CHD is likely to emerge as major paediatric health problem in many developing countries-Shakeel Qureshi


NICVD Golden Jubilee celebrations

CHD is likely to emerge as major paediatric health
in many developing countries - Shakeel Qureshi

When I left NICVD in 2002, we had 11 cardiac surgeons, 6 anesthetists, 4 OTs,
20-Bed ICU and number of support staff had also increased- Prof. M. Rehman

Cardiac surgeons should adopt Clinical assessment as the primary
approach, possess leadership qualities, should be optimist 
to adopt new technology and uphold professional ethics

KARACHI: National Institute of Cardiovascular Diseases (NICVD) organized a three day symposium to celebrate its golden jubilee from August 23-25th2013 which was very well attended. The salient features of the celebrations included live telecast of paediatric interventions and peripheral interventions besides a special session on Role of NICVD in promoting the discipline of cardiology in Pakistan, session on Non-Communicable Diseases and ethical issues in medical practice. The morning session on Friday 23rd August was chaired by Prof. Ghaffar Billoo and Prof. Kalimuddin Aziz. Dr.Khusro Niazi was in the Cath Lab showing live procedures and discussed evaluation of peripheral arterial diseases highlighting Tips and Tricks in these procedures.
Participating in the discussion Dr. Basheer Haneef from Taba Heart Institute said that below knee are very complex cases for which one needs all sort of equipment apart form coronary catheters. Inventory should be such which takes care of such complex disease. Dr.Khusro Niazi opined that peripheral equipment and even balloons were cheaper than coronary equipment. Dr. Basheer Haneef remarked that here in Pakistan they cost the same but Dr. Khusro Niazi felt that peripheral balloons should be cheaper.
This was followed by a presentation by Dr. Ameen on adult congenital heart disease. This was an eighteen years old patient with complex congenital heart disease. For how long therapeutic coagulation is required in such cases also came under discussion. Dr. Shakeel Qureshi from London participating in the discussion said that we do not frequently start coagulation in such cases.

Prof. Qasim Memorial lecture

Prof. S. M.Rab along with Prof. Aziz Jamal Naqvi chaired the next session which was moderated by Prof.Akhtar Hussain. Dr. Shakeel Qureshi from UK delivered Prof. A.M.Qasim Memorial lecture. He mentioned that late Dr. Qasim was the first Director of NICVD who died in 1964. He then elaborated the achievements of interventional programme at NICVD. It was felt that there was a need for paediatric interventional cardiology in Pakistan and it needed both internal and external help. Prof.Kalimuddin Aziz and Dr. Najma Patel made a commendable contribution and international experts came here to show live interventional procedures. For any interventional programme to be successful, commitment of the local team, Dr. Shakeel Qureshi stated is needed. One needs support of paediatric cardiologists for complex procedures. The first paediatric cardiology symposia were held at NICVD for which late Mr. Asad Arain extended valuable help and assistance from the industry. Reports show that less than five child mortality was rising in four countries which include India, Nigeria, China and Pakistan. Apart from diarrhea, pneumonia, malaria and malnutrition are major problems. Disease burden is rising and developing low income countries face lot of problems in cardiac care. He also referred to the apathy of government, society, medical profession and the industry which are all responsible for the present state of affairs, he remarked.
The prevalence of congenital heart disease in Pakistan is reported to be six per thousand live births and six lac fifty thousand patients are added every year. There are about twelve million total populations with congenital heart disease and 50% of them have significant congenital heart disease that requires treatment. We must take interest in treating congenital heart diseases. Dr.Shakeel Qureshi was of the view that congenital heart disease is likely to emerge as major paediatric health problem in many developing countries. The discipline of paediatric cardiology is either absent or is very poorly developed in most countries. The problems include lack of manpower, training facilities and brain drain. Management of CHD, he stated, has to be a local decision, local faculty support and funding and not by foreign experts. For training of personnel, visits of teams from developed countries can be helpful and one can look into some sort of an exchange programme for training of doctors, nurses and paramedics.
He then referred to the impact such collaboration had in Warsaw. From 1990 to 2006, they have done over three thousand interventional procedures. In Pakistan we saw foreign experts started visiting Karachi and Lahore, worked in collaboration with the local team and performed one hundred seventy interventional procedures in a year and this number rose to four hundred seventy four in 2006. Some of the procedures performed included ASD, PDA closure, complex ASD case, post mustard VSD closure. Dr.Shakeel Qureshi emphasized that not all cardiac centers are capable of developing paediatric cardiology services. Increasing burden of CHD is a challenge and we were just sowing the seeds, he added.

