Chapter 2 Cardiovascular system by dfhrf555fcg


Chapter 2 Cardiovascular system

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									                     Chapter 2: Cardiovascular system
                         The NBT Formulary does not apply to paediatrics.

2.1   Positive inotropic drugs
2.1.1 Cardiac glycosides
      Recommended:       Digoxin

      Digoxin-specific antibody
      Specific indication: Digibind - reversal of life-threatening Digoxin overdose

2.1.2 Phosphodiesterase inhibitors
      Specific indication: Enoximone

2.2   Diuretics
2.2.1 Thiazides and related diuretics
      Recommended:        Bendroflumethiazide

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

      Specific indication: Indapamide 2.5mg tablets – as per PROGRESS study
                           Indapamide 1.5mg m/r tablets – Stroke Physicians
                           Chlortalidone – Benign intracranial hypertension
                           Metolazone – for use in combination with a loop diuretic

             Metolazone is significantly more potent than Bendroflumethiazide and will
              cause profound diuresis in combination with Furosemide. Careful monitoring is
              required to avoid electrolyte disturbance and dehydration.

2.2.2 Loop Diuretics
      Recommended:          Furosemide

      Alternative:          Bumetanide

             Bumetanide is significantly more expensive than Furosemide in primary care.
             If an IV loop diuretic is required, Furosemide is recommended.

2.2.3 Potassium-sparing diuretics and aldosterone antagonists
      Recommended:       Amiloride
          Amiloride is a weak diuretic, but is useful for potassium conservation and is the
               most appropriate alternative to potassium supplements.

      Specific indications: Spironolactone - Heart Failure
                                           - Oedema in liver cirrhosis
                                           - Conn’s Syndrome
                            Eplerenone – adjunct in left ventricular dysfunction and heart
                                          failure following MI (start therapy within 3 to 14
                                          days of event) only for patients intolerant of
                                 Next revised edition: July 2007
             Potassium supplements should be avoided with potassium-sparing diuretics.
             Use of potassium-sparing diuretics with ACE inhibitors may provoke severe
             Please refer to the BNF for dosage information of spironolactone in the various

2.2.4 Potassium-sparing diuretics with other diuretics

             Potassium-sparing diuretics are not usually necessary in the routine treatment
              of hypertension, unless hypokalaemia develops.

      Recommended:          Co-amilofruse

2.2.5 Osmotic Diuretics
      Recommended:          Mannitol Infusion 20%

2.2.6 Mercurial diuretics

2.2.7 Carbonic anhydrase inhibitors
      Specific indication: Acetazolamide 250mg tablets - Benign intracranial hypertension

      For use of acetazolamide: in ophthalmology see 11.6
                                in epilepsy see 4.8.1

2.2.8 Diuretics with potassium

             Most patients on diuretics do not require potassium supplements. The amount
              of potassium in combined preparations is insufficient for those patients
              requiring supplementation, therefore their use is discouraged. Potassium
              sparing diuretics are more effective than using potassium supplements in
              maintaining potassium levels.

2.3   Anti-arrhythmic drugs
             Caution when first prescribing

      Recommended:          Adenosine
                            Amiodarone – monitor liver function and thyroid function tests
                                             before treatment and then every 6 months
                            Magnesium sulphate – see
                            Sotalol – ECG to be performed 1 week after initiating treatment

                                Next revised edition: July 2007
2.4   Beta-adrenoceptor blocking drugs
      Recommended:         Atenolol

      Alternative:         Bisoprolol

      Specific indications: Carvedilol - Heart failure only
                            Metoprolol – Renal patients only
                            Nadolol – Portal hypertension
                            Propranolol - anxiety, portal hypertension and thyrotoxicosis

            Bisoprolol and carvedilol are the only beta-blockers licensed for use in heart
             failure. For this indication use should be initiated cautiously, titrated very slowly
             and adequately monitored.
            Oral labetalol is restricted to use in pregnancy and breastfeeding only.

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

2.5.1 Vasodilator antihypertensive drugs
          For use as an adjunct, or where other treatments have failed.

      Recommended:         Hydralazine
      Alternative:         Minoxidil
      Specific indication: Diazoxide – hypertensive crisis
                           Sodium nitroprusside – hypertensive crisis

2.5.2 Centrally acting antihypertensive drugs
      Specific indications: Methyldopa – hypertension in pregnancy
                                       - treatment resistant cases

2.5.3 Adrenergic neurone blocking drugs

2.5.4 Alpha-adrenoceptor blocking drugs

      Recommended:      Doxazosin
         Not including Doxazosin m/r preparation.

