cardiology Update symposium
organized by Isra University recently.

Non office blood pressure, Dr.Ali Raza said is a better predictor of events.  Now Ambulatory blood pressure measurement is recommended to confirm hypertension. At present there are over one hundred twenty five drugs available to control hypertension. SPRINT trial was the latest one in which three to four drugs were used. Cost effective intensive therapy was highlighted in the SPRINT trial and the target BP was 120. It was suggested that one should use thiazide diuretics in combination with ACE Inhibitors and CCBs and if still the blood pressure is not controlled, one should add Beta Blocker if there is an indication. He then referred to controlled resistant hypertension which also needs three to four drugs. If the patient is not yet responding, talk to the patient. He may be taking alcohol or there could be some problems with drug compliance. Responding to questions during the discussion he said that hypertension emergency means a blood pressure of 200mmHg or more and these patients need to be hospitalized and their blood pressure brought down gradually using intravenous drugs as there is a danger of target organ damage. On the other hand in hypertension urgency, there is no risk of target organ damage and these patients do not need to be hospitalized.

Prof. Ejaz Ahmad Vohra a noted physician also from Zia Uddin Medical University Karachi made a presentation on Role of Statins in Ischemic Heart Disease. Four-S study, he stated, highlighted the importance of Statins in reducing morbidity and mortality. Atherosclerosis starts early in life and Statins are good for secondary prevention but giving Statins to healthy population was controversial. There is some link with LDL and vascular disease. Statins reduce events, stroke, cardiovascular events, result in 50% reduction in DVT, reduce pulmonary embolism and reduces the rate of infection. However, there is an increased risk of patient developing diabetes if Statins are used for a period of five years and more. They are safe in reducing cardiovascular disease and offer many benefits. The chances of developing Myopathy is rare. However, one should be careful while combining Statins with Fibrates. Hepatic toxicity is very rare. Statins are also reported to be renoprotectives. It is generally observed that cholesterol lowering therapy is under used and under use of Statins leads to more cardiovascular events. If the patient is between the age of 40-75 years with diabetes and the LDL-C is 70-189 with clinical ASCVD, these patients must be put on Statins. Dietary advice and food, Prof. Ejaz Ahmad Vohra opined is very important. Patients should be advised to use lean fish, poultry products without skin. As regards cooking methods, grilling, biling and steaming were good.  There is no evidence that Statins has primary prevention in patients less than seventy five years of age. In diabetes, the benefits over weigh the small risk. Diabetes only occur in those patients using Statins who already are at high risk of developing diabetes. He also highlighted the importance of regular exercise, diet, life style modifications which are other options. Advice patients to use fish but remember fish supplements can be used with Statins but not with Fibrates, he added.

This was followed by an excellent presentation on Role of Aspirin in Primary Prevention of cardiovascular diseases by Dr. Fawad Farooq from NICVD Karachi. His presentation was based on case scenarios which helped the audience understand the subject better. He discussed in detail in which patients one should use Aspirin, Why and who should receive Aspirin therapy. He also referred to the assessment of cardiovascular disease and risk of bleeding and advocated rational use of Aspirin.

Dr. Fawad Farooq pointed out that the role of Aspirin in atherosclerosis is well established. Atherosclerosis starts early in life and it leads to plaque rupture. The whole process starts with lipid deposition which leads to inflammation and then thrombosis. Clot formation is the main culprit that is why we need antiplatelet therapy. He then showed the initiation and progression of plaque formation and when plaque ruptures, it leads to events like stroke and myocardial infarction. The plaque can rupture any moment that is why we give Aspirin to cover that risk.  In acute MI, the benefits of single tablet of soluble Aspirin 300mg is equal to streptokinase as regards reduction in mortality. However, he emphasized that irregular use of Aspirin will not be beneficial because an event may occur on the day when Aspirin was not taken. If Aspirin is used regularly, it will be there to take care of that event. One should always weigh benefits and risk. In patients with high risk of cardiovascular disease, benefits of Aspirin are much more. For the use of Aspirin therapy one needs to calculate the absolute risk. If the absolute ten years risk is less than 7%, there is no need for Aspirin therapy but if this risk is between 7-10%, one should discuss it with the patient before putting them on Aspirin therapy. However, if the risk is more than 10%, then these patients must be prescribed low dose Aspirin therapy of 75mg, 81m or 100mg. The most practical and easy way of calculating the risk, he opined, was to look at the risk factors. If a patient has more than two risk factors i.e. hypertension, smoking, diabetes or over weight etc., they should be candidates for primary prevention of CVD with Aspirin therapy.

