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 10th 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 expertís 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.
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.
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
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.
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
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.