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

Antiplatelet drugs

Antiplatelet guidance is under review and will be updated in due course to reflect the new GGC Acute Chest Pain Pathway.

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.

 

Guideline reviewed: November 2023

Page updated: November 2023