Continuing Dr. Fawad Farooq said that in emergency, one should do proper assessment. All patients must have proper work up for TGs, Dyslipidemias. If a patient is more than forty years of age, is smoker and also suffers from diabetes, they are candidates for Aspirin therapy. His advice to his colleagues was to look at the patient as a whole, do proper work up before using Aspirin therapy.  He concluded his presentation by stating that one should identify and treat patients with significant risk factors.  Do not start treatment with Aspirin therapy with just one risk factor as regards primary prevention. Do complete risk assessment and take care of modifiable risk factors along with the use of Aspirin therapy. Replying to questions Dr. Fawad Farooq said that the concept of primary prevention is not properly understood. By Aspirin therapy we are preventing the events not the disease. Plaque can rupture any moment and we do not know which plaque is going to rupture and which will not rupture. That is why we advocate the use of Aspirin as it will protect that event taking place.

Prof. Najmul Islam from Aga Khan University discussed the management of diabetes in cardiovascular disease. He pointed out that Type-2 diabetes patients are increasing in every country. Most of the patients between the ages of 40-60 years will develop diabetes. That is why FDA says that all new diabetes drugs should have cardiac safety. Referring to MRFIT trial he said that it showed the efficacy of life style modification, exercise, behavior modification. At present twelve group of drugs are available for the management of diabetes including Insulin’s, Metformin, Bigunides and sulfonylureas. Speaking about the role of glycemic control he said that HbA1c level of about seven is good but lower than that is not recommended. Metformin is a safe drug to be used in patients with cardiovascular diseases. New generation of sulfonylureas offer more benefits. TECOS trial enrolled 14,661 patients which showed that GLP1 analogues are useful and more potent, safe as well as effective. In case of GI events with the use of Liraglutide one should discontinue therapy. He then discussed in detail the possible mechanism of action of SGLT2 Inhibitors the newer agents as regards cardiovascular safety and weight reduction. He also discussed the profile of anti-diabetic medications. TZD and Insulin both lead to weight gain. His conclusions were that one should educate the patients on life style modification, diet, exercise, weight reduction and use of Metformin. Choice of therapy should be individualized taking into account the risk profile of the patients. Replying to a question regarding maximum dose of Insulin, Prof. Najmul Islam said that there is no maximum dose, it should be used as per patient requirement. There are no scientific studies to prove the anti-aging effect of Metformin and it should not be used in acute setting.

Dept. of Cardiology at Isra University Hyderabad organized a Cardiology Update Symposium recently. 
Picture shows Dr. A.G. Qazi Hospital Director presenting mementoes to Dr. Ali Raza, 
Mr. Shaukat Ali Jawaid, Dr. Farooq Fawad, Prof. Najmul Islam and Dr. Syed Riazul Hassan.

Dr. Syed Riazul Hassan from Govt. Qatar Hospital Karachi talked about role of Beta Blockers in Heart Failure. He pointed out that there are no  local guidelines though we should have one but at the moment there are Guidelines from USA and Europe which are commonly followed. As per National Health Survey carried out in Pakistan, about 25% of our population over the age of forty five years have diabetes. The prevalence of heart failure is estimated at 23% as per one study done in Pakistan. He laid emphasis on assessment of risk factors, treating hypertension and diabetes. Treatment should be started with ACE Inhibitors and ARBs. All symptomatic patients should get ACE Inhibitors and beta blockers.  He then gave details of AHA Guidelines on Heart Failure issued in 2013 which says that patients with MI and reduced EF, one must add a beta blocker with ACE Inhibitors. He further stated that now use of beta blockers was increasing. Use of BBs for three to six months increases EF by 10%. The three beta blockers Bisoprolol 10mg, Metaprolol 200mg and Carvidolol 25mg are considered to be most safe and effective. One should always start with a low dose and gradually increase the dose in two weeks’ time. Studies have shown that with the use of Beta Blockers, all-cause mortality is reduce by 30-35% and various trials have showed that Beta Blockers are the drug of choice for Heart Failure patients. Carvidolol has shown risk reduction by 35%, Metaprolol has shown mortality reduction by 30% and reduction in other mortality and sudden death. COMET trial showed that Carvidolol was superior as compared with Metaprolol. He suggested thorough examination of the patient before increasing the dose.

At the end of the presentations A.G.Kazi Director of the Hospital presented mementoes among the speakers. He also thanked them for participating in the symposium and commended the efforts of Prof Feroze Memon and his team which keeps on organizing such academic activities from time to time. He is head of the Cardiology Department at Isra University and was in fact the Heart of Isra University as well, he remarked. Earlier Dr. Kashif Sheikh in his welcome address emphasized the importance of preventive measures, early detection and appropriate treatment. He also pointed out that facilities of primary PCI and interventional cardiology were available at Isra University Hospital.

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