History of cardiac surgery in Pakistan

Prof. Surgeon M. Rehman was the next speaker who talked about history of cardiac surgery in Pakistan. His presentation focused the developments from 1975 onward and he divided it into two phases’ i.e decade of equipment and improvement and decade of training. Dr. Boss, he said is reported to have performed the first cardiac surgery in Pakistan. Then Surgeon Iftikhar Rathore, Gen.Akram, Prof. Col.Cheema and Prof.Amjad Husain performed cardiac surgery at various centers in Pakistan. I joined NICVD in September 1975. At that time we had four beds in ICU, two monitors and two ventilators. We did not have any dedicated surgical ward till 1977. From1980-1990 the quality of work improved and cardiac surgery facilities were extended to all over the country. Training of human resources was taken up and we were able to gain confidence of the public but the elite class still went overseas for cardiac surgery treatment.
Start of cardiac surgery at OMI a private hospital in Karachi was a significant development. Later on cardiac surgery started at AFIC, LNH, PIC, Quetta, Multan and many private healthcare facilities in Pakistan. From 1990-2000 was the decade of training and we put lot of emphasis on training of cardiac surgeons. FCPS in cardiac surgery started in 1999 when NICVD was recognized for training. We also started MS in cardiac surgery at the same time. During ten years we produced eighteen cardiac surgeons and two did MS in cardiac surgery. I left NICVD in 2002 and at that time we had eleven trained cardiac surgeons, six anesthetists, four operation theaters, twenty beds ICU and the number of other support staff had also increased. Giveing figures of open heart surgery at NICVD, Prof.Rehman said that during 1980-1988 the number of CABG procedures increased enormously. While there was 50% reduction in mortality in UK between 1963-1990 because of management protocol and risk reduction programme but we had a very poor risk reduction programme. AIM of CABG, he said, is relief of symptoms and increased survival of patients with conventional CABG. Off pump coronary artery bypass was also started followed by port access programme and robotic surgery are the new developments. Future of cardiovascular diseases, he said, depends on life style, genetics, and management facilities. He also talked about different prosthetic valves and the qualities of an ideal prosthetic valve. Valvular repair is durable. Tricuspid mitral valve can be repaired but need monitoring and follow up. Aortic valve repair has lot of complications and it is better to replace it, he remarked.
Speaking about congenital heart diseases, Prof. Rehman said that some diseases need total correction in neonatal stage. Some CHDs seen in infancy include PDA, ASD and LVOTO lesions. His message to cardiac surgeons was that while managing patients, clinical assessment should be the primary approach. Good leadership qualities, be optimist to adopt new technology and keep up the professional ethics.

Paediatric Cardiology in Pakistan

Prof. Kalimuddin Aziz discussed evolution of paediatric cardiology in Pakistan which he said had been intellectually stimulating for him. USA has played a great role in promoting paediatric cardiology followed by Japan, Australia, Europe and then by the Indo-Pakistan sub-continent as well. He was of the view that public services at NICVD are unparalleled. He commended the contributions of Prof.Shaukat Ali Syed for NICVD and it was he who helped start paedaitric cardiology here in 1980. We started with two OPDs per week and we had eight beds. CPSP started FCPS in paediatric cardiology in 1986 and it was Prof. Surgeon M. Rehman and Prof.A.J.Naqvi who started doing paediatric cardiac surgery at NICVD. He also referred to the great contributions by William Raskind to promote this specialty as he created all sort of devices. It was in 1997 that Pakistan Paediatric Cardiac Society was founded and now we have thirty five paediatric cardiologists in Pakistan. Prof.S.M.Rab and Prof.Sultan Farooqui at CPSP were very considerate which paved the way for starting FCPS in paediatric cardiology, he added.

