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BNSSG Adult Joint Formulary

2.7 Myocardial ischaemia

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Last edited: 28-08-2024

First line drugs

Second line drugs

Specialist drugs

Secondary care drugs

Glycoprotein IIB/IIA Inhibitors

Tirofiban (TLS Red)

Acute coronary syndrome
Tirofiban may only be prescribed according to chest pain protocols.

Piperazine Derivatives

Ranolazine (TLS Amber 1 month) (SCP click here)

Potassium-channel Openers

Nicorandil (TLS Green)

Nicorandil is reserved for second or third line treatment as an adjunct.

Selective Sinus Node I_f Inhibitors

Ivabradine (TLS Amber 3 months) (SCP click here)

2.7.1 Acute coronary syndromes

Antiplatelets

Prasugrel (TLS Amber 1 month) (SCP click here)

In accordance with NICE TA317

Ticagrelor (TLS Amber 1 month) (SCP click here)

NICE TA236 In combination with aspirin for the prevention of atherothrombotic events
NICE TA420 Ticagrelor for preventing atherothrombotic events after myocardial infarction

Cangrelor (TLS Red)

In combination with aspirin, for the reduction of thrombotic cardiovascular events in patients with coronary artery disease undergoing percutaneous coronary intervention (PCI) who have not received treatment with oral clopidogrel, prasugrel or ticagrelor prior to the procedure and in whom oral therapy with these drugs is not suitable. For those patients who have suffered an out of hospital arrest.

Nitrates

Recommended: (TLS Green)

Isosorbide mononitrate

Tolerance:

Many patients on long-acting or transdermal nitrates rapidly develop tolerance (with reduced therapeutic effects). Reduction of blood-nitrate concentrations to low levels for 4 to 12 hours each day usually maintains effectiveness in such patients. If tolerance is suspected during the use of transdermal patches they should be left off for 8–12 hours (usually overnight) in each 24 hours; in the case of modified-release tablets of isosorbide dinitrate (and conventional formulations of isosorbide mononitrate), the second of the two daily doses should be given after about 8 hours rather than after 12 hours. Conventional formulations of isosorbide mononitrate should not usually be given more than twice daily unless small doses are used; modified-release formulations of isosorbide mononitrate should only be given once daily, and used in this way do not produce tolerance.

Isosorbide mononitrate modified-release

Isosorbide mononitrate modified-release preparations should only be prescribed once a day to prevent tolerance developing.

Glyceryl trinitrate

500microgram tablets
400microgram spray
5mg and 10mg patches - when nil by mouth
Intravenous infusion

Isosorbide dinitrate Infusion (TLS Red)

Sympathomimetics (ionotropic)

Dobutamine (TLS Red)

Fibrinolytic Drugs (TLS Red)

Tenecteplase

Streptokinase

Alteplase (For all indications except acute MI)

For Stroke (acute, ischaemic) see NICE TA264 guidance.
Treatment of acute ischaemic stroke: A physician trained and experienced in neurological care who has undergone specific stroke thrombolysis training, must directly supervise the administration of alteplase
Refer to local protocols for details of recommendations.

Actilyse Cathflo

For use in blocked haemodialysis catheters

Acetylcholine

For assessment of microvascular angina, restricted to Bristol Heart Institute only

2.7.2 Cardiac arrest

Cardiopulmonary Resuscitation

Sympathomimetics (Vasoconstrictor)

Recommended:

Adrenaline (epinephrine) 1 in 10,000 (100micrograms/mL) (TLS Green)

Intravenous

Isoprenaline (TLS Red)

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