Aspirin remains the wonder drug in the 21st century which reduces cardiovascular diseases, stroke, morbidity and mortality and colorectal cancer with long term use-Prof. Ejaz Ahmad Vohra


 Breakfast Session on Aspirin at PHL Symposium Faisalabad

Aspirin remains the wonder drug in the 21st century
which reduces cardiovascular diseases, stroke, morbidity and mortality and colorectal cancer
with long term use- Prof. Ejaz Ahmad Vohra

Aspirin is essential for primary prevention of atherosclerosis induced
cardiovascular diseases in selected group of patients-Dr. Junaid Zafar

FAISALABAD: Pakistan Aspirin Foundation organized a Breakfast Session on Medical Uses of Aspirin on February 24th 2018 during the 21st Annual Symposium of Pakistan Hypertension League held here from February 23-25, 2018. The speakers included Dr. Junaid Zafar Associate Professor of Cardiology Fatima Jinnah Medical University Lahore, Consultant Cardiologist at Hameed Lateef Hospital Lahore and Prof. Ejaz Ahmad Vohra an eminent physician, Director Postgraduate Studies (Clinical) and Chairman Department of Medicine at Ziauddin University Karachi who is also a former President of Pakistan Aspirin Foundation. Members of the Experts Panel included Prof. Abdul Hafeez Chaudhry former President of Pakistan Hypertension League, Prof. Akbar Chaudhry Principal Azra Naheed Medical College who is also former President of the Pakistan Aspirin Foundation, Prof. M. Ishaq, and Prof. Feroze Memon while Dr. Muhammad Sarfraz was the Moderator of the session.

Prof. Ejaz Ahmad Vohra, Dr. Junaid Zafar, Mr.Shaukat Ali Jawaid and Muhammad Sarfraz speaking at
the Aspirin Breakfast Session held during the PHL symposium at Faisalabad on Feb. 24th 2018.

Dr. Junaid Zafar who talked about use of Aspirin in primary and secondary prevention of cardiovascular diseases highlighted the safety and efficacy of Aspirin in heart diseases. He discussed in detail atherosclerosis related cardiovascular diseases besides highlighting the findings from various studies which have shown significant reduction in morbidity and mortality, cardiac and non-cardiac events. He specially referred to cardiovascular diseases risk calculator for patients suffering from hypertension as well as diabetes mellitus.

Aspirin-Guide App he further stated can be used for calculation of risk. He opined that Aspirin is essential for primary prevention of atherosclerosis induced cardiovascular diseases in selected group of patients. The guidelines recommend the use of Aspirin in patient who have high ten years cardiovascular risk score. The risk of benefit with Aspirin should be weighed against the risk of bleeding.

The Aspirin-Guide app

The Aspirin-Guide app, it may be mentioned here has been developed by researchers at Brigham and Women’s Hospital, Harvard Medical School. It helps clinicians to decide which patients are candidates for the use of low-dose Aspirin (75 to 81 mg/d) in the primary prevention of atherosclerotic cardiovascular disease (ASCVD) by balancing the ASCVD benefits against the risk of harm. Gastrointestinal bleeding is the major risk apart from other side effects. Physicians can easily use this Aspirin-Guide app, incorporate information about the patient’s risk factors to calculate a 10-Years ASCVD risk score. Balancing the risk score, helps the clinicians implement clinical guidelines on the use of Aspirin in primary prevention. One has to calculate the ten years likely risk before taking a decision to use Aspirin for primary prevention.

Aspirin Update in the 21st Century

Prof. Ejaz Ahmad Vohra’s presentation was on “Aspirin Update in the 21st Century”. Low dose daily aspirin, he stated, has demonstrated its efficacy in substantially reducing the risk of cardiovascular diseases with more than 10% risk and colorectal cancer in adults. However, adherence to Aspirin is a major problem as even in United States, less than 50% patients with ischemic vascular disease are prescribed antiplatelet medications while the rates are even lower in primary care. Aspirin, he opined, remains the wonder drug in the 21st century because besides decreasing cardiovascular diseases, stroke, morbidity and mortality, it reduces colorectal cancer with long term use more than ten years. It also reduces the incidence of pre-eclampsia.

It can be used as an alternative in atrial fibrillation if other anti-thrombotic agents are not suitable. Its other uses include prevention of Deep Vein Thrombosis (DVT). Every day there are new studies highlighting new uses of Aspirin which surprises the healthcare professionals? He discussed in detail the pharmacology of Aspirin, its well established sues, the new and emerging uses of Aspirin, primary prevention of cardiovascular diseases and colorectal cancer, other cancers besides prevention and treatment of pregnancy induced hypertension, preeclampsia.

