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2: Cardiovascular System

Approved: 10 Nov 2010. Last amended: 16 Feb 2024.

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2.1 Positive inotropic drugs

2.1.1 Cardiac glycosides

GHNHSFT DigiFab® guideline

Recommended

  • Digoxin

    • Specific Indication

  • DigiFab®

    reversal of life-threatening digoxin overdose

    • 2.1.2 Phosphodiesterase type-3 inhibitors

  • Enoximone

    for use in DCC and anaesthesia

  • Milrinone

    for use in DCC and anaesthesia

    • 2.2 Diuretics

    2.2.1 Thiazides and related diuretics

    Recommended

  • Indapamide (standard release)

    first line thiazide for hypertension

    • Alternative

  • Bendroflumethiazide

    2.5mg daily produces a near maximal blood pressure lowering effect, with very little biochemical disturbance.

    • Specific Indication

  • Chlortalidone

    Benign intracranial hypertension

  • Metolazone

    Severe heart failure and diuretic resistance – it is significantly more potent than bendroflumethiazide and will cause profound diuresis in combination with loop diuretics. Careful monitoring is required to avoid electrolyte disturbance and dehydration. Sometimes prescribed as a twice or three times weekly dose.

    • 2.2.2 Loop Diuretics

    Recommended

  • Furosemide

    • Specific Indication

  • Bumetanide

    when furosemide not tolerated or ineffective

    • 2.2.3 Potassium-sparing diuretics and aldosterone antagonists

    Recommended

  • Amiloride

    a weak diuretic, but is useful for potassium conservation and the most appropriate alternative to potassium supplements.

  • Spironolactone

    • Heart Failure
    • Oedema in liver cirrhosis
    • Conn’s Syndrome

    Spironolactone 25mg tablets are not scored. Ensure that patients have access to a tablet cutter if lower doses (e.g. 12.5mg) are required at home

  • Eplerenone

    Intolerance / adverse effects with spironolactone (heart failure patients only)

  • Finerenone

    Chronic kidney disease in type 2 diabetes NICE TA877

    Shared Care Guideline

    • 2.2.4 Osmotic Diuretics

  • Mannitol Infusion 20%

    • 2.2.5 Mercurial diuretics

    None

    2.2.6 Carbonic anhydrase inhibitors

  • Acetazolamide 250mg tablets

    • Benign intracranial hypertension

    For use of acetazolamide in:

    • ophthalmology see section 11.6
    • epilepsy see section 4.8.1

    • 2.2.7 Diuretics with potassium

    None. Most patients on diuretics do not require potassium supplements. The amount of potassium in combined preparations (e.g. Burinex K®) is insufficient for those patients requiring supplementation, therefore the use of these products is discouraged. Potassium sparing diuretics are more effective for maintaining potassium levels.

    2.3 Anti-arrhythmic drugs

  • Digoxin
  • Verapamil
  • Disopyramide
  • Flecainide

    avoid if history of MI / heart failure / structural heart disease.

  • Propafenone
  • Sotalol

    can prolong QT interval, ECG required following dose change

  • Amiodarone

    GHNHSFT Local Guidelines – Amiodarone Policy

    Amiodarone Shared Care Guideline

  • Adenosine
  • Dronedarone

    As per NICE TA197

  • Lidocaine

    injection

  • Magnesium sulphate injection

    for documented long QT related ventricular arrhythmias (beware of risk of significant sinus node suppression, particularly when used with other antiarrhythmics such as amiodarone)

    • 2.4 Beta-adrenoceptor blocking drugs

  • Atenolol
  • Bisoprolol
  • Carvedilol

    Heart failure only

  • Labetalol

    • pregnancy
    • aortic dissection
    • anaesthesia

  • Metoprolol

    short-acting agent to establish if patient can tolerate beta blocker, and long term use in renal impairment

  • Propranolol

    • anxiety
    • portal hypertension
    • thyrotoxicosis

  • Esmolol

    • 2.5 Drugs affecting the renin-angiotensin system and some other antihypertensive drugs

    2.5.1 Vasodilator antihypertensive drugs

    Specific Indication

  • Hydralazine

    4th line adjunct

  • Minoxidil

    4th line adjunct

    • 2.5.2 Centrally acting antihypertensive drugs

    Specific Indication

  • Moxonidine

    4th line adjunct

  • Methyldopa

    • 4th line adjunct
    • 2nd line antihypertensive in pregnancy

    • 2.5.3 Adrenergic neurone blocking drugs

    None

    2.5.4 Alpha-adrenoceptor blocking drugs

    Hypertension

    Doxazosin or prazosin may be useful for treatment of hypertension in patients with benign prostatic hyperplasia.

