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We need anti-platelet therapy for longer period as compared to the West-Prof. Samad.

As a part of its Continuing Medical Education programme and creating awareness about the uses of Aspirin among healthcare professionals, Pakistan Aspirin Foundation in collaboration with Atco Laboratories organized a meeting here on February 25, 2017. Prof. Akbar Chaudhry Principal Azra Naheed Medical College and Dr. Qazi Abdul Saboor Associate Professor from Shaikh Zayed Hospital were the two guest speakers. The panel of experts included Prof. Abdus Samad, Prof. Shahryar Sheikh, Prof. Khalid Masood Gondal and Prof. Javed Akram Vice Chancellor Shaheed Zulfikar Ali Bhutto Medical University who is also President of Pakistan Aspirin Foundation. The meeting was very well attended by family physicians, postgraduates and House Officers.

Dr. Qazi Abdul Saboor was the first speaker who talked about the use of Aspirin in primary prevention. He discussed in detail why and who should receive Aspirin for primary prevention of vascular diseases, rational use of antiplatelet therapy, assessment of cardiovascular diseases and bleeding risk. In the arterial disease, lipid deposition he said, leads to inflammation which then results in thrombosis. Talking about platelet cascade in thrombus formation he mentioned about adhesion, activation of platelet and then aggregation.

Vascular disease, Dr.Qazi Abdul Saboor stated is a generalized and progressive process. Aspirin at all clinical relevant doses produces a clinically relevant antiplatelet effect by irreversibly acetylating the active site of cyclooxygenase-1 which is required for the production of thromboxane A2 which is a powerful promoter of aggregation. Thrombus formation is superimposed on eroded atherosclerotic plaque. Major manifestations of thrombotic events include ischemic stroke, Transient Ischemic Attack, Myocardial Infarction, Unstable Angina and critical limb ischemia.

In secondary prevention the absolute benefits on occlusive events are far >the absolute risks of major bleeding. Low dose aspirin therapy has clearly and consistently shown substantial benefits for persons at high risk of subsequent events secondary to existing cardiovascular disease. A dose of higher than 75mg per day has shown no increased benefit, he added. Use of other antiplatelet do not offer superiority over Aspirin. This decrease in serious vascular events corresponds to an absolute reduction of 10-20 per thousand population in the yearly incidence of non-fatal events besides definite reduction in vascular related deaths.

In patients with aspirin allergy, other antiplatelet agents like clopidogrel can be used. These agents can also be used in case of intolerance to aspirin and in those patients who have had stents implanted. He further stated that despite well-established role of Aspirin in secondary prevention of MI, Stroke and deaths from vascular causes, Aspirin is substantially under prescribed. In primary prevention trials the Meta analysis showed a statistically significant 12% reduction in serious vascular events and 23% reduction in nonfatal MI. However, there were no significant effects on total stroke or vascular mortality. It also showed 14% reduction in risk of ischemic stroke and a 32% increased risk of hemorrhagic stroke.

As regards the use of Aspirin in patients with diabetes, data suggests that it produces modest reduction in MI and stroke. Trials have also shown a therapeutic benefit for aspirin on recurrent venous as well as arterial events after anticoagulants are discontinued with no apparent increase in risk of major bleeding. The US Preventive Services Task Force has encouraged the use of Aspirin in men over 45-79 years of age and 55-79 years of women. Continuing Dr. Qazi Abdul Saboor said that use of Aspirin for at least ten years decreases the risk of myocardial infarction and possible all-cause mortality.

Several meta-analysis have shown that aspirin reduces the risk of CVD in apparently healthy men and women. The potential benefits on cardiovascular diseases events from long term Aspirin therapy are achieved with a dose of 75-100mg daily. Those with low risk should not be given aspirin and in case of moderate risk, one should discuss with the patient but in high risk, low dose aspirin therapy is absolutely recommended. He concluded his presentation by stating that identifying and treating single risk factor was not enough to reduce CVS risk.

One should do comprehensive risk assessment and take care of all modifiable risk factors along with Aspirin treatment which should be the goal. Patients with diabetes and hypertension should be put on low dose aspirin therapy. Similarly those with high blood pressure and high cholesterol, hypertension and family history of IHD, Hypertension, smokers and with family history of heart disease should also be put on regular low dose Aspirin therapy which is also indicated for secondary prevention.

Prof. Akbar Chaudhry in his presentation first highlighted the disease burden and real threat to urban health with the epidemic of heart diseases. Solution, he emphasized, lies in prevention. He also gave a historical background to the development and use of Aspirin which was now being used in clinical practice for over hundred years. It was Dr. Felix Hoffman who first discovered Acetylation of salicylic acid in 1897. As regards well established indications of Aspirin he mentioned AMI, Acute Coronary Syndrome, Secondary prevention of MI, primary prevention of CAD, TIAs, and Prophylaxis of thrombo embolism following surgery, hypertension and diabetes. Major uses of Aspirin today was in cardiovascular diseases.