Historical background

Tracing the history Prof. Ejaz Vohra stated that it was in 1897 when Felix Hoffman first developed Aspirin. In 1945, Singer noted increasing bleeding when ASA was used as an analgesic. In 1950, Craven recommended ASA for male patients between the ages of 40-65 for prevention of coronary thrombosis. John Vance was awarded Noble Prize for prostaglandin inhibitory mechanism of Aspirin in 1982. In 1988 the Antiplatelet Trialists Collaboration Trial showed that regular use of Aspirin leads to 25-30% reduction in cardiovascular events. Data confirms the efficacy in primary and secondary prevention of vascular diseases. The extended use of Aspirin is based on antiplatelet and anti-inflammatory effect. He then referred to the role of Aspirin beyond Cox-inhibition. There is a slight risk of bleeding with the use of Aspirin, the incidence of major bleeding is reported to be 1.54%.

Prof. M. Ishaq along with Prof. Ejaz Ahmad Vohra other distinguished cardiologists and members of
Pakistan Aspirin Foundation presenting a Cheque for Rs. Five hundred thousand to the
representative of Citizens Foundation as a donation on behalf of Atco for education
of children at
the Aspirin Session during PHL Symposium at Faisalabad.

Use of Aspirin for the treatment of Acute Coronary Syndrome was also discussed in detail. A comparative study with Placebo regarding primary prevention of cardiovascular events in hypertension which enrolled over nine thousand patients in each group showed significant reduction in major cardiovascular events, acute myocardial infarction, stroke, cardiovascular mortality besides all-cause mortality.

Regular use of Aspirin in patients with diabetes also showed about 11% reduction in cardiac diseases, cerebrovascular diseases. Similarly the regular use of Aspirin in patients without diabetes also showed risk reduction of 4.8% in cardiac diseases while 9.3% reduction in overall causes. With the use of Aspirin and Statin, patients suffering from diabetes without CAD has the same risk for myocardial infarction as that on Non-diabetics. This was shown by a Danish study published in Diabetes Care in 2017.

Use of Aspirin in Neurology

Talking about the use of Aspirin in Neurology, Prof. Ejaz Ahmad Vohra said that it increases the risk for intra cerebral hemorrhage hence one needs to balance the risk against its benefits. Most common use of Aspirin in stroke is for acute stroke, acute TIA or minor stroke. Different guidelines recommend Aspirin for acute ischemic stroke, he added. The effects of Aspirin in TIA and minor stroke are probably larger and more beneficial than high risk events. Combination of Aspirin and Clopidogrel is more effective in preventing stroke after TIA compared to aspirin alone.

For long term prevention of stroke, Aspirin monotherapy is an option in treatment guidelines. The initial benefit of Aspirin is maintained. Other antiplatelet drugs like Clopidogrel are also effective and combination of Aspirin and Clopidogrel is also recommended. Various studies have also confirmed that medical treatment substantially reduces the risk of early recurrent stroke after TIA and minor stroke and Aspirin is identified as the key intervention. Early benefits from Aspirin therapy demands that we must educate the public about self-administration after possible TIA, he remarked.

Aspirin in combination with other drugs

Speaking about the use of Aspirin in combination with other drugs, Prof. Ejaz Ahmad Vohra stated that there are numerous studies which shows that Aspirin if added to streptokinase reduces the mortality by 40%. For secondary prevention, Aspirin is combined with Clopidogrel which reduces vascular mortality by 8.7% during the first year.

Ticagrelor improves benefits but there are no long term effects. Aspirin added to Rivaroxaban and Clopidogrel though reduces the mortality but it has three times more risk of bleeding.

Aspirin and Cancer Prevention

Safety and efficacy of long term use of Aspirin in colorectal cancer is now well established but the benefit is only after almost ten years use. It also reduces the risk of cancer in Esophageal Cancer, Gastric Cancer, Lung cancer etc. A study published in Lancet in 2012 showed that use of aspirin was associated with 46% reduction in risk for adenocarcinoma, common malignancy of lung, colon and prostate. Researchers have also found that use of low dose Aspirin for a period of five years or more reduced the risk of dying from cancer by 37% and developing cancer by 25%.

Similarly regular use of Aspirin after diagnosis of colorectal cancer could significantly increase survival of patients. In yet another study significant reduction in digestive cancer incidence has been linked to long term use of Aspirin. There was 47% reduction in liver and esophageal cancer incidence, 38% reduction in the incidence of gastric cancer, 34% reduction in incidence of pancreatic cancer and 24% reduction in incidence of colorectal cancer.