    Recommended

  • Doxazosin

    4th line adjunct. A standard release product is preferred because the modified release preparation offers no pharmacokinetic benefit and is significantly more expensive.

    • Alternative

  • Prazosin

    4th line adjunct

    • Specific Indication

  • Phentolamine

    anaesthesia and management of phaeochromocytoma

  • Phenoxybenzamine

    management of phaeochromocytoma

    • 2.5.5 Drugs affecting the renin-angiotensin system

    2.5.5.1 Angiotensin-converting enzyme inhibitors

  • Enalapril
  • Lisinopril
  • Perindopril

    2mg, 4mg, 8mg

  • Ramipril

    • 2.5.5.2 Angiotensin-II receptor antagonists

  • Candesartan
  • Losartan
  • Valsartan

    • 2.5.5.3 Angiotensin-II receptor antagonist with neprilysin inhibitor

    Specific Indication

  • Entresto® (valsartan / sacubitril)

    NICE TA388
    Shared Care Guideline

    • 2.5.5.4 Renin inhibitors

  • Aliskiren

    4th line adjunct; for the treatment of resistant essential hypertension

    Aliskiren should not be prescribed in combination with an ACE inhibitor or ARB MHRA Drug Safety Advice

    • 2.6 Nitrates, calcium-channel blockers, and other antianginal drugs

    2.6.1 Nitrates

    Recommended

  • Isosorbide Mononitrate

    Standard release: asymmetrical dosing: (e.g. 0800 and 1400 for day-time angina; 1800 and 2200 for night-time angina).

    Modified release: more expensive - reserve for when standard release unsuitable

  • Glyceryl Trinitrate 400microgram

    Sublingual spray

    • Alternative

  • Glyceryl Trinitrate 500microgram

    tablets

  • Glyceryl Trinitrate 300microgram

    tablets (for patients unable to tolerate standard doses)

  • Glyceryl Trinitrate

    Patches – Distal to TPN infusion site (unlicensed)

  • Glyceryl Trinitrate

    Infusion – GTN infusion prescription chart

    • 2.6.2 Calcium-channel blockers

    2.6.2.1 Dihydropyridines

    Recommended

  • Amlodipine

    • Alternative

  • Lercanidipine

    • Specific Indication

  • Nifedipine capsules (non-m/r)

    Raynaud’s Phenomenon

  • Nifedipine capsules (non-m/r)

    Rapid control of blood pressure (e.g. DCC or cardiac catheter laboratory)

  • Nimodipine

    Subarachnoid haemorrhage only

    • 2.6.2.2 Non-dihydropyridines (not to be used concomitantly with beta blockers)

  • Diltiazem

    Modified Release (M/R) diltiazem preparations must be prescribed by brand name to avoid confusion.

  • Verapamil

    • 2.6.3 Other antianginal drugs

    Recommended

  • Nicorandil

    reserved for second or third line treatment as an adjunct.

    • Specific Indication

  • Ivabradine

    • stable angina in patients with intolerance or contraindications to beta blockers and where diltiazem / verapamil is not appropriate
    • chronic heart failure as per NICE TA267
    • MHRA Safety Warning: Risk of cardiac side effects

  • Ranolazine

    Cardiologist initiation only. Add-on treatment for angina where heart rate or blood pressure prevents up-titration of other agents. Shared Care Guideline

    • 2.6.4 Peripheral vasodilators and related drugs

    Specific Indication

  • Naftidrofuryl

    Peripheral arterial disease as per NICE TA223

    • 2.7 Sympathomimetics

    2.7.1 Inotropic sympathomimetics

  • Adrenaline

    • 1 in 1000
    • 1 in 10,000

  • Dobutamine
  • Dopamine
  • Dopexamine
  • Ephedrine
  • Isoprenaline
  • Noradrenaline

    • Specific Indication

  • Levosimendan

    Acute decompensated heart failure (unlicensed) - DCC consultant use only

    • 2.7.2 Vasoconstrictor sympathomimetics

  • Adrenaline

    • 1 in 1000
    • 1 in 10,000

  • Ephedrine
  • Metaraminol
  • Midodrine (Bramox®)

    second-line treatment of severe orthostatic hypotension due to autonomic dysfunction, as per Shared Care Guideline

