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 Aspirin Update Session at KIHD Symposium
All high risk patients need to be put on low dose
Aspirin Therapy to reduce morbidity and mortality
Aspirin cannot prevent IHD but it can reduce
Athero Thrombotic events - Fawad Farooq
It is extremely useful in pre-eclampsia besides
many other gynecological disorders - Dr. Saira Aziz Siddiqui

KARACHI: In order to create awareness among the healthcare professionals and promote the use of Low Dose Aspirin therapy in various well established indications, An Aspirin Update session was organized by Pakistan Aspirin Foundation during KIHD symposium on Saturday morning February 10th 2023. It was chaired by Prof. Abdus Samad while the members of the panel of experts included Prof.M.Ishaq, Prof. Mansoor Ahmad, Prof.Feroz Memon, Prof.Rashid Khan, Prof.Abid Amin and Prof. Javed Akbar Seyal. Prof. Fawad Farooq from NICVD and Dr. Saira Aziz Siddiqui, assistant professor of obstetrics & Gynaecology at DUHS were the two guest speakers.

 Prof. Fawad Farooq

Dr. Saira Aziz spoke on use of low dose Aspirin therapy in pregnancy. She pointed out that Aspirin was being used as prophylaxis in pregnancy, in patients with still birth, fetal growth restrictions, pre term births, frequent pregnancy loss as well. Women at high risk of developing pre eclampsia are also put on low dose aspirin therapy on regular basis. It must be stated before 12th week of pregnancy. Women suffering from Type-2 diabetes have high risk of developing other risk factors. Adverse pregnancy outcome is not a modifiable risk factor. One should continue aspirin till the 36th week of pregnancy. Start with 150mg for first few weeks and then continue with 75-81mg till the 36th week of pregnancy some studies have used 100mg dose as well. She laid emphasis that women must adhere to Aspirin therapy and then also highlighted some of the reasons for non-adherence which included forgetting to take it or the pill burden as they also have to take some other drugs.

Members of the Panel of Experts during the session siting on the Dais shows from (L to R)
Prof. Abdus Samad, Prof. Ishaq , Prof. Mansoor Ahmed, Prof. Feroz Memon,
Prof. Nawaz Lashari and Prof. Rashid Khan.
 

In case of pre- term labour the Aspirin trial used 75mg dose, it was started from sixth to thirteen week of pregnancy which significantly reduced the pre-term delivery. Aspirin has also been found quite useful in various gynecological malignancies and it did increase survival. Aspirin is also being routinely used in sub-fertility cases, she remarked.

Prof. Fawad Farooq in his presentation discussed in detail the rational use of antiplatelet therapy, assessment of cardiovascular diseases and bleeding risk and shared the present evidence available. CVD, he said is a progressive disease. Plaque rupture creates problems. He referred to the adhesions of platelets, their activation and then aggregation in the arteries. There is a long list of well-established indications for the use of low dose aspirin therapy, including primary and secondary prevention. Aspirin, he further stated, cannot prevent IHD but it can reduce the athero thrombotic events. While prescribing Aspirin one should always weight the risks and benefits. It is important that all high risk patients are put on low dose aspirin therapy if there is no contra indication. He also referred to various trials and shared their results. He was of the view that it is important that we look at the age of the patient. In case the patients are between 40-59 years of age, always discuss with the patient.

Pakistan Aspirin Foundation organized a Session on Aspirin Update during the Dr.Abdul Haq
Cardiology Symposium organized by Karachi Institute of Heart Diseases. Group photograph
taken on the occasion shows the members of Panel of Experts alongwith some
of the senior cardiologists and physicians present on this occasion.

Almost all the panelists also favoured the use of low dose aspirin therapy in high risk patients. Bleeding risk should also be considered as first it is important to do no harm. Prof. Ishaq and Prof. Mansoor Ahmad remarked that people are using Aspirin for the last twenty five years or more but there are no reported side effects or bleeding risks. As a precautionary measure, one can add PPIs with aspirin therapy. It is an extremely safe antiplatelet agent which reduces morbidity and mortality in various disorders significantly.
In his concluding remarks Prof Abdus Samad said that the cardiovascular disease burden has increased. There is an enormous increase in the number of primary angioplasties being performed in the country. Patients survive, some develop heart failure and some complain of stable, unstable angina. We need to concentrate on prevention of diseases, Hence it is essential that we act before the event takes place. It is only possible if we promote the use of low dose aspirin therapy in primary prevention. There has been an increase in patients suffering from sudden cardiac death, hence preventive measures should get preference which is also beneficial and cost effective, he remarked.

Dr. Saira Aziz

Earlier Mr.Shaukat Ali Jawaid General Secretary Paksitan Aspirin Foundation welcomed the speakers, panelists and participants to the meeting. He also thanked M/s Atco Laboratories for continuously sponsoring the CME activities and such academic events for the last many years despite the fact that keeping up professional ethics, we do not promote any particular company and a brand name. Mr. Akhtar Director Marketing and Sales from Atco also briefly addressed the meeting and thanked all the speakers, members of the Expects Panel and KIHD administration for providing them an opportunity to organize this session.

 Aspirin update meeting at CARDIOCON 2022 Peshawar
For treatment of acute ASCVD early administration of aspirin
is lifesaving in ACS & ischemic strokes - Prof. Shahbaz Kureshi
Decision to use Aspirin for primary prevention should be based
on risk assessment and should be a shared decision with patient
If calcium risk score is more than one hundred, start the patient on Aspirin & Statin therapy

PESHAWAR: Pakistan Aspirin Foundation organized an early Breakfast Session on Aspirin- A Wonder Drug on November 12th the second day of the CARDIOCON 2022 organized by Pakistan Cardiac Society here from November 18th to November 20th 2022. Prof. Shahbaz Kureshi a noted cardiologist from Islamabad who is also the current President of Pakistan Aspirin Foundation was the guest speaker. The session was chaired by Prof. Shaharyar A. Sheikh another well-known cardiologist and former President of World Heart Federation. Members of the Experts Panel included Prof. M. Ishaq, Prof. Akbar Chaudhry, Prof. Feroz Memon, Prof. Rashid Khan and Prof. Abid Amin. Prof. Sadaqat Jabeen an eminent obstetrician & gynecologist was specially invited to highlight the role of use of Aspirin in obstetrics. Dr. Abdul Rauf was the moderator of the session.

Prof. Shahbaz Kureshi

Prof. Shabazz Kureshi in his comprehensive presentation referred to numerous studies, clinical trials and RCTs highlighting the safety and efficacy of Aspirin in cardiovascular diseases besides its use in primary prevention which often remains under discussion due to the likely risk of bleeding. Aspirin, he pointed out, has complete one hundred twenty five years of is clinical use this year which has been labeled as a Wonder Drug. It was the first antiplatelet drug but there have been some concerns about its safety due to chances of bleeding in chronic use. Some researchers felt that despite these risks, this drug needed further research as antithrombotic therapy. Pakistan Aspirin Foundation considers it a wonder drug in fact a drug for all times. It has proven its safety and efficacy in the treatment of acute cardiovascular diseases, is used for primary prevention of cardiovascular diseases and there are no doubts about its safety and efficacy as regards secondary prevention of cardiovascular diseases.

Its efficacy in Acute Myocardial Infarction, he stated, is now well established with 23% risk reduction in cardiovascular deaths as compared to placebo. There was 53% reduction in ischemic stroke. Reeducation in Fatal and non-fatal stroke was also noted just after six weeks treatment with Aspirin therapy. Hence, there is no doubt as regards it efficacy in acute cardiovascular diseases. Hence as soon as one experiences chest pain, the patient should be advised to take300mg soluble Aspirin.

As regards its use in primary prevention, Prof. Shahbaz Kureshi said, during the last three decades there have been seventeen Randomized Controlled Trials which included one lac sixty eight thousand patients. On the whole there was little or no benefit but increase in bleeding was noted. Studies by US Task Force looked at eleven low dose Aspirin trials which showed 10% decrease in myocardial infarction and 18% risk reduction of ischemic stroke. Hence the decision to use Aspirin for primary prevention, Prof. Shahbaz Kureshi opined should be based on calculating the risk of bleeding and it should be a shared decision with the patient. However, after the age of sixty years, it had no benefit but more chances of bleeding. Combining Aspirin in Polypill offers much more benefits. One should also calculate the calcium risk score and if it is more than one hundred, start the patient on Aspirin and Statin therapy. One can also add PPIs to protect from the risk of bleeding. In patients suffering from diabetes, one can combine Aspirin with PPIs. Lipoprotein-a (LPa) is also important. If it is high, the use of aspirin for primary prevention has a role. As such in high risk cardiovascular disease and high LPa one needs to educate the patient and put the patient on low dose aspirin therapy provided there are no other contraindications. Use of Aspirin beyond the age of seventy years is not recommended. Those patients who cannot tolerate Aspirin, one can put them on Clopidogrel.

Members of the Experts Panel during Aspirin Update Session held during Pakistan Cardiac
Society conference held on November 19th 2022 from (L to R) are Prof.M.Ishaq, Prof.Feroz
Memon, Prof. Akbar Chaudhry, Prof.Shahryar Sheikh (Chairman) Prof.Abid Amin, Prof.
Rashid Khan, Prof. Sadaqat Jabeen and Prof. Hafeezullah Khan Patron of CARDIOCON 2022.

Prof. Shahbaz Kureshi concluded his presentation by stating that in the treatment of acute atherosclerotic cardiovascular disease (ASCVD) early administration of aspirin s lifesaving in ACS and ischemic strokes and this recommendation remains unchallenged for many years. For primary prevention of ASCVD current emphasis is on intensive control of measurable risk factors. Routine use for primary prevention is not recommended particularly if starting at age equal to or more than 60 years. However, estimated net benefits are significantly positive for selected patients with high ASCVD risk and low bleeding risk. A precision medicine approach holds promise to improve selection. Finally, for secondary prevention of ASCVD, no antithrombotic is not a choice. Considering a second antithrombotic with aspirin represents a rational approach in selected patients. Aspirin monotherapy remains a cornerstone antiplatelet therapy in the secondary prevention of ASCVD, he added.

The panel discussion was moderated by Prof. Fawad Farooq Prof. of Cardiology at NICVD Karachi. Use of Aspirin, he said, is lifesaving in AMI though there remains some grey areas as regards its use in primary prevention. Prof. Feroz Memon participating in the discussion stated that in high risk patients, why one should wait for a cardiac event to occur and then prescribe Aspirin for secondary prevention. Wisdom demands that we must prevent this event from taking place hence put high risk patients on low dose aspirin therapy. Prof. M. Ishaq suggested evaluating the risk and then putting all patients suffering from diabetes on Aspirin therapy 150mg daily. Prof. Akbar Chaudhry opined that there are lot of benefits in primary prevention with Aspirin because even at present despite so much evidence about its safety and efficacy, Aspirin remains underused and very few patients are taking Aspirin before they get AMI. His advice was that the patient must be given 300mg of Aspirin immediately when they notice chest pain and even on way to the to the hospital.

Prof. Sadaqat Jabeen a noted obstetrician and gynecologist highlighting
the safety and efficacy of Low Dose Aspirin in Obstetrics during the panel
discussion on Aspirin Update at CARDIOCON 2022 held on November 19th 2022.
Also sitting alongwith her arefrom (L to R) Prof. Shahryar Sheikh,
Prof.Abid Amin, Prof.Rashid Khan.

Prof. Sadaqat Jabeen participating in the discussion pointed out that we the obstetricians are extensively using it in our practice to prevent repeated miscarriages. We start using low dose Aspirin from 12th week of pregnancy in high risk cases as there is risk of pre-eclampsia. It reduces the incidence of pre-eclampsia. We also use low dose Aspirin in patients when there is a risk of intra uterine growth retardation, small for gestational babies we start using Aspirin from 12th week and continue it till 37th week. We also use Aspirin in Antiphospholipid syndrome, recurrent miscarriages. It is extremely important that these patients should be put on low dose Aspirin therapy before 16th week of pregnancy because after that, it will be of no use. We usually use 75-150mg daily, she added.

Prof. Abid Amin said that many elderly patients take Aspirin though they have no cardiovascular disease. For treatment of hypertension, one has to control the blood pressure first and then use low dose aspirin therapy. Prof. Rashid Khan also endorsed the use of low dose Aspirin therapy for treatment of hypertension alongwith other antihypertensive therapy. The panelists also referred to its use in numerous other new and emerging indications particularly in colorectal cancer.

Prof. Shahryar Sheikh in his concluding remarks commended the excellent presentation by Prof. Shahbaz Kureshi who he said has covered almost all the aspects in detail. He also thanked the other panelists for their contribution in the discussion. He specially thanked Mr. Shaukat Ali Jawaid General Secretary of Pakistan Aspirin Foundation stating that it is his commitment and devotion that most of us were here in the hall at 7.30 AM early in the morning. The session concluded with the presentation of a Cheque to The Citizen Foundation on behalf of Atco Laboratories and a group photograph.

A representative of Citizen Foundation Karachi being presented a cheque of Donation on
behalf of Atco Laboratories during the Aspirin Update Session during the recently held
annual conference of Pakistan Cardiac Society at Peshawar. Prominent among the picture
 are Dr. Raj Kumar, Dr. Kashif Hashmi, Prof. Ishaq, Khalida Soomro, Bilal Mohyuddin,
Feroz Memon, Fawad Farooq, Akbar Chaudhry, Shahryar Sheikh, Shahbaz Kureshi,
Abid Amin, Rashid Khan, Sadaqat Jabeen, Hafeezullah Khan, Kashif Riaz and others.

These meetings and other CME programmes of Pakistan Aspirin Foundation, it may be mentioned here are being sponsored by M/s Atco Laboratories for the last many years. They not only sponsor the travel and accommodation of the speakers but also panel of experts despite the fact that the Foundation do not support or promote any particular company or brand name in its academic activities. Mr. Kashif Riaz and his team from Atco Laboratories has always played a vital role in the success of these programmes.

World Heart Day meeting by PCS Sukkur and Pakistan Aspirin Foundation
Control modifiable risk factors to avoid increasing
 epidemic of heart diseases - Prof. Feroze Memon
Covid patients should be put on Low Dose Aspirin therapy for three months
and those with symptoms should also be prescribed LMWH with other drugs

From our correspondent

SUKKUR: Pakistan Cardiac Society Sukkur Chapter in collaboration with Pakistan Aspirin Foundation organized a meeting on September 29th to celebrate World Heart Day. The programme included an awareness walk followed by a scientific meeting where Prof. Feroz Memon Prof. of Cardiology at Indus Medical College who is also former President of Pakistan Cardiac Society was the chief guest. The meeting was organized by Dr. Raj Kumar Sachdewani Associate Professor and Head of the Dept. of Cardiology at Sardar Ghulam Mohammad Mahar Medical College. It was attended by SGMMC faculty members, physicians from the city and other adjoining areas besides representatives of the civil society.

Prof. Feroze Memon in his address discussed in detail the fast increasing heart diseases which he pointed out was declining in the West but has assumed an epidemic proportion in the developing countries including Pakistan. The main intervention to check this epidemic was change in life style besides avoiding the modifiable risk factors, use of healthy diet and regular exercise. We need to create awareness among the people about heart diseases and convince them to adopt simple life style. Obesity was a serious issue. Today about four to five lac people die annually due to heart diseases globally. He showed a normal artery and the one with lot of plaque formation which leads to acute myocardial infarction. It can also lead to ischemic stroke, Peripheral Artery Disease, and cardiovascular death. At present there is no solution to this for a longer period. Patients suffering from high blood pressure can develop heart failure and sudden death can occur after fifteen minutes of chest pain.

Prof. Feroze Memon, Prof. Zulfiqar Ali Soomro, Prof. Altaf Sheikh, Dr. Raj Kumar Sachdewani and Dr. Ahmad Mujtaba Memon
speaking at the World Heart Day meeting held at Sukkur on September 29th, 2020.

Continuing Prof. Feroz Memon talked about irregular heartbeat, poor handling of the fat, urbanization which make the situation worse. It is in this context that he would like to congratulate Prof. Jan Mohammad Memon who established a medical college in the rural areas of Sindh to provide healthcare to the people. Sudden change in our life style is highly dangerous and it is essential that we must make all efforts to save lives. We need to take care of high cholesterol, increase HDL, stop smoking, treat high blood pressure, diabetesmellitus, avoid obesity and avoid alcohol. He also advised the younger generation to look at the family history of those with whom they plan to get married as it was also an important risk factor. Pear or Apple obesity is much more dangerous. We can prevent obesity by using healthy diet, increased use of fruits and vegetables, avoid sedentary life style, do not sit for longer periods in front of Television and avoiding fast food was also extremely important. It is also advisable to have twenty five to thirty minutes exercise at least five days a week regularly. IHD, he said, cannot be prevented. Low Dose Aspirin therapy is indicated in Acute Coronary Syndrome. It is just like poor man’s streptokinase which is lifesaving most safe and effective antiplatelet therapy which is also affordable. Its regular use can lead to 12% risk reduction if used for primary prevention. Regular use of Low Dose Aspirin therapy has a long list of indications in various medical disorders including colorectal cancer, it is used after interventional cardiac procedures as well. In case of Covid, the patient must get Aspirin at least for three months and in case of symptoms, the patients should also receive Low Molecular Weight Heparin (LMWH) in addition to other drugs. Aspirin has been used in clinical practice for now over one hundred twenty years and it has an important role in prevention of diseases. There is no doubt about its safety and efficacy in secondary prevention but in high risk patients, one can also use it for primary prevention. Medication has to be tailor made to individual patients. The audience was advised to check their blood pressure at home regularly and start immediate treatment in case of high blood pressure by consulting their physician. People should try to maintain healthy weight, relax and smile avoiding stress.

Pakistan Cardiac Society Sukkur Chapter in collaboration with Pakistan Aspirin Foundation organized a
meeting on World Heart Day at Sukkur on September 29th, 2020. Sitting on the dais in the session from (L to R) are
Dr. Raj Kumar Sachdewani, Prof. Zulfiqar Ali Soomro, Prof. Feroze Memon, Mr. Shaukat Ali Jawaid and Prof. Altaf Sheikh.

Prof. Altaf Sheikh in his brief address also re-emphasized that Aspirin has an important role in secondary prevention but it can also be used safely for primary prevention in high risk cases. He also referred to mild, moderate and severe risk factors and opined that those with severe risk must take aspirin regularly. It will help reduce the cardiac risk and events. Take care of the modifiable risk factors like high blood pressure, diabetes, high cholesterol and increased weight leading to obesity. Regular exercise and preventing modifiable risk factors will ensure healthy life. Take care of your diet and make regular exercise a habit.

Earlier Dr. Raj Kumar Sachdewani in his welcome address thanked the guest speaker, participants and his colleagues who always extend their valuable help in such academic activities. He also thanked Pakistan Aspirin Foundation and Atco Laboratories for collaborating and sponsoring this meeting. We always work as a team. We can control heart diseases by life style modifications, he remarked.

Dr. Raj Kumar Sachdewani presenting the traditional Sindhi Ajrak to Mr.Shaukat Ali Jawaid, Dr. Zahoor Soomro
while on extreme right Prof. Zulfiqar Soomro is presenting the Ajrak to Prof. Feroze Memon 
during the World Heart Day meeting at Sukkur on September 29th, 2020.

Mr. Shaukat Ali Jawaid General Secretary of Pakistan Aspirin Foundation in his speech said that they are grateful to Atco Laboratories for sponsoring their academic activities to create awareness among public as well as medical profession. We follow professional ethics and do not promote any particular company or brand name but promote the use of Aspirin therapy in its well established indications. He further stated that in high risk patients, it is much better to start Aspirin therapy for primary prevention rather than waiting for a cardiac event to occur and then using it for secondary prevention. He thanked Dr. Raj Kumar, Prof. Altaf Sheikh, Dr. Zahoor Soomro, President of local PMA, Principal of the medical college Prof. Zulfiqar Soomro for organizing and participating in celebration of World Heart Day.

Dr. Raj Kumar Sachdewani, presenting traditional Sindhi Ajrak to Dr. Pir Bakhsh Magsi, Mr. Kashif Riaz General Manager Marketing
 Atco while on extreme right chief cardiologist at Dewan Mushtaq CCU Sukkur presenting Ajrak to Prof.Altaf Sheikh during
the World Heart Day meeting held at Sukkur on September 29th 2020.

Prof. Zulfiqar Ali Soomro Principal of Sardar Ghulam Mohammad Mahar Medical College in his concluding remarks thanked the speakers, organizers and sponsors besides PMA and Pakistan Aspirin Foundation. Today’s meeting has provided an opportunity to remind the people about prevention of heart diseases. Prof. Feroze Memon presented traditional Ajrak to the organizers and other guests present on this occasion. Earlier the Awareness Walk started from Dewan Mushtaq Coronary Care Unit towards the college where scientific meeting was planned. The meeting was held in the renovated hall and its proceedings were shown live on Face Book.

Photographed after the Aspirin Session during CARDIOCON at Islamabad on November 23, 2019 from (L to R) are Dr. A. Rashid
Khan, Mr. Kashif Riaz, Prof .M. Ishaq, Prof. Shahryar Sheikh, Prof. Abdus Samad, Dr. Zohra Samad, Mr.Shaukat Ali Jawaid,
Prof. Feroze Memon, Prof. M. Akbar Chaudhry and Mr. Waqar from Atco Labs.