Use of Aspirin for primary prevention

There have been some studies on use of Aspirin for primary prevention of cardiovascular diseases as well as colorectal cancer. However, more data is needed on primary prevention in patients at high risk for cardiovascular diseases.

Emerging uses of Aspirin

Other emerging uses of Aspirin include prevention of pulmonary embolism and Deep –Vein Thrombosis after Hip Fracture and other major surgeries. WARFASA Clinical trial concluded that Aspirin reduces the risk of recurrence of thromboembolism when given to patients with unprovoked venous thromboembolism who had discontinued anticoagulant treatment with no apparent increase in the risk of major bleeding.

Aspirin in Pregnancy

Aspirin is the drug of choice for prevention of pre-eclampsia. Meta-analysis of individual patients published in Lancet in 2007 showed that use of Aspirin by women at risk of pre-eclampsia gestation hypertension or fetal growth restriction had relative risk reduction. Low dose Aspirin is not recommended for the prevention of pregnancy loss. American College of Gynecologists supports the recommendation to consider the use of low-dose Aspirin which should be initiated between 12-28 weeks of gestation for the prevention of pre-eclampsia.

Speakers and Members of the Panel of Experts responding to various questions from the participants
regarding medical uses of Aspirin at the Aspirin Breakfast Session held during
PHL Symposium at Faisalabad on February 24, 2018.

Continuing Prof. Ejaz Ahmad Vohra said that numerous trials have tested the hypothesis that platelet inhibition with aspirin can lower subsequent vascular events in people with cardiovascular disease. The benefits of Aspirin in secondary prevention significantly outweigh the risks, Prof. Ejaz Ahmad Vohra concluded.

Panel Discussion

The presentations were followed by lively discussion. Those who actively participated in the discussion included Prof. Akbar Chaudhry, Prof. Shahbaz Kureshi, Prof. Shahbaz Sarwar, Prof. M.Ishaq and Prof. Shaukat Malik. Responding to a question regarding Aspirin resistance, Dr. Junaid Zafar remarked that its incidence was less than 6-7%. Mr.Shaukat Ali Jawaid pointed out that they are the non-responders as some patients do not respond to different drugs. Responding to a question from Prof. Shahbaz Kureshi it was stated that one has to take low dose Aspirin daily because new platelets are formed daily. While using combination of Aspirin and Clopidogrel, the increased side effects of bleeding must be kept in mind.

However, if an antiplatelet in monotherapy has to be used, then Aspirin is preferred. In acute conditions, one has to use soluble Aspirin one full tablet and routinely it is preferred that low dose Aspirin should be taken at night as it will take care of early morning spike in blood pressure as well. However, when the patients are taking too many drugs, the treating physician should decide when the patient should take Aspirin. As regards the use of Aspirin for primary prevention of cardiovascular diseases, it was stated that ARRIVE study which was sponsored by Bayer, has just completed and its findings when published will give a clear answer. However, it is being used for primary prevention in patients who have some other risk factors.

Mr.Shaukat Ali Jawaid also pointed out that some gynecologists are also using low dose Aspirin with excellent results in infertility, in patients with recurrent miscarriages and bad obstetric history. However, since there are no properly planned scientific studies, one cannot include it in the recommendations.

Photographed during the Aspirin Session at PHL Symposium at Faisalabad on February 24th from
(L to R) are Mr. Kashif Riaz from Atco, Prof. Haroon Babar, Prof. Shaukat Malik,
Prof. Ejaz Ahmad Vohra, Dr. Jalal Uddin Achakzai, Mr.Shaukat Ali Jawaid and Prof. M. Ishaq.

Earlier Mr.Shaukat Ali Jawaid General Secretary Pakistan Aspirin Foundation in his brief address pointed out that ever since its inception, Pakistan Aspirin Foundation, has kept up the professional ethics. There is no company bias nor Pakistan Aspirin Foundation promote any particular brand name of Aspirin. However, we are extremely grateful to M/s Atco Laboratories who are sponsoring our Continuing Medical Education programmes for the last many years creating awareness among the healthcare professionals as well as public about the use of Aspirin in its well established indications. We have a very democratic set up. All the founder members are being elected as President by rotation and no one is eligible for a second term.

M/s Atco Laboratories had sponsored this Breakfast Session which was very well attended by members of the medical profession attending the annual symposium of Pakistan Hypertension League. A cheque for Rs. Five hundred thousand was also presented to the Representative of The Citizen Foundation on behalf of Atco Laboratories for education of children from the sale of Ascard.