  • Noradrenaline
  • Phenylephrine

    • 2.7.3 Cardiopulmonary resuscitation

  • Adrenaline

    1 in 10,000

  • Atropine
  • Amiodarone

    injection

    • 2.8 Anticoagulants and anticoagulant reversal

    2.8.1 Parenteral Anticoagulants

    GHNHSFT Local Guidelines – Fondaparinux for Acute Coronary Syndrome

    Recommended

  • Dalteparin

    for treatment and prophylaxis of venous thromboembolism

  • Fondaparinux

    Acute Coronary Syndrome

  • Heparin

    Unfractionated heparin infusion chart

    • Specific Indication

  • Bivalirudin

    Percutaneous coronary intervention (PCI) NICE TA230

  • Danaparoid

    specialist use for patients with heparin induced platelet deficiency

  • Enoxaparin

    Prophylaxis and Treatment of Venous Thromboembolism (VTE) in Patients with Renal Impairment

  • Epoprostenol

    renal dialysis

    • 2.8.2 Direct Oral Anticoagulants (DOACs)

    Gloucestershire Guideline - Choice of DOAC for Non-Valvular Atrial Fibrillation

    2.8.2.1 Non-valvular Atrial Fibrillation (NVAF)

    Recommended

  • Apixaban

    NICE TA275

    • Alternative

  • Rivaroxaban

    NICE TA256

  • Edoxaban

    NICE TA355

  • Dabigatran

    NICE TA249

    • 2.8.2.2 VTE Treatment

    Recommended

  • Apixaban

    NICE TA341

  • Rivaroxaban

    NICE TA287

    • Alternative

  • Dabigatran

    NICE TA327 (NB parenteral anticoagulant treatment is required for 5 days prior to starting dabigatran for this indication)

  • Edoxaban

    NICE TA354 (NB parenteral anticoagulant treatment is required for 5 days prior to starting dabigatran for this indication)

    • 2.8.2.3 VTE prophylaxis post knee or hip replacement surgery

  • Apixaban

    NICE TA245

  • Dabigatran

    NICE TA157

  • Rivaroxaban

    NICE TA170

    • 2.8.2.4 Other Indications

  • Rivaroxaban

    Prevention of atherothrombotic events in CAD and PAD patients NICE TA607

  • Rivaroxaban

    ACS treatment. Cardiologist initiation only NICE TA335

    • 2.8.3 Vitamin K Antagonists (Coumarins)

    GHNHSFT Local Guidelines – Warfarin Initiation (intranet)

    GHNHSFT Local Guidelines – Warfarin bridging protocol (perioperative)

    Recommended

  • Warfarin

    • Alternative

  • Phenindione

    Warfarin intolerance where other oral anticoagulants are unsuitable (e.g. mechanical heart valve)

    • 2.8.4 Anticoagulant reversal

    GHNHSFT Treatment Guideline: Direct Oral Anticoagulant (DOAC) Reversal

  • Protamine

    Heparin reversal

  • Andexanet alfa

    Reversal of apixaban or rivaroxaban in adults with life-threatening or uncontrolled G.I. bleeding, as per NICE TA697

  • Idarucizumab

    Reversal of dabigatran in adults with life-threatening bleeding

    • 2.9 Antiplatelet drugs

  • Aspirin
  • Clopidogrel

    • True aspirin hypersensitivity (use aspirin plus PPI for aspirin-induced gastric symptoms)
    • Myocardial Infarction
    • Percutaneous coronary intervention (PCI)
    • Secondary prevention of Stroke / TIA (unlicensed)
    • Prevention of occlusive vascular events: NICE TA210

    • GHNHSFT Local guideline – Acute Coronary Syndrome (ACS)

    Gloucestershire guideline – Antiplatelets

    GHNHSFT Local guideline – Clopidogrel / PPI interaction

  • Dipyridamole MR with aspirin

    Secondary prevention of Stroke / TIA in patients who cannot take clopidogrel Local Guideline NICE TA210

  • Dipyridamole MR

    Secondary prevention of Stroke / TIA in patients who cannot take clopidogrel or aspirin Local Guideline NICE TA210