World Heart Day at Indus Medical College Hospital
Use of more carbohydrates are most dangerous
for heart diseases-Prof. Samad
Use of healthy balanced diet, control of hypertension, blood glucose,
regular exercise and cessation of smoking will reduce the risk - Feroze Memon

Prof. Abdus Samad in his usual style speaking in Urdu supplemented his talk with numerous interesting anecdotes and stories which helped the audience understand better and the message was effectively conveyed. Heart diseases, he said, was common in South East Asia where it remains a major killer while in the West it is on decline. He then narrated the story of Young Thief of Baghdad who was forgiven by the Khalifa in appreciation of his intelligence when he said that he comes here to this mosque to steal shoes because they were good and costly and he could make enough money by selling them. Patients, Dr. Samad opined, should be persuaded by creating awareness that blood pressure and blood glucose needs to be controlled, make sure that the cholesterol is not high. The kitchen, he said, plays an important role in the causation or prevention of heart diseases. If the male member of the family brings in good healthy food to cook, the lady at home will have no other choice but to cook that. Hence make sure to use more vegetables, pulses, less fats.

Dr. Iqbal Memon Pro VC presenting a memento to Guest Speaker Prof. Abdus Samad at the
World Heart Day meeting held  at Indus Medical College Hospital recently.  On extreme
 left picture shows Prof. Feroze Memon, Prof. of Cardiology and VC of the
Modern Sciences University, Tando Mohammad Khan, Sindh.

Exercise, Prof. Samad said is a problem for ladies to whom he advised to have exercise at home. Unfortunately our cities are not properly planned and it is not safe even for male to exercise outside and in Parks. He jokingly remarked that those who already have CABG and do not care of their health, should plan their next bypass on Thursday so that they can be buried on Friday as most of them are not going to survive surgery, he added. Patients should be advised the timings for walk, if exercise outside is not safe, they can buy bicycle and have regular in-house exercise. Awareness, attitudes and action are all important to prevent heart diseases. Sedentary life style is a serious risk factor. It is important that one should walk at least six thousand steps daily and now it is possible to count it by downloading the App on the mobile. Active life and regular exercise is more important between the ages of 30-50 years as most of the heart attacks occur during this highly productive life. Our life expectancy is now also increasing and with active life one can escape from myocardial infarction before the age of seventy years. If someone suffers from MI, it is his/her mistake but after the age of seventy years, it is possible. Use of more carbohydrates are most dangerous for heart diseases.

He urged the participants to discourage the use of soft drinks as they contain large quantity of sugar which is dangerous. White bread, white sugar should be avoided. Try to use Red wheat flour or Chakki Ka Atta. Use more vegetables and fruits. Make sure that children avoid junk food, they should he provided fruits before meals. Unhealthy food results in accumulation of fats, carbohydrates around organs and in the abdomen. They are only used with muscle exercises. Passive smoking is equally dangerous. Prefer to have walk or exercise on top floor on the roof which will have more oxygen. He laid emphasis on use of balanced healthy diet. Environment, air pollution Prof. Samad remarked were equally dangerous. Early morning walk or walk on roof top will ensure fresh air. Air pollution has also been recognized as a major risk factor for heart diseases. Take care of the known risk factors and keep yourself in low risk group.

Prof. Feroze Memon VC Modern Sciences University, senior faculty members, eminent cardiologists from Hyderabad, participants and
organizers of the World Heart Day meeting held at Indus Medical College Hospital photographed alongwith the Guest Speaker Prof. Abdus Samad.

Speaking about the safety and efficacy of low dose Aspirin therapy in prevention of heart diseases Prof. Samad said that 75mg to 81mg were safe and effective in secondary prevention. In acute conditions, it saves life and is known as poor man’s Statin. In high risk patients, Aspirin can also be used for primary prevention if there are no contra indications. Thousands of patients have used it and on long term use, it also prevents colorectal cancer. Low dose Aspirin therapy is safe and effective in pregnancy induced hypertension (PIH), pre-eclampsia. Gynecologists are using it regularly for patients with bad obstetrics history, recurrent abortions, treatment of infertility as its antiplatelet effects improve the blood circulation. In case of risk of acidity, it should be treated or one can combine the use of low dose Aspirin with proton pump inhibitors (PPIs) to overcome the risk of GI bleeding. Do not stop Aspirin in case of minor surgery like cataracts or dental surgery. However, in case of surgery in the cavity like brain surgery or heart surgery one may stop it for few days before surgery and then restart it. Low Dose Aspirin therapy is always included in cardiologist’s prescription for management of heart diseases. Aspirin has proved its efficacy in prevention of stroke, recurrent stroke, and different types of cancers as well.

Responding to various questions Prof. Samad said that high dose of Aspirin will increase the risk of side effects. Up to 75mg dose is good enough and one should use enteric coated Aspirin for long term use. Responding to another question he said that one should find out the risk factor before declaring oneself Fit. Genes and environment both have effect on CAD, healthy environment will reduce the risk. Identification of heart disease at young age will be easier for prevention. We need more awareness programmes to educate the people about heart diseases.

Prof. Feroz Memon Vice Chancellor of University of Modern Sciences in his welcome address pointed out that control of blood pressure, regular exercise, no smoking, use of healthy diet were some of the important factors for prevention of heart diseases. In the West, heart diseases are reducing while now Cancer is the No. 1 killer but in low income countries including Pakistan, heart diseases still remains a major burden. We need to promote the use of healthy diet, ensure life style changes, cook healthy food, and help patients give up smoking. Investment in healthy heart, he further stated, will save you lot of expenditures on drugs as well as doctors’ fees. Do not give stress to others, live a stress free life and enjoy life which was in everybody’s interest. Our guest speaker today, he said, is a renowned interventional cardiologist who has done pioneering work in the prevention of heart diseases and we are grateful to him for making it possible to grace the occasion with his presence and enlighten the audience with his words of wisdom. Risk factors of heart disease and some educational messages were highlighted in a song. Dr. Zaman Baloch presented vote of thanks.

Symposium on Cardiovascular Diseases at Quetta
Low Dose Aspirin therapy can be used for primary prevention
in high risk patients - Prof.Ejaz Ahmad Vohra
PPIs can be added to reduce the chances of GI bleeding & Dyspepsia Nebivolol 5mg daily
is an ideal antihypertensive which reduces LVH, end organ damage - Prof. Abid Amin

Prof. Ejaz Ahmad Vohra in his presentation “Medical Uses of Aspirin: An Update in the 21st century” pointed out that with the use of Aspirin reduction in cardiovascular diseases is well-established but more recently there have been some studies about its use in primary prevention which has raised lot of discussion among the healthcare professionals. While in low risk cases, there is no need to use Aspirin for primary prevention but in high risk cases, regular use of Low Dose Aspirin therapy still has a role. The treating physicians should take the patient into confidence and discuss with them the benefits and risks in detail, he remarked.

Prof. Ejaz Ahmad Vohra, Prof. Abid Amin, Dr. Haqdad Khan, Dr. Asif Tabba, Mr. Shaukat Ali Jawaid , Mr. Kashif Riaz from Atco alongwith
other senior physicians photographed during the symposium on cardiovascular diseases held at Quetta recently.

Speaking about the established uses of Aspirin, he mentioned its use in emergency situations like acute myocardial infarction, Acute Coronary Syndrome, prevention and treatment of preeclampsia, colorectal and other cancers and it can also be combined with many other agents. Apart from patients with AMI, it is being used in unstable angina, patients with acute occlusive stroke, patients with stable Cardiovascular diseases, ischemic heart disease, patients who have undergone revascularization with coronary artery bypass graft surgery, stable peripheral artery diseases or carotid artery disease besides patients who have undergone coronary stenting. If Aspirin is added to streptokinase it reduces mortality by 40%. In secondary prevention if combined with Clopidogrel it reduces vascular mortality by 8.7%. It can also be combined with Ticagrelor and Rivaroxaban but there is an increased risk of bleeding.

Continuing Prof.Ejaz Ahmad Vohra said that in United States Aspirin is now being used by 90% of patients for prevention of heart attacks. Studies have also shown that it reduces the chances of heart attack and stroke in both men as well as women. There is a small risk of increase in intra cerebral hemorrhage hence one should balance the risk against the benefits in such patients. Most common use of Aspirin in stroke is for acute cases, acute TIAs and minor stroke. Most of the guidelines recommend use of Aspirin for acute ischemic stroke. Its effects in TIA and minor stroke are probably larger and more beneficial than in higher risk events. When combined with clopidogrel, it is more effective in preventing stroke after TIA compared to the use of Aspirin alone. However, Aspirin is highly effective for secondary prevention of TIA and minor stroke, he added.

Speaking about the use of Aspirin in pregnancy and cancers, Prof. Ejaz Ahmad Vohra said that it is drug of choice for prevention of pre-eclampsia. Meta-analysis have showed that women at risk of pre-eclampsia gestation hypertension or fetal growth restrictions, it has relative risk reduction of 0.90 CL 95%. It is also effective in various types of cancer but greatest effect was seen in those patient who were taking it for at least five years. It reduces mortality in colorectal cancer, esophageal cancer, gastric cancer, lung cancer and prostate cancer besides breast cancer. Daily aspirin therapy may also be associated with a reduced risk of HBV-related HCC. American College of Cardiology and American Heart Association Guidelines for the year 2019 both recommend low dose aspirin (75-100mg) in primary prevention of ASCVD among selected adult of 40-70 years of age who are at higher ASCVD risk but not increased risk of bleeding. However, it should not be administered on a routine basis for primary prevention of ASCVD in adults less than 70 years of age. Aspirin should not be administered for primary prevention in adults who are at increased risk of bleeding.

Prof. Ejaz Ahmad Vohra and Prof. Abid Amin speaking at a symposium on Cardiovascular Diseases organized by Pakistan Aspirin Foundation
 in collaboration with Pakistan Hypertension League at Quetta on August 24th 2019 at Quetta.

He also referred to various trials of Aspirin in primary prevention in cardiovascular diseases. Both AHA and ADA recommend use of aspirin for diabetes patients who have a ten years cardiovascular disease risk of at least 10% but not at risk of increased bleeding. However, there were some limitations of these Trials in primary prevention. It included compliance with random assignment was relatively poor resulting in substantial crossover, population studies had CV events lower than anticipated which leaves the questions unanswered whether aspirin might have benefitted in higher risk younger population. Again only a small number of patients were on PPI which might have cut down aspirin induced dyspepsia and GI bleeding. There was no information regarding the use of NSAIDs in these patients. Median follow up was too short. Moreover improved control of CV risk factors including smoking, hypertension and hyperlipidemia compared to early trials may be the reason aspirin is not needed for primary prevention. Above all the ASCEND trial had only 17% patients with high risk and observed events for lower than expected. On the contrary patients in Pakistan, Prof. Ejaz Ahmad Vohra reiterated are high risk, the use of Statins is very poor, they are obese, overweight, there is increase in smoking and the non-compliance with drug therapy is very common. Hence, in such circumstances, the use of Aspirin for primary prevention in carefully selected high risk patients can be beneficial. It is thus better to prevent the disease. It also results in 40% reduction in Venous Thrombo Embolism (VTE).

He concluded his presentation by stating that in places of the world where CVD risk is increasing, where other preventive strategies such as Statins are less available, Aspirin as a low cost intervention may have a more important role to play. The benefits of Aspirin in secondary prevention significantly outweigh the risks.

Management of Hypertension

Prof.Abid Amin in his presentation on “New trends in management of Hypertension” said that by 2025 it is expected that there will be a 60% increase in hypertensives. As per National Health Survey done some year ago, in Pakistan 18% of our adult population suffer from hypertension, 50% are diagnosed and only 50% of them are treated while just about 12.5% patients have their blood pressure under control. Hypertension accounts for 7.6 Million global mortality. As regards complications of hypertension, it can affect all body organs. A 20/10mmhg increase in blood pressure results in 20% increase in mortality while a mere 2mmhg reduction in blood pressure leads to 7-10% reduction in mortality.
JNC-8 Guidelines on management of hypertension, Dr. Abid Amin said recommend the following:

• Heart Failure ACEIs, ARBs, Diuretics, Spirolactone
• Post MI, CAD BBs are indicated
• Recurrent Stroke ACEIs and Diuretics
• CKD ACEIs and ARBs

In endothelial dysfunction Nebivolol, he stated, was the most effective and safe beta blocker. It is a third generation beta blockers. The recommended dosage is 5mg daily and one can up to ten mg. There is no sleep disturbance and it has a bioavailability of 96%. Giving details of the ENECA trail which enrolled two hundred sixty patients, he pointed out that there was 80% increase in LVEF, survival rate also improved. It also reduced mortality by 38% as compared to 34% mortality reduction with other Beta Blockers. The adverse effects noted were also 21% as compared to 15% in the placebo group.

In yet another trial 6376 patients with atrial hypertension were enrolled. After six weeks therapy, erectile function of the patients improved and their sexual activity also improved. TGs were reduced, new onset of diabetes also reduced by 1.8%. The dosage of Nebivolol for angina and hypertension is 5mg daily. He concluded his presentation by stating that Nebivolol is an ideal antihypertensive agent which reduces LVH, end organ damage, it is a high potency selective beta blocker which is preferred in the management of hypertension.

Discussion

During the discussion it was pointed out that Asian population use lot of carbohydrates. The patients should be advised to increase the use of protein and reduce carbohydrates. Our patients also have much more risk factors as compared to the patient population in the West, hence we need to keep these things in mind while treating our patients. Aspirin may not be used for primary prevention in patients with diabetes but we must remember that most of our patients are not on Statins which increases their risk factors. Prof. Ejaz Ahmad Vohra remarked that once stroke or myocardial infarction occurs, it is a disaster, hence prevention is always better and preventive strategies should be given preference. If there are concerns for safety and to take care of risk of GI bleedings, one should use PPIs but in low risk patients, there is no need to use Aspirin for primary prevention. Dr. Asif Tabba pointed out about the possibility of bleeding from other sources like Hemorrhoids etc. Responding to this, it was stated that one has to take care of all these aspects while initiating low dose aspirin therapy.

Earlier Mr. Shaukat Ali Jawaid Secretary Pakistan Aspirin Foundation welcomed the guest speakers Prof. Ejaz Ahmad Vohra and Prof.Abid Amin besides participants. Such meetings, he stated, are part of the CME activities we organized to create awareness and promote the use of Aspirin in its well established indications.
The meeting was sponsored by M/s Atco Laboratories. Mr. Kashif Riaz Business Unit Head from Atco Laboratories also thanked the speakers and the participants to grace the occasion with their presence.

Use of Aspirin in Primary Prevention of CAD
All high risk patients over age of 45 years, those suffering from diabetes, hypertension & smokers should be put on Aspirin Therapy-Dr. Rasheed Khan

Dr. Rasheed Khan

Role of Aspirin in secondary prevention of cardiovascular diseases, he said, is well established but its role in primary prevention remains under discussion and there are different views by various physicians and the professional organizations, institutions. One of the most often highlighted risk is bleeding. Usually in old age all high risk patients are advised to take one low dose 75mg Aspirin tablet daily to protect them from acute myocardial infarction and stroke. Some of the guidelines recommend use of low dose Aspirin daily by men over the age of forty five years with risk factors and by women over the age of fifty five years. All those who suffer from diabetes or hypertension are also advised to use low dose Aspirin daily as they have a risk of stroke but there is also a possibility of bleeding. Now one has to choose between bleeding and death. Remember we can treat bleeding but cannot treat death. Hence it is advisable to prescribe low dose Aspirin Therapy to all high risk patients so that they do not have any further cardiac event. In elderly the risk of bleeding is there but the treating physicians have to tailor the therapy to suit the individual patients. His conclusions were that all high risk patients over the age of forty five years, those suffering from diabetes, hypertension and smokers must be put on Aspirin therapy. One must first control the blood pressure before prescribing Aspirin to the hypertensive patients. Use of Aspirin in low risk patients will be less beneficial as regards its use in primary prevention.

New research also shows that Aspirin is very useful in colorectal cancer but still we need more research and one has to be extremely careful while treating elderly patients. Guidelines being followed in Australia and New Zealand recommend that Aspirin should be used in elderly in those who have five years risk of cardiovascular diseases of over 15%. Guidelines by American Task Force also recommend the use of Aspirin for primary prevention and it is also recommended by various professional body Guidelines.

Prof. Saeed Sangi discussed the use of Aspirin in various cardiovascular diseases. His presentation was based on the Urdu Booklet on Use of Aspirin: A Life Saving Miracle Drug published by Pakistan Aspirin Foundation edited by late Dr. Maqbool H. Jafary and Mr. Shaukat Ali Jawaid.

During the discussion it was pointed out that low dose Aspirin is being used by Obstetricians & Gynecologists during pregnancy as it increases the blood flow to the fetus. One of the gynecologists remarked that they use Aspirin from 16th week of gestation and it is continued till delivery. Prof. Feroze Memon remarked that we are impressed with the knowledge of cardiology by the gynecologists and we did learn something from their comments and suggestions. Prof. Abrar Sheikh another noted physician from Sukkur remarked that myocardial infarction and hemorrhages is unlikely in elderly patients but one has to be careful about their co-morbid conditions. One must avoid the excessive use of NSAIDs and while using Aspirin one can combine it with Proton Pump Inhibitors to reduce the risk of bleeding.

Prof. Abdus Samad in his concluding remarks said that one cannot generalize things. Every patient is different and every population is different. While most of the patients in the West and other developed countries are already taking Statins, this is not the case in Pakistan. Our patients have more clot and less atheroma. Clot is a major risk hence we do need to use Aspirin in primary prevention of coronary artery disease. Another point which must be kept in mind is that our life expectancy is about ten years less as compared to the West. In Pakistan the life expectancy is now about 68.4 years. We have low literacy rate. Pakistan has a female literacy rate of about 46%. One should check hemoglobin levels once in a while in case there is a risk of bleeding. If stomach is clear, do not stop the use of Aspirin. He also jokingly remarked that one should not look at the model of the car but see how much mileage it has covered so far. Hence the severity of the disease and the risk factors should be kept in mind rather than just looking at the age of patients while deciding about the use of low dose Aspirin Therapy, he remarked.

Aspirin Session during PHL Symposium at Lahore
Long term use of Low Dose AspirinTherapy is quite safe &
effective in various medical disorders-Prof. Akbar Chaudhry
All Type-1 & Type-2 patients with diabetes, smokers and those with family history of CAD
are at high risk of developing heart disease should consider using Aspirin-Shahbaz Kureshi
Clot is a major risk not atheroma. We should put our patients on Aspirin and Statins- Prof. Samad

LAHORE: Research is still going on and this debate regarding the regular use of Low Dose Aspirin Therapy for primary prevention of coronary artery disease will go on. CAD is increasing. Since our enemy is strong, we have to be strong enough since survival is of the fittest. There have been numerous studies on the use of Aspirin in primary prevention of heart diseases but all these studies have been done in the West but not in Asian patients. Population in Asia is different and patients living in India, Pakistan, Bangladesh and other Asian countries are at high risk. To say that low dose aspirin therapy in diabetics and other high risk patients may not be effective is not true. Most patients in Asia are getting diabetes at a much younger age whereas diabetes in the West is being controlled. Clot is the major risk factor not atheroma. Hence, we must put our patients on Aspirin therapy and Statins. This was stated by Prof. Abdus Samad an eminent interventional cardiologist while speaking at the Aspirin Session during the Pakistan Hypertension League symposium held at Lahore from 21-24th February 2019.

Prof. Abdus Samad

The same, Prof. Samad opined, may be true in Africa. Until and unless we conduct research in our own patient in Asia and the Pakistan Aspirin Foundation plans to conduct this study (A4P) we should continue to use Aspirin in high risk patients unless it is contra indicated. Majority of us in Asia have a feeling that our patients are a bit different. Aspirin is indicated in secondary prevention of CAD and there is no doubt about it. As such we must use and promote its use in our patients to prevent our patients getting a cardiovascular event again. At the same time we must continue to educate our physicians as well as the patients and take all preventive measures, he added.
Earlier Prof. M. Akbar Chaudhry a former President of Pakistan Aspirin Foundation and currently Dean of Medicine at Azra Naheed Medical College in his presentation pointed out that cardiovascular diseases are most common, major cause of mortality and it accounts for 28% of deaths the world over. It is estimated that by 2030, almost 23.6 million will die from cardiovascular diseases. Studies have shown that almost 82% of CVDs occur in low and middle income counties. CAD is also becoming an epidemic in Pakistan. Recent studies by BIDE shows that 52% of our overall population suffer from hypertension, 26.3% are diabetics, 14.4% are pre-diabetics, 62% of our population is overweight while 47.5% suffer from obesity. Hence solution lies in prevention.

Prof. Akbar Chaudhry

Risk intervention Prof. Akbar Chaudhry remarked includes Aspirin therapy. A recent study has showed that use of Aspirin is also increasing but still it is not enough. Almost 37.6% of Aspirin use is in cardiovascular diseases. Use of Streptokinase within six hours of chest pain results in mortality reduction by 25% but if it is combined with Aspirin this benefit in mortality reduction increases to 45%. He also referred to the use of Aspirin for secondary prevention which leads to significant reduction in fatal and non-fatal myocardial infarction, stroke and the overall risk reduction is by 13%.

