Risk factors should be treated aggressively and Reduction in blood pressure must be in Therapeutic range-Prof. Shahbaz Kureshi


Proceedings of PHL Conference-IV
Risk factors should be treated aggressively
and Reduction in blood pressure must be in
Therapeutic range-Prof. Shahbaz Kureshi
Training of CHWs, LHWs, and Provision of affordable
medicines in the form of combination Pill may help in
control of Hypertension-Dr. Amar Hameed

Peshawar: Prof. Shahbaz Kureshi an eminent cardiologist from Islamabad was one of the invited guest speakers at the Paksitan Hypertension League conference held here last month. In his presentation he discussed in detail the Distinct Role of ARBs beyond Hypertension Management. In co-morbid conditions, he said, the number of drugs being used to manage hypertension is going to increase. Hypertension is the cause of death more than other risk factors. Just 2mmHg reduction in blood pressure will reduce IHD by 10%, similarly there will be significant reduction in mortality from stroke and all other cause mortality. Reduction in blood pressure, he opined, must be in therapeutic range. Hypertension management is a team work in which nurses, pharmacists and technicians also play a vital role. Risk factors, Prof. Shahbaz Kureshi sated must be treated aggressively. Advise for salt reduction, screening and proper diagnosis of hypertension, early identification of those at high risk. Studies with Telmisartan show good results. Night dose will also cover the early morning surge of blood pressure, he remarked.

Prof. Shahbaz Kureshi

Prof. Intikhab Alam discussed the usefulness of early use of combination therapy in management of hypertension. He also laid emphasis on salt reduction, advised walk after dinner, regular exercise for at least twenty minutes a day. It is important to find out reasons for not achieving optimal control. Patients need to be told that it is a long term treatment and they must not discontinue therapy. Lack of compliance is the main reason for non-adherence. Combination Polypill has numerous advantages. He then shared the results of EFCITE Trial which studied twenty six drugs including Valsartan and Metformin.

Dr. Mustafa Iqbal from Khyber Teaching Hospital discussed ophthalmic complications due to hypertension and referred to retinal vein occlusion, effects on optic nerve blood supply which leads to sudden decrease in vision which is due to central retinal vein occlusion.

Dr. Zahid Miyan from BIDE Karachi in his presentation on Diabetes and Cardiovascular Diseases said that diabetes increases the risk of cardiovascular diseases. Mortality is also increased from chronic kidney disease. Speaking about Heart Failure and Diabetes, he said, the risk of heart failure or AMI is the same in people suffering from diabetes. Often patients who suffer from heart failure do not know that they are also suffering from diabetes. Any new drug for management of diabetes must prove to be cardio protective, it should have benefits or no effect on cardiovascular diseases only then it will be approved by the FDA. He then shared the results of an EMPA trial which had enrolled thousands of patients at five hundred ninety sites and in forty two countries. It showed significant reduction in death just after three months of treatment. One only needs to treat thirty nine patients to prevent one death. It showed that SGLT2 Inhibitors work very well. However, these SGLT2 Inhibitors should not be used in patients with eGFR less than 45. It is important that one selects the right candidates for these drugs. Those patients who are already on Metformin or have HBA1C of more than seven, one can add these SGLT2 Inhibitors in the therapy. During the discussion it was pointed out that more glucose loss may lead to some other problems, complications. In a study of osteoporosis, 75% of the patients were on Statins and 80% were on ACEIs or ARBs.

Dr. Usman Khalid in his presentation emphasized that blood glucose control is more important in the treatment of hypertension in patients suffering from diabetes mellitus. Dr. Nawaz Lashari from DUHS Karachi discussed management of Hyperlipidemias in the era of PCSK91 and said that these agents offer lot of advantages in patients with familial dyslipidemias. It has long duration of action, rapid onset effects but the disadvantages are the high cost.

Last day of the conference

On last day of the PHL annual c conference on March 8th, Dr. Zahoor was the first speaker in the session devoted to electrophysiology and he presented a few case histories managed at Heart Hospice. In the first case he presented, he said Appendage AT is a rare condition and there is always risk of perforation. Second case was a 28 years old female primary Gravida. It was yet another rare case involving pregnant women, though there was risk of radiation but it was also managed successfully. The third case was a thirty eight years old male. It was case of PVC which is also a rare condition.