      Alternative:         Prazosin
           Doxazosin and prazosin may be useful for treatment of hypertension in
             patients with benign prostatic hyperplasia.

      Specific indication: Phentolamine – management of phaeochromocytoma
                           Phenoxybenzamine – management of phaeochromocytoma

                                Next revised edition: July 2007
       Benign Prostatic Hyperplasia – see section 7.4.1

2.5.5 Drugs affecting the renin-angiotensin system Angiotensin-converting enzyme inhibitors
           Concomitant use with potassium-sparing diuretics (or supplements) increases
             the risk of hyperkalaemia and with NSAIDs increases the risk of functional
             renal impairment.

       Hypertension and Ischaemic Heart Disease
       Recommended:        Lisinopril
           Lisinopril and ramipril are the most cost-effective choices in primary care and
             are therefore the preferred choices.

       Recommended:        Perindopril
                           Ramipril Angiotensin-II receptor antagonists
           Indication is intolerance to ACE inhibitors

       Specific indication: Telmisartan - hypertension
                            Candesartan - congestive cardiac failure
                            Irbesartan - treatment of renal disease in type 2 diabetics
                            Valsartan – congestive cardiac failure post-MI

2.5.6 Ganglion-blocking drugs

2.5.7 Tyrosine hydroxylase inhibitors

2.6    Nitrates, calcium-channel blockers, and potassium-channel
2.6.1 Nitrates
      Recommended:           Isosorbide Mononitrate – asymmetrical dosing
                             Isosorbide Mononitrate m/r 60mg tablets
                             Glyceryl Trinitrate 500microgram tablets
                                                400microgram spray
                                                5mg and 10mg patches – when nil by mouth
                             Isosorbide Dinitrate Infusion
      Isosorbide mononitrate m/r tablets are significantly more expensive than normal
       release tablets in the community.
      Isosorbide mononitrate m/r preparations should only be prescribed once a day to
       prevent tolerance developing.

                                Next revised edition: July 2007
2.6.2 Calcium channel blockers
          Diltiazem m/r doses greater than 60mg and nifedipine m/r preparations must
            be prescribed by brand name to avoid confusion.
          Patients admitted on an alternative brand to those shown will be maintained on
            their usual brand unless clinically appropriate to change brands.

      Dihydropyridines     Amlodipine – new patients
                           Felodipine m/r – established patients

                             Nifedipine m/r
         If a nifedipine m/r once daily preparation is required Coracten XL  is the preferred
          choice as it is significantly less expensive than Adalat LA in primary care.
          Adalat LA is reserved for established patients only.

      Non-dihydropyridines: Diltiazem m/r – Slozem
                           Verapamil m/r

      Specific indications: Nimodipine – subarachnoid haemorrhage only
                            Nifedipine capsules (non-m/r) – Raynaud’s Phenomenon/ ITU

2.6.3 Potassium-channel activators
      Recommended:        Nicorandil
       Nicorandil is reserved for second or third line treatment as an adjunct.

2.6.4 Peripheral and cerebral vasodilators
      Recommended:        Nifedipine – see 2.6.2

2.7   Sympathomimetics
2.7.1 Inotropic sympathomimetics
      Recommended:       Adrenaline (epinephrine) 1 in 1000 and 1 in 10,000
                         Noradrenaline (norepinephrine)

2.7.2 Vasoconstrictor sympathomimetics
      Recommended:       Adrenaline (epinephrine) 1 in 1000 and 1 in 10,000
                         Noradrenaline (norepinephrine)

2.7.3 Cardiopulmonary resuscitation
      Recommended:      Adrenaline (epinephrine) 1 in 10,000
                        Atropine (see section 15.1.3)

                                Next revised edition: July 2007
2.8   Anticoagulants and protamine
2.8.1 Parenteral Anticoagulants {Traffic light system (TLS) category = amber}
      Recommended:       Heparin Sodium
                         Dalteparin (Restricted to Obstetrics)

      Specific indications: Lepirudin – specialist use

2.8.2 Oral Anticoagulants
      Recommended:        Warfarin

      Specific indications: Phenindione - specialist use

2.8.3 Protamine sulphate
       Recommended:      Protamine

2.9   Antiplatelet drugs
      Recommended:         Aspirin

      Specific indications: Dipyridamole m/r in combination with aspirin preferably as
                                   Asasantin Retard – as per Stroke protocol

                           Dipyridamole – adjunct to oral anticoagulation in patients with
                                         prosthetic heart valves and to prevent access
                                         clotting in haemodialysis patients Appendix 2.