Continuing Prof. Akbar Chaudhry said that we must individualize the patient and calculate their ten years risk. If the risk is more than 10%, put these patient on Aspirin therapy, if the risk is between 6-10%, discuss with the patient and start aspirin therapy with is consent but if the risk is less than 6%, do not use Aspirin. A recent study has reported that 31% of the patients were using low dose Aspirin therapy for primary prevention, 43% of patients were already on Aspirin and over 90% of patients in the wards were getting Aspirin. He also talked about the well-established indications for Aspirin therapy besides new and emerging indications like colorectal cancer where it is effective after ten years of use, other GI malignancies. Its use in pre-eclampsia is now well established. Other emerging indications for use of aspirin therapy include Alzheimer’s disease, dementia, renal diseases, DVT and embolism. Use of Aspirin also improves insulin resistance. Aspirin is a lifesaving miracle drug and its long term use is quite safe and effective which significantly reduces morbidity and mortality in a wide range of medical disorders. However, we still have a long way to go. It is being used in PCI and in those patients where aspirin is contra indicated one can use other antiplatelet agents like clopidogrel. All high risk patients must be put on Aspirin therapy, he added.
 

Prof. Shahbaz Kureshi

Prof. Shahbaz Kureshi a noted cardiologist from Islamabad was the next speaker in this session. He pointed out that we need to do something to check the epidemic of CAD. He also traced the history of discovery of Aspirin, discussed the clinical manifestations of cardiovascular diseases. Peripheral artery disease, he further stated, affects all. He also discussed in detail the platelet aggregation, thrombus formation and the use of antiplatelet agents. Efficacy of Aspirin in different doses has been studied and it has been proved that a dose of 75mg is effective and much better. Low Dose Aspirin therapy in 75mg or 81mg or 100mg is all effective in secondary prevention.
Continuing Prof.Shahbaz Kureshi remarked that CAPRIE trial had showed that clopidogrel is better but it is more expensive than Aspirin. Traditionally we always use low dose aspirin therapy if it is not contra indicated or not well tolerated, the use clopidogrel. The benefits of its use in patients above fifty years are much more. All Type-1 and Type-2 people with diabetes, those with family history of cardiac disease or smoking are at increased risk of developing heart disease. Hence they all should be put on low dose aspirin therapy. In order to avoid the risk of bleeding, one can use the PPIs along with Aspirin.

The issue of Aspirin resistance, Prof.Shahbaz Kureshi stated has been over emphasized but it is because of non-compliance and some of the patients may be non-responders to Aspirin just like other drugs. At present Aspirin is under used. We can use the Aspirin App to calculate the risk and this can be downloaded on mobile phone and used for decision making regarding use of Aspirin therapy. COMPASS study showed that combination of Rivoraban and Aspirin gives good results. ASCEND trial showed more bleeding linked with Aspirin when used to prevent heart disease; hence one can use proton pump inhibitors in such cases. ARRIVE trial showed that low dose aspirin therapy was not beneficial in primary prevention and was also associated with increased bleeding. One has to weigh the benefit and risks. In secondary prevention of CAD we must use Aspirin therapy and in primary prevention calculate the ten years risk based on age, other risk factors like diabetes and then decide about the use of Aspirin. However Aspirin is an essential part of dual antiplatelet therapy. Bleeding risk is low with low dose and enteric coated tablets. Aspirin is economically priced antiplatelet agent which is extremely safe and effective.
Prof. Shaukat Malik another noted cardiologist participating in the discussion asked for the use of Aspirin in elderly patients. It was pointed out that one has to be careful after the age of eighty years. Monitor the haemoglobin regularly after six months, watch for the other side effects. It was also pointed out that most of the elderly patients are very sick, take lot of drugs and sophisticated equipment is needed for secondary prevention and we do not have facilities for that at many places particularly in the far flung rural areas and small town. Hence, primary prevention is ideal for our population. Our population also gets heart diseases at a bit younger age. We see heart diseases even in 30s. Hence the studies done in the West may not apply to our patients that are why primary prevention is much more beneficial.

Prof. M. Ishaq President of Pakistan Aspirin Foundation in his welcome address thanked the speakers and members of the expert’s panel. Aspirin, he further stated, is a wonder drug being used in low dose in primary and secondary prevention of CAD. Speakers will discuss when this is indicated in primary and secondary prevention. However, it remains the most cost effective antiplatelet agent to prevent cardiovascular events. Prof. Abdus Samad thanked M/s Atco Laboratories for continuously sponsoring the CME activities of PAF to create awareness among physicians and public about the use of low dose aspirin therapy. Mr.Shaukat Ali Jawaid Secretary of the PAF announced that keeping up the professional ethics; they do not promote and patronize any particular company or brand of Aspirin. A representative of The Citizens Foundation was also presented a cheque as a donation by Atco to promote education and literacy in the country.

Prof.  M. Ishaq elected new President
of Pakistan Aspirin Foundation

Dr. Shahbaz Kureshi chosen as President-elect

LAHORE: Prof. M. Ishaq a noted cardiologist from Karachi was unanimously elected as the new President of Pakistan Aspirin Foundation at a meeting held here on April 27^th 2018 for a two years term. Prof. Shahbaz Kureshi another noted cardiologist from Islamabad was also chosen as President-elect. The meeting was chaired by Prof. Javed Akram the outgoing President of the Foundation. The participants also thanked Prof. Javed Akram for his contribution to promote the aims and objectives of Pakistan Aspirin Foundation during his term and hoped that the new President will follow the traditions set by all the former Presidents to create awareness among the public as well as healthcare professionals to promote the use of Aspirin in its well established indications.

The meeting also thanked Prof. M. Akbar Chaudhry another former President of the Foundation for organizing the National Conference for the third time in Lahore. The meeting was attended by most of the founder members including former Presidents i.e. Prof. Mahmood Ali Malik, Prof. Abdus Samad, Maj. Gen. Ashur Khan, Prof. Ejaz Ahmad Vohra, Prof. Akbar Chaudhry. Other senior cardiologists who graced the occasion with their presence included  senior cardiologists Dr. Shaukat Malik and Dr. Shahbaz Kureshi,  Dr. Dawar Majeed from Rawalpindi, Islamabad, Prof. A. Rashid Khan and Prof. Mansoor Ahmad from Karachi, Prof. Naeem Aslam from Faisalabad, Prof. Saulat Siddique from Lahore. Prof. M. Ishaq in his brief address thanked the members for reposing their trust in him and said he will try to come up to their expectations.

Pakistan Aspirin Foundation had a meeting at Lahore on April 27th, 2018. Group photograph taken during 
the council meeting shows sitting from (L to R) Maj. Gen. Ashur Khan, Prof. Abdus Samad, Dr. Shaukat 
Malik, Prof. Ejaz Ahmed Vohra, Prof. Mahmood Ali Malik, Prof. M. Akbar Chaudhry. Standing from (L to R) 
Prof. Saulat Siddique, Dr. Dawar Majeed, Mr. Shaukat Ali Jawaid, Prof. Javed Akram, Prof. M. Ishaq, 
Prof. A. Rasheed, Prof. Mansoor Ahmed, Prof. Naeem Aslam, Prof. Shahbaz Kureshi and Mr. Kashif Riaz 
from Acto Laboratories which sponsor CME Activates of the Foundation.

Earlier Mr. Shaukat Ali Jawaid General Secretary Pakistan Aspirin Foundation presented details of the CME activities, organizing seminars, multidisciplinary Group Discussions besides Breakfast Sessions at PHL and Pakistan Cardiac Society meetings in various cities of Pakistan. He thanked the members for their devotion, dedication to the cause to promote Aspirin and hoped that they will continue to uphold professional ethics as in the past. The participants of the meeting also appreciated the unlimited help and support extended by Atco Laboratories for the CME and other academic activities organized by Pakistan Aspirin Foundation for the last many years. Mr. Kashif Riaz Business Unit Head of Atco who coordinates with the Pakistan Aspirin Foundation in its CME activities was also present on this occasion.  Detailed report on the National Conference of Pakistan Aspirin Foundation held at Azra Naheed Medical College in collaboration with Superior University on April 28^th 2018 which was followed by pre-conference Workshops on April 27th to follow.

PAF and PMA Sukkur organize Seminar on use of Aspirin in CVD

Low Dose Aspirin therapy leads to 23% reduction
in MI mortality, 50% reduction in Non-fatal
MI and Stroke - Prof. M. Ishaq

It is the most cost effective anti-platelet agent,
safe in long term use

Asian population is at very high risk of cardiovascular
diseases even without smoking-Prof. Samad

From our correspondent

SUKKUR: Regular use of Low Dose Aspirin therapy leads to 23% reduction in mortality in Myocardial Infarction, 50% reduction in Non-fatal MI and Stroke. It is the most cost effective anti-platelet agent which is safe in long term use. Its use in primary prevention of heart disease is conditional and one should calculate the risk before prescribing it. This was stated by Prof. Muhammad Ishaq, a noted cardiologist and Secretary of Pakistan Hypertension League. He was making a presentation on Use of Aspirin in the prevention of cardiovascular diseases at a seminar organized here on Saturday January 27^th 2017 by Pakistan Aspirin Foundation in collaboration with Pakistan Medical Association Sukkur.

Dr. Raj Kumar Head of the Dept.of Cardiology at Sardar Ghulam Muhammad Maher Medical College was the main organizer of this meeting. It was chaired by Prof. Abdus Samad an eminent cardiologist of Pakistan who is also former President and Chairman of Experts Panel of Pakistan Aspirin Foundation on Medical Uses of Aspirin. Others who jointly chaired the session included Dr.Zahoor Soomro, President of PMA Sukkur, Prof. Altaf Shaikh and Mr. Shaukat Ali Jawaid General Secretary of Pakistan Aspirin Foundation.

Prof. Abdus Samad (Chairman) Prof. M. Ishaq (Guest Speaker) photographed along with Dr. Zahoor Soomro, Dr. Raj Kumar,
 Prof. Altaf and others at the seminar on Use of Aspirin in CVD held at Sukkur on January 27, 2018.

Prof. Ishaq in his presentation on Primary and Secondary prevention of coronary artery disease and the use of Aspirin pointed out that Aspirin is a lifesaving miracle drug which is considered an orphan drug. Since three is not much profit, no one is interested in its promotion. However, it is a fact that it is one of the most widely used drug.   Quoting a Hadees Prof. Ishaq said that “ there is a flesh in the body, if it is sound, one is healthy but if it is corrupt, it is very bad and serious and it is Heart”.

Mortality from cardiovascular diseases Prof. Ishaq said is about 30%.  Of this cardiovascular mortality 55% is due to CAD, 17% from stroke, 6% from Congestive Heart Failure and 5% from hypertension. Cardiovascular diseases, Peripheral Artery Disease and cerebrovascular diseases all affect at the same time. Tracing the history of Aspirin, Prof. Ishaq said that it was first used as pain killer as it offers potent pain relief. In 1967, its anti-platelet properties were discovered. PAD is very common in Pakistan. About 26 Million people in Untied States are at present using Aspirin daily. Heart disease is the main indication for its use. He then discussed in detail the thrombotic disease process, how platelets are formed, they aggregate, plaque formation and then clotting which results in heart attack. Aspirin, he stated, is the mother of all anti platelet agents. He also briefly talked about its mechanism of action. It kills all the platelets thus results in relief from stable and unstable angina. The role of Aspirin in all sub-sets of Acute Coronary Syndrome patients is very well established. In coronary interventions, it offers maximum benefit i.e. 53% reduction in MI and Stroke as well as vascular death besides preventing second event. Various studies have confirmed that it leads to reduction in morbidity and mortality in AMI, Acute stroke, PAD, TIA and CAD. It is useful in high risk of embolism as well as in diabetes mellitus. In acute MI, one has to use soluble Aspirin one full tablet of chew three to four coated tablets for immediate relief. Soluble Aspirin should however be preferred in acute conditions. Despite its usefulness in a wide range of medical disorders, it is still under used in many countries including Pakistan. Speaking about the effective dosage, he said, 75-100mg is both effective. The only known side effect is bleeding but it has a very low toxicity profile. It has high safety profile as compared to clopidogrel, small dose of up to 100mg has a risk of bleeding of 1.9% which is far less as compared to other NSAIDS which are so commonly used, he remarked.

In acute vasculitis in children it is safe and effective. Similarly it is used in Kawasaki Disease. Aspirin resistance is very low. In Diabetes Mellitus Type-2, if there is no clinical CAD, one should not use Aspirin but in case of any risk factor, its use is recommended. As regards use of Aspirin in primary prevention, there are different reports.  American Heart Association says that if the CAD risk is more than 10%, use Aspirin. Joint British Society recommends the use of 75mg of Aspirin in all people over the use of fifty years. It is better to calculate the absolute risk of cardiovascular disease. If the risk is less than 6%, do not use it but if the risk if more than10%, use of low dose aspirin is recommended. In case of risk between 6-10%, ask the patient and go by his preference regarding use of Aspirin. Responding to various questions Prof. Ishaq said that there is no doubt that Aspirin is a very effective analgesic and antipyretic but today we wanted to highlight its anti-platelet properties and usefulness in prevention of cardiovascular diseases.

Earlier Dr. Zahoor Soomro President of PMA Sukkur in his speech said that PMA keeps on organizing such CME programmes for its members which is also requirement of the PM&DC. Today’s session has been organized in collaboration with Pakistan Aspirin Foundation. Proper use of drug in proper dosage at proper time saves lives. Aspirin is very useful in numerous cardiac conditions including AMI and Sudden Death. Aspirin is an important component of Medicine.  In clinical practice a small tablet of Aspirin makes lot of difference. It is simple, economical and easily affordable and available everywhere. He suggested we all must keep Aspirin with us in our clinic, office and home as it may be needed in any emergency and it can prove lifesaving.

Dr. Raj Kumar in his address highlighted the usefulness of Aspirin which he said was a lifesaving, wonder drug. He also reminded the participates that they should always keep Aspirin with them and in case of chest pain irrespective of the fact whether it is cardiac or non-cardiac use it immediately. It is as effective as streptokinase. 

Pakistan Aspirin Foundation in collaboration with PMA Sukkur organized a seminar on Use of Aspirin in Cardiovascular Diseases
at Sukkur on Saturday January 27, 2018. Picture shows Prof. Abdus Samad, Prof. M. Ishaq, Dr. Zahoor Soomro, Dr. Raj Kumar,
Mr. Shaukat Ali Jawaid and Prof. Altaf speaking at the occasion.

Prof. Abdus Samad in his concluding remarks commended Prof. Ishaq for his excellent presentation on Aspirin. He further pointed that cardiovascular diseases is going to be the leading cause of death all over the world. Hence, its prevention is most important. If one does not wish to die due to CVD, it is important to take low dose aspirin daily. It is safe and effective even in long term use. Use of any drug, he further stated must be medically based. One should always look at benefits and side effects. Use the drug where benefit is more. Asian population in general he said was at a higher risk of developing cardiovascular disease even without smoking. If the risk is more than 6%, one must use Aspirin. Speaking in his typical style, he said that it is just like if the crime in the society is more, one should be careful in opening the door but if there is no crime, there is no harm in opening the door. Similarly use Aspirin if the risk is there.

Continuing Prof. Samad said that a person is as old as his arteries. We in Pakistan see  CAD and PAD in patients in their 30s. If a seventy years old patient has good arteries, he may be very healthy. Age is in fact determined by the arterial age. Aspirin is known as Poor Man’s Statin and it is as effective as Streptokinase. It is economically priced. We all must take care of our own health, our family’s health and cost effective drugs like Aspirin should be preferred. Age, cholesterol, LDL and smoking are some of the important risk factors in Asian population. In Pakistan AMI occurs at a very young age, hence it is advisable that one should always calculate the risk of your patient which is easy to do and then prescribe low dose Aspirin therapy. If anyone gets CAD before the age of seventy years, it is considered his own fault as he or she failed to take preventive measures.

Speaking about the use of Aspirin in surgical procedures, Prof. Samad said that use of Aspirin should not be stopped in surgical procedures except in case of surgery in close cavity like brain surgery or chest surgery. In all other conditions one should continue the use of Aspirin. We have seen patients with MI soon after surgery as Aspirin was stopped. In young people, clot is more and less atherosclerosis. Use of low dose Aspirin has to be lifelong. We all must develop a habit of preventing coronary artery disease in our families and children as it is our duty. Avoid fast food and go for slow food.  All heart disease patients should be advised to use Aspirin, Statin regularly unless there are some contra indications. Avoid soft drinks and all other sugary drinks, go for regular exercise, do not take tension, and avoid stress. He also recalled that late Prof. Iftikhar Ahmad used to teach us that there is only one animal donkey which does not get heart attack because donkey works hard, does not complain, eats grass, and does not eat meat, beef, butter and other fats. Hence always prefer the use of vegetables, fruits, healthy diet, take no tension and work hard to avoid any heart attack.

Mr. Shaukat Ali Jawaid General Secretary of Pakistan Aspirin Foundation speaking on the occasion thanked Dr. Raj Kumar, Dr. Zahoor Soomro and PMA Sukkur. He also announced that though M/s Atco Laboratories have sponsored their visit and are sponsoring CME activities of Pakistan Aspirin Foundation for the last many years but we do not patronize any particularly pharmaceutical company or any particular brand name of Aspirin. We are extremely grateful to Atco Laboratories for their generous help and assistance which has gone a long way in creating awareness among public as well as healthcare professionals regarding the medical uses of Aspirin particularly it’s effective in prevention of cardiovascular diseases.  However, one must remember that with the use of every drug, there are some non-responders and Aspirin is no exception.  Some people might still suffer from CVD despite taking Aspirin. At the end Prof. Altaf Sheikh thanked the speakers and the participants for making the meeting a great success.

 Breakfast Session on Aspirin during CARDIOCON 2017

We cannot prevent atherosclerosis but can reduce 
Athero-thrombotic events with Aspirin

All high risk CVD patients should be put on regular 
low dose Aspirin Therapy-Dr. Farooq Fawad

HYDERABAD: Scientific programme of the CARDIOCON 2017 held here recently started on November 25^th 2017 with a Breakfast Session devoted to Medical Uses of Aspirin. This session was jointly chaired by Prof. Ejaz Ahmad Vohra an eminent physician and former President of Pakistan Aspirin Foundation along with Prof. Shahryar Sheikh former President of World Heart Federation and Prof. Feroze Memon. Dr. Shaukat Memon acted as the Moderator.  Apart from Prof. Ejaz Ahmad Vohra who talked about Use of Aspirin beyond Cardiovascualr disease, Dr. Fawad Farooq from NICVD was the other speaker who highlighted the use of Aspirin in prevention of cardiovascular disease. He pointed out that we cannot prevent atherosclerosis which leads to Ischaemic Heart Disease but we can reduce Athero-thrombotic events with Aspirin therapy.

Prof. Ejaz Ahmad Vohra along with Prof. Feroze Memon and Prof. Shahryar Sheikh chairing
 a session on Medical Uses of Aspirin during Cardiocon 2017 held at Hyderabad recently.

Prof. Ejaz Ahmad Vohra in his presentation discussed in detail the historical background to the development of Aspirin, the mechanism of action of Aspirin, safety and efficacy of Aspirin in ACS, CAD besides its new emerging indication in prevention of colorectal cancer.  Various studies, he said, have shown that regular use of aspirin reduces the long term risk of several cancers and the risk of distant metastasis. Drop in digestive cancer incidence is also linked to long term intake of Aspirin. Another study has shown that dual clopidogrel and aspirin treatment is safe regarding the cancer risk. This study has generated hypothesis that clopidogrel may reduce the cancer incidence. Aspirin also reduces the risk and severity of early recurrent stroke after TIAs as well as ischaemic stroke. Daily low dose aspirin given before sixteen weeks of gestation to women at high-risk of adverse pregnancy outcomes mitigates that risk. Randomized trials have also showed that combining a Statin with one or more antihypertensive drugs and aspirin improves treatment adherence rates and safely reduces Cardiovascualr risk factors in patients with Cardiovascualr diseases.   Use of the above medications along with folic acid is estimated to reduce the risk of IHD by 88% and stroke by 80% in individuals aged 51-65 years if taken for two years. In view of the high burden of NCDs, the developing countries, Prof. Ejaz Ahmad Vohra remarked should focus on getting prevention and treatment programmes right. Lifelong daily low dose Aspirin for secondary prevention of CVD is well established and is included in numerous guidelines.  Yet adherence to aspirin is a major problem as even in United States 46.9% of patients with Ischaemic vascular disease were prescribed antiplatelet medications in 2007-2008 while the rates were even lower in primary care.  As such it is important to promote the use of regular low dose aspirin therapy in its well established indications to prevent morbidity and mortality in various disorders.

Prof. Ejaz Ahmad Vohra along with Prof. Shahryar Sheikh presenting a Cheque of rupees five hundred 
thousand to the representative of Citizen Foundation on behalf of M/s Atco Laboratories during the 
Aspirin session in Cardiocon 2017. Picture on left also shows Prof. Feroze Memon besides 
Mr. Akhtar Tahir and Mr. Kashif Riaz from Atco Laboratories.

