2: Cardiovascular System
Approved: 10 Nov 2010. Last amended: 29 Aug 2024.
On this page
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Positive inotropic drugs
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Diuretics
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Anti-arrhythmic drugs
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Beta-adrenoceptor blocking drugs
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Drugs affecting the renin-angiotensin system and some other antihypertensive drugs
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Nitrates, calcium-channel blockers, and other antianginal drugs
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Sympathomimetics
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Anticoagulants and anticoagulant reversal
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Antiplatelet drugs
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Stable angina, acute coronary syndromes, and fibrinolysis
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Antifibrinolytic drugs and haemostatics
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Lipid-regulating drugs
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Local sclerosants
-
Miscellaneous
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
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)
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
Specific Indication
Bivalirudin
Percutaneous coronary intervention (PCI) NICE TA230
Danaparoid
specialist use for patients with heparin induced platelet deficiency
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
Alternative
Rivaroxaban
Edoxaban
Dabigatran
2.8.2.2 VTE Treatment
Recommended
Apixaban
Rivaroxaban
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
Dabigatran
Rivaroxaban
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: Management of Bleeding in Adult Patients Taking Oral Anticoagulants
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
Tenecteplase (25mg vial)
Fibrinolytic treatment of acute ischaemic stroke: NICE TA990
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
2.12.1 Statins
Recommended
Atorvastatin
Alternative
Simvastatin
Pravastatin
Specific Indication
Rosuvastatin
Rosuvastatin should only be considered in the following circumstances:
- 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).
- 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).
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
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
- Chronic heart failure with reduced ejection fraction NICE TA679
- Chronic heart failure with preserved or mildly reduced ejection fraction NICE TA902
Empagliflozin
- Chronic heart failure with reduced ejection fraction NICE TA773
- Chronic heart failure with preserved or mildly reduced ejection fraction NICE TA929
Mavacamten
Obstructive hypertrophic cardiomyopathy, as per NICE TA913
Tafamidis
Transthyretin amyloidosis with cardiomyopathy, as per NICE TA984
On this page
-
Positive inotropic drugs
-
Diuretics
-
Anti-arrhythmic drugs
-
Beta-adrenoceptor blocking drugs
-
Drugs affecting the renin-angiotensin system and some other antihypertensive drugs
-
Nitrates, calcium-channel blockers, and other antianginal drugs
-
Sympathomimetics
-
Anticoagulants and anticoagulant reversal
-
Antiplatelet drugs
-
Stable angina, acute coronary syndromes, and fibrinolysis
-
Antifibrinolytic drugs and haemostatics
-
Lipid-regulating drugs
-
Local sclerosants
-
Miscellaneous