Cardiovascular system - BNF chapter 2

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NHS Dumfries and Galloway

1. Anti Arrhythmics

Class I membrane stabilising drugs

Class II beta blockers

Class III anti-arrhythmic agents

  • Sotalol
  • Amiodarone
  • Dronedarone – for the prevention of recurrence of AF in patients in whom beta-blockers, class 1c drugs or amiodarone are contraindicated, ineffective or not tolerated. ✓ Specialist Initiation Only

Class IV calcium channel blockers (not to be used in patients with LVSD)

  • Diltiazem - MR preparations should be prescribed by brand (Alizem XL®, Zemtard XL® capsules)
    Verapamil (Securon®) ✓ First Choice

Other

Prescribing note:
Refer to the clinical handbook for further info on narrow complex tachycardia

Cardiac glycosides

2. Bleeding disorders

Anti-fibrinolytic drugs and haemostatics

3. Blood clots

3.2 Anticoagulants

Parenteral anticoagulants

Prophylaxis of DVT

Treatment of DVT and/or PE

Unstable angina and non-Q-wave MI

Oral anticoagulants

Prevention of stroke and systemic embolism in patients with valvular AF, treatment of DVT and /or PE

Prevention of stroke and systemic embolism in patients with non-valvular atrial fibrillation, treatment of DVT and /or PE

Prescribing note:
Please contact Haematology for advice on anticoagulant treatment for recurrent DVT/PE

Other – Restricted to use only on advice of Consultant Haematologist in accordance with local protocol

  • Idarucizumab (Praxibind®) injection/infusion ✓ Specialist Initiation Only
  • Andexanet alfa (Ondexxya®) infusion ✓ Specialist Initiation Only

4. Blood pressure conditions

4.1 Hypertension

NICE Patient decision aid - Hypertension
NICE: Hypertension in adults: diagnosis and treatment

Prescribing note:
Please note use calcium channel blocker amlodipine if patient is > 55 years or Afro-Caribbean ethnicity

Angiotensin-converting enzyme inhibitors

Post stroke / prevention of vascular events in at risk patients

Angiotensin-II receptor antagonists

Prescribing note:
In patients who are intolerant of ACE inhibitors (e.g bradykinin cough angioedema), an angiotensin-II receptor antagonist may be considered as an alternative.


Calcium-channel blockers

Prescribing note:
Longer-acting calcium channel blockers generally appear to have fewer adverse effects associated with them (such as flushing, headache, and palpitations), although this is not thought to be the case when considering ankle oedema.

Beta-adrenoceptor blocking drugs

Mineralocorticoid Receptor Antagonist (MRA)

Thiazides

Alpha-adrenoceptor blocking drugs


Prescribing note:
Doxazosin should be used with caution in patients with heart failure or impaired left ventricular function.
It may cause postural hypotension and first dose hypotension. Treatment should be initiated at the lowest dose possible and titrated upwards.

6. Heart Failure

For advice on prescribing in HF (heart failure) please contact the Heart Failure Nurse Specialists (HFNS) directly on dg.hf-referrals@nhs.scot.

Please do not stop any patient’s HF medications indefinitely without discussing with the HFNS first. If stopping for a period, please ensure they are reviewed for restarting when appropriate – the HFNS team can offer guidance with this.

Heart Failure with reduced ejection Fraction (HF-rEF) - LVEF ≤40% 

Prescribe the 4 Pillars of Heart Failure:

  • Entresto: If LVEF ≤40%, titrate up dose every 2–3 weeks (accept a little light-headedness if the patient stands up too quickly). Ensure ACE Inhibitors are stopped 48 hours prior to initiating Entresto.
  • Beta-blocker: Bisoprolol or Carvedilol
  • Mineralocorticoid Receptor Antagonist (MRA): Spironolactone or Eplerenone (use Eplerenone in men to reduce risk of gynecomastia). MRAs can be used if potassium is <5.0 mmol/L. If K+ >5.5 mmol/L, consider Lokelma (Sodium Zirconium Cyclosilicate) 5g daily – discuss with HFNS.
  • SGLT2 inhibitor: Dapagliflozin or Empagliflozin (continue Empagliflozin if already prescribed for diabetes)

Diuretics

If K+ >5.5 mmol/L, consider prescribing Lokelma (Sodium Zirconium Cyclosilicate).