  • Prasugrel

    Cardiologist initiation only: NICE TA317

    • GHNHSFT Local Protocol – Prasugrel

  • Ticagrelor

    Cardiologist initiation / advice only: NICE TA236, NICE TA420

    • GHNHSFT Local Protocol – Ticagrelor

  • Cangrelor

    Primary PCI where oral route is unavailable

    • 2.9.1 Glycoprotein IIb/IIIa Inhibitors

    GHNHSFT Local Protocol – Tirofiban

  • Tirofiban

    Acute coronary syndrome: NICE TA47

    • 2.10 Stable angina, acute coronary syndromes, and fibrinolysis

    2.10.1 Fibrinolytic drugs

    Primay PCI is now the first-line treatment for acute STEMI

    GHNHSFT Local Guideline: Massive pulmonary embolism (intranet)

  • Alteplase

    • Fibrinolytic treatment of acute ischaemic stroke NICE TA264
    • Massive pulmonary embolism
    • Thrombolysis of ST Elevation Myocardial Infarction where primary PCI unsuitable NICE TA52

    • 2.11 Antifibrinolytic drugs and haemostatics

  • Tranexamic Acid
  • Aprotinin

    management of life-threatening thrombolytic-induced haemorrhage

    • 2.12 Lipid-regulating drugs

    GHNHSFT Local Guideline: Statin Guidelines

    Gloucestershire Secondary Prevention Lipid Management Pathway

    2.12.1 Statins

    Recommended

  • Atorvastatin

    • Alternative

  • Simvastatin
  • Pravastatin

    • Specific Indication

  • Rosuvastatin

    Rosuvastatin should only be considered in the following circumstances:

    1. Patients taking potent CYP3A4 inhibitors (see page 6) for whom pravastatin is not a clinically appropriate alternative (when total cholesterol >7.5mmol/L; LDL >4.5mmol/L).
    2. Patients who require a high-intensity statin who:

    • are intolerant to atorvastatin, or
    • have demonstrated an inadequate response to the maximum tolerated dose of atorvastatin, or
    • have undesirably low HDL (<1mmol/L in men; <1.2mmol/L in women); If HDL< 0.5mmol/L please refer to Lipid Clinic).

    • 2.12.2 Fibrates

    Recommended

  • Fenofibrate

    • Alternative

  • Bezafibrate

    • 2.12.3 Anion-exchange resins

  • Colestyramine

    • 2.12.4 Other

  • Ezetimibe

    Ezetimibe should only be considered in the following circumstances:

    1. Monotherapy in patients who have demonstrated intolerance to at least 3 different statins (including pravastatin & rosuvastatin); or because of contraindications to all initial statins.

    2. In combination with an initial statin only when an inadequate response to maximum tolerated doses of statin monotherapy (avoid simvastatin 80mg) has been demonstrated.

    When decision has been made to treat with ezetimibe co-administered with a statin, ezetimibe should be prescribed on the basis of lowest acquisition cost (i.e. avoid proprietary combination preparations).

    NICE TA385

    • Specific Indication

  • Bempedoic acid

    In combination with ezetimibe where statins are contraindicated or not tolerated and ezetimibe monotherapy is inadequate: NICE TA694

  • Icosapent Ethyl

    For reducing the risk of cardiovascular events in people with raised triglycerides, as per NICE TA805

  • Inclisiran

    Primary hypercholesterolaemia (heterozygous familial and non-familial) or mixed dyslipidaemia if:

    • History of cardiovascular disease, and
    • LDL-C persistently 2.6 mmol/l or more, despite maximum tolerated lipid-lowering therapy

    As per NICE TA733

    Inclisiran information

  • Volanesorsen

    Familial chylomicronaemia syndrome, as per NICE HST13

    • 2.12.5 Omega-3 fatty acid compounds

  • None

    (exceptional use for resistant hypertriglyceridaemia and only under the recommendation of a specialist)

    • 2.12.6 PCSK9 Inhibitors

  • Alirocumab

    Primary hypercholesterolaemia and mixed dyslipidaemia, as per NICE TA393

  • Evolocumab

    Primary hypercholesterolaemia and mixed dyslipidaemia, as per NICE TA394

    • 2.13 Local sclerosants

  • Ethanolamine Oleate
  • Sodium Tetradecyl Sulphate

    • 2.14 Miscellaneous

  • Dapagliflozin
  • Empagliflozin
  • Mavacamten

    Obstructive hypertrophic cardiomyopathy, as per NICE TA913

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    Key

    Hospital / Specialist only

    Specialist initiated / advised (with Shared Care Guideline)

    Specialist initiated / advised (without Shared Care Guideline)

    Non-specialist or Specialist

    Treatment Guidelines

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