Dr. Fawad Farooq’s presentation was based on certain case scenarios wherein he discussed why and who should receive Aspirin for prevention of Coronary Artery Disease. He also talked about rationale of using antiplatelet, assessment of cardiovascular disease as well as bleeding risk and then deciding as to who should receive aspirin therapy.   Speaking about platelet cascade in thrombus formation he pointed out that platelet adhesions is followed by platelet activation, aggregation which results in plaque formation. Major manifestations of thrombotic events include ischaemic stroke, Transient ischemic attack, myocardial infarction, unstable angina and critical limb ischemia.

Cardiovascualr risk is calculated based on sex, age, race, total cholesterol, HDL, systolic blood pressure, treatment for high blood pressure, history of diabetes and smoking. As regards risk levels, less than 3% risk over ten years period is considered low risk, from 7.5 to 10% over ten years period is considered high risk. In case of low risk, there is no need to prescribe aspirin therapy, in medium risk discuss the pros and cons of aspirin and use patient’s preferences to decide what to do. However, in high risk all patients should be put on regular low dose aspirin therapy.  He concluded his presentation by stating that identifying and treating single risk factor is not enough to reduce the Cardiovascualr disease risk.  Comprehensive risk assessment and taking care of all modifiable risk factors along with Aspirin treatment should be the goal. However, all those patients with known coronary artery disease should receive Aspirin, he added.

Photographed during the cardiocon 2017 held at Hyderabad recently from (L to R) are Prof. Khawar 
Kazmi, Dr. Tahir Saghir, Prof. Nadeem Qamar, Mr. Akhter Ali Tahir (Atco), Dr. Farooq Fawad 
and Mr. Kashif Riaz from Atco Laboratories.

At the end of session Prof. Ejaz Ahmad Vohra along with Prof. Feroze Memon presented a cheque of Rs. 500,000 to the representative of Citizen Foundation on behalf of Atco Laboratories. In order to fulfill its corporate social responsibilities, Atco Laboratories, it may be mentioned here has signed an MOU with Citizen Foundation to pay a percentage of its sale of Aspirin (Ascard) to them to promote education. Prof. Ejaz Vohra commended the initiative of Atco Laboratories and hoped that other pharmaceutical companies will also come forward and play their role to fulfill their corporate social responsibility. This session was organized by Pakistan Aspirin Foundation in collaboration with Atco Laboratories which are sponsoring CME programmes of the Foundation for the last many years.

Group photograph of participants in the interactive small group discussions on Medical Uses
of Aspirin organized at Mianwali on August 21st 2017.

Group photograph of participants in the interactive small group discussions on Medical Uses of Aspirin
organized at Dera Ismail Khan on August 22st 2017.

Seminar on Medical Uses of Aspirin

Low Dose Aspirin is currently cornerstone
of antithrombotic component for secondary
prevention of CVD-Prof. Ejaz Ahmad Vohra

Aspirin, BP Control, Cholesterol management and smoking

cessation figure prominently in Million Hearts

Programme of USA - Prof. Samad

IHD cannot be prevented but we can reduce
atherothrombotic events with Aspirin - Fawad Farooq

KARACHI: Low dose aspirin is currently the cornerstone of the antithrombotic component of secondary prevention of cardiovascular diseases.  New research studies underway are investigating the best way to use aspirin as well as new approaches for antithrombotic therapy for secondary prevention. This was stated by Prof. Ejaz Ahmad Vohra, an eminent physician from Ziauddin Medical University. He was speaking on Aspirin in the 21st Century highlighting its safety and efficacy in a wide range of medical disorders from cardiovascular diseases to stroke, diabetes, cancer prevention, in pregnancy and HIV. The seminar was organized by Pakistan Aspirin Foundation as a part of its CME programme on May 10^th 2016. It was chaired by Prof.Abdul Samad another eminent cardiologist of the country. Dr. Fawad Farooq Assistant Prof. from NICVD was the other speaker who talked about Aspirin in secondary prevention of IHD. The members of the expert’s panel included Prof. Mansoor Ahmad from KIHD, Prof. Zaman Sheikh from SSIMS, and Prof. Wasim Akhtar from Abbasi Shaheed Hospital KMDC, Karachi.

In his presentation Prof. Ejaz Ahmad Vohra discussed in detail the role of aspirin beyond Cox-inhibition, its adverse effects, economics of Aspirin use, and its established uses for the treatment of Acute Coronary Syndrome besides benefits of Aspirin maintenance therapy during the first year.He also highlighted efficacy of aspirin in prevention of recurrent stroke. Referring to various studies Prof. Ejaz Ahmad Vohra opined that more data is needed on primary prevention in people at high risk of cardiovascular diseases. US Task Force on Preventive Services has recently recommended theuse of Aspirin for primary prevention of cardiovascular diseases and colorectal cancer as a preventive medication in those who are at high risk and have no risk of bleeding. 

 Prof. Abdus Samad chairing the seminar on Medial Uses of Aspirin organized by Pakistan Aspirin Foundation at Karachi on May 10th. Also sitting on the dais from (L to R) are Dr. Wasim Akhtar, Prof. Mansoor Ahmad, 
Prof. Zaman Sheikh, Prof. Ejaz Ahmad Vohra (speaker) and Dr. Fawad Farooq the other speaker.

Speaking about the use of Aspirin in Neurology, Prof. Ejaz Vohra said that most common use of Aspirin is in acute stroke, acute TIA and minor stroke. Studies have confirmed that it reduces the early recurrence of second stroke by 30-40%. Various Guidelines have recommended Aspirin for acute Ischaemic strokes. However, it may be noted that there could be an increased risk of intracereberal haemorrhage, hence one needs to balance risk against its benefits, he added. Continuing he further stated that effects of aspirin in TIA and minor stroke are probably larger and more beneficial than in higher risk events. Combination of Aspirin and clopidogril is more effective in preventing stroke after TIA compared to aspirin alone. However, it is highly effective for secondary prevention of TIA and Minor strokes when given alone.

For long term prevention of stroke, aspirin monotherapy was an option. Initial benefits of aspirin are maintained while other antiplatelet drugs like clopidogril are also effective and combination therapy is recommended for prevention of stroke. Various trials has shown safety and efficacy of aspirin long term use in primary prevention of stroke. Its effects in cerebral aneurysm, migraine, depression and cerebral tumors are being investigated. In acute chest pain, it is advised to use aspirin formulation with faster onset of action like soluble aspirin. Long term use of NSAIDS, Prof. Ejaz Ahmad Vohra stated is well known to increase the risk of serious GI events such as perforation, ulcer and bleed. Speaking aboutthe use of Aspirin in diabetes, he said that ADA, AHA and American College of Cardiology Foundation have provided additional information for the use of aspirin in diabetes. In their joint statement they have said that aspirin in low dose is reasonable for adults suffering from diabetes who are at increased risk of cardiovascular diseases, with no previous history of CVD and who are not at increased risk of bleeding. Aspirin is also recommended for those who have intermediate risk of developing cardiovascular disease. The recommended dose of Aspirin is between 75-162mg daily.

Long term use of low dose Aspirin has alsodemonstrated reduction in cancer incidence and mortality with aspirin in colorectal cancer, esophageal cancer, gastric cancer, lung cancer, prostate cancer and breast cancer. Now there is increasing evidence that aspirin has anticancer effect possibly mediated through platelets. With the every passing day, there is an increase in emerging indication for the use of aspirin and now short term effects of Aspirin in people with HIV have also been reported. It is said that low dose aspirin may have a therapeutic role in alternating immune activation and inflammation. Aspirin is also a drug of choice in prevention of Pre-eclampsia, he added.

Dr. Fawad Farooq in his presentation described three case histories of patients and how lipid deposition, inflammation and thrombosis takes place. Discussing the process of thrombus formation Dr. Fawad Farooq said that itstarts with endothelial damage or plaque rupture which is followed by adhesion, activation and aggregation of platelets which eventuallytriggers clotting mechanism.  The various antiplatelet agents available include Aspirin, P2Y12inhibitors like Ticlopidines, Clopidogril, Prasugrel, Ticagrilor, Dipyridamole, Cilostazol, GP 11b IIIa inhibitors. He pointed out that we cannot prevent IHD which is an atherosclerosis process which starts much early in adult life but we can reduce the atherothrombotic events with the use of Aspirin.

Group photograph taken at the seminar on Medical Uses of Aspirin held at Karachi on May 10th shows 
from (L to R) Mr. Farhan, Shaukat Ali Jawaid, Dr. Waseem Akhtar, Prof.Mansoor Ahmad, Prof. Zaman 
Sheikh, Prof. Abdus Samad, Prof. Ejaz Ahmad Vohra, Mr. Akhtar and Mr. Kashif Riaz 
from Atco Laboratories sponsors of  the meeting.

Aspirin can be used 75-162 mg daily in case of known cardiovascular diseases or NSTE-Acute coronary syndrome, following PCI oras Fibrinolytic therapy for a STEMI. Its clinical uses include secondary prevention of stableIHD, NSTEMI/Unstable Angina, STEMI as well as Peri-PCI procedures like stenting.

Various guidelines suggest that in acute coronary syndrome dual antiplatelet therapy can be used for a year. Then clopidogril can be stopped while one can continue with low dose aspirin therapy. He concluded his presentation by stating that atherosclerosis is a process which starts very early in life. Atherothrombosis leads to major vascular events at any stage of atherosclerotic process. Platelets play a key role in atherothrombotic process to prevent events.

During the discussion Prof. Zaman Sheikh pointed out that during Ramzan one should take Aspirin after Iftar while all other anti-diabetic medications including insulin dosage will have to be adjusted accordingly after consultation with the treating physician. Prof. Wasim Akhtar opined that since the prevalence of diabetes and hypertension is very high in Pakistan, it is advisable to use low dose aspirin therapy which has shown to reduce morbidity and mortality in various diseases significantly. Prof. Mansoor Ahmad opined that use of Aspirin in ACS, in acute myocardial infarction and prevention of stroke have all been adequately highlighted by the speakers. One of the participants said that one of the gastroenterologist told him that he was seeing more cases of gastric ulcer and 30% of them were related to use of Aspirin. At this Prof. Abdus Samad remarked that anecdotal evidence has no value in the present era of evidence based medicine. All these things have got to be documented and reported. He further stated that we in Indo-Pakistan use lot of spicy foods and if a study is conducted to find out gastric ulcer among those who are taking low dose aspirin and those who are not, it is quite likely that those not on aspirin therapy will have more gastric ulcer. Hence we need to change our dietary habits, life style modificationis extremely important in prevention of cardiovascular diseases, diabetes and numerous other diseases. Mr. Shaukat Ali Jawaid General Secretary of Pakistan Aspirin Foundation remarked that they had looked at all the data related to Aspirin until 2014 before finalizing the Guidelines. All the recommendations in this document are properly referenced. He further stated that we are extremely grateful to Atco Laboratories who are sponsoring our CME activities for the last many years but keeping up the professional ethics, we do not patronize any company or promote any particular brand name of Aspirin. It was up to the physicians to use whichever aspirin preparation they want to use.

Summing up the discussion Prof. Abdus Samad referred to the Million Hearts Programme of United States of America. Adopting the preventive strategy which consists of life style modification, use of drugs, interventions, surgery and genetic intervention, they wish to save millions of heart attacks by 2025. This programme lays special emphasis on ABCS which stands for use of Aspirin when appropriate, Blood Pressure Control, Cholesterol Management and Smoking Cessation. US Preventive Services Task Force has also recommended initiation of low dose aspirin therapy in individuals over the age of fifty years with moderate risk. Those who have a relative risk of developing cardiovascular disease of more than 10% must be put on low dose aspirin therapy. However, in elderly over the age of seventy years there was not sufficient evidence. Since in Pakistan life expectancy is ten years less, hence we in Pakistan recommend the use of Aspirin therapy in individuals over the age of forty years who are at risk of developing cardiovascular disease. Speaking in a lighter vein Prof. Samad remarked that it is not difficult to remember 10% in Pakistan. We should be happy as we have only seen PANAMA leaks, had there been PAJAMA leaks, it would have proved to be a far serious situation, he remarked.

Panel Discussion on Medical Uses of Aspirin at Sargodha and Faisalabad

Experts highlight safety and efficacy of Low
Dose Aspirin Therapy in reducing morbidity
and mortality in various medical disorders

From our correspondent

SARGODHA & FAISALABAD: Pakistan Aspirin Foundation in its Continuing Medical Education programme organized Panel Discussions on Medial Uses of Aspirin at Sargodha on April 20^th and at Faisalabad on April 21^st 2016.  The meeting at Sargodha was chaired by Prof. Siddique the senior most physician in the city while the meeting at Faisalabad was presided over by Prof. Abdul Hafeez Chaudhry a well-known cardiac physician. The panel of Experts at Faisalabad meeting included Prof. Naeem Aslam, Prof. of Cardiology at Punjab Medical College, In charge of Coronary Care Unit at Allied Hospital Faisalabad and Dr. Javed Iqbal Consultant Cardiologist and in charge of Cardiac Center at DHQ Hospital Faisalabad.

Prof. Abdul Hafeez Chaudhry moderated the Panel Discussion on Medical Uses of Aspirin organized
by Pakistan Aspirin Foundation at Faisalabad on April 21st 2016. Group photograph taken on the 
occasion shows Prof. Abdul Hafeez Chaudhry along with other members of the Experts panel 
Prof. Naeem Aslam and Dr. Javed Iqbal and Mr. Shaukat Ali Jawaid and some of the participants.

Copies of the Consensus Report on Guidelines on Medical Uses of Aspirin prepared by a panel of experts headed byProf.Abdul Samad an eminent cardiologist of Pakistan in collaboration with Prof. Ejaz Ahmad Vohra and Prof. M.Akbar Chaudhry besides a Booklet in Urdu authored by late Dr. Maqbool Jafary and Mr. Shaukat Ali Jawaid Chief Editor of Pakistan Journal of Medical Sciences and Pulse International were distributed among the participants before the discussion. In his introductory remarks at both the places Mr. Shaukat Ali Jawaid General Secretary of the Pakistan Aspirin Foundation gave the background of the consensus document which gives comprehensive details about the established indications with doses in various medical disorders. It also gives details about the absolute as well as relative contra indications for the use of Aspirin therapy.

The literature on Aspirin till 2014,he  said,  was reviewed in detail before finalizing this document and each and every recommendation has been properly referenced. He also highlighted the salient features from the latest US Preventive Services Task Force on the use of Aspirin in Primary Prevention of Cardiovascular Diseases and Colorectal Cancer published on April 13^th 2016. It also recommends use of Aspirin for primary prevention in patients over the age of fifty years with one or two risk factors while its efficacy in colorectal Cancer is only after it is used for a period of ten years. Since life expectancy in Pakistan is about ten years less as compared to the developed world, Pakistan Aspirin Foundation has recommended the use of Aspirin for primary prevention in patients above forty years of age. Those with one or two risk factors, must get aspirin while for others one has to calculate the risk score which can be done using the information provided in these Guidelines, he added.

Participating in the discussion at Sargodha, Dr. Jamil said that we use Low Dose Aspirin therapy in angina, after acute myocardial infarction and in all Acute Coronary Syndromes regularly.  It is a lifesaving drug for patients with heart diseases while it also has a preventive role in stroke. Our patients cannot afford expensive medications and there are compliance issues as well. Aspirin is economically priced antiplatelet agent which is also easily available everywhere. It has come as a revolution for the poor. It is also known as Poor Man’s Streptokinase or Poor Man’s statin. For the poor countries it is not less than a blessing, he remarked.

Participating in the Panel Discussion on Medical Uses of Aspirin organized by Pakistan Aspirin Foundation at Sargodha on April 20th from (L t R) are Prof. M. Siddique, 
Dr. Jamil, Dr. Humaira and Dr. Nusrat.

Stroke he pointed out was a big burden and the patient often remain wheel chair bound for ten to fifteen years. Its regular use prevents stroke.  The dosage recommended for cardiovascular diseases was  75-100mg daily while for stroke the maintenance dosage is 150mg. For acute myocardial infarction one has to use the full tablet of 325mg and soluble aspirin is preferred. However, for long term use, enteric coated aspirin tablets are safe and should be preferred.

Dr Fida remarked that Aspirin has a very wide range of uses in a number of medical disorders starting from ACS, Acute MI, prevention of secondary AMI, Stroke, after angioplasty and stenting, for prevention of deep vein thrombosis and pulmonary embolism, hypertension and diabetes mellitus. However, he cautioned that one has to be careful of gastropathy. Low Dose Aspirin therapy can be used for primary prevention in patients with one or two risk factors or those who are in high-risk and family history of heart disease. One also has to be careful in cardiomyopathy and inpatients with diabetes who also suffer from atrial fibrillation, it should not be used.

Dr. Humaira and Dr.Nusrat sharing their views pointed out that Aspirin has also come as a wonder drug for the obstetricians and gynecologists.  We use it with excellent results in intra uterine growth retardation, DVT, Pulmonary embolism, in those patients who have a history of pregnancy loss, recurrent abortions and miscarriages where it is used in combination with low molecular weight heparin, bad obstetric history and infertility. It is also useful to take care of intra uterine deaths, dysfunctional uterine bleeding where it is used along with Metformin. Aspirin also improves endometrial lining. It has a good role in IVF cases as well. It is effective in pregnancy induced hypertension as well.

Dr. Munawar Jamshed participating in the discussion said that its side effects are dose dependent.Dr. Iqbal pointed out that let us not forget the brain. Its efficacy in prevention of stroke are well established and it also prevents recurrent strokes and TIAs. He further stated that if used on alternate days, it does not work since the life of the platelets is about eight to ten days and every day about 10% new platelets are formed. He further stated that there is no increased antiplatelet activity with increases dose hence one has to use 75-100mg which has been recommended in various studies.

In response to a question Mr. Shaukat Ali Jawaid clarified that in various studies doses of 75mg, 81mg and 100mg has been used. It is because in United States low dose Aspirin is mostly marketed in 81mg, in Europe and other countries it is marketed as 75mg, hence these doses have been used in various studies conducted in United States and Europe. It was also stated that one should first get the blood pressure under control and only then the patients should be prescribed low dose aspirin therapy.  In addition since most of the cardiac events take place early in the morning, it is preferable to take Aspirin after dinner at bed time to take care of early morning peaks in blood pressure.

Dr. Mumtaz referred to Aspirin resistance.  At this it was pointed out that it  wasvery expensive to study resistance to aspirin but in fact these are the patients who can be termed as non-responders.  There are some patients who do not respond to any hypertensive medication or anti-depressant. Likewise there are some patients who may not respond to Aspirin therapy as well. Dr. Zafar from WAPDA Hospital said that one has to careful while using various NSAIDs as well.

A group photograph of some of the participants in the Panel Discussion on Medical Uses of Aspirin
held at Sargodha on April 20th along with Prof. Siddique who chaired the session.

Prof Siddique in his concluding remarks said that Aspirin has a wide range of indications which are now very well established. However, one has to be careful and weigh the benefit vs. harm. Higher dose of aspirin can lead to serious complications. Real problems comes with the patient comes for surgery. Now it is said that one does not need to stop aspirin therapy though previously it was recommended to stop it five to seven days before surgery. However, one has to take into account individual patient as all patients are not the same. Those who have a tendency of bleeding should not be given aspirin. In such patients one has to be very careful and do not use it unless it is indicated. There is still some controversy as regards its use in primary prevention of cardiovascular diseases but small dose is not harmful and is quite safe and effective. We can use it prophylactically. If used in combination with clopidogril, it increases the antiplatelet activity but one must be mindful of the fact that the combination of these two anti-platelets also increases the risk and side effects.

Meeting at Faisalabad

Prof. A. Hafeez Chaudhry moderated the session at Faisalabad where it was attended by cardiac physicians and a select group of family physicians besides a neurosurgeon.

Addressing the participants Prof. Naeem Aslam said that the use of low dose Aspirin therapy became very popular when ISIS study showed that when compared with Streptokinase, there was equal reduction in mortality after AMI. If Aspirin was combined with Streptokinase, the mortality reduction was also significantly increased. Now it is recommended that every patient with chest pain must have aspirin immediately whether they are at home, in office or in the hospital as it could prove lifesaving. Not to use Aspirin in such a situation is not advisable at all. In Acute Myocardial Infarction one has to use 325mg tablet of Aspirin and soluble aspirin should be preferred and if it is enteric coated, these tablets should be chewed immediately. In case of myocardial infarction one can use Aspirin, Clopidogril and Streptokinase together. However, one has to be careful about the chances of bleeding in patients with history of acute bleeding or chronic liver disease.

Responding to a question as to how long one should take Aspirin after AMI, Prof. HafeezChaudhry remarked that it has to be taken for life long. Low dose aspirin therapy should also be prescribed to all the patients after interventional procedures like angioplasty and stenting unless it is contra indicated.

Mr. Shaukat Ali Jawaid clarified that in the developed world, Aspirin is promoted direct to the patients and it is available as OTC product but keeping in view the low literacy rate in Pakistan and to ensure that it is not misused andto  promote its rational use, Pakistan Aspirin Foundation had decided from the very beginning that we will promote it through the healthcare professionals.

