On the basis of ACCF-AHA-HRS 2012 Guidelines, we can tell which patients will benefit from CRT-Dr. Azam Shafqat

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Cardiology Updates at Cardio Live 2014

On the basis of ACCF-AHA-HRS 2012 Guidelines,
we can tell which patients will benefit
from CRT - Dr. Azam Shafqat

Life style modifications are the foundations for
ASCVD prevention - Dr. Basheer Haneef

KARACHI: The morning session on September 28th during the recently concluded Cardio Live 2014 organized by National Institute of Cardiovascular Diseases was devoted to Cardiology Updates. It was chaired by Prof. Asadullah Kundi along with Prof. Salahuddin Afsar, Prof. Khalida Soomro and Prof. Feroze Memon. Dr.Zahid Jamal acted as the moderator.

Dr. Azam Shafqat from Saudi Arabia was the first speaker who discussed new indications for CRT and ICD. He pointed out that in the West; too many devices were being put in leading to mortality. With Cardiac Resynchronization therapy prolongation of QRS duration occurs in one third of patients with advanced heart failure. It leads to worsening of heart failure and sudden cardiac death or total death. As regards benefits of CRT, it leads to 30% decrease in hospitalization, 24-36% decrease in mortality. Sometimes CRT, Dr.Azam Shafqat opined has dramatic effects, it improves mortality, decreases hospitalization. As per 2008 guidelines, CRT was put in all patients with EF less than 35.Clinical trials have showed that one third of the patients did not get better. It was lot of burden on the family and physicians. Patients who are more likely to benefit have efficient target of therapy. QRS outcome is indication for this therapy. Patients with wider QRS benefit the most. Referring to the Meta Analysis of five clinical trials, he pointed out that if QRS duration is less than 150, benefits of CRT are restricted. LBBB benefits the most from CRT.

Giving details of ACCF/AHA/HRS focused Update 2012; Dr. Azam Shafqat said that if LBBB is more than 150 QRS is indicated. If QRS duration is less than 150, LBBB QRS is not indicated. On the basis of these guidelines, we can now tell which patients will benefit more from CRT. It is better to put bilead pacemaker than single lead pacemaker. He also referred to the single dual chamber ICR and said that there were more death of patients because of more pacing. His conclusions were that CRT benefit is the same in NYHA-II. CRT benefits in Atrial Fibrillation but combined with AV node ablation. In case of narrow QRS, there is no role for CRT.

Dr. Bashir Haneef from Taba Heart Institute Karachi was the next speaker and he talked about Novel changes in treatment goals for dyslipidaemias. He pointed out that preventive cardiology is more important. Almost 55% of total deaths, he said take place because of cardiovascular diseases and stroke. There is one third decline in cardiovascular mortality in the West. Use of Statins does reduce mortality and if LDL cholesterol goes up, mortality also goes up. Basis for the new guidelines are based on patient centered approach. It is important to know who should be treated at what intensity and which therapy should be used. Studies have showed that 39% reeducation in LDL resulted in 20% reduction in ACVD. He also discussed the dosing of Statins and said that in secondary prevention group, high intensity Statin therapy is needed. In Primary prevention group, diabetics, desired cholesterol is between 70-189. If there is more than 50% reduction in LDL with the use of one, two or three drugs, it does not mean treatment failure. He then gave details about the ASCVD Risk Calculator which he opined, was quite easy to calculate. Life style modifications, Dr.Basheer Haneef remarked is the foundations for ASCVD prevention. He also pointed out that single injection of a new Statin PCSK-9 now under trials will eliminate the need for daily pills. However, he also cautioned that one treatment does not fit all patients. If the ten years risk is more than 7.5%, all these patients should be put on Statin Therapy, he added.

Dr. Najib Basir from Aga Khan University was the next speaker who said that American Medical Association has now declared obesity a disease. Cardiovascualr diseases risk factor start form childhood. Those children who are obese today will develop hypertension and diabetes in adulthood; they will suffer form stroke as well as respiratory problems, sleep apnea, orthopaedic problems. Obesity also leads to insulin resistance. It is important that one achieves the treatment objectives and maintains a healthy weight. Role of exercise and dietary changes is most important while medications should be used as a last resort. He also talked about obesity surgery.

Prof. Feroze Memon from Isra University Hyderabad discussed guidelines for management of heart failure and laid emphasis on carefully taken history and physical examination. When we were told about this by our teachers, we never listened to them and never gave it the importance it deserved. He hoped that our students will listen to it and do not make the mistake we did. It is not advisable to use ACEI and ARBs together. ICD therapy is useful for primary prevention of sudden cardiac death in selected cases. Diuretics are helpful in hospitalized patients. He reiterated that history and physical examination was the mainstay for treatment of heart failure and it is possible to reduce effective reduction in re-admission after heart failure.

Dr. Najma Patel from NICVD was the last speaker in this session. She discussed when and how to use pulmonary vasodilators in pulmonary hypertension. She also discussed in detail the treatment goals in pulmonary hypertension and use of anticoagulation, diuretics, and digoxin. Pulmonary Hypertension, she opined, should be treated by specialists and not by everyone and it was important to do proper investigations before writing a prescription.

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