I kept advising this young man; all of 23 years only, not to make public his watertight views on religion and Karl Marx. But he is more than obstinate or why would he insist despite all shades of warnings to jot down such inflammatory phrases that religion is the opium of the masses or that religion has served little service apart form providing untold miseries to people. Worse, he noted, one must be wary from the control of machines or people with machines wishing to control men. He had already thought of the title, “ Jail Notebook and Other Writings.” Worse, he is a firm atheist. Not for him the slightest participation in any ritual of Hindu or Sikh mythology. Ladies and gentlemen I present who else but one of the greatest revolutionary’s the world has ever seen, Shaheed Bhagat Singh, who was hanged by our colonial masters 8 days after the Ides of March in 1931. Remarkably the morning he was hanged Shaheed Bhagat Singh was reading a book on Lenin, the architect of the Russian revolution. He did not want a scripture or a sermon uttered the day he died, he could not be bothered.He went to the gallows without a single prayer in his lips, along with his comrades, Sadguru and Sukhdev. Shaheed Bhagat Singh had been charged primarily for the assassination of the policeman John Saunders ( 17 December 1927), who in turn had led the charge that eventually killed Lala Lajpat Rai. Saunders however had not been the intended victim, the target was James Scott the superintendent of police who had ordered the deadly charge. Ironically , Shaheed Bhagat Singh in todays times may be charged an atheist plus a dangerous an urban Naxal. He would certainly today be a subject of the ire of a great number of people .



Ironically, Vinayak Damodar Savarkar ji too was an atheist and clearly desired that after he died no rituals were to be performed. He in fact most probably did not attend his wife funeral and ensured she went into an electrical crematorium, as he himself would be. Savarkar ji vehemently objected to orthodox Hindu beliefs. He was completely against the caste system, and had had 2 boys of the tailoring community as his best friends. Crucially Savarkar ji was against cow worship, which he dismissed as superstition. He believed that worship of the cow was a consequent to her utility in providing milk and numerous edibles from that milk. He would never hesitate to protect the cow but was reluctant to worship her as a goddess. But despite being an atheist he was of the firm opinion that he was a Hindu just as others who were monists, pantheists, and theists. He attacked the caste system all his life and would have been surely deeply dismayed by the (repeated) contemporary assaults against Dalits; he most certainly would not have kept silent (Savarkar: Echoes From a Forgotten Time by Vikram Sampath). Savarkar ji demanded full and complete independence more than 20 years before the Congress party took up the cause; but curiously met almost all the players who participated in the murder of The Mahatma, a few days before that sad evening of 30th January 1948.



Remarkably, Madan Lal Pahwa ( of the failed bomb attack on Gandhi ji) had been arrested 10 days before, and interrogated by the police in custody; Pahwa was a member of the gang that eventually participated in the killing of Gandhi ji ; it is difficult to believe that the police of those days was unable to extract information on the imminent mortal attack; also almost the entire top Bombay police brass had been informed of the impending murder ( including the premier of Bombay), and yet no adequate security was provided to Gandhi ji. Some serious investigative journalism is required for this humongous intelligence lapse. Despite having Pahwa, a close associate of Nathu Ram Godse, in the cooler for 10 days , the police had no clue what was about to happen at Birla House on 30 January 1948. Utter incompetence or something murkier than that. But more to the point; Savarkar ji would have felt awkward in today’s season of Hindutva, that he had almost single-handedly conceived. Careful rigorous reading on Shaheed Bhagat Singh and Veer Savarkar ji will reveal that it is near impossible to compare the two or even club them together, the only common factor would be their immense unease amid contemporary political currents.





German investigators, however, had the easier task of comparing head to head two powerful anti platelet agents, enjoying a class 1 recommendation during percutaneous coronary intervention (PCI) in patients with acute coronary syndrome (ACS); that is patients admitted for unstable angina, ST segment elevation Myocardial infarction (STEMI) or non ST segment elevation myocardial infarction (NSTEMI). The ISAR React 5 trial included more than 4000 ACS patients and assigned them in a randomised manner to either ticagrelor or prasugrel. Both ticagrelor and prasugrel are P2Y12 inhibitors that are not only more powerful than clopidogrel but also act quicker. When combined with aspirin or what is termed DAPT (dual antiplatelet therapy ) they significantly prevent ischemic events such as heart attacks, death or stroke after PCI. They also prevent stent thrombosis that can be fatal in quite a few cases. The researchers had anticipated that ticagrelor would come out tops because of past data. Ticagrelor was the favourite to be the winner because of its superior record when compared with clopiodogrel. The PLATO study ( N Engl J Med 2009;361:1045-57) had shown superior efficacy with ticagrelor when compared to clopidogrel in ACS patients. Prasugrel on the other hand has been found to be wanting when given before coronary angiography in patients with non ST elevation myocardial infarction in the ACCOAST trial.There was no advantage with before angiography prasugrel administration but in fact there were significantly more bleeds. More than 4000 patients were randomised in this trial ( N Engl J Med 2013;369:999-1010).




Prasugrel was unable to trump clopidogrel in the TRILOGY ACS trial that included more than 7000 ACS patients who not subjected to PCI, but given medical therapy. There were no differences in ischemic clinical endpoints or bleeding complications when Prasugrel was compared to clopidogrel in such patients. The researchers of the ISAR REACT 5 were therefore taken aback when their data revealed that prasugrel was in fact superior to ticagrelor without increasing clinical significant bleeds ( N Engl J Med September 1st, 2019).




Primary end point, a composite of death, myocardial infarction, or stroke at I year was 6.9% with prasugrel versus 9.3% with ticagrelor. Moreover stent thrombosis was almost halved with prasugrel (0.6%) versus ticagrelor 1.1%. The authors were compelled to conclude that in patients of acute coronary syndrome with or without ST segment elevation myocardial infarction, incidence of death, myocardial infarction or stroke was significantly lower among those given prasugrel as compared to ticagrelor. Prasugler was administered as a 60 mg bolus dose followed by 10 mg maintenance daily dose. In people more than 75 years or having weight less than 60 Kg daily Prasugrel was reduced to 5 mg. Ticagrelor was given as 180 mg bolus and 90 mg twice a day maintenance dose. Prasugrel was not given before coronary angiography in NSTEMI patients. The ISAR REACT 5 trial is the first ever head to head comparison of ticagrelor with prasugrel. Forty one percent patients enrolled had ST elevation myocardial infarction, 46% had non ST segment elevation myocardial infarction, and 12% were admitted for unstable angina.



The results of ISAR React 5 are yet to sink in. It is however well known that prasugrel is once a day regimen while Ticagrelor has to be taken twice day. In India a weeks course of ticagrelor is almost Rupees 700 while a 10 day course of prasugrel is around Rupees 100 only. The reaction of professional societies remains to be seen, but the makers of ticagrelor must be surely scrambling for a suitable response. For now unlike a choice between Shaheed Bhagat Singh and Veer Savarkar ji, the choice between ticagrelor and prasugrel ( in patients with acute coronary syndrome) appears far clearer. Prasugrel is the victor. Remember more than 700,000 people suffer with acute coronary syndrome (heart attack or close to one) for the first time in a year with around 333,000 having a recurring episode the same year, in the United States (Circulatiuon 2019;139(10):e 56-e528). The numbers from India are bound to be substantially greater; a shot in the arm for a diminishing GDP. The importance of an effective anti platelet agent cannot be overestimated. Nor can Veer Savarkar’s diktat that no crow was to be fed after he died ( ‘Savarkar: The True Story of the Father of Hindutva’ by Vaibhav Purandare).



The majority of Indian cardiologists including myself will now have to rethink on the role of prasugrel during percutaneous intervention in patients with acute coronary syndrome. Between the ages 30-69 years in 2015 there we’re 1.3 million ( 13 lakhs) deaths in India due to cardiovascular disease. About 70%b were because of heart attack while 30% due to stroke.Cardiovascular disease resulted in 2.1 million deaths ( 21 lakhs) in all ages in 2015. The ISAR REACT 5 trial, it should be noted was not sponsored by the industry, but further confirmation of prasugrel’s superiority will be difficult in the near future, because an adequately powered randomised trial is both hard work and expensive. As far as Bhagat Singh and Veer Savarkar are concerned; both were atheists till the end, Shaheed Bhagat Singh a Marxist till his last breath and Veer Savarkar anti caste activist. Would they have felt comfortable today when the cow is worshipped and  while poor school children are served rotis (bread) with salt in their mid day meals. Importantly, however, probably the biggest difference between the 2 was that Savarkar in attempting to get back non-Hindus into what he described the Hindutva peoples, he actually was driving deep wedge between Hindus and non-Hindus. He insisted that oil-Hindus accept India not only as their Father land but also as their holy land. By insisting on Hinduism as a religion he ceased to be as described some to be an agnostic or an atheist. Bhagat Singh on the contrary steered away from religion upto his last breath.



LANCET GLOBAL HEALTH 2018;6:e 914-23


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