Drug | Use | |
---|---|---|
Angiotensin-converting enzyme (ACE) inhibitors | ||
Benazepril Captopril Enalapril Fosinopril Lisinopril Moexipril Perindopril Quinapril Ramipril Trandolapril | All patients with CAD, especially those with large infarctions, renal insufficiency, heart failure Heart Failure (HF) Heart failure (HF) is a syndrome of ventricular dysfunction. Left ventricular (LV) failure causes shortness of breath and fatigue, and right ventricular (RV) failure causes peripheral and abdominal... read more , hypertension Hypertension Hypertension is sustained elevation of resting systolic blood pressure (≥ 130 mm Hg), diastolic blood pressure (≥ 80 mm Hg), or both. Hypertension with no known cause (primary; formerly, essential... read more , or diabetes Diabetes Mellitus (DM) Diabetes mellitus is impaired insulin secretion and variable degrees of peripheral insulin resistance leading to hyperglycemia. Early symptoms are related to hyperglycemia and include polydipsia... read more Contraindications include hypotension, hyperkalemia, bilateral renal artery stenosis, pregnancy, and known allergy | |
Angiotensin II receptor blockers (ARBs) | ||
Candesartan Eprosartan Irbesartan Losartan Olmesartan Telmisartan Valsartan | An effective alternative for patients who cannot tolerate ACE inhibitors (eg, because of cough); currently, not first-line treatment after MI Contraindications include hypotension, hyperkalemia, bilateral renal artery stenosis, pregnancy, and known allergy | |
Anticoagulants | ||
Argatroban | As an alternative to heparin in patients with ACS and a known or suspected history of heparin-induced thrombocytopenia Heparin-induced thrombocytopenia Platelet destruction can develop because of immunologic causes (viral infection, drugs, connective tissue or lymphoproliferative disorders, blood transfusions) or nonimmunologic causes (sepsis... read more | |
Bivalirudin | ||
Fondaparinux | ||
Apixaban | ||
Dabigatran | ||
Rivaroxaban | ||
Low molecular weight heparins:
| Patients with unstable angina Unstable Angina Unstable angina results from acute obstruction of a coronary artery without myocardial infarction. Symptoms include chest discomfort with or without dyspnea, nausea, and diaphoresis. Diagnosis... read more or NSTEMI Infarct extent Acute myocardial infarction is myocardial necrosis resulting from acute obstruction of a coronary artery. Symptoms include chest discomfort with or without dyspnea, nausea, and/or diaphoresis... read more Patients < 75 years receiving tenecteplase Almost all patients with STEMI Infarct extent Acute myocardial infarction is myocardial necrosis resulting from acute obstruction of a coronary artery. Symptoms include chest discomfort with or without dyspnea, nausea, and/or diaphoresis... read more as an alternative to unfractionated heparin (unless PCI is indicated and can be done in < 90 minutes); drug continued until PCI or CABG is done or patient is discharged | |
Unfractionated heparin | Patients with unstable angina or NSTEMI as an alternative to enoxaparin | |
Patients who have STEMI and undergo urgent angiography and PCI or patients > 75 years receiving tenecteplase | ||
Warfarin | Recommended for primary prevention in patients at high risk of systemic emboli (ie, with atrial fibrillation, mechanical heart valves, venous thromboembolism Deep Venous Thrombosis (DVT) Deep venous thrombosis (DVT) is clotting of blood in a deep vein of an extremity (usually calf or thigh) or the pelvis. DVT is the primary cause of pulmonary embolism. DVT results from conditions... read more , hypercoagulable disorders, or LV thrombus) May be useful for primary prevention in patients with STEMI and anterior wall akinesis or dyskinesis if risk of bleeding is low Reasonable for patients with asymptomatic mural thrombus | |
Antiplatelet agents | ||
Aspirin | All patients with CAD or at high risk of developing CAD, unless aspirin is not tolerated or is contraindicated; used long-term | |
— | ||
Clopidogrel | Used with aspirin or, in patients who cannot tolerate aspirin, alone | |
For elective PCI, maintenance therapy required for at least 1 month for bare-metal stents and for at least 6–12 months for drug-eluting stents For ACS, dual antiplatelet therapy (typically with aspirin) is recommended for at least 12 months (for any type of stent) | ||
Prasugrel | Only for patients with ACS undergoing PCI Not used in combination with fibrinolytic therapy | |
Ticagrelor | — | |
Ticlopidine | Rarely used routinely because neutropenia Neutropenia Neutropenia is a reduction in the blood neutrophil count. If it is severe, the risk and severity of bacterial and fungal infections increase. Focal symptoms of infection may be muted, but fever... read more is a risk and white blood cell count must be monitored regularly | |
Glycoprotein IIb/IIIa inhibitors | ||
Abciximab | Some patients with ACS, particularly those who are having PCI with stent placement and high-risk patients with unstable angina or NSTEMI and large thrombus burden Therapy started during PCI and continued for 6–24 hours thereafter | |
Eptifibatide | ||
Tirofiban | ||
Beta-blockers | ||
Atenolol | All patients with ACS, unless a beta-blocker is not tolerated or is contraindicated, especially high-risk patients; used long-term