                           Clopidogrel - aspirin hypersensitivity / contraindication

                                        - non-ST-segment-elevation acute coronary
                                              syndrome (ACS) 6 months only

                                         - post-angioplasty or stent insertion – 1 month only

                                         - post drug-eluting stent insertion – 12 months only

         Please ensure that it is clearly stated in the patient’s notes and on the TTA the
          indication for using clopidogrel.
         NICE have recommended for stroke patients that Clopidogrel is only used (within
          its licensed indications) in patients who are intolerant of low dose aspirin. NICE
          clarifies intolerance to aspirin as: proven hypersensitivity to aspirin-containing
          medicines or a history of severe dyspepsia induced by low dose aspirin.
         Clopidogrel imposes a significant financial burden on primary care and use should
          be kept to a minimum within the above indications.

                          Tirofiban – acute coronary syndrome
         Tirofiban may only be prescribed according to the NBT chest pain protocol.

                           Abciximab – as an adjunct to percutaneous coronary intervention

                                Next revised edition: July 2007
2.10 Myocardial infarction and fibrinolysis
2.10.2 Fibrinolytic drugs
       Recommended:          Streptokinase
                             Tenecteplase (TLS = red)
                             Alteplase (not for acute MI)

              Refer to local protocols for details of recommendations.
              In the treatment of acute ischaemic stroke, a physician trained and
               experienced in neurological care who has undergone BASP thrombolysis
               training, must directly supervise the administration of alteplase.

2.11 Antifibrinolytic drugs and haemostatics
       Recommended:          Tranexamic Acid

       Specific indications: Aprotinin
                             Drotrecogin alfa (activated) – severe sepsis as per NICE

2.12 Lipid-regulating drugs
              Statins are first line choice for treating hypercholesterolaemia
              Fibrates are first line choice for treating hypertriglyceridaemia
              Mixed hyperlipidaemia can be treated with either a statin or a fibrate or a

       Recommended:          Simvastatin

          Simvastatin is now off patent and so due to financial considerations it is the
           preferred statin.
          The following drugs interact with Simvastatin and the Committee on Safety of
           Medicines have issued the following guidance:

                Interacting drug                    Prescribing advice
                Potent CYP3A4 inhibitors:
                HIV protease inhibitors, azole
                antifungal agents, erythromycin,    Avoid simvastatin
                clarithromycin, telithromycin

                Ciclosporin, gemfibrozil,           Do not exceed 10 mg simvastatin
                niacin (>1 g/day)

                Verapamil, amiodarone               Do not exceed 20mg simvastatin
                Diltiazem                           Do not exceed 40mg simvastatin
                Grapefruit juice                    Avoid grapefruit juice when
                                                    taking simvastatin

       Alternative:          Atorvastatin (particularly mixed hyperlipidaemia)
                                  Next revised edition: July 2007
     Specific indication: Rosuvastatin – for use as an alternative when atorvastatin would
                           have been considered (consultant use only in secondary care).

        In primary care rosuvastatin should only be tried after a trial of simvastatin and
         atorvastatin or on the advice of the lipid clinic.
        Rosuvastatin should not be prescribed to patients with a GFR < 30 ml / min.
        Changes to the prescribing information of rosuvastatin have been prompted by a
         concern about reports of rhabdomyolysis and are as follows:
         - All patients (including those who are switching from another statin) must start
             on the initial dose of 10 mg rosuvastatin once daily and should only be titrated
             to 20mg if considered necessary after a 4 week trial of 10 mg.
         - The 40 mg dose is contraindicated in patients with predisposing risk factors for
         - Specialist supervision is recommended when the 40 mg dose is initiated
             (through local lipidology, diabetic or cardiac clinics). The 40mg dose should
             only be necessary for the minority of patients with severe
             hypercholesterolaemia at high cardiovascular risk.
         - Patients who are currently taking 40 mg and who have not already been seen
             by a specialist should have their treatment reviewed at their next routine
             appointment and appropriate down-titration of dose or specialist referral should
             be considered.

     Specific indication: Ezetimibe – for use in patients who cannot tolerate high doses of
                                     statins to achieve sufficient cholesterol lowering
                                     (Consultant use only in secondary care)

     Recommended:         Fenofibrate (micronised or m/r)
     Alternative:         Bezafibrate

     Anion-exchange resins
     Recommend:       Colestyramine

     Fish oils
     Specific indication: Omega-3-acid ethyl esters (Omacor) – for use in primary care
                          only on the advice of NBT Lipid Clinic for patients with
                           hypertriglyceridaemia who are unable to tolerate fibrates.

2.13 Local sclerosants
     Recommended:         Ethanolamine Oleate
                          Sodium Tetradecyl Sulphate

                               Next revised edition: July 2007

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