Prof. M. H. Nuri

In the other session Dr. Amar Hameed from Aga Khan University talked about Pakistan Hypertension Guidelines and its current status. Referring to the landmark Hypertension Trial, he pointed out that 50% of the time people do not have medicines. There is lack of data regarding life style changes. We also lack good role models. We are trained to be emotional, sensitive and passionate. Physicians are too busy and we do not take the side effects of drugs seriously. He highlighted the importance of taking blood pressure outside the hospital environment. We need to set up Blood Pressure centers and promote physical activity. We need to put more emphasis on management of hypertension during undergraduate and postgraduate training. We need to train dedicated nurses for management of Hypertension which gives good results. We also need to train our community health workers. Home Health should be given due importance. We need to show commitment to hypertension control, use all resources and provide enabling environment. We should start a Registry, prepare locally relevant training guidelines. Ensure proper follow up of patients under treatment and promote the use of combination Pill therapy. Using some of these measures, the BP control was increased from 45.7% to 76.3% in just ten years time. We need to come up with a National Plan. Government should be on board and it must also show its commitment. We must develop a document, use social media and artificial intelligence. Once we have the data, we can use it.

Dr. Amar Hameed concluded his presentation by emphasizing that training of healthcare professionals was very important. We also need to have a network of clinics, pharmacy, promote home health education, have Data Registry and do some self assessment, provide enabling environment. We must ensure provision of evidence based affordable medicines in the form of combination Pill. During the discussion the idea of Hypertension Houses was also floated where all facilities should be available and people can go and get their BP checked. Setting up Hypertension Counters in Hospitals, training of community health workers, lady health visitors also figured in the discussion. Physicians cannot have too much time but we need some Champions and we can make a start from the PHL involving the young doctors, Dr. Amar Hameed remarked.

Maj. Gen. M.H. Nuri from Tahir Heart Institute discussed the usefulness of Stents, Denervation and Novel Devices in resistant hypertension. He showed some interesting slides of renal artery stenting, renal denervation, RF Ablation, Cryo Ablation, Laser Ablation, Baroceptor Activation Therapy, some novel devices to control resistant hypertension like Baroflex Activation Therapy. He also talked about stem cell repair, cardiac repair and after six weeks to six months, remarkable improvement was witnessed. He then talked about normal methods of improving renal function. Renal hypertension, he said, is a serious problem and medication is only partially helpful. We need to understand the mechanism of this activity. His conclusions were that life style change and medication in conjunctions with device therapy may cure renal hypertension.

Dr. Iqbal Haider in his presentation remarked that both genders have some differences in treatment of hypertension due to differences in pathophysiology. Dr. Sheikh Fahad Falah spoke about Concordance with Ant hypertension treatment and highlighted the issues related to poor concordance, poly pharmacy, side effects of drugs, complex treatment schedule, depression and lack of patient’s insight into their illness. He suggested that one should have high index of suspicion about those patients taking medicines before deciding to add a new drug.

Dr. Imtiaz Jehan presented details of a community based intervention for managing hypertension in rural South Asia. This study enrolled 2,250 patients from rural areas of Pakistan, Sri Lanka and Bangladesh. After two years intervention these patients were all followed up. Patients with a BP of 140/90 or above were enrolled for treatment. Thirty clusters were selected in these three countries. The healthcare facilities available in the area were looked at, GP’s Basic Health Unit staff were trained in Blood Pressure measurement. BP was taken after a six months visit. There was a twenty four months follow up. From Pakistan, ten Union Councils in Thatta District were selected for this study. Sri Lanka has a well developed primary healthcare care set up than Pakistan but in Bangladesh the situation is similar to Pakistan. Our study showed an overall hypertension prevalence of 19%. We had encouraging results as regards blood pressure control. Co-morbidities in these patients included diabetes and stroke. She pointed out that if we keep on waiting for patients to come to us, they will never come but we will have to move into the community if we are sincere to control hypertension. Those working in the rural areas can refer the patients to healthcare facilities. Medicines should be made available at these facilities. In this study four drugs were given to the patients at the Basic Health Unit. Public awareness about these facilities, education of the patient community to use these facilities is important. Using the Lady Health Workers at primary healthcare set up in Pakistan could be the way forward, she added.

During the discussion many participants expressed surprise at the low prevalence of hypertension i.e. just 19% in this study whereas all other studies have quoted much higher prevalence figures.

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