Public Awareness Session on August 9th will be followed
by formal inauguration by Governor of Baluchistan

QUETTA: The 5th National Preventive Cardiology conference will be held here from August 9th to 10th 2014. It is being organized under the auspicious of Cholesterol Awareness Society of Pakistan. It is after a long time that Quetta will be hosting any medical conference which is expected to attract a large number of eminent guest speakers from all over Pakistan. Prof. A. Manaf Tareen is the Patron of the conference while Dr. Haq Dad Tareen was elected as Chairman of the conference at a meeting held during the Pakistan Cardiac Society’s Biennial conference at Islamabad while Dr. Jalaluddin Achakzai was elected as the Secretary. Mr. Mohammad Khan Achakzai Governor of Baluchistan is expected to inaugurate the conference in the evening of August 9th 2014.

According to Dr. Haq Dad Tareen the organizing committee is making every effort to ensure participation of healthcare professionals from all over the province in the conference so that they benefit from the presence and presentations by various experts in the scientific sessions. Giving details of the scientific programme, Dr. Haq Dad Tareen said that a Public Awareness Session is being organized at Hotel Sarena the conference venue on the first day of the conference. He himself will be making a presentation on cardiovascular disease risk assessment in the light of recent guidelines which will be followed by a lecture by Prof. Abdus Samad on cardiovascular disease risk interventions. It will be followed by question answer session and the panel of experts will include Prof. Manaf Tareen, Prof. Abdus Samad, Maj. Gen. Azhar Mehmood Kayani, Dr. Haq Dad Tareen and Dr. Jalaluddin Achakzai. It will be followed by a Basic Life Support demonstration by Dr. Roohi Ilyas. The public awareness session will be from 4.00 PM to 6.30 PM. The formal inauguration will be at 8.15 PM. After welcome address by chairman of the organizing committee, Prof. Samad will talk about the scope of the conference followed by the Address of the Chief Guest. After vote of thanks by Dr. Jalaluddin Achakzai the conference dinner will be at 9.30 PM.

On second day of the conference i.e. August 10th, the first session will be jointly chaired by Dr. Haqdad Tareen along with Gen. Azhar Kiyani and Prof. Feroze Memon. Prof. Naeem Aslam will talk about risk evaluation for coronary heart disease while Dr. Fawad Farooq will speak on historical overview of present updates in managing hypertension. This will be followed by Dr. Shahbaz Kureshi who will discuss life style modification- Are we doing enough. Other presentations in this session and the panel of experts are Prof. Manaf Tareen, Prof. Khalida Soomro and Dr. Tariq Ashraf. The topic of Dr. Abu Bakar Sheikh’s presentation is Do preventive strategies work? Prof. Nusrat Ara will discuss prevention of CAD in women. Dr. Bilal Mohiyuddin will be speaking on obesity the forgotten risk factors.

Speakers and the topics to be discussed in the second session include One Million Heart programme- What is the lesson for Pakistan by Prof. Abdus Samad, Current hypertension guidelines in Pakistan’s perspective by Prof. Feroze Memon while obesity will be discussed by Dr. Jalaluddin. The panel of experts for this session is Prof. Abid Ameen, Dr. Abu Baker Sheikh and Dr. Fawad Farooq. Gen. Azhar Kayani will speak on prevalence of risks factors in Pakistan, Dr. Tariq Ashraf will discuss the role of Statins in primary preventon of CHD. Dr. Rehan Umer will speak on innovations in Hyperlipidemia.

Panel of experts in this session will be Prof. Manaf Tareen, Dr. Shehbaz Kureshi and Dr. Khalid Shah. In the third session Prof. Khalida Soomro will speak on guidelines for prevention of CAD, Dr. Najmul Islam will discuss prevention of CAD in diabetes mellitus, while Dr. Tahir Majid will speak on CT Angio guidelines for very early detection of CAD.. Panel of experts for this session include Prof. Abdul Samad, Prof. Nusrat Ara, Mujeebullah Tareen and Dr. Zahir Khan. In the last session Prof. Muhammad Akbar Chaudhry from Lahore will discuss role of Aspirin in prevention of CAD and other diseases while Dr. Haqdad Tareen will present Summary of congress deliberations & Take Home messages. The panel of experts in this session will consist of Prof. Naeem Aslam, Dr. Haqdad Tareen and Dr. Baqi Durrani.