Speaking about the benefits of Aspirin Prof. Akbar Chaudhry said that it reduces the risk of first MI by 33%, Reduces the risk of first stroke by 25% and risk of CVD death by 17%. As regards its benefits in secondary prevention there is 46% reduction in events in unstable angina, 33% reduction instable angina, 23% reduction in peripheral arterial disease and 53% reduction of serious events in those patients who are undergoing angioplasty. Over the years there has been an increase in the use of Aspirin by Family Physicians as well as in hospitals, in emergency in its well established indications. Prof. Akbar Chaudhry also referred to the Guidelines on Medical Uses of Aspirin produced by Pakistan Aspirin Foundation which gives a detailed account of dose of aspirin in various diseases along with its contra indications.

A recent study at CPE Institute of Cardiology Multan published in Pakistan Journal of Medical Sciences has shown that Aspirin can be safely given early after CABG without fear of bleeding complications and it also confers the advantage of increased graft patency. His conclusions were that long term use of Aspirin therapy is extremely safe and effective which can go a long way in reducing morbidity and mortality. Aspirin has established role in secondary prevention in patients who are undergoing PCI and in those patients clopidogrel can also be added for some time. In high risk individuals, one should add Statins to Aspirin for primary prevention.

Prof. Khalid Masood Gondal Senior Vice President of CPSP and Head of the Dept. of Surgery at King Edward Medical University in his remarks said that normally the surgeons stop Aspirin a few days before surgery but now in some cases, Aspirin is continued. However, he was of the view that all those over the age of fifty years and healthcare professionals in particular should take Low Dose Aspirin Therapy regularly as it offers enormous benefits against a wide range of medical disorders.

Prof. Javed Akram President of Pakistan Aspirin Foundation also responded to numerous questions and pointed out that one has to continue taking Aspirin for lifelong and it is quite safe and effective particularly in a low dose of 75-100mg daily. For primary prevention, one has to calculate the risk and those with absolute risk of over 10% are candidates for Aspirin therapy.

Prof. Shahryar Sheikh in his remarks stated that the epidemic of heart diseases was already there in Pakistan. Stenting and Coronary Artery Bypass Graft surgery is not going to help us. The answer to our problems lies in prevention. Unfortunately we do not care about ABC in which A in English and Alaf in Urdu stand for Aspirin. Its use needs to be promoted in its well established indications.

Prof. Abdus Samad in his concluding remarks stated that in vitro studies have shown that even a small dose of 37mg of Aspirin per day is quite effective. It has very few side effects and its half-life is just two to three hours. It is the platelets which initiate arterial clot formation hence anti platelet therapy is very effective. We in Pakistan need to use anti-platelet therapy more and for a longer period as compared to the West as we have more clot formation. However, in venous thrombosis, the platelets get trapped, and if only anti-platelets are used, it won't be effective.

That is why in such patients we also use anti-coagulants in combination with aspirin. However, in patients with liver disease and children, one should not use Aspirin. Similarly it has certain other contra indications as well like bronchial asthma etc. One also needs to take care of dietary habits of the patients. The physicians should advise the patients regarding healthy diet, use more fiber, vegetables and fruits and take low dose Aspirin therapy regularly in combination with lifestyle modifications and taking care of all other modifiable risk factors.

He also cautioned the participants that be careful of risks of bleeding and it is advisable to get the hemoglobin tested of patients taking low dose aspirin at regular intervals. If the color of the patients changes from brown to whitish, it is an indication of blood loss, hence immediately get the hemoglobin tests done. Healthcare professionals themselves, Prof. Samad opined are at a greater risk hence we ourselves should be taking low dose Aspirin therapy regularly, he remarked.

Earlier Mr.Shaukat Ali Jawaid General Secretary of Pakistan Aspirin Foundation welcomed the guest speakers, chairpersons and the participants to the meeting. He also thanked M/s Atco Laboratories for sponsoring the CME programme of the Foundation for the last so many years to create awareness among healthcare professionals for improving the use of Aspirin in its well established indications though a large number of new and emerging indications for LDA therapy were also being discussed in the literature and various studies.

He also declared that his and Prof. Abdus Samad's travel to Lahore and stay was sponsored by Atco Laboratories. However, keeping up the professional ethics, we from Pakistan Aspirin Foundation platform do not patronize any particular pharmaceutical company nor we promote any particular brand name of Aspirin. It is up to the prescribing physicians to choose any Aspirin preparation, they wish, he remarked.

Mr. Akhtar Tahir Director Marketing and Sales from Atco Laboratories also briefly addressed the participants and thanked the speakers, chairpersons and all those present for gracing the occasion with their presence. The programme was initiated by Mr. Kashif Riaz Senior Product Manager from Atco Laboratories.
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Publication:Pulse International
Geographic Code:9PAKI
Date:Mar 31, 2017
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