Drugs for acute coronary syndrome / STEMI and secondary prevention of MI

Antiplatelet drugs

Refer to the Secondary Prevention of Coronary Heart Disease and Stroke – Antiplatelet guideline

Beta-blockers

Atenolol oral 25–50mg twice daily

Or if evidence of heart failure:

Bisoprolol oral 1.25–10mg daily or

Carvedilol oral 3.125–25mg twice daily

Caution: Avoid beta-blockers in patients with a history of asthma or bronchospasm.

Alternative options are:

• Cautious test dose with a short-acting beta-blocker such as metoprolol (which may be switched to an alternative beta-blocker if tolerated).
• A rate limiting calcium antagonist e.g. verapamil or diltiazem instead of a beta-blocker.

Statins

Refer to the Secondary Prevention of Coronary Heart Disease and Stroke - Cholesterol guideline

ACE inhibitors (ACEI)

Ramipril oral 1.25mg–2.5mg twice daily initially depending on blood pressure. Increase after 2 days to 5mg twice daily if tolerated.

Lisinopril - dose according to systolic blood pressure:

• Systolic blood pressure over 120mmHg – initially give lisinopril oral 5mg, followed by a further 5mg 24 hours later, then 10mg after a further 24 hours. Continue with 10mg once daily orally for 6 weeks (or continue if heart failure).
• Systolic blood pressure 100–120mmHg – initially give lisinopril oral 2.5mg once daily and increase to maintenance of 5mg once daily orally.

For ACEIs:

• Check U&Es before first prescription to exclude significant renal impairment.
• Check U&Es at one week following initiation and each up-titration to assess renal function.
• If renal function deteriorating (>20% increase in creatinine or creatinine >220micromol/L), consider stopping ACEI and seek specialist advice.
• If ACEI not tolerated due to cough, substitute with an angiotensin II receptor blocker.
• Avoid potassium supplements / potassium sparing diuretics, if possible.

Calcium-channel blockers – may be considered if indicated for anginal symptoms

Amlodipine oral 5–10mg daily. This is the preferred calcium-channel blocker for patients on a beta-blocker.

or

Diltiazem oral 60mg three times daily or 200–500mg long-acting formulation once daily (e.g. Tildiem LA^®). Always prescribe diltiazem by brand name. Never prescribe a rate limiting calcium-channel blocker together with a beta-blocker unless advised by a consultant.

Nitrates - may be considered if indicated for anginal symptoms

Isosorbide mononitrate oral 10–40mg twice daily (prescribe 8am and 2pm). Nitrate free period recommended (usually at night) to avoid developing tolerance.