Past, Present and Future of cardiology in Pakistan

Prof. Azhar M.A. Farooqui made a presentation on past, present and future of cardiology in Pakistan. He pointed out that Rheumatic Fever and Rheumatic Heart Disease were rampant in Indo Pakistan and IHD was a major problem. It was late Col.M.H.Shah who first started the Heart Clinic at JPMC. Later Prof. A.M. Qasim and Prof. Shaukat Ali Syed contributed a great deal to develop this specialty. First angiography and intracoronary thrombolysis was performed in Pakistan in 1982. We started Diploma in Cardiology at NICVD in 1980, FCPS in 1982 and MD cardiology in 1986. As regards future of cardiology, he referred to the increasing gap between haves and have nots in Pakistan. At present we are delaying major cardiovascular events and not curing the disease. Lot of CVD is preventable. Prevention should be our priority. Future challenges are not in technology. There will be little gains with technology and it will become an ethical problem. Unless we wake up, there is no bright future for cardiology in Pakistan, he added.
Summing up the deliberations Prof.S. M. Rab who was chairing this session said that the affluent class did not allow promotion of health services and progress of this country. We have failed to stop migration from the country and all good role models have gone. Academicians have gone and mechanics have come in. Materialistic virus has infected every one in Pakistan medical profession being no exception. Materialistic attitude is very much evident but devotion, dedication, morality is lacking. Young people want short cuts for progress but still we had few people who loved Pakistan. Jinnah Central Heart Clinic established by late Col.M. H.Shah laid the foundation of NICVD hence Col. Shah can be rightly termed as the founder of NICVD. As is often said, all developments including health services in developing Third world countries revolve around the illnesses of the king and that is what we have seen happening in Pakistan including the establishment of cardiac tertiary care facilities, Prof.Rab remarked.
Prof. A. G. Billo who was co-chairing the session commended the contribution of NICVD to promote cardiology and cardiac care services in Pakistan. This great institution, he said, has given so much to Pakistan. Almost every cardiologist or cardiac surgeon has been trained here. As such it has made great contribution in this field. Prof.M.Rehamn contributed a great deal and so was the case with all the Executive Directors including the present Director Prof. Khan Shah Zaman Khan and they should continue to give much more, he added.
Prof. Masood Hameed Khan along with Dr.Samad Shera chaired the first session on August 25th wherein Dr. Zahid Jamal was the moderator. Prof. Kalimuddin Aziz was the first speaker who opined that we have to train physicians for primary care and it requires an integrated health delivery system. He laid emphasis on change in life style at early age. Full blown disease, he stated, is easier to treat. Prof.Saulat Siddique spoke about Home Blood Pressure monitoring which he stated was most prevalent fast growing service. He referred to various guidelines and also talked about reasons for non-compliance with therapy. Hypertension, he said, should be treated early and aggressively to get to target and prevent organ damage. Home blood pressure monitoring is possible. He then referred to the benefits of combination therapy and home blood pressure monitoring. His advice was that one should use validated monitor, use appropriate cuff size and follow accurate resting technique. BP should be taken before medication in the morning or two hours after dinner. Numerous studies have showed that with home blood pressure monitoring, patients are likely to take medications regularly and it also prevents organ damage, he added.
Dr. Naila Zahid in her presentation talked about screening and early diagnosis of cancer. Invasive cancer she said is end stage of tumor genesis. Cancer is a heterogeneous disease; the understood risk factors include genetics, life style environment, history, age etc. She then talked about breast self examination, clinical examination, mammography in detail. In case of colorectal cancer, early diagnosis ensures better survival. Early removal of adenomas prevents colorectal cancer. Flexible sigmoidoscopy offers many advantages.
Prof. Masood Hameed Khan in his address said that we need more institutions like NICVD in Pakistan for teaching and training. Early life style changes are important. Dr.Ajmal Kazmi talked about Hypertension and Depression. Patients with depressed mood show lack of interest and they do not enjoy life. They need to be looked after by psychiatrists, he remarked. Prof. A. Basit Director BIDE discussed diabetes mellitus in developing world and pointed that we have 6.6 million people with diabetes and another 7.6 million with IGT which is known as prediabetes stage. Our study in Layari area showed the prevalence of metabolic syndrome to be 49% among people above twenty five years of age. Two years later survey showed that prevalence of hypertension had doubled and obesity tripled in the same area. As per estimates we have about 9.6 million children who are obese or over weight and we need indigenous solutions to our problems, he stated. He also gave details of various programmes BIDE is running like Diabetes education, Diabetic Foot care programme and Diabetes in Children. So far BIDE, he said, has trained ninety seven diabetes educators and with diabetic foot care clinic, we have achieved 75% reduction in amputation at our center. We have established 115 diabetic foot clinics in the country but we need at least 1700 such clinics all over Pakistan. During the last one year we have trained 310 primary care physicians in diabetes care and we will soon start Gestational Diabetes project, Prof. Basit remarked.
Others who spoke in this session included Dr. Samad Shera, Dr. Basheer Haneef and Dr. Javed A. Khan. Prof. Kalimuddin Aziz referring to the various presentations remarked that the speakers should share with the audience what they have done and how to solve our problems. It is of no use to present statistics from USA and other developed countries which is all available on the internet. People come here to attend such meetings sparing their valuable time and spending lot of money, hence they need to get some knowledge to improve their practice thereby improving patient care, he remarked.