KARACHI: Effective affordable treatment for Hepatitis-C is now available and the availability of new oral therapy Sofosobuvir ensures cure with complete elimination of the virus. This was stated by Prof. Saeed Hamid while speaking on Treatment of chronic Hepatitis-C at the World Hepatitis Day meeting organized at Aga Khan University Hospital on July 27th 2014. Other speakers in the meeting included Prof. Wasim Jafri, Prof. Husnain Ali Shah and Prof. Shahab Abid. The meeting was well attended by patients, medical students besides some healthcare professionals.

Hepatitis-B is a lifelong dynamic disease which can
be controlled but cannot be cured – Wasim Jafri

During the last two three years, Prof. Saeed Hamid said, lot of advances have taken place which has made viral cure achievable. This has also reduced the risk of liver failure and subsequent development of Hepatocellular Carcinoma. It has improved survival as well. He was of the view that all Hepatitis-C patents should be treated except those with very advanced disease with liver failure and development of malignancy. All patients with positive PCR need to be treated but there is no treatment for highly advanced liver disease. Mild disease, he said, is easier to treat and the response to therapy is also better but in case of advanced disease, immediate treatment response may be impaired. Treatment with the combination of Peg Interferon, Ribavarin and Direct Acting Antivirals (DAA) is almost 70% in Genotype-I infection. In Pakistan Genotype-3 are more common and our experience at AKU shows the cure rate to be 62.5%. However, in case of patients less than 35 years of age, the response rate was 72% and in patients between the ages of 15-30 years the response rate was still better i.e. 82%. This shows that early treatment ensures good response but one must remember treatment has its own side effects which include fever, fatigue, depression etc.

After the Year 2011, DAA became available and now even interferon free treatment is available. With the development of Sofosobuvir complete cure from Hepatitis-C is possible. Combination of Sofosobuvir, Peg Interferon and Ribavarin gives almost 90% cure rate in Genotype-I. In Genotype-3, it can be treated without interferon. According to reports a twenty four weeks course of Sofosobuvir plus Ribavarin gives almost 85% cure rate. However, in advanced disease, the response rate is reduced. It is now also possible that treatment duration may be reduced to eight weeks and twelve weeks in the coming few years with more developments and new more potent and effective drugs become available. At present in 2013 the standard treatment for Hepatitis-C is combination of Sofosobuvir plus Ribavarin. Advanced disease may also require interferon. Hence now most Hepatitis-C patients can be treated.

Earlier Prof. Wasim Jafari speaking about treatment of Hepatitis-B said that it was a lifelong dynamic disease. It can be controlled but not cured. Drugs can decrease progression of fibrosis. Speaking about the natural history of Hepatitis-B, he said, some can be carriers of this infection. Effective vaccination is available. There are different phases of chronic Hepatitis-B from acute, chronic to cirrhosis and development of HCC. He also briefly talked about therapeutic end points and pointed out that patients with elevated ALT levels must be treated. Liver biopsy becomes essential in case of prolonged Hepatitis B and family history of HBV. Liver biopsy shows the stage of the disease and it must be done if need be and advised by the treating physician. Affordable treatment is available for Hepatitis-B. The pharmacological agents being used include Interferon, Peg Interferon, Adenovir, Entecavir, Tenofovir etc. The treatment available in Pakistan is much cost effective a lot economical than the developed world. He then discussed the goals of treatment and monitoring of the virus level. Due to misuse and abuse of the antiviral drugs, some of these agents Lamivudin in particular have developed lot of resistance. Entecavir and Tenofovir are both most effective agents. For HBV now liver transplant is also possible. Hepatitis-B is not a problem in pregnancy and some of the basic tests have to be done before starting treatment.

