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BNSSG Adult Joint Formulary

2.7 Myocardial ischaemia

Last edited: 19-04-2024

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 If Inhibitors

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

  • NICE TA267 Ivabradine for treating chronic heart failure


2.7.1 Acute coronary syndromes


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

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.



Recommended: (TLS Green)

Isosorbide mononitrate


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 (UHB)

Isosorbide dinitrate Infusion (TLS Red)


Sympathomimetics (ionotropic)

Dobutamine (TLS Red)


Fibrinolytic Drugs (TLS Red)



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


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


2.7.2 Cardiac arrest

Cardiopulmonary Resuscitation


Sympathomimetics (Vasoconstrictor)


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

  • Intravenous

Isoprenaline (TLS Red)


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