2: CARDIOVASCULAR SYSTEM
2.1.1
Cardiac glycosides
digoxin
2.2.1
Thiazide diuretics
bendroflumethiazide
2.2.2
Loop diuretics
furosemide
2.2.3
Potassium-sparing
diuretics
spironolactone
amiloride
Heart failure post MI (specialist initiation only)
Eplerenone▼
2.2.4 Combined diuretics
not recommended
Anti-arrhythmic drugs
To be initiated on specialist advice
Class 1 (membrane stabilising drugs):
Flecainide SR 200mg
propafenone
Class 2 (beta-blockers):
atenolol
Class 3 anti-arrhythmic agents:
sotalol
amiodarone
dronedarone▼ – specialist initiation only & reviewed 3 monthly see MHRA warnings
Class 4 (calcium-channel blockers):
verapamil
Other anti-arrhythmics:
atropine
digoxin
Beta-adrenoceptor blocking drugs
atenolol for angina and hypertension
bisoprolol / nebivolol for heart failure titrate to 10mg
carvedilol for heart failure starting dose 3.125mg titrate to 25mg bd or 50mg bd if > 85kg
propranolol for palpitations, anxiety, migraine
2.5.4 Alpha-adrenoceptor blocking drugs
doxazosin (suggest not more than
4mg daily)
Doxazosin MR may be prescribed when
patient experiences side effects with
doxazosin but it is more expensive
2.5.5.1 Angiotensin-converting enzyme inhibitors
Hypertension:
enalapril
lisinopril
Heart failure and prophylaxis after myocardial infarction:
ramipril
lisinopril
(titrate to recommended dose)
Post stroke / prevention of vascular events in at risk patients
ramipril
perindopril erbumine
2.5.5.2 Angiotensin-II receptor antagonists (can be used in hypertension where ACE blockade of the renin angiotensin system is
necessary but ACE is not tolerated)
Hypertension:
losartan
Heart failure:
candesartan
Diabetic nephropathy in type 2 diabetes mellitus:
losartan
Please note XL preparations are
given once daily.
2.6 Nitrates
glyceryl trinitrate
isosorbide mononitrate
(Please start patients on asymmetric
doses for symptom control i.e. twice
daily 6 hours apart)
If MR preparations are required
advice is to prescribe generically as
25/50mg caps or 60mg tabs
2.6.2 Calcium-channel blockers
Hypertension:
amlodipine
Adipine MR/XL ® (nifedipine)
Angina:
patients not receiving beta-blocker
Zemtard XL® 120/180/240/300 (diltiazem)
Angitil SR® 90/120/180
Securon SR ®(verapamil)
patients receiving beta-blocker
amlodipine
Adipine XL® (nifedipine)
30/60
2.6.3 Other anti-anginal drugs (not first line but may be considered as add on treatment or if intolerant to standard initial
treatment)
nicorandil
ivabradine▼
Supraventricular arrhythmias:
Securon SR® (verapamil)
2.7 Sympathomimetics(secondary care)
Sympathomimetics:
adrenaline
Inotropic sympathomimetics:
dobutamine
dopamine
Vasoconstrictor sympathomimetics:
noradrenaline acid tartrate
2.8 Parenteral anticoagulants
Prophylaxis of DVT:
enoxaparin
Unstable angina and non-Q-wave MI:
enoxaparin
Treatment of DVT and PE:
dalteparin
Oral anticoagulants
warfarin
dabigatran▼ - on specialist initiation only as per SMC advice by indication
2.9 Anti-platelet drugs
Secondary prevention of cerebro-vascular disease or myocardial infarction:
aspirin dispersible 75mg
(co-prescribe omeprazole if dyspeptic)
Acute coronary syndrome:
aspirin 75mg + clopidogrel
(see local guidance on website)
Post stroke:
aspirin dispersible 75mg
PersantinRetard® (dipyridamole
MR) 200mg bd
Clopidogrel - see SIGN 108 for
advice re anti-platelet intolerance
2.10 Fibrinolytic drugs
Acute myocardial infarction:
tenecteplase
Stroke thrombolysis
tenecteplase
Antifibrinolytic drugs and
Haemostatics
tranexamic acid for menorrhagia
2.12 Lipid-regulating drugs
(see treatment guidelines for
primary & secondary prevention
of CHD and stroke p35/36)
Primary Prevention
simvastatin 40mg
Secondary Prevention
simvastatin (with evening meal)
pravastatin (where potential drug interactions with other statins)
atorvastatin (to be initiated if pre-treatment total cholesterol level is >6mmol/l. Atorvastatin 10mg should not be used (unless patient
cannot tolerate simvastatin 40mg) as atorvastatin 10mg is less effective than simvastatin 40mg)
First-line adjunct therapy in patients not meeting target on atorvastatin 80mg.
colestyramine
see local guidance
For advice on the use of ezetimibe, fibrates and rosuvastatin please see treatment guidelines in Appendix 1