For HF patients with eGFR above 30 ml/min, a rise in creatinine or fall in eGFR by up to 25% is acceptable. If more than this, contact HFNS for advice. The first drug to temporarily stop in mild AKI is the MRA (Eplerenone or Spironolactone).

Heart Failure with mildly reduced Ejection Fraction (HFmrEF) - LVEF 41–49%

Treat the same as HF-rEF using the 4 pillars, but start with ACEi/ARB instead of Entresto.

Heart Failure with preserved Ejection Fraction (HFpEF) - LVEF ≥50–55% with symptoms of HF and raised NTproBNP

SGLT2 inhibitor:

Hypertension treatment:

  • First line: ACEi (e.g. Ramipril)
  • Second line: ARB (e.g. Candesartan)
  • Note: ARB only if ACEi not tolerated (e.g. bradykinin cough or angioedema). No added benefit with Entresto if LVEF >40%.

AF rate control:

Oedema management:

7. Hyperlipidaemia

Please see D&G Coronary Heart Disease and Stroke, Primary and Secondary Prevention Guideline

Primary Prevention

Secondary Prevention

  • Target LDLc <2mmol/L

1st Line: Statins

If statin intolerant, please follow NICE guidelines: NICE Statin Intolerance Pathway

2nd Line:

3rd Line:

  • Bempedoic acid (Nilemdo®) or Bempedoic acid / Ezetimibe (Nustendi®)

Specialist Initiation

  • Evolocumab (Repatha®) ✓ Specialist Initiation Only
  • Alirocumab (Praluent®) – IPTR required ✓ Specialist Initiation Only
  • Inclisiran (Leqvio®) ✓ Specialist Initiation Only

8. Anti-anginals

Nitrates

MR preparations are more cost effective; prescribe generically as MR 25/50mg caps or 40/60mg tabs.

Beta blocker

Ivabradine

  • Ivabradine if in sinus rhythm and heart rate >70 bpm. If patient is in AF, use Beta-blocker (+ digoxin if needed for rate control).

Calcium channel blocker

Nicorandil

  • Nicorandil – may be considered as add-on treatment or if intolerant to standard initial treatment.

If normal LV function, consider:

Acute Coronary Syndrome

See guidance: NICE 185, SIGN 148

  • Dual Antiplatelet therapy (consider PPI for gastro protection)
  • ACEi/ARB
  • Beta-blocker
  • Statin
  • GTN
Prescribing note:
Patients with acute coronary syndrome should receive dual antiplatelet therapy for six months. Longer durations may be used where the risks of atherothrombotic events outweigh the risk of bleeding. Shorter durations may be used where bleeding risk outweighs the benefit.

Antiplatelet

  • Aspirin dispersible 75mg OD
  • Clopidogrel 75mg OD
  • Prasugrel 10mg OD – contraindicated in patients with a history of Stroke/TIA
  • Ticagrelor 90mg BD – no longer being commenced but some existing patients may still be on it
Prescribing note:
If on a DOAC and triple therapy is required, use Aspirin and Clopidogrel due to higher bleeding risk with Prasugrel. If DOAC is ever stopped and the patient has had PCI, restart Aspirin/Clopidogrel lifelong after stopping DOAC.

Sympathomimetics

Fibrinolytics

9. Oedema

Prescribing note:
Combination diuretics are not recommended

Loop diuretics

Thiazide and related diuretics

Aldosterone antagonist

  • Spironolactone – avoid in men where possible due to risk of gynecomastia