PHL Symposium proceedings-II

Hypertension is first easily measurable irreversible
sign that many organs in the body are
under attack- Ejaz Ahmad Vohra

In Chronic conditions like CKD or heart failure BP target
should be less than 130/80 with appropriate medications

 We need Disease Registries to plan interventions
 Reduce disease burden-Prof. Abdul Basit

FAISALABAD: The first scientific session during the PHL symposium held here from February 23-25th was jointly chaired by Prof. Muhammad Tufail, Prof. Ghaffar Memon and Prof. Abdul Rasheed Khan. Prof. Ejaz Ahmad Vohra from Ziauddin University Karachi was the first speaker who talked on Hypertension 2017-2018 Times and Guidelines are changing. He pointed out that uncontrolled hypertension has conquered the world. In 2015 1.3 Billion patients were suffering from hypertension. Mortality from Non-communicable diseases is increasing. Hypertension, Diabetes Mellitus and obesity are all increasing with urbanization. People are moving from rural areas to urban slums.

Who takes the blood pressure and when you start the treatment is important. Blood pressure monitoring should be more reliable. Thickness of cloth while taking BP also matters. Speaking about the causes of obesity and overweight he also referred to some genetic predisposition. NCDs are estimated to account for 50% of total mortality as per WHO. Times have changed and treatment of hypertension is a difficult and almost hopeless task. Physicians need to convey the message that hypertension is the first and easily measurable irreversible sign that many organs in the body are under attack. It accounts for 30-40% of myocardial infarction and stroke. We need to reduce salt intake while physical activity has become very difficult in the cities. In case of co-morbidity, a BP measurement of 130/80 is ideal while 140/90 is treatable.

Prof. A. Hafeez Chaudhry President PHL presenting a memento to Prof.Ahmad Bilal
the chief organizer of the PHL symposium recently held at Faisalabad.

Prof. Ejaz Vohra also referred to various Guidelines for treatment of hypertension like ISH, NICE guidelines, AHA guidelines and said that it is an evolving process. In Pakistan, PHL in collaboration with Pakistan Cardiac Society had also published its Guidelines which has recently been revised. Prevalence of hypertension in USA is reported to be 30%. In elective surgery, beta blockers should be continued. Blood pressure should be re-evaluated one month after initiation of therapy and treatment. Hypertension is also responsible for up to 5% of heart failure cases and it also accounts for atrial fibrillation up to 50% and renal failure up to 25-30%. SPRINT trial has supported lower targets. Speaking about the justification of lower target BP as per AHA/ACC guidelines 2017, he said, meta-analysis has showed decreased strokes CVD events. He was of the view that ACE Inhibitors and ARBs should not be combined. He laid emphasis on primary prevention and felt that since it needs lifelong treatment, we need to educate the GPs and Family Physicians and make sure that all the essential drugs are used by the primary care physicians to control hypertension.

Prof. Ejaz Vohra concluded his presentation by stating that change in classification has resulted in increased prevalence of hypertension. A meta-analysis has demonstrated a fairly linear positive relationship for cardiovascular disease as the SBP increased past 115mmHg and the DBP increased past 75 mmHg. Thiazide or thiazide type diuretics, ACE inhibitors, ARBs, CCBs all are quite safe and effective though some of these agents like CCB Non-ihydropyridines B Blocker are excluded as primary agent. In black patients, thiazide diuretics and CCBs are preferred. One should start treatment with two first line agents separately or use fix dose combinations. In Chronic conditions such as CKD or heart failure BP target should be less than 130/80 with appropriate medications. In diabetes the target BP should also be less than130/80 and all first line antihypertensive like ACE inhibitors, ARBs are preferred in the presence of albuminuria. Home monitoring of BP should be encouraged. ABPM is not easily available and is also expensive. We also need to give emphasis on primary prevention to promote awareness, affordable treatment in primary prevention and educating regarding dangers of hypertension, the need for lifelong treatment besides importance of lifestyle modifications including reduction of salt intake to just five mg per day.

Dr. Samad Shera from DAP Karachi spoke about hypertension and diabetes UKPDS, he said had showed 50% reduction in complications with blood glucose control and treatment of hypertension. BP control leads to 67% reduction in heart attacks, 52% reduction in stroke and 51% reduction in amputation. Type-2 diabetes is more prevalent in Asia and we are genetically more predisposed to diabetes mellitus. Diastolic Blood Pressure of less than 60 mmHg, he said, was dangerous. Exercise improves insulin sensitivity, increases HDL cholesterol, decreases TGs and increases insulin absorption.

Prof. Abdul Basit from BIDE Karachi talked about Hypertension, Dyslipidemias and Obesity, Where do we stand today? He pointed out that survey done in 1994-98 had showed the prevalence of diabetes mellitus and impaired glucose tolerance was about 22%. Pakistan Health Research Council survey showed the prevalence of diabetes between 13-26%. Prevalence of overweight was 9.8%. Today our recent survey has showed the prevalence of diabetes was 26.3% among all adults over the age of twenty years. About 14.4% were pre-diabetics. Overall prevalence of hypertension was 52.6%. Hypertension and diabetes put together has a prevalence of 67.9%, prevalence of hypertension was 43% with diabetes. As regards obesity, at present 76.1% are overweight. Prevalence of dyslipidemia was 92.3%. He then shared the details of PROMPT Guidelines which are based on input by multiple stake holders. He concluded his presentation by emphasizing the importance of setting up Disease Registries and also gave details of some work which they had accomplished in this regard so far.

Dr. Owais Fazal was the next speaker who spoke on New Methodology for teaching medical students about diabetes and hypertension being implemented at Punjab Medical College, Faisalabad. This, he said, creates interests among students as we try to make it interesting. We have target patient selection, prescribed time schedule is now being followed. All wards at Allied Hospital teach the same thing at the same time. We have selected six main diseases which includes diabetes, hypertension, heart failure, stroke, Acute Renal Failure, COPD, and Asthma. Students are given Hands on training on how to control blood pressure. The students are confident, it clears their concepts and they clearly understand what they were talking.

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