Prof. Husnain Ali Shah spoke about complications of cirrhosis and their management. The complication, he said, include hepatic encephalopathy, Hepatorenal syndrome, Ascites/Sub acute bacterial Peritonitis (SBP) and portal hypertension. Portal hypertension develops in 35-80% of the patients of which 25-40% will ultimately bleed. Mortality in cirrhosis is between 30-50%, risk of rebreeding is there. Almost 40-50% of patients will suffer from variceal bleeding ten years after diagnosis. Different treatment strategies include injection Sclerotherapy, balloon tamponade, and variceal ligation. In case of recurrence of variceal bleeding TIPS procedures can be performed, Beta blockers can be used or surgical shunts may also be possible. However, in case of frequent bleeding, liver transplantation is advised. Cause of ascites is chronic liver disease in 75-80% of the cases. Almost 60% patients will develop ascites in cirrhosis. Ultrasound is very important investigation but malignancy is shown much better by CT scan. Diagnostic paracentesis can also be done.

Treatment of Ascites includes complete salt restriction which is very difficult but extremely important. Diuretics are also used but in case of large volume of ascites, paracentesis is done after hospitalization. SBP infection can be very dangerous. Ascites can also affect kidneys. In case of Hepatorenal syndrome, death is likely within weeks. Hepatic encephalopathy is reversible. Almost 55-85% of cirrhosis patients will develop hepatic encephalopathy. It starts from confusion and eventually end up in coma, he added.

Dr. Shahab Abid in his presentation on Hepatitis transmission first defined hepatitis which is inflammation of the liver which can be acute or chronic which have different outcome. Hepatitis result from infection, metabolic causes, drugs and even the cause could be autoimmune status of the patient. Speaking about chronic hepatitis infection, he said that its prevalence in Pakistan is reported to be 2.5 to 10% and it is increasing. PMRC Survey in 2010 showed HBV prevalence of 4.8%, taking into consideration various studies and surveys, it can be said that the overall prevalence of Hepatitis B in Pakistan is 4.3% and Hepatitis-C 2.5% though it can be very high in some areas depending on various factors.

Transmission of Hepatitis B and C is through shaving by Barbers, blood transfusion, handling of blood products, dental treatment or wound care. As regards progression of hepatitis, 75-85% will become chronic, 5-20% will develop cirrhosis and 1.5% will eventually develop liver failure or liver cancer. In case of Hepatitis-B, 5-10% will become chronic, 23% will develop cirrhosis and then liver failure. As regards signs and symptoms, they are non specific. For diagnosis, one has to have high degree of suspicion, opt for early tests and ensure early detection. Avoid risk factors. Hepatitis, he concluded is a leading cause of liver cancer.

Panel Discussion

Presentations by the speakers were followed by panel discussion and it was pointed out that though now complete cure of Hepatitis-C is possible but it is dependent on various co-factors. Some patients have been treated in Pakistan with Sofosobuvir with encouraging results that got it from abroad. It is quite expensive but hopefully is will become available in Pakistan soon and will be quite affordable. Professional societies are doing their best to help get this new drug Sofosobuvir registered as early as possible. Vasculitis leading to blindness after treatment with interferon is a very very rare side effects but it has been documented. Moral support by the treating physician to the patient is very important. It is extremely important for the healthcare professionals to know their limitations and do no harm if he or she cannot do any good to the patient. As regards the results of various prevention and treatment programmes for hepatitis run by federal and provincial governments, it they get their results evaluated and audited, then their claims will be quite acceptable. There is no risk of Hepatitis-C transmission from mother to infant and from husband to wife or from wife to husband.

National Institute for Health and Care Excellence (NICE) have lowered the threshold for people being offered statins to a 10% risk of developing cardiovascular disease in the next decade from 20% amid controversy. It is said that new guidelines lowering the threshold for statin use mean “forty per cent of adults,” or roughly “17.5 million people” will now be eligible for the drug in the UK.
Although NIC says the decision will “save lives,” critics have charged that those “drawing up the guidance” were “influenced by the pharmaceutical industry,” amid “wider arguments about ‘medicalising’ a nation and encouraging patients to take pills rather than change their unhealthy lifestyle.”