One of the participants pointed out that many patients come with high blood pressure and when they are asked if they were taking any drug, they say they are taking Aspirin. As such the patients’ needs to be educated that Aspirin was not a drug for control of high blood pressure. It should only be used after blood pressure has been controlled where it is effective in BP management and keeping it under control. While performing surgery one can continue with Aspirin therapy but clopidogril has to be stopped.

Dr. Javed Iqbal pointed out that one has to be extremely careful with high doses of Aspirin. We give a loading dose of 325mg of Aspirin with Heparin and 600mg of Clopidogril before PCI because after PCI patient might come with acute thrombosis.  PCI patients should take aspirin forat least one year. In case of Drug Eluting Stents, patients should take aspirin for at least one year as they are high risk cases including those who are suffering from diabetes. After stenting care, some patients may end up with coronary occlusion if anti- thrombotic therapy is stopped.

Mr. Shaukat Ali Jawaid Chief Editor Pulse International presenting 
his latest book “Plight of a Medical Editor: an autobiography” to 
Prof. Mohammad Siddique at Sargodha on April 20th after 
the panel discussion on Medical Uses of Aspirin.

When asked about the use of Proton Pump Inhibitors (PPIs) for H. Pylori eradication and in gastric ulcer cases, it was pointed out that one should use the PPIs at leastfor six to eight weeks. If GERD patients come, do not continua using PPIs for too long? Replying to another question about stroke patients,it was stated that if CT is available it is advisable to get the CT immediately to eliminate the chances of hemorrhagic stroke and to see that  there is no bleeding. Once it is ruled out, then use Aspirin. However, in case of an emergency and if CT facility is not available, one can take chance with one tablet of Aspirin. Let the patient stabilize and then manage it appropriately. However, it is always advisable to have CT in such patients during the first twenty four hours.

In the end Mr. Shaukat Ali Jawaid thanked Prof. Siddique and all the distinguished participants at the meeting in Sargodha. He also thanked Prof. Hafeez Chaudhry for presiding over the session at Faisalabad and Prof. Naeem Aslam and Dr. Javed Iqbal for their valuable contributions during the panel discussion. He further clarified that these are manmade Guidelines and we in Pakistan Aspirin Foundation have tried our best to come up with Evidence Based Guidelines but still it was up to the treating physicians to look at the patients and after careful history, physical examination, calculate the risk and then decide for prescribing low dose aspirin therapy. He also thanked Atco Laboratories in general and Mr. Kashif Riaz their Business Unit Head and his team in particular for making all the arrangements for these meetings and sponsoring all the CME activities of the Foundation. However, he make it clear that keeping up the professional ethics, Pakistan Aspirin Foundation from its platform does not  promote any company or patronize any particular brand name of Aspirin. It was up tothe healthcare professionals to use any aspirin preparation, he remarked.

 Regular use of Low Dose Aspirin Therapy
reduces morbidity and mortality in ACS

Aspirin should be prescribed to patients with

hypertension after their BP has been controlled

RAJANA: Pakistan Aspirin Foundation as a part of its Continuing Medical Education programme organized a panel discussion at Foundation Hospital Rajana to highlight the safety and efficacy of regular use of Low Dose Aspirin Therapy on April 20^th 2016. The meeting was jointly chaired by Prof. Altaf Hussain Rathore and Dr. Zeeshan Medial Superintendent of the Hospital. It was attended by all the consultant staff and Medical Officers of the hospital while Dr. Salman Athar Consultant Cardiologist at DHQ Hospital Toba Tek Singh also specially came to attend this meeting which was sponsored by Atco Laboratories.

Copies of the Guidelines for Medical Uses of Aspirin prepared by the Experts Panel of Pakistan Aspirin Foundation headed by Prof. Abdus Samad an eminent cardiologist of Pakistan as well as an informative booklet in Urdu entitled “Aspirin- the lifesaving miracle drug” were distributed among the participants.  Earlier a similar meeting was organized at Gogra on April 19^th which was attended by a select group of cardiac physicians and Family Physicians. In his introductory remarks at both the meetings Mr.Shaukat Ali Jawaid General Secretary of the Foundation traced the history of the formation of this multidisciplinary group and its achievements, accomplishments so far.

Prof. Altaf Hussain Rathore and Dr. Mian Zeeshan Omar chairing the 
panel discussion on Medical Uses of Aspirin organized by Pakistan 
Aspirin Foundation at Foundation Hospital Rajana on April 20,2016.

The main objective is to promote the use of Aspirin in its well established indications by creating, awareness among the healthcare professionals and the public. The established uses of Aspirin include Acute Myocardial Infarction, Acute Coronary Syndromes, Secondary prevention of AMI, Primary Prevention of CAD, Acute Ischemic Strokes, TIAs, Hypertension, Diabetes Mellitus, Acute Rheumatic Fever, prophylaxis against Deep Vein Thrombosis and Pulmonary Embolism. In addition it has many emerging uses like pregnancy induced hypertension, Phospholipids Antibody Syndrome, colorectal cancer etc.

During the discussions Dr. Mian Omar Zeeshan and Dr. Salman Athar shared their views on the use of low dose aspirin therapy in ACS and other cardiovascular diseases and termed it as a lifesaving drug which is extremely economically priced and affordable for everyone and which is also easily available. However, it was pointed out that sometimes patients with severe hypertension come and when they are asked which drug they are taking, they say Aspirin which needs to be discouraged. Patients need to be educated that Aspirin is not a drug for treatment of high blood pressure. However, it should be used once the blood pressure has been controlled. In the past it was said that one should stop Aspirin before surgery but now it is recommended that one does not need to stop it and surgery can be performed safely. It was emphasized that in case of Acute Myocardial Infarction one full tablet of Aspirin 325 should be used and soluble Aspirin should be preferred in such cases. It was also stated that there is no difference in the efficacy of various doses of Aspirin and one can take 75mg, 81mg and 100mg whichever is available for long term use for prevention of cardiovascular events. Maintenance dose for Stroke and other cerebrovascular disorders including diabetes mellitus was 150mg daily. Responding to a question it was stated that there are no studies to prove that if one takes Aspirin on alternate days or once a week full tablet of 325 mg Aspirin which proves effective. Hence one has to take low dose aspirin therapy daily and enteric coated tablets were quite safe in long term use.

Participants of the panel discussion on Medical Uses of 
Aspirin organized at Gojra on April 19th 2016.

The participants were also informed that though one can take aspirin after meal any time in the day but now it is preferred that one should take it after dinner at bed time because it takes care of the early morning spikes as most of the cardiovascular events occur early in the morning. Aspirin was also being used with good results in patients with bad obstetric history, recurrent miscarriages in combination with low molecular weight heparin and in cases of infertility.

Hypersensitivity to Aspirin, Hemorrhagic diathesis, documented acute gastric or duodenal ulcer and pregnancy after thirty six weeks of gestation are some of the absolute contra indications for the use of Aspirin. The relative contra indications include G6PD deficiency, breast feeding, chronic and recurrent peptic ulcer, and bronchial asthma, severs renal or hepatic damage. Bronchial asthma is one of the contra-indications due to Aspirin sensitivity.  Guidelines on Aspirin it was stated have reviewed the literature on Aspirin till 2014 before finalizing this document which gives comprehensive details about its use, dosage in various disorders and contra indications. Pakistan Aspirin Foundation keeping up professional ethics, Mr. Shaukat Ali Jawaid stated does not recommend any particular brand of Aspirin and it is up to the physicians to use any aspirin preparation. However, we are extremely grateful to Atco Laboratories which is helping Pakistan Aspirin Foundation by sponsoring its CME programmes. Recommendations of the US Preventive Services Task Force on Aspirin Use for the Primary Prevention of Cardiovascular Diseases and colorectal cancer released on April 13, 2016 were also shared with the participants.  They recommend use of low dose Aspirin Therapy for primary prevention in patients with no risk of bleeding and one or two risk factors after the age of fifty years.  Since our life expectancy is about ten years less as compared to the developed countries, Pakistan Aspirin Foundation recommends it after the age of forty years.

In the end Dr. Mian Zeeshan Omarand Prof. Altaf Hussain Rathore thanked Pakistan Aspirin Foundation and Atco Laboratories for organizing this academic activity at Foundation Hospital Rajana which the participants found quite informative and useful. The participants were encouraged to share their observations and in case they have any queries, send it to Pakistan Aspirin Foundation and an effort will be made to provide an answer in the shortest possible time. Mr. Kashif Riaz from Atco Laboratories thanked the management of Foundation Hospital and the participants for sparing some of their precious time to attend this meeting.

The meeting at Gojra was attended by cardiac physician Dr. Mian Atif Mahmood andDr. M. Sultan, noted Family Physicians Dr. M. Ishfaq Wahla, Dr. M. Akram, Dr.M. Ishfaq, Dr. Asif Mehmood, and Dr. M. Waseem ophthalmologist.

 Panel discussion on use of Aspirin at Gujranwala and Sialkot

Healthcare professionals reminded to promote
the use of Low Dose Aspirin therapy in 
its well established indications

Guidelines prepared by Pakistan Aspirin Foundation 

gives comprehensive details about indications, dosage, 

contra-indications as well as emerging uses of Aspirin

GUJRANWALA & SIALKOT: Pakistan Aspirin Foundation as a part of its Continuing Medical Education programme for healthcare professionals organized panel discussion on Medical Uses of Aspirin at Gujranwala and Sialkot on March 8^thand 9^th respectively. A select group of cardiologists, physicians, obstetricians &gynecologists and Surgeons besides leading Family Physicians were invited to have their feedback on these Guidelines which were distributed among the participants along with an informative booklet in Urdu on Aspirin- a lifesaving miracle drug authored by late Dr. Maqbool H. Jafary and Mr. Shaukat Ali Jawaid Chief Editor of Pulse International who is also Secretary of the Foundation.

It may be mentioned here that despite lot of studies and literature proving the safety and efficacy of low dose aspirin therapy in a wide range of medical disorders, cardiovascular diseases in particular, aspirin is still under used in Pakistan and the situation is not different in many other countries as well. That is why Pakistan Aspirin Foundation has started this campaign of creating awareness about the use of Low Dose Aspirin therapy among the healthcare professionals.

Pakistan Aspirin Foundation organized a panel discussion on Medical Uses of Aspirin in its 
well established indications at Gujranwala on March 8th2016. Picture taken on this occasion 
shows Dr. Ikram Warraich and Mr. Shaukat Ali Jawaid (in the center) speaking on this 
occasion along with the participants.

Some of the well-establishedindications for regular use of low dose aspirin therapy are as under:

1. Acute Myocardial Infarction(AMI)
2. Acute Coronary Syndrome
3. Secondary prevention of AMI
4. Primary prevention of CAD
5. Acute Ischemic strokes
6. Transient Ischemic Attacks(TIAs)
7. Primary and Secondary prevention of strokes
8. Hypertension
9. Diabetes Mellitus
10. Acute Rheumatic Fever
11. Prophylaxis against DVT and Pulmonary Embolism

In addition to the above there are some emerging indications for the use of Aspirin therapy which includes colorectal cancer, pregnancy induced hypertension, Eclampsia, Phospholipid Antibody Syndrome, Dementia and Alzheimer’s Disease etc.

At the Gujranwala meeting after brief introduction of the Pakistan Aspirin Foundation and the Guidelines by Mr. Shaukat Ali Jawaid, Dr. IkramWarraich moderated the session and asked for input from the participants who actively participated in the discussion and put forward their views. Dr. Ikram Warraich remarked that Aspirin is also called as poor man’s Streptokinase and poor man’s Statin as it reduces mortality after acute myocardial infarction by 23% if one soluble tablet of Aspirin is taken immediately while the streptokinase injection which costs about five thousand rupees achieves similar mortalityreduction. However, if both are combined the mortality reduction is further increased. He also pointed out that even in impending cases of myocardial infarction, Aspirin is highly effective and proves lifesaving. Hence in case of chest pain, cardiac or non-cardiac in nature, one tablet of Aspirin 325mg should be give immediately. In acute conditions soluble aspirin should be preferred while for longer use low dose Aspirin enteric coated tablets are preferred because of safety.

Dr. Zeeshan and Mr. Kashif Riaz speaking at the Panel Discussion on Medical Uses of Aspirin 
organized by Pakistan Aspirin Foundation at Sialkot on March 9th 2016. Prof. Eice Mohammad
Prof. of Medicine at Islam Medical College presided who is also seen in the picture along 
with Mr. Shaukat Ali Jawaid. On extreme right is a view of the participants.

During the discussion it was also highlighted that first the patients should be advised to change their life style and reduce the known risk factors before starting any therapeutic intervention. Elderly patients who are already taking too many medications should avoid the use of Aspirin or use it very carefully. Replying to a questions regarding the use of Aspirin in Gout and Hyperuricemia, it was pointed out that in order to provide protection against cardiovascular disease to these elderly patients who are also suffering from Gout, low dose aspirin therapy is quite safe and can be given. However, it was emphasized that for long term use, lose dose of 75mg, 81mg or 100mg was recommended but for stroke the recommended dosage of Aspirin was 150mg daily. One of the participants suggested that in case of chest pain radiating to left side, one should first take an ECG. However, it was pointed out that it is neither feasible nor practical and ECG facilities may not be available at that time. It was also highlighted that the toxicity score of NSAIDs which are being extensively used was much higher as compared to Aspirin.

An obstetrician and Gynaecologist remarked that Aspirin therapy is indicated in patients with bad obstetric history, frequent miscarriages, secondary infertility besides pregnancy induced hypertension and we use it regularly. The panel discussion at Sialkot was chaired by Prof. Eice Mohammad and it was also attended by  cardiologists, physicians, surgeons, nephrologists, postgraduate students and leading family physicians. Consultant cardiologist Dr. Zeeshanspeaking at the occasion said that without cardiology there is no Medicine and without Aspirin there is no Cardiology which highlights the importance of Aspirin in management of cardiovascular diseases. He reiterated its use in well-establishedindications like AMI, CAD, primary and secondary prevention of AMI, stroke, IHD, TIAs, Acute Coronary Syndrome after PCI, angioplasty and Stenting besides numerous emerging indications for the regular use of low dose aspirin therapy. 

All individuals after the age of forty years with more than two risk factors like hypertension, obesity, overweight, family history of heart disease etc., should be put on regular low dose aspirin therapy.  One of the participants remarked that most of the doctors have a sedentary life style, hence they should also take low dose aspirin regularly. Dr. Zeeshan further stated that one can also use combination therapy of Aspirin with clopidogril which further enhances its efficacy. If it cannot be taken orally, one can administer aspirin through rectal route in emergency in acute conditions.

Some of the participants at the Panel Discussion on Medical Uses of Aspirin organized 
by Pakistan Aspirin Foundation at Sialkot on March 9th 2016.

Dr. Khawar Qureshi participating in the discussion endorsed the use of low dose aspirin therapy in its well established indications which he said, have been discussed in detail. Aspirin is being used now for more than one hundred years and its safety and efficacy in a wide range of medical disorders has been well established. For the first time it was also used for the treatment of arthritis. Dr. Mrs. Khawar Qureshi consultant obstetrician and Gynaecologist referred to the use of Aspirin therapy in PIH, cases of secondary infertility, repeatedmiscarriages, Eclampsia where Aspirin was being used regularly. Dr. Khawar Qureshi was of the view that while using Aspirin therapy one should always calculate the risk benefit ratio which is quite easy to calculate and then prescribe aspirin therapy. Responding to a question Mr.Shaukat Ali Jawaid said that there was no difference in efficacy hence one can use either 75mg, 81mg or 100mg enteric coated Aspirin tablets for long term use.  He also informed that recent studies suggest that low dose Aspirin therapy should be taken at night which will take care of the early morning spike in blood pressure as most of the heart attacks occur early in the morning.

Prof. Eice Mohammad in his remarks thanked Pakistan Aspirin Foundation for promoting the medical uses of Aspirin. However, he cautioned that in case of combination of Aspirin and Clopidogril, the risk of bleeding also increases and one has to be careful in such conditions.

Earlier in his introductory remarks Mr. Shaukat Ali Jawaid General Secretary of Pakistan Aspirin Foundation pointed out that the Foundation has no company bias. We strictly uphold professional ethics and do not support or promote any company or brand name. It is up to the healthcare professionals to use any Aspirin they like. However, he thanked Atco Laboratorieswhich has been sponsoring these CME programmes for the last many years. We are extremely thankful to them for this generosity and extending us their valuable help and assistance in this noble cause. These Guidelines, he further stated, have been prepared by an Experts Panel of Pakistan Aspirin Foundation headed by Prof. Abdus Samad an eminent cardiologists of Pakistan. Other members of the group included Prof. Ejaz Ahmad Vohra another distinguished physician from Ziauddin Medical University, Prof. M. Akbar Chaudhry presently Principal of Azra Naheed Medical College and all of them have served as Presidents of Pakistan Aspirin Foundation.  We reviewed the literature on Aspirin until 2014 before finalizing these guidelines and it was shared with a large number of eminent cardiologists to have their input before its final publication. He also thanked the participants for joining in the panel discussion and specially thanked Prof. Eice Mohammad who was kind enough to have graced the occasion with his presence and share his views on use of low dose aspirin therapy. Both these meetings were sponsored by Atco Laboratories.

HCPs are keen to promote Low Dose Aspirin
Therapy in its well established indications

Experts in group discussion highlight the safety, efficacy of this
most cost effective antiplatelet therapy which reduces morbidity
and mortality in various diseases

MULTAN: Pakistan Aspirin Foundation organized Group Discussions on Medial Uses of Aspirin at Rahim Yar Khan on November 16th, at Bahawalpur on November 17th and at Multan on November 18th 2015. It was attended by a select group of cardiologists, physicians, surgeons, gynecologists, neuro physicians, General Practitioners besides plastic surgeons. These meetings were sponsored by M/s Atco Laboratories and it generated lot of useful discussion providing an opportunity to the participants to share their knowledge and experience with the use of Aspirin.

Pakistan Aspirin Foundation, it may be mentioned here, has been organizing seminars for the last many years all over the country to create awareness among the healthcare professionals as well as general public about the usefulness of this highly economically priced anti-platelet therapy which reduces morbidity and mortality in a number of diseases. It has also been called as Poor Man’s Statin and Poor Man’s Streptokinase and just one tablet of 325mg taken immediately after acute myocardial infarction could prove lifesaving. This was first established by Dr. Peter Elwood the eminent Scottish Physician who published his findings in Lancet in 1974 and since then there has been a large number of studies on Aspirin in various diseases. Apart from cardiovascular diseases and cerebrovascular diseases i.e. Acute Coronary Syndrome, Coronary Artery Diseases, TIAs and Stroke, there are a large number of emerging indications for Aspirin therapy which are being studied and reported in the medical literature.

The Experts Panel of Pakistan Aspirin Foundation headed by Prof.Abdus Samad an eminent cardiologist and former General Secretary of Pakistan Cardiac Society who retired as Prof. of Cardiology from NICVD a few years ago has revised and updated its Consensus Report on Medical Uses of Aspirin which was published in December 2014. The copies of these guidelines as well as another highly useful informative booklet in Urdu on Aspirin the lifesaving miracle drug, are being distributed among the healthcare professionals. These group discussions were organized in the light of these guidelines and the main objective was to hear from the participants about their practice of using Aspirin therapy. They were also provided copies of these Guidelines and the booklet on Aspirin.

The first group discussion was organized at Rahim Yar Khan. In his introductory remarks Mr.Shaukat Ali Jawaid General Secretary of Pakistan Aspirin Foundation gave background information of Pakistan Aspirin Foundation and then highlighted salient features of this Consensus Report. The well-established indications for Aspirin therapy are:

1. Acute Myocardial Infarction
2. Acute Coronary Syndrome
3. Secondary prevention of AMI
4. Primary prevention of CAD
5. Acute Ischemic Strokes
6. Transient Ischemic Attacks(TIAs)
7. Primary and secondary prevention of strokes
8. Hypertension
9. Diabetes Mellitus
10. Acute Rheumatic Fever
11. Prophylaxis against DVT and Pulmonary Embolism

Some of the emerging indications for Aspirin Therapy include Phospholipids Antibody Syndrome, Pregnancy Induced Hypertension, Colorectal Cancer and Insulin resistance etc. The guidelines also give details about the mechanism of action of Aspirin, its pharmacokinetics, dosage in various diseases, side effects and contra indications. All the information included in this document has been properly referenced. Enteric coated Aspirin therapy is preferred because of its safety and long term use.

Absolute Contra-indications

Aspirin should not be used if the patient has Hypersensitivity to Aspirin or other Salicylate, Hemorrhagic diathesis, documented acute gastric or duodenal ulcer and in pregnancy after 36 weeks of gestation. Relative contraindications include G6PD deficiency, breast feeding, chronic or recurrent peptic ulcer, bronchial asthma, severe renal or hepatic damage etc.

Sharing their experience participants at Rahim Yar Khan Meeting said that they use Aspirin therapy in ACS, AMI, TIAs, Stroke. However, there was some discussion on the use of Aspirin in primary prevention, some felt it should be used while others were of the view that still there was not enough evidence for its use. Consensus Report on Medical Uses of Aspirin therapy contains over half a dozen studies in primary prevention with different results. Mr.Shaukat Ali Jawaid pointed out that the results of a multicenter multicounty study of Aspirin in primary prevention (ARRIVE) will be available soon which will give us a clear message. However, physicians are using it in primary prevention as well. Aspirin is also used in combination with clopidogrel in certain conditions which enhances its usefulness and efficacy in further reducing the morbidity and mortality. Dr. Shaukat Ali Rao, Dr.Abdul Majid, Prof. Tariq Rehan, Dr. Akhtar Malik, Dr. Ghulam Fareed, Dr. Abid Shah, Dr. Haque Nawaz Rahi and many others shared their experience. Prof.Tariq Rehan said that they stop Aspirin a few days before elective surgery. There was discussion on various doses of Aspirin being used and mentioned in the literature at which it was stated that any dose above 50mg has adequate antiplatelet effect hence 75mg, 81mg or 100mg were all effective.

Dr. Shahadat Hussain moderated the discussion at Bahawalpur. Dr. Altaf highlighted its use in diabetes and hypertension besides antiphospholipid syndrome. Dr. Shahid said they use it in TIAs and stroke besides Deep Vein Thrombosis and pulmonary embolism. Dr. Asifa Shahid said that Aspirin was very beneficial in complicated pregnancy, in patients with poor fetal outcome, even it is advised to use it in pre conception period about three months prior to conception. It is suggested that the pregnant women should be prescribed calcium, aspirin and folic acid regularly. Aspirin can be discontinued three months after pregnancy. Dr.Fahad plastic surgeon said that they do stop aspirin during surgery but once wound healing starts; use of aspirin allows adequate blood supply. Dr.Waseem said they use Aspirin in Hypertension and DVT. However, it was emphasized that one must make sure to control blood pressure first and then start low dose aspirin therapy.

Prof. Munir Azhar Chaudhry in his detailed discourse said that Aspirin was safe and an effective antiplatelet therapy in thrombosis, antiphospholipid syndrome, auto immune disorders, scleroderma, cardiomyopathies as well apart from ACS and CAD. However, it is contraindicated in chronic liver failure and cardiac failure as there was an additional risk of bleeding. One of the general practitioners opined that after the age of forty years, regular use of low dose aspirin was desirable. As regards use of Aspirin in primary prevention it was generally felt that one should calculate the risk score and if it was more than 10%, only then Aspirin therapy should be used. Dr. Shahadat opined that since the platelets have a half-life of six days, one should always weigh the benefits and risks as regards side effects. If the benefits outweigh the risks, then aspirin therapy should be started. He suggested calculating the risk scores in men over forty five years and women over fifty five years before putting them on regular low dose aspirin therapy. Low dose aspirin has to be taken daily and not once, twice or three times a week. Others who actively participated in the discussion included Dr. Sarwar Khalid, Dr. Aftab Jameel, Dr. Akram Ahsan, Dr. Arif Ali Zaidi and Dr.Shaukat Ali. Prof.Haroon Khursheed Pasha, Principal of QAMC and Prof. Javed Iqbal Head of the Dept. of Surgery at QAMC also came to the meeting venue for a while and left soon after since they were having a meeting with the Audit team.

Winding up the discussion Prof. Usman Ghani emphasized that Aspirin remains the ideal anti platelet agent and the most cost effective antiplatelet in atherosclerosis, IHD, prevention of recurrence of acute myocardial infarction. Those patients who have many other risk factors like diabetes, smoking, obesity, strong history of sudden death, family history of CAD should benefit from the regular use of low dose aspirin therapy. However one should be careful in case of hemorrhages. Similarly those patients who have bleeding diathesis, active ulcer are seen with bleeding from the whole stomach and these hemorrhages could be catastrophic. Always control the blood pressure first and then start using low dose aspirin therapy. It can be safely used in pregnancy induced hypertension. Some patents may complain of bleeding from gums and have many other similar problems hence in such cases one should always avoid use of aspirin. However, those with sedentary life style, high LDL cholesterol can benefit from Aspirin. Stroke and strong family history of IHD are highly disabling diseases. Hence use of aspirin in these patents, if there are no contra indications, can reduce the morbidity and mortality.

Dr. Tariq Abbas from CPI Institute of Cardiology moderated the group discussion at Multan. The meeting was very well attended by cardiologists from institute of cardiology, cardiac surgeons, faculty members from Nishtar Medical College Multan, eminent Family Physicians besides gynecologists. Participating in the discussion cardiac surgeon Dr.Haider Zaman said that Aspirin is a wonder drug. We use it regularly in post CABG. It is also used after stenting and angioplasty. Another participant opined that we use it with other anti-coagulants in high risk cases for dilatation of the vessels. American Heart Association has also recommended the use of low dose aspirin therapy in may cardiac diseases including post CABG. It is also recommended for primary prevention. Others who actively participated in the deliberations included Prof. Ajmal Malik, Dr. Ali Bin Saeed, Dr. Abdul Sattar, Dr. Saeed Ahmed, Dr. Nisar and Dr. Sadaf.

The participants were of the view that in high risk cases with other co morbidities like hypertension, diabetes one can use aspirin therapy for primary prevention. Its efficacy in pregnancy induced hypertension was also highlighted. However, it was emphasized that every drug has certain side effects which must be kept in mind. The first and foremost duty of the healthcare professionals is education of patient, advising them to modify their life style, use healthy balanced diet and also do regular exercise. Promotion of health and healthy life style should be given due importance and preference. It was also pointed out that one can use low dose aspirin therapy in Gout because it will ensure protection from cardiac diseases in these elderly patients who are also suffering from many other co morbidities. It was further stated that low dose aspirin therapy should be taken at bed time as it will take care of early morning spike in blood pressure since most of the acute myocardial infarction occurs early in the morning. The dose recommended for patients with stroke was 150mg daily.

Mr. Shaukat Ali Jawaid General Secretary of Pakistan Aspirin Foundation addressing the participants of these group discussions at all the places emphasized that they were extremely grateful to Atco Laboratories for sponsoring their CME programmes for the last many years. However, keeping up the professional ethics, the Foundation does not have any company bias and does not patronize any particular brand of aspirin. It is up to the healthcare professionals to choose any aspirin preparation.

Mr. Akhtar Tahir Director Marketing from Atco Laboratories thanked the participants of these group discussions at Rahim Yar Khan, Bahawalpur and Multan for sparing their precious time to share their knowledge and experience. Atco Laboratories, he said was very conscious of quality control and to ensure production of high quality drugs, it has made huge investments in modernization and expansion of its drug manufacturing plant. Hence they can use with confidence drugs produced by Atco Laboratories at its state of the art most modern drug manufacturing facility as we follow current Good Manufacturing Practices to ensure availability of high quality cost effective medications. Earlier Mr. Kashif Riaz Business Unit Head in Atco Laboratories welcomed the participants of the meeting on behalf of Atco and Pakistan Aspirin Foundation.

 Seminar on Medical Uses of Aspirin during  PAFP Familycon 2015

CAD patients with absolute risk of more than
10% should be put on low dose Aspirin
therapy - Prof. Akbar Chaudhry

Regular use of LDA significantly reduces morbidity,
mortality and vascular events - Prof. Javed Akram

ISLAMABAD: The first scientific session during the Mid Year Familycon 2015 organized by Pakistan Academy of Family Physicians in collaboration with SZABMU PIMS as well as Pakistan Aspirin Foundation held here on July 26th was devoted to Medial Uses of Aspirin. Prof. Javed Akram Vice Chancellor of Shaheed Zulfikar Ali Bhutto Medical University who is also current President of Pakistan Aspirin Foundation was the first speaker. He made a presentation on mode of action of Aspirin. He discussed in detail platelet adhesions and activation, platelet aggregation leading to thrombosis which eventually leads to myocardial infarction. Anti Platelet Trialists Collaboration study, he said, has showed that regular use of low dose Aspirin results in 30% reduction in morbidity and mortality and it is also known as poor man’s Statin. Aspirin works in primary as well as secondary prevention. It is quite effective in unstable angina and prevents vascular events. Low dose Aspirin therapy overweighs benefits as compared to harm. Those who wish to donate blood, if taking Aspirin should stop Aspirin therapy at least ten days before donating blood.

Dr. Aftab Iqbal President Pakistan Academy of Family Physicians
presenting a mementoe to Prof. Javed Akram VC SZABMU at
the Familycon 2015 Mid Year Conference held at Islamabad on
July 26th2015. Also seen in the picture are Prof. Maj. Gen.
M.Aslam VC UHS, Dr. Altaf Cheema and others.

Continuing Prof. Javed Akram said that Aspirin was a wonder drug which continues to surprise us every day with its new and emerging indications. It is very effective in antiphospholipid syndrome and quite useful in infertility. The reported resistance to Aspirin was just about 9%. Most often we use 75mg of Aspirin for long term use but in some cases like stroke, upto 150 Mg is used which is quite safe and effective. In severe cases it can be combined with clopidogrel. Aspirin is a gold standard antiplatelet agents and all other antiplatelet are judged while comparing with Aspirin. In acute MI, soluble Aspirin should be used for immediate effect which reduces mortality by 23%, he added.

Prof. Akbar Chaudhry an eminent physician, former President of Pakistan Aspirin Foundation who is currently Principal of Azra Naheed Medical College in his most comprehensive presentation on Medical Uses of Aspirin discussed in detail its well established indications. Speaking about the real threat to urban health, he pointed out that about 7.8 million deaths occur annually in developing countries due to coronary artery disease. Cardiovascular diseases also account for 29% of global deaths and 82% of CVD deaths are in poor and low income countries. Cardiovascular diseases are also more prevalent in India, China and it is reported that almost 25% of people above the age of forty years suffer from coronary artery disease.

Prof. M. Akbar Chaudhry and Dr. Shehryaar Bhatti speaking at the Familycon 2015
meeting by PAFP held at Islamabad on July 26, 2015.

In Pakistan, Prof. Akbar Chaudhry said, we develop cardiovascular diseases a bit early; hence we should lay more emphasis on prevention which is also cost effective rather than on treatment of these diseases. Some of the known risk factors for CAD which can be modified include hypertension which accounts for almost 18%, diabetes mellitus from which 6.9 million people are suffering in Pakistan, dyslipidaemias account for 27.54%, obesity which accounts for 46-68% and metabolic syndrome 34-49%. Smoking cessation, physical activity, diet therapy, weight control, blood pressure, lipids and diabetes control should be combined with regular use of low dose Aspirin Therapy. At present 37.6% Aspirin use is in cardiovascular diseases and its regular use reduces mortality by 25% in MI but if it is combined with clopidogrel, the mortality reduction can be up to 45%. If we treat one thousand patients with low dose Aspirin, we will prevent thirty Myocardial Infarction and angina. As regards its usage in primary prevention, it leads to one third reductions in Myocardial Infarction and one sixth reduction in vascular events. Following are the well established indications for use of aspirin therapy:

1. Acute Myocardial Infarction

2. Acute Coronary Syndrome

3. Secondary prevention of AMI

4. Primary prevention of CAD

5. Acute Ischemic Strokes

6. Transient Ischemic Attacks

7. Primary and Secondary Prevention of Strokes

8. Hypertension

9. Diabetes Mellitus

10. Acute Rheumatic fever

11. Prophylaxis against DVT and Pulmonary Embolism

Continuing Prof. Akbar Chaudhry said that those CAD patients who have an absolute ten years risk of less than 6% should not be prescribed aspirin therapy but those whose risk is between 7-9%, it should be patient’s choice and this should be discussed with the patient. However in those CAD patients whose absolute ten years risk is over 10%, they must be put on Low Dose Aspirin therapy. Use of enteric coated Aspirin in low dose is quite safe and effective in long term use. It will result in 46% reduction in unstable angina, 33% reduction in stable angina. Despite the fact that the safety and efficacy of Aspirin has been very well established in numerous studies, even then it is quite under used. Pakistan Aspirin Foundation, Prof. Akbar Chaudhry said conducted Aspirin Usage and Awareness Study some years ago which revealed that only 16% of patients got Aspirin at home when they suffered from chest pain, only 20% of these patients were prescribed Aspirin by Family Physicians within six hours of MI while Aspirin use in Emergency Room was 60% and 71% in the Ward. However, what was more surprising was the fact that only 50% of these acute coronary syndrome patients were prescribed low dose aspirin therapy on discharge. This prompted us to start these CME programmes to create awareness among public as well as healthcare professionals about the use of Aspirin. Now a latest study Climate Asia has showed that 31% of patients were taking Aspirin for primary prevention, 43% of patients were already on low dose Aspirin therapy, 92% of these ACS patients were prescribed Aspirin whereas 42% were using it along with Clopidogrel. Patients suffering from Type 2 Diabetes Mellitus should also be put on low dose aspirin therapy using 150mg daily.

Prof. M. Akbar Chaudhry, Dr. Aftab Iqbal Sheikh President PAFP,
Prof. Javed Akram VC SZABMU, Prof. Waris Qidwai performing
the cake cutting ceremony celebrating the 20 Years of launch
of Ascard after the seminar on Medical Uses of Aspirin
organized during the Mid Year Familycon 2015
held at Islamabad on July 27th 2015.

Speaking about the new and emerging indications for Aspirin therapy Prof. Akbar Chaudhry mentioned colorectal cancer, prostate cancer, pre eclampsia, DVT, pulmonary embolism, insulin resistance etc. In high risk cases it should be combined with Statins. Some of the contraindications for use of Aspirin therapy include allergy to Aspirin, active peptic ulcer disease and other blood disorders. It should also be used with caution in people over eighty years of age.

Earlier Mr. Shaukat Ali Jawaid General Secretary of Pakistan Aspirin Foundation gave a historical background of the formation of PAF, its activities and accomplishments so far. He mentioned the series of CME programmes which are being organized all over the country in collaboration with various professional specialty organizations and PMA in different cities which are all sponsored by Atco Laboratories. Publication of Book on Aspirin, publication of a booklet in Urdu besides revision and updating the Guidelines on Medial Uses of Aspirin. These revised guidelines were finalized by a panel of experts headed by Prof. Abdus Samad. Other members included Prof .Ejaz Ahmad Vohra, Prof. M. Akbar Chaudhry, Mr. Shaukat Ali Jawaid while a large number of eminent physicians have also contributed to this document. Lt.Gen. Mahmud Ahmad Akhtar former Surgeon Gen. of Pakistan Army has also made significant contribution to the development and finalization of these Guidelines which are now being distributed among the healthcare professionals. Pakistan Aspirin Foundation, Mr. Shaukat Ali Jawaid further stated has a very democratic set up, office bearers are elected every two years. Its website www.Pakaspirin.org.pk gives details of members, CME activities, achievements and accomplishments so far. It also has the latest revised Guidelines on Medical Uses of Aspirin. Its membership is open to Healthcare professionals and public and life membership is just Rs. 2,000/- (Rupees two thousand only). We are extremely grateful to Atco Laboratories for sponsoring our CME activities for the last many years but keeping up the professional ethics, we do not patronize any particular brand name of Aspirin and doctors are advised to use Aspirin in its well established indications and ensure its optimal usage which will go a long way in reducing morbidity and mortality in a wide range of diseases.

Prevention and Treatment of CAD, ACS
Family Physicians advised to promote the
 use of Low Dose Aspirin Therapy to
reduce morbidity and mortality
Aspirin remains the most economically
priced safe and effective antiplatelet agent

LAHORE: Pakistan Aspirin Foundation in collaboration with Pakistan Association of Family Physicians organized a special session on Aspirin during the recently concluded FAMILYCON 2014 at Lahore. This session was chaired by Prof. Bilal Zakariya Khan, Chief Executive of Punjab Institute of Cardiology. The speakers included Prof. Javed Akram President of Pakistan Aspirin Foundation and Vice Chancellor of Benazir Bhutto University (PIMS) Islamabad and Prof. Akbar Chaudhry Principal of Azra Naheed Medical College Lahore besides Mr. Shaukat Ali Jawaid General Secretary of Pakistan Aspirin Foundation.
Prof. Javed Akram in his presentation highlighted the mode of action of Aspirin and how it inhibits the aggregation of platelets. He also referred to various studies highlighting the safety and efficacy of Aspirin in CAD and various other medical disorders.
Prof. Akbar Chaudhry another eminent physician who is also former President of Pakistan Aspirin Foundation highlighted the use of Aspirin in its well established indications wherein it has proved that it significantly reduces morbidity and mortality. Even a single tablet of 325mg of Aspirin, taken immediately after myocardial infarction can be life saving and its regular use reduce the chances of re-infarction. Studies Prof. Akbar Chaudhry said have shown that the burden of cardiovascular diseases is going to increase further in the coming years and most of this burden will be in developing low resource countries. Since curative services are extremely expensive, prevention remains the only viable option for these countries.
He then referred to various studies which showed that regular use of Aspirin not only prevents heart attacks but is also quite useful in Acute Coronary Syndromes. Coronary Artery Disease has emerged as an epidemic in Pakistan. Modifiable risk factors include control of hypertension, diabetes mellitus, Dyslipidemia, obesity, metabolic syndrome and smoking and this should be supplemented with regular use of low dose Aspirin therapy. Talking about benefits of Aspirin, Prof. Akbar Chaudhry said that it reduces risk of first MI by 33%, risk of first stroke by 25%, risk of CVD death by 17%. In Secondary prevention with Aspirin the risk of serious vascular events are reduced by 46% in unstable angina, 33% in stable angina, 23% in peripheral arterial disease and 53% in patients undergoing angioplasty. Previously Aspirin Awareness and Usage study (AAUS) conducted by Pakistan Aspirin Foundation which enrolled over fifteen hundred patients in seventeen CCUs all over Pakistan showed that only 50% of ACS patients were prescribed Aspirin at the time of discharge, only 20.8% of patients were prescribed Aspirin by their family physicians and only 16% of patients took aspirin at home when they suffered from chest pain. Now as a result of CME activities by Pakistan Aspirin Foundation the use of Aspirin has increased but still the Family Physicians, he said, need to promote its use in its well established indications. It is an extremely safe and effective antiplatelet agent which is economically priced. It is useful in hypertension once the blood pressure has been controlled, is recommended in patients undergoing interventional procedures like angioplasty and stenting, after CABG, in Type-2 diabetics, pulmonary embolism, TIAs and Stroke while its new and emerging indications include colorectal cancer, gastric ulcer, dementia and renal diseases. In case of contra indication like peptic ulcer, asthma, or allergy to Aspirin, other antiplatelet agents should be used. The combination of Aspirin and Clopidogrel, he said is more effective in reducing morbidity and mortality in CAD. Various studies have also showed its efficacy in primary prevention of CAD, he added.
Mr. Shaukat Ali Jawaid Chief Editor Pulse International speaking on the occasion said that you go to any medical conference, use of Aspirin always figures in presentations and discussion. This is the most widely researched drug and every month thousands of papers are published on the safety and efficacy of Aspirin in various medical disorders. Eminent Scottish Physician Dr. Peter Elwood who first proved in 1974 that Aspirin reduces the chances of death in Acute Myocardial Infarction and also prevents secondary infarction always carries Aspirin tablets in his Jacket saying that he or any of his friend might use it any time. Mr.Shaukat Ali Jawaid urged the family physicians to educate the patients to take one tablet of Aspirin immediately when they feel chest pain. They should also keep Aspirin with them all the time in office, clinic and home. Most often heart attacks occur early in the morning when neither the doctor nor transport is available easily hence if the patients experiencing chest pain take one tablet of Aspirin immediately, it might save their lives. Regular use of Low Dose Aspirin 75-100mg is preferable at night. Enteric coated Aspirin is extremely safe and effective in long term use. However, in case of any contraindication, other antiplatelet agents can be used, he added.
Pakistan Aspirin Foundation, he pointed out has also published an informative booklet on Aspirin in Urdu which gives comprehensive details about indications as well contra indications for Aspirin therapy and its doses in various indications. These guidelines are available on its website www.pakaspirin.org.pk. He also advised the family physicians to adhere to ethical medical practice and improve the quality of general practice and make sure that their services are affordable for the common man. If they failed to do so, they will be indirectly promoting quackery which is already a great menace.
It was also announced that though Pakistan Aspirin Foundation is extremely grateful to M/s ATCO Laboratories for sponsoring its CME activities for the last many years but keeping up the professional ethics, we do not patronize and support any particular brand of Aspirin. It is up to the physicians to prescribe any Aspirin preparation.
Prof. Bilal Zakariya in his concluding remarks said that there have been some reports of Aspirin resistance. The doctors should prescribe Aspirin which is produced by quality conscious pharmaceutical companies so that there are no dissolution problems.

Healthcare professionals must balance risk
and benefits before prescribing any
medication- Prof. Khawaja Saadiq Hussain
Aspirin like any other drug has its own side effects, hence
must be used carefully in its well established indications

LAHORE: Healthcare professionals must balance the risk and benefits before prescribing any medication. Aspirin like any other drug has its own side effects hence members of the medical profession should be careful and use it judiciously in its well established indications. This was stated by Prof. Khawaja Saadiq Hussain an eminent physician former Principal of King Edward Medical College and former President of College of Physicians and Surgeons Pakistan. In his concluding remarks at the first scientific session of the 6^th National Conference of Pakistan Aspirin Foundation which he chaired along with Prof. Mahmood Ali Malik another noted physician and former Principal of King Edward Medical College, Prof. Khawaja Saadiq Hussain said that Aspirin was very economically priced, safe and effective drug which is easily available everywhere. This conference was held at FJMC Lahore on October 5^th and it attracted a large number of members of the medical and nursing profession while many medical students from Azra Naheed Medical College and few  postgraduates were also present.

Prof. Kh. Saadiq Hussain along with Prof.Mahmood Ali Malik chaining the
 first scientific session of National Conference of Pakistan Aspirin Foundations
held at FJMC on October 5th2013. Also sitting on the dais along with them are
speakers of this session Prof. Saulat Siddique, Prof. Naeem Qasuri,
Prof. M. Akbar Chaudhry and Prof. Muneeza Qayum.

Prof. Khawaja Saadiq Hussian further stated that according to reports over one hundred billion tablets of Aspirin are used daily all over the world for various indications. It has been in clinical use for now over hundred years and its use was now being seen more and more ever since it’s antiplatelet activities were discovered proving it to be a life saving drug in acute myocardial infarction. It is useful in a wide variety of medical disorders including cardiovascular diseases but he cautioned that one must be careful if its side effects as well. It is advisable to look at individual patient, take proper detailed history and do comprehensive clinical examination before prescribing any medication. Patient education was also extremely important he added.

Prof. Kh. Saadiq and Prof.Mahmood Ali Malik being present flower
Bouquet on arrival at FJMC for the Aspirin Conference. Also seen on
right is  Prof. Sardar Fakhar Imam Principal FJMC and Chairman
of the organizing committee of the conference.

Prof. Muneeza Qayum Prof. of Pharmacology at FJMC was the first speaker in this session which was moderated by Prof. Zubair Akram.  In her most comprehensive presentation Prof, Muneeza Qayum discussed the historical perspective as well as mechanism of action and pharmacokinetics of Aspirin. She dealt at length how this wonderful molecule was discovered by Dr. Felix Hoffman and first used by various people for different conditions including arthritis.  Since then its antiplatelet properties have been further highlighted and now it is extensively used to treat a variety of medical disorders where it has proved to reduce morbidity and mortality.

Prof. Bilal Zakariya along with Prof. Sardar Fakhar Imam
Principal JMC and Prof. Abdus Samad chairing one of
the scientific sessions during the Aspirin Conference. On extreme
left is Prof. Maryam Malik moderator of the session.

Prof. Zubair Akram Prof. of Cardiology at Allama Iqbal Medical College gave an update on use of Aspirin in cardiovascular diseases with particular reference to Acute Coronary Syndrome and secondary prevention of cardiovascular diseases. It has proved its life saving properties in acute myocardial infarction and studies have shown upto 30% reduction in mortality. However, if it was combined with clopidogrel, the mortality reduction is increased upto 43%.

Members of the Experts Panel during the Panel Discussion at Aspirin Conference held at JMC on October 5th from
 (L to R) are Prof Sardar Fakhar Imam, Prof.Nazeer Memon, Prof.Abdus Samad, Prof. Zaman Sheikh, Mr. Lateef Sheikh,
Prof. Akbar Chaudhry, Prof. Javed Akram, Prof.Tujamal, Prof. Maryam Malik, Dr.Shahid Karim and Prof. S.H.Shafqat.

Prof. Naeem Qasuri Prof.of Neurology at King Edward Medical University gave an update on use of Aspirin in cerebrovascular diseases and highlighted the safety and efficacy of Aspirin in acute ischaemic stroke, TIAs besides secondary prevention of stroke. Prof. Naeem Qasuri suggested that it was advisable to go for the option of managing various risk factors and removal of potential causes. Judicious use of anti-coagulants and antiplatelet can be extremely helpful.  He also referred to various markers and contra indications for the use of these medications.  He also gave details of International Stroke Trial and CAST stroke trial in China which showed 36% reduction in mortality in stroke. CAST trial included 21,106 patients and it also showed the beneficial effects of Aspirin. In both these trials which included over forty thousand patients, there was mortality reduction of seven per thousand and four per thousand respectively. It also showed further reduction in stroke and death. Speaking about secondary prevention he highlighted the results of ESPS2 trial. Some studies have showed that there was no benefit of Aspirin in primary prevention of stroke but other studies like ATC trial showed 25% risk reduction in secondary prevention. Dual antiplatelet therapy did not show any significant reduction in stroke but it was associated with 7% increase in hemorrhagic stroke. The risk of bleeding was 1% to 2.1%.  Combined use of Aspirin and Clopidogrel increases the risk of hemorrhagic stroke. For secondary prevention a dose of 75-150mg a day is recommended but it is twice as effective in a combination of extended release form. He also referred to Aspirin resistance and non-responders and said that as per some studies one third of patients may not respond to Aspirin. Further studies have showed that use of Aspirin results in 22% relative risk reduction whiles with the use of Warfarin the relative risk reduction is increased upto 68%, he added.

Prof. Aamar Zaman Khan, Mr.Lateef Sheikh, Prof. Maryam Malik, Dr.Rehan Umar and Dr.Abbas Raza
speaking at the 6th National Conference f Pakistan Aspirin Foundation held at FJMC on October 5th2013.

Prof. Akbar Chaudhry in his presentation on use of Aspirin in primary prevention of Ischaemic Heart Disease and Stroke said that cardiovascular diseases will remain the number one cause of death globally and by 2030 it is estimated that 23.6 million people will die from CVD mainly from heart diseases and stroke. The largest percentage of increase of these deaths will be in Eastern Mediterranean Region in which Pakistan is located. Speaking about the risk factors he mentioned hypertension, diabetes mellitus, dyslipidemia, obesity, metabolic syndrome and smoking etc. For countries like Pakistan it is not curative but preventive strategies which is the solution. As regards guidelines for primary prevention it includes risk intervention like smoking cessation, physical activity, diet therapy, weight control, blood pressure control, lipid control, diabetes control besides Aspirin therapy.

Currently Aspirin is extensively used in cardiovascular diseases followed by arthritis, headache, body aches and as antipyretics. The established uses of Aspirin include Acute Myocardial Infarction, Acute Coronary Syndrome, Secondary prevention of MI, Primary prevention of CAD, TIAs and Stroke, Hypertension and diabetes. Elaborating the use of Aspirin in primary prevention of CAD, he said that if the absolute ten years risk is less than 6%, there is no need for Aspirin therapy but if it is upto 9%, it should be left at patient’s choice but if the ten years risk is more than 10%, these patients must be put on low dose Aspirin Therapy, he added. Women Health Study showed that it reduced 17% stroke, reduction of ischaemic stroke was 24% but what was more important was the fact that it reduced non-fatal stroke by 19% in women besides 22% reduction in TIAs. Meta analysis of six studies also showed that Aspirin lead to 17% stroke reduction in women as compared to 14% reduction of stroke in men. Referring to the Aspirin Awareness and Usage Study (AAUS) conducted in Pakistan, Prof. Akbar Chaudhry said that at the time of discharge only 50% of ACS patients were prescribed Aspirin, only 20.8% of patients were prescribed Aspirin by their Family Physicians while only 16%   patients took Aspirin at home when they suffered from chest pain.  This is a very dismal picture but these figures are six years old and over these years use of Aspirin has increased due to the CME activities by Pakistan Aspirin Foundation. Summing up the overall benefits of low dose Aspirin Therapy Prof. Akbar Chaudhry said that  risk of serious vascular events is reduced by 46% in unstable angina, 33% in stable angina,  23% in peripheral arterial diseases and 53% in patients undergoing angioplasty.  Aspirin with its life saving properties in cardiovascular diseases does not fail to surprise us all as a miracle chemical. With the every passing day, we see a variety of new indications emerging for the use of Aspirin but we need more data to start their routine use in those indications, Long term use of low dose aspirin therapy is extremely safe, effective and could go a long way in reducing morbidity and mortality. To prevent significant number of first MIs in men and Stroke in women and premature deaths, low dose aspirin should be used while in high risk individuals, Statins should be added to Aspirin.

On left a group of medical students from Azra Naheed Medical College photographed with
 Prof. M. Akbar Chaudhry Principal ANMC during the national conference of
Pakistan Aspirin Foundation held at FJMC while on right the picture shows
Prof. S. H.Shafqat, Prof.Abdus Samad and Prof.Kh.Saadiq Hussain.

Use of Aspirin in Hypertension

Prof. Saulat Siddique Prof. of Cardiology at Shaikh Zayed Postgraduate Medical Institute Lahore highlighted the use of Aspirin in Hypertension.  He first described the complications of hypertension which is a risk factor for TIAs and Stroke, retinopathy, peripheral vascular disease, LVH, CHD, HF and renal failure. A large number of meta analysis have shown that antiplatelet treatment is highly beneficial in secondary CV prevention but in patients with low risk,  antiplatelet treatment is associated with only a very little excess of benefits over harm. Some trials have also shown that bed time use of Aspirin lowers the blood pressure but some other studies have also showed increase in risk of developing hypertension in Aspirin users. In Pakistan only about 3% of hypertensive’s have controlled their blood pressure and as we know hypertension is a major risk factor for not only stroke but myocardial infarction, heart failure, chronic kidney disease, cognitive decline and premature death. Untreated hypertension can cause vascular and renal damage leading to treatment resistant state. Low Dose Aspirin therapy is useful in control of hypertension and primary CV events, he added.

Benefits of Aspirin in Diabetes

Prof. Mahmood Ali Malik highlighted the benefits of Aspirin in Diabetes Mellitus. He pointed out that people with Type-2 diabetes are at high risk of cardiovascular events from the time of diagnosis and this risk is often present in the pre-diabetic phase of the disease. Hence an approach that focuses on early risk factor identification and management to prevent or delay accelerated atherosclerosis and thrombosis in diabetes is an attractive strategy.  Atherosclerosis can be prevented or delayed by controlling hyperglycemia, hypertension and dyslipidaemias while for thrombosis the use of Aspirin is recommended. Low dose aspirin therapy, Prof. Mahmood Ali Malik stated is indicated as a preventive strategy in all high-risk diabetic patients regardless of blood pressure or blood lipid level.   All diabetic patients who have had one major vascular event like myocardial infarction, stroke or TIA, history of angina, vascular surgery, atrial fibrillation and valvular heart diseases are high risk individuals, he added. Continuing Prof. Mahmood Ali Malik said that prolonged Aspirin therapy has been shown to offer significant protection against myocardial infarction, stroke, and vascular death in patients with clinically apparent vascular disease.  Effects of Aspirin treatment on survival in non-insulin dependent diabetic patients with CAD were studied which showed that it was associated with a significant reduction in cardiac and total mortality among NIDDM patients with CAD. Absolute benefit of Aspirin was greater in diabetic patients as compared to those without diabetes. Use of Aspirin in patients with diabetic retinopathy is safe as EDRTS study has shown that there was no significant increase in gastrointestinal bleeding or hemorrhagic stroke. The recommended dose is 75-325mg and all of them are equally effective. There is some advantage of initial loading dose and for long term safety one should use enteric coated aspirin tablets. However, aspirin is contra indicated in patients who have allergy to Aspirin, have bleeding tendency, are on anticoagulant therapy, have recent gastrointestinal bleeding or have clinically active hepatic disease.

The presentations were followed by lively discussion. Responding to one of the questions Prof. Javed Akram remarked that in Dengue Fever patients, one should not use Aspirin but paracetamol. Similarly patients with ulcer should also not be put on Aspirin therapy.

Stopping use of Aspirin three to five days before
surgery or endoscopic procedures is ideal in
most of the cases - Prof. Aamer Zaman Khan
Aspirin therapy is useful in colorectal cancer prevention
but in low risk patients, it offers no benefits - Dr. Abbas Raza

LAHORE: Prof. Abdus Samad along with Prof. Sardar Fakhar Imam and Prof. Bilal Zakariya chaired the second scientific session during the 6^th National Conference of Pakistan Aspirin Foundation held at FJMC on October 5, 2013. Prof.Maryam Malik was the moderator of this session.   Dr. Abbas Raza from AIMC was the first speaker who talked about Aspirin and Gastrointestinal Tract. He discussed in detail the spectrum of Aspirin induced mucosal injury, NSAIDs induced ulcerations, use of NSAIDs leading to gastric lesions and pointed out that it is associated with 15% gastric ulcer, 5% duodenal ulcer and 2% chronic rectal ulcers. Dual antiplatelet therapy Dr. Abbas Raza stated increases the risk while toxicity is also increased with increased dose. During the first month use, the patients may have higher complications. Its use is beneficial in colorectal cancer but in low risk patients, use of Aspirin may not have any benefits.

Prof.M.Akbar Chaudhry, Prof. Ejaz Ahmad Vohra, Prof.Saulat Siddique, Prof. Naeem Qasuri, and Prof.Zubair Akram
speaking at the 6th National Conference f Pakistan Aspirin Foundation held at FJMC on October 5th 2013.

Continuing Dr. Abbas Raza said that the risk of overt bleeding can increase with dual antiplatelet therapy. Studies have also shown that while use of low dose aspirin was associated with prevention of heart attacks but it also increased the risk of major GI bleeding. In case the use of Aspirin is essential, one must identify the risk factors of NSAIDs gastropathy, use gastro protective drugs, safer NSAIDs or alternative drugs if possible. The risk UGI bleeding with different formulations of Aspirin varies from 2.6% to 3.2%. It is suggested that one should reintroduce use of Aspirin after eight weeks of treatment with proton pump inhibitors (PPIs). It may not be possible in high risk CVD patients. CAPP2 study showed almost 60% decrease in colorectal cancer incidence among men who took 600mg of Aspirin daily.  It is still not sure whether this benefit of prevention extends to other cancers as well, what dose to be use and for how long? He concluded his presentation by stating that absolute benefits of aspirin outweigh risks of major GI bleeding in patients with moderate to high risk coronary heart disease. Use of PPIs allows patients to get most benefit from their NSAID therapy by reducing GI risks. Aspirin-Lipoxin agonist combination therapy trials are only at animal experimental stages and it may hold promise in the days to come, he remarked.

Some founder members, life members of Pakistan Aspirin Foundations
photographed after the business meeting held on October 4th2013.
Prof. Sardar Fakhar Imam Principal FJMC is also seen
second from right in the first row.

Aspirin and Surgery

Prof. Muhammad Aamer Zaman Khan Prof.of Surgery at FJMC discussed the role of Aspirin in surgery. He pointed out that one should stop the use of aspirin seven to ten days before surgery or undertaking any endoscopic procedure. However, three to five days before surgery is the ideal time to stop Aspirin. In moderate to high risk patients, one can continue Aspirin therapy till the time for surgery. American College of Surgeons recommends that one should try to continue aspirin as much as possible and have platelets available for transfusion during emergency procedures both pre and post operatively. Current guidelines are that in semi-elective or urgent surgery stop one of the agents but in emergency surgery one does not have a choice, hence platelets must be available. There is no benefit of increasing aspirin dose above 100mg for most patients and it seems reasonable to use 75-81mg as periopertive dose. For non-cardiac surgery, apart from low coronary risk situations, patients on aspirin should continue their treatment throughout surgery, except when bleeding might occur. One of the studies has recommended that Aspirin is a lifelong therapy and should never be stopped before surgery when prescribed as a secondary prevention after stroke, acute coronary syndrome, MI or coronary revascularization except for surgery in closed cavities. 

Group photograph of speakers and chairpersons of the second scientific
session of Aspirin Conference held at FJMC Lahore from (L to R) are
Prof. Maryam Malik, Prof. Aamar Zaman Khan, Mr. Lateef Sheikh,
Prof. Sardar Fakhar Imam, Dr. Shahbaz Kureshi, Prof.Abdus Samad,
Prof. S.H. Shafqat, Prof.Ejaz Ahmad Vohra, Prof. Bilal Zakariya
and Prof. Muneeza Qayum.

Continuing Prof.Aamer Zaman Khan said that the new exciting possible indications for Aspirin are its chemo preventive characteristics. Many studies have shown significant decrease in tumor genesis with Aspirin.  Long term use of Low Dose Aspirin appears to be associated with lower incidence of colorectal carcinomas in patients with high cardiovascular risk. For chemoprevention, studies recommend dose of 325mg every other day while Women’s Health Study has recommended 100mg every other day. At present it is advisable to give Aspirin after discussing its potential benefits with the patients, he added. Regular use of Aspirin is also associated with reduction in incidence of venous thromboembolism in cancer patients besides prevention of recurrence of VTE.

Emerging issues and Resistance to Aspirin, other antiplatelet

Dr.Shahbaz Kureshi consultant cardiologist from Islamabad highlighted the emerging issues of Aspirin resistance as well as non-responders.  Non-responders, he stated, are a sub-group of patients taking therapeutic doses of Aspirin and not responding. Congestive Heart Failure patients are resistant to Aspirin. Similarly End Stage Kidney Disease patients may also not respond to Aspirin therapy. Aspirin resistance is significantly associated with major adverse events during long term follow up. Aspirin non-responders have increased stiffness of elastic type arteries. Treatment of aspirin resistant patients by adding omega-3 fatty acids or increasing the aspirin dose seems to improve the response to aspirin and it effectively reduces platelet reactivity.

Prof. Ejaz Ahmad Vohra in his presentation stated that the physicians should know in which patients to use Aspirin therapy and how to use it and which are the patients who will benefit with long term use of low dose aspirin therapy. One should be aware of the fact that aspirin is known to cause hemolytic anemia in G6PD deficiency. Aspirin is the most cost effective antiplatelet agent with proven safety and efficacy. Referring to long term safety of Aspirin use, he referred to a study published in Lancet which reported that more than seventy thousand people fond 46% reduction in risk for adenocarcinoma, common malignancy of lung, colon and prostate.  Oxford review of fifty one studies showed that taking aspirin for five years reduces the risk of death from cancer by 37% and developing cancer by 25% as compared to those who did not use aspirin. He was of the view that we should encourage middle age people with high risk of CVD to start taking low dose aspirin on regular basis.

Mr. Asif Sattar presenting a mementoe to the outgoing President of
Pakistan Aspirin Foundation at the business meeting of the
Foundations held on October 4th2013 at Lahore.

Dr.Rehan Umer from KIHD Karachi talked about Antiplatelet therapy and pointed out that managing antiplatelet therapy for patients for ACS is complex. Current therapeutic options and approaches are suboptimal and recurrence rate is high, bleeding remains an issue. Prevention of bleeding is as important as prevention of ischemia.  ACS patients who can benefit most from antiplatelet therapy also have the greater risk of bleeding complications. An ideal antiplatelet drug  should be effective without risk of bleeding,  have no resistance, offer simple dosage, no side effects, no drug interactions and available at reasonable price. It is important for healthcare professionals to be aware of drug interactions and bleeding.

Prof. Javed Akram President of Pakistan Aspirin Foundation was the last speaker in this session who talked about the use of Statins. He pointed out that studies have suggested that decrease in CHD related mortality rates was associated with the reduction in modifiable risk factors and improvements in evidence based therapies. Statins play an important role in stabilizing the arteriosclerotic plaques and in atherosclerosis regression.  The use of Statins as a primary prevention is still ambiguous because of inconsistent findings in various research studies. In patients without established cardiovascular disease but with cardiovascular risk factors, Statins use was associated with significantly improved survival and large reductions in the risk of major cardiovascular events. He concluded his presentation by stating that Statins play an important role in reducing clinical relevant cardiovascular outcomes across broad populations most likely by reducing the LDL-C levels. The current guidelines aim to establish target LDL-C reductions to improve a patients long-term reduction in clinical events.  Statins are effective for primary and secondary prevention of cardiovascular events. In addition Statins also show reduction in all cause mortality. Statins are relatively safe to use with low incidence of major adverse events.

Prof. Bilal Zakirya who was chairing the session in his concluding remarks said that Aspirin remains the most used drug in cardiovascular field and it has also been found to be effective in primary prevention. Prof. Abdus Samad the other chairperson opined that Aspirin was not an old drug but has emerged as a gold standard for antiplatelet therapy. Cardiologists use Aspirin a lot. It is useful in primary prevention in patients with higher risk of developing any cardiac events. We have been working with PharmEvo to develop a risk calculation formula.  If the GPs learn to calculate this risk, it will enhance their practice as patients are very much interested to know their risk of developing a heart disease.  He had a word of advice for the speakers and asked them to avoid repetition which is not at all liked by the participants.

A group of medical students of Azra Naheed Medical College photographed with members of the experts panel
 during the panel discussion at National Conference of Pakistan Aspirin Foundation held at FJMC on October 5th 2013.

Panel Discussion

In the afternoon session the panel discussion on the use, safety and efficacy of antiplatelet agents with special reference to Aspirin was chaired by Prof.Abdus Samad. This session was moderated by Dr.  Bilal Mohayudin. Members of the Experts Panel included Prof. Sardar Fakhar Imam, Prof. S.H.Shafqat,   Prof. Nazeer Memon, Prof. Zaman Sheikh, Mr.Lateef Sheikh, Prof. M.Akbar Chaudhry, Dr.Shahid Karim, Prof. Maryam Malik and Prof. Tujamal.  Dr. Bilal Mohayudin pointed out that so far Pakistan Aspirin Foundation has failed to convince the laboratories to start testing antiplatelet agents. It is important that these tests should be done.  Prof. Abdus Samad responded by saying that what we see is mostly industry driven research.  It is time that we should tell them what they should be doing but another panelist remarked that the industry can also push physicians for research which suits their own requirements. However, it was emphasized that tests for antiplatelet agents should be available.  The patients need to be educated how to safely use this antiplatelet and justify the use of various devices, implants. Prof. Samad further stated that the recent European Guidelines suggest that the antiplatelet tests should be done only in high risk cases i.e in patients who have had acute myocardial infarction or Acute Coronary Syndrome and are going to have stents inserted. These tests are not required for every patient, he remarked.

Responding to another question it was stated that we will use any new drug only if we have some studies reporting its safety and efficacy. Mr. Lateef Sheikh said that what we saw at Punjab Institute of Cardiology leading to numerous deaths was a total system failure. We need to supervise the supply chain management. We need to look at the way drugs are handled by healthcare facilities.  If a drug is not working, it is known as non-responders but it is not an adverse drug reaction, he remarked.

Prof. Nazeer Memon opined that low dose aspirin is available in various dosages i. e, 75mg, 81mg and 100mg and all of them are effective.  Sometimes patients complain that they are suffering from indigestion and stop taking Aspirin though it is not related to this drug. It is difficult to say if the drug is not working. It was further suggested that healthcare professionals should take proper history, clinical examination and order essential investigations, take ECG and if need be one can increase the dose of one of the antiplatelet agents. Prof.Zaman Sheikh said that it is difficult to see the response of Aspirin. To the best of his knowledge there has been no study of Aspirin in Type one or Type two diabetics. Prof.S.H.Shafqat referred to the availability of counterfeit drugs which look alike but are not at all effective. Hence we must advise the patients to be careful of these counterfeits. Mr. Lateef Sheikh opined that how drugs are handled in pharmacies and hospitals also matters.  Prof. Shafqat also stated that he had seen one patient who developed renal failure with prolonged use of Aspirin. Prof. Akbar Chaudhry said that we must calculate the risk before starting the patient on low dose aspirin therapy for long term use.

Prof.Samad opined that the political problems need political answers and it is upto the administration to solve them to improve the patient care and ensure patient safety. Risk evaluation was also essential for use of Aspirin and Statins for primary prevention. He also narrated a story that one of his patients said that ever since he has started taking these drugs, he has become handsome. His wife also confirmed this.  I asked him to get his hemoglobin which was 7.5, which meant he was not aware of the blood loss due to bleeding. Hence we must educate the patients and be careful of such incidents. Prof. Maryam Malik said that in most cases the family physicians know the patient and their family and are also aware of their disease, but at times they do have their limitations. Prof. Javed Akram said that for long term use, a dose of 75mg of enteric coated aspirin is quite safe and effective in ACS patients but in diabetics the recommended dose is 150mg. Asthma and active ulcer disease are some of the contra indications for use of Aspirin. When we need blood donors, and if the entire population is taking antiplatelet agents, it will become a problem. People should be asked to stop taking aspirin or any other antiplatelet agent ten days before they donate blood. The people should be educated to take a 300mg soluble Aspirin or chew it in case of chest pain. During the deliberations it was also emphasized that Pakistan Aspirin Foundation should convince the laboratories to start antiplatelet tests. Sometimes the patients spend more on investigations than on drugs. It is important that basic investigations must be done but one should avoid un-necessary investigations. Prof. S.H.Shafqat remarked that almost about 80% of diseases can be diagnosed with good detailed history and clinical examination and investigations are needed just to confirm those.

Press Briefing

       On Sunday 6^th October a session with the media was also organized at Lahore Press Club where Prof. Javed Akram President of Pakistan Aspirin Foundation, Prof. M.Akbar Chaudhry, Prof.Zaman Sheikh and Mr.Shaukat Ali Jawaid highlighted the aims and objectives of the Foundation. They called upon the media personnel to play their role in educating the public on the use of Aspirin. The public should be informed to immediately take a soluble Aspirin tablet when they have chest pain as it could prove life saving and always keep Aspirin with them at home and in office. Long term use of Low Dose Aspirin therapy they were told is extremely safe and effective in reducing the morbidity and mortality in a variety of medical disorders which has been proved in numerous research studies.  

Pakistan needs to introduce culture of patient
safety and medication safety – Mr. Lateef Sheikh
Pakistan’s total pharmaceutical market is over
200B rupees and there is no supervision at all

LAHORE: Pakistan has a total pharmaceutical market of over two hundred billion rupees and most of it was not being monitored at all. In Pakistan it is estimated that over one million patients use Aspirin daily for prevention of cardiovascular diseases.  Pakistan’s Pharma market consists of 85% retail pharmacy and 15% institutional pharmacy and none of them was being supervised. Had there been some supervision, the incidents which took place at Doctor’s Hospital and Punjab Institute of Cardiology at Lahore would not have occurred. This was stated by Mr. Abdul Latif Sheikh Director Pharmacy Services at Aga Khan University Hospital Karachi. He was making a presentation on pharmacists monitoring parameters in Aspirin use, efficacy and compliance at the 6^th National Conference of Pakistan Aspirin Foundation held at Fatima Jinnah Medical College Lahore on October 5^th 2013. This conference was very well attended by members of the medical and nursing procession besides some medical students. At present   major consumption of Aspirin was in cardiac patients, he added.

 Mr. Lateef Sheikh further stated that for monitoring and supervision of pharmacy services, a team approach is needed. We must select a team.  It is the physicians who prescribe drugs, dispensing and monitoring should be done by pharmacists and nurses administer drugs. Referring to the global scenario as regards medication usage and safety, Mr. Lateef Sheikh said that upto 20% of drugs administered in hospitals were given in error. There were many potential Adverse Drug Events which included 1% fatal, 12% life threatening and 56% of preventable ADRs occurred when the drugs were ordered. A review of 14,179 admissions in Australia showed that ADEs occurred in 16.6% of patients, 10.7% had permanent disability, 4.9% had death and almost 54% of these ADRs were preventable.

Continuing Mr. Lateef Sheikh said that 15-25% of medication errors are due to confusing names while other 20-30% medication errors are associated with look-alike and sound alike names. The global burden of unsafe medical care is enormous. He also showed medication errors related to Beta Blockers and Aspirin at admission and discharge in various hospitals and highlighted the roadmap to medication safety as regards adverse drug events. While use of Low Dose Aspirin daily offers many benefits as regards cardiovascular diseases but it also has some risks. Hence one must speak to the physician first before starting to take Aspirin. What we need is to give importance to issues like patient safety and medication safety and establish multidisciplinary teams to promote medication safety. Senior consultants should undertake monitoring while clinical pharmacists should assist physicians and help the patients, Mr. Lateef Sheikh concluded.

Prof. Javed Akram elected President
of Pakistan Aspirin Foundation
Prof. Akbar Chaudhry’s services to promote the aims
and objectives of the Foundation commended

LAHORE: Prof. Javed Akram FRCP, an eminent physician and former Principal of Allama Iqbal Medical College was unanimously elected as the new President of Pakistan Aspirin Foundaiton at the business meeting held on Friday October 4^th 2013 for a two years term. The meeting was chaired by Prof. Mahmood Ali Malik founder President of Pakistan Aspirin Foundation along with Prof. M. Akbar Chaudhry the outgoing President. Those who attended the business meeting included Prof. Ejaz Ahmad Vohra, Major Gen.Ashur Khan, Mr. Lateef Sheikh, Dr. Shahbaz Kureshi, Prof. Nazir Memon,Prof. S. H.Shafqat, Mr. Shaukat Ali Jawaid. Prof. Sardar Fakhar Imam Principal of Fatima Jinnah Medical College, Mr. Asif Sattar from Atco Laboratories who are sponsoring academic and CME activities of the foundation for the last many years attended the meeting on a special invitation.

Addressing the participants Prof. M.Akbar Chaudhry said that during his tenure, he tried his best to promote the aims and objectives of the Foundation which are to promote the use of Aspirin in its well established indications besides creating awareness about its safety and efficacy among the healthcare professionals as well as public. For this purpose we travelled to many small and big cities all over the country in Punjab and Sindh provinces but could not visit Baluchistan and Khyber KPK due to security concerns. He specially thanked M/s Atco Laboratories for their generous help and assistance in sponsoring these CME activities of the foundation. He hoped that his successor who is a young dynamic personality will carry our mission forward with greater zeal and devotion.

Prof. Javed Akram thanked the members for their confidence in electing him as the new President and promised to do his best to come upto the expectations of the members.  I look forward to the support of my seniors and other founder members in this regard, he added.

Prof. Mahmood Ali Malik and all the members present commended the services rendered by Prof. M.Akbar Chaudhry and hoped that the new President will carry this message forward in the days to come.  Participating in the discussion Mr. Lateef Sheikh said that there is much more to do and apart from physicians, we also need to have healthcare professionals from other disciplines of medicine as use of Aspirin is indicated in a wide range of disorders which needs to be discussed and promoted.  Gen. Ashur Khan, Prof. S. H. Shafqat, Dr. Shahbaz Kureshi also briefly addressed the meeting and expressed their satisfaction with the activities of the Foundation. Prof. Nazeer Memon said that it is for the first time that he was attending the business meeting. We appreciate the work being done and offered his whole hearted cooperation.

Prof. Sardar Fakhar Imam Principal FJMC addressing the participants thanked them for selecting Fatima Jinnah Medical College as a venue for their 6^th National Conference which was a great honour and privilege for the institution. On behalf of the faculty he reiterated that all possible help and assistance will be provided to Pakistan Aspirin Foundation for its academic activities in future as well.

Mr. Shaukat Ali Jawaid General Secretary of Pakistan Aspirin Foundation in his introductory remarks thanked the members for tolerating him ever since the Foundation was established in 1996 and expressed the wish that it is better if the members could elect someone else as the General Secretary and promised that he will continue to work with the same zeal and dedication for the Foundation .However, the members  did not accept his suggestion and asked him to continue working as the General Secretary. He also informed the participants that Guidelines on Medical Uses of Aspirin have been revised and updated and published on the Foundation’s website.(www.pakaspirin.org.pk) He specially thanked Prof. Abdus Samad, Prof.Ejaz Ahmad Vohra, Prof. Khawar Kazmi, and Major Gen.Ashur Khan for their useful suggestions. Lt. Gen.Mahmud Ahmad Akhtar former Surgeon General of Pakistan Army who is an expert in clinical pharmacology, he said, deserve special mention for his valuable contribution in preparation and finalizing the guidelines. The members were requested to visit the website and have a look at these guidelines and forward if they have any suggestions in the next two to three weeks after which these guidelines will be sent for printing and distribution among the healthcare professionals. Members also expressed their sincere thanks to M/s Atco Laboratories for sponsoring the academic activities of Pakistan Aspirin Foundation for the last many years and requested Mr. Asif Sattar to convey their gratitude and appreciation to Mr. Saeed Allawala Chief Executive  of Atco Laboratories.

 Later Mr. Asif Sattar on behalf of Atco Laboratories presented a memento to the outgoing President of Pakistan Aspirin Foundation Prof. Akbar Chaudhry in recognition and appreciation of his services.  Prof.Akbar Chaudhry was also presented a gift on behalf of the Foundation by Prof. Mahmood Ali Malik. Mr. Akhtar Tahir GM Marketing and Mr. Farhan Raza Product Manager from Atco Laboratories who are also members of the Foundation were also present on this occasion.

FAMILYCON Lahore celebrates Aspirin Day
Regular use of Low Dose Aspirin reduces
Myocardial Infarction, Acute Coronary Syndrome
by 33% in men and 17% of strokes in women
We must emphasize on prevention and modifiable risk
factors to reduce morbidity and mortality from
cardiac diseases - Prof. Akbar Chaudhry

LAHORE: Pakistan is a poor country hence our major efforts in the health sector should be on prevention of cardiovascular diseases since curative services are extremely expensive. This is possible by intervention in the modifiable risk factors i.e. stop smoking, control diabetes, hypertension, lipids, weight and in addition prescribe low dose Aspirin for primary & secondary prevention unless contra indicated. This was stated by Prof. M. Akbar Chaudhry President of Pakistan Aspirin Foundation who is also Principal of Azra Naheed Medical College, Lahore. Hew was the guest speaker at Aspirin Day celebrated by Familycon, a group of family physicians here recently. It was very well attended by their members.


Prof. M. Akbar Chaudhry President Pakistan Aspirin Foundation speaking on Aspirin – a wonder drug at a meeting organized by Familycon for family physicians at Lahore recently. Picture also shows Dr. M. Sarwar Chaudhry
 participating in the discussion besides a view of the participants.

The theme of the lecture was “Aspirin: A Wonder Drug”. Prof. Chaudhry said that the real threat to the urban health is the cardiovascular diseases, which is more common in the urban areas as compared to rural areas. It is estimated that 17.1 million people died of CVD in 2004 representing 29% of all global deaths and by 2030 it is expected that 23.6 million people will die from heart disease and stroke annually. The major disease burden (82%) is in the low & middle income countries affecting the men and women equally.
Prof. Chaudhry presented data from many international studies with the clear benefits of Aspirin in the primary & secondary prevention of cardiovascular and cerebrovascular diseases. He heighted the fact that Aspirin in low doses 75 – 100mg as Primary prevention reduced the incidence of MI, ACS by 33% in men and 17% of strokes in women. He recommended that all healthy individuals over the age of 45 with 10 years global risk of 10% or more of developing CVS & Strokes should be prescribed Aspirin.
He also discussed the recommendations of US Prevention Services Task Force and American Heart Association and also spoke about the benefits of combination treatment of Aspirin & Clopidogrel. One must ensure that blood pressure is under control before these hypertensive patients are prescribed low dose Aspirin therapy, he remarked.
Prof. Akbar Chaudhry also highlighted the aims and objectives besides accomplishments of Pakistan Aspirin Foundation ever since its inception. It has a very democratic set up and all the former Presidents of the Foundation as well as founder members have played an important role in creating awareness about the use of Aspirin in its well established indications besides CME programmes organized all over the country on regular basis for the last many years.
The presentation was followed by lively discussion. Responding to various questions Prof. Akbar Chaudhry said that for cardiac patients, the recommended dose is 75-150mg daily and all are equally effective. For cerebro vascular diseases the recommended dose is 150 – 300mg. He also stressed that in case of Acute MI, ACS, Soluble Aspirin should be given to the patient immediately dissolved in water or sublingually and if given within six hours, is as effective as Streptokinase. Side-effects of Aspirin and recommendations to stop Aspirin before elective surgery were also discussed in detail. Enteric coated Aspirin, he said, is preferred because of its safety in long term use, he added
At the end Prof. Akbar Chaudhry paid special thanks and tribute to the management of Atco Laboratories who have been sponsoring all the Academic Activities of Pakistan Aspirin Foundation for the last 12 years. We are extremely grateful to them. However, keeping up the professional ethics, we do not patronize or recommend any particular brand of Aspirin and it is up to the treating physician to make a choice. He also commended the local Atco team for organizing such a useful academic activity for the family physicians in Lahore. The session was moderated by Dr. Farrukh Mahmood.

Aspirin Update seminar at PHL Symposium
Speakers highlight the efficacy of Low Dose Aspirin
therapy in various well established indications
This economically priced anti-platelet agent reduces morbidity
and mortality in many medical disorders

HYDERABAD: As a part of its Continuing Medical Education programme, Pakistan Aspirin Foundation organized a breakfast session during the recently held 16th annual symposium of Pakistan Hypertension League at Hyderabad on February 9th 2013. It was chaired by Prof. Nazeer Ahmad Memon along with Dr. Fazalur Rehman Memon and Dr. Shahbaz Kureshi, consultant cardiologist at Red Crescent Institute of Cardiology at Hyderabad and Central Government Polyclinic at Islamabad respectively. Prof. Mohammad Akbar Chaudhry an eminent physician/cardiologist and President of Pakistan Aspirin Foundation who is also Principal of Azra Nahid Medical College Lahore was the main speaker.

Pakistan Aspirin Foundation organized an Update on Aspirin at the recently
held annual symposium of Pakistan Hypertension League at Hyderabad.
Picture shows Prof. Nazeer Memon along with Dr. Fazalur Rehman Memon
and Dr. Shahbaz Kureshi chairing a session.

In his brief introductory presentation, Prof. Akbar Chaudhry talked about the burden of diseases in the world in general and Asia in particular. Apart from communicable diseases, non-communicable diseases, he said, have also assumed epidemic form. Cardiovascular diseases and diabetes mellitus apart from Cancer account for millions of deaths worldwide. Most of the deaths in Asia and developing countries, he said, were due to hypertension and diabetes which are both preventable to a great extent if we adopt healthy lifestyle and use balanced diet. He laid emphasis on control of modifiable risk factors like low intake of salt, control of high blood pressure, reduction in cholesterol, TGs, controlling obesity and avoiding smoking etc. Safety and efficacy of Low Dose Aspirin therapy has been documented in numerous studies which shows that it is reduces morbidity and mortality. Some of the well established indications for Aspirin therapy include Acute Myocardial Infarction, Acute Coronary Syndrome, Secondary prevention of AMI, Primary prevention of CAD, Acute Ischemic Strokes, Transient Ischemic Attacks, Primary and secondary prevention of strokes, hypertension, diabetes mellitus, prophylaxis against deep vein thrombosis and pulmonary embolism. In addition there are numerous emerging indications for use of Aspirin like colorectal cancer etc.
A study conducted by Pakistan Aspirin Foundation many years ago had showed that only 50% of ACS patients were prescribed Aspirin at discharge, only 20.8% of Family Physicians prescribed aspirin to their patients while 16% got aspirin at home when they had chest pain. However, ever since the awareness campaign and CME programmes started by Pakistan Aspirin Foundation, the use of Aspirin has increased to a great extent. Enteric coated Aspirin tablets, it was stated are safe in long term use.

Pakistan Aspirin Foundation organized an Update on Aspirin during the recently held PHL symposium
at Hyderabad on February 9th 2013. Picture taken on this occasion shows from (L to R) Dr. Shaukat
Malik presenting mementoe to Prof.Nazeer Memon, Prof. M. Akbar Chaudhry President of PAF
(keynote speaker) and Prof.M. Ishaq presenting mementoe to Dr. Shahbaz Kureshi.

Participating in the discussion Dr. Shaukat Malik from Islamabad stated that he was taking Aspirin for the last twenty five years. He advised his colleagues to promote the use of Aspirin therapy in its well established indications. Prof. M. Ishaq President of PHL and Director of KIHD opined that it was a pity that despite its usefulness, Aspirin was still under used. It can be life saving if the patient takes one full tablet of Aspirin 325mg or uses soluble Aspirin immediately when they experience chest pain. Prof. Feroze Memon pointed out that Aspirin was an effective therapy in acute coronary syndromes and its use need to be promoted. One of the family physicians referred to its anti-analgesic and anti-pyretic properties. At this it was stated that in the beginning it was used as anti-pyretic, analgesic agent but Aspirin became more popular when its anti-platelet activity was proved and now it is widely used all over the world. Prof. Waris Qidwai Head of the Dept. of Family Medicine at Aga Khan University said that the Family Physicians are the first one who come in contact with the patients, it is essential that they prescribe this extremely useful and life saving drug to their patients when indicated.
Dr. Shahbaz Kureshi referred to the use of low dose Aspirin therapy after interventional cardiac procedures, angioplasty, stenting where it is very useful. He also remarked that Aspirin has shown to reduce colorectal cancer in numerous new studies as well. Dr. Fazalur Rehman Memon also highlighted the usefulness of Aspirin therapy. Prof. Nazir Ahmad Memon in his concluding remarks thanked the guest speaker Prof. Akbar Chaudhry for his excellent review and presentation on use of Aspirin therapy. He also commended the efforts of Pakistan Aspirin Foundation to educate the healthcare professionals in the use of this extremely useful anti-platelet agent.
Earlier Mr. Shaukat ‘Ali Jawaid Secretary General of Pakistan Aspirin Foundation who moderated the session stated that Guidelines on the use of Aspirin were now being revised. It has major emphasis on assessment of risk factors. A draft has already been prepared by Prof. Abdus Samad and Prof. Ejaz Ahmad Vohra and Prof. Akbar Chaudhry. We have had very useful comments and suggestions from Prof. Mahmud Ahmad Akhtar former Surgeon General of Pakistan Army. The draft guidelines have also been reviewed by Prof. Khawar Kazmi Head of the dept. of cardiology at Aga Khan University. It has also been forwarded to Dr. Basheer Haneef consultant cardiologist at Taba Heart Institute for his input. We hope to finalize these guidelines in a month’s time when it will be upload on the Pakistan Aspirin Foundation website. As regards use of Aspirin in Primary prevention, he said the results of ARRIVE study which has enrolled over twelve thousand patients in five countries will be available by the end of this Year. It will provide an evidence based information on its use in primary prevention. He also thanked M/s Atco Laboratories who have been sponsoring these CME programmes all over the country for the last many years. However, upholding professional ethics, we do not patronize or promote any particular brand of Aspirin, he remarked.