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2.7 Myocardial ischaemia

First line drugs Second line drugs Specialist drugs Secondary care drugs

Traffic light status (TLS) explained:

  • Green: Routine prescribing within licensed indication
  • Amber 1: specialist recommendation followed by GP initiation and continuation
  • Amber 2: specialist or GP initiation in line with local guideline after 1st line failure followed by GP continuation
  • Amber 3: specialist initiation and stabilisation followed by GP continuation
  • Amber SCG: specialist initiation and stabilisation followed by GP continuation in line with an agreed shared care guideline
  • Red: Hospital or specialist prescribing only

 

 

Glycoprotein IIB/IIA Inhibitors

Tirofiban

  • Concentrate for intravenous infusion, 250mcg/mL; 50mL (12.5mg) vial  

 

Piperazine Derivatives

Ranolazine (Amber 2)

  • Tablets 375mg, 500mg, 750mg

 

Potassium-Channel openers

Nicorandil 

  • Tablets 10mg, 20mg

Notes:

  • Nicorandil has similar efficacy to other antianginal drugs in controlling symptoms but there is little evidence about its efficacy in combination with other antianginal drugs. However, when added to maximal therapy with other antianginal drugs in refractory unstable angina (unlicensed indication) it may produce additional benefit.
  • We recommend that nicorandil should only be prescribed on the advice of a specialist or by someone with a specialist interest.

 

Selective sinus Node If inhibitors

Ivabradine (Amber 2)

  • Tablets 5mg, 7.5mg 

 

Notes: 

  • For Consultant initiation only

 

  • Treatment of coronary artery disease: Ivabradine is to be used only in patients with chronic stable angina pectoris with normal sinus rhythm, who have a contraindication or intolerance for beta-blockers. This intolerance must be shown before Ivabradine is considered. 

 

 

  • Treatment with ivabradine should be started by a specialist. But after that either a GP with a special interest in heart failure or a heart failure specialist nurse can adjust the dose and monitor the patients condition. 

 

  • Unlicensed Use - For Hospital Cardiology Specialist Precribing Only: As pre-treatment for optimising heart rate prior to CT coronary angiography (unlicensed indication)

 

 

2.7.1 Acute coronary syndromes

Antiplatelets

 

Prasugrel

  • Tablets 5mg, 10mg

 

Notes:

 

 

Ticagrelor (Amber 1)

  • Tablets film-coated 60mg, 90mg

Notes:

 

 

  • Specialist recommendation as per local guideline available on the hospital intranet

 

Nitrates

Glyceryl trinitrate

  • Tablets, sublingual 300 micgrograms, 500 micrograms, 600 micrograms
  • Spray 400 micrograms
  • Patches 5mg/24 hours, 10mg/24hours (Amber 1)
  • Ointment 2% (Amber 2)
  • Buccal modified release tablets 2mg, 3mg, 5mg (Hospital only)
  • Injection 5mg in 5ml, 50mg in 10ml, 25mg in 5mL (Hospital only)

 

 

Isosorbide dinitrate

  • Tablets 10mg, 20mg
  • Tablets modified release, 20mg, 40mg
  • Injection 0.1% = 1mg/mL (10mL amp) 

Notes:

  • Nitrate free periods can be achieved by prescribing ordinary release nitrates twice a day, first thing in the morning and mid afternoon.

 

Isosorbide mononitrate

  • Tablets 10mg, 20mg, 40mg
  • Tablets modified release 60mg (tablets can be halved) 

 

 

 

Sympathomimetics (ionotropic)

Dobutamine

  • Injection 12.5mg per 1ml (250mg in 20mL)
  • Injection 5mg per 1ml (250mg in 50mL)

 

Fibrinolytic drugs 

 

Alteplase (rt-PA, tissue-type plasminogen activator)

  • Injection 20mg, 50mg vial 

Note:

 

Streptokinase

  • Injection, powder for reconstitution 250 000-unit vial
    • Injection, powder for reconstitution 1.5 million-unit vial (hospital only)

 

Tenecteplase

  • Injection, powder for reconstitution 40mg (8000-units), 50mg (10000-units) vial  

 

 

 

2.7.2 Cardiac arrest 

Cardiopulmonary resuscitation

Sympathomimetics (Vasoconstrictor) 

Adrenaline / Epinephrine

  • Injection 1 in 10 000 (100mcg/mL), 10mL amp - To be diluted

 

Anaphylaxis

Adrenaline / Epinephrine 

  • Injection 1 in 1000;        1mL amp;           IM or SC              (1mg/mL)
  • Injection 1 in 10,000;     10mL amp;          IV use                (100mcg/mL)
  • Minijet 1 in 1000;           1mL IM, 1mL SC disposable syringe  (1mg/mL)
  • Minijet 1 in 10,000;        10mL IV disposable syringe             (100mcg/mL) 

(Subcutaneous injection not generally recommended). 

Dose of intramuscular injection of adrenaline (epinephrine) for the emergency treatment of anaphylaxis by healthcare professionals

Age

Dose

Volume of adrenaline 

1 in 1000 (1mg/mL)

Child under 6 years

150 microgram

0.15mL

6-12 years

300 microgram

0.3mL

Adult & and child 12-18 years

500 microgram

0.5mL

 

 

 

Self-administration of adrenaline (epinephrine)

 

Summary 

People who have been prescribed an adrenaline auto-injector because of the risk of anaphylaxis should carry two with them at all times for emergency, on-the-spot use. After every use of an adrenaline auto-injector, an ambulance should be called (even if symptoms are improving), the individual should lie down with their legs raised and, if at all possible, should not be left alone. 

 

Drug safety update: Adrenaline auto-injector advice for patients, May 2014 

 

Emerade®

  •  150 micrograms solution for injection in pre-filled pen 
  •  300 micrograms solution for injection in pre-filled pen 
  •  500 micrograms solution for injection in pre-filled pen  

 

Epipen®  

  • Auto-injector 300 microgram dose
  • Junior Auto-injector 150 microgram dose

Note: 

  • It is advisable to prescribe adrenaline auto-injector by brand (Epipen) to avoid confusion, as two brands are now available. 

 

 

 

Anapen® 

  • Auto-injector 500 microgram dose

 

 

 

Miscellaneous

Acute and Recurrent Pericarditis

Colchicine (Unlicensed)

  • 500 microgram tablets

Notes:

  • Colchicine does not currently have a licence to be used to treat pericarditis in the UK. However, studies have shown that colchicine can be effective in treating pericarditis.
  • Colchicine is recommended on top of standard anti-inflammatory therapy, without a loading dose and using weight adjusted doses (500 micrograms daily if body weight is less than 70kg, or 500 micrograms twice daily if body weight is equal or greater than 70kg, for at least 6 months)

 

 

 

 

 

 

Traffic light status (TLS) explained:

  • Green: Routine prescribing within licensed indication
  • Amber 1: specialist recommendation followed by GP initiation and continuation
  • Amber 2: specialist or GP initiation in line with local guideline after 1st line failure followed by GP continuation
  • Amber 3: specialist initiation and stabilisation followed by GP continuation
  • Amber SCG: specialist initiation and stabilisation followed by GP continuation in line with an agreed shared care guideline
  • Red: Hospital or specialist prescribing only 

 

Return to Chapter: 2. Cardiovascular system

Last updated by: Dupe Fagbenro on 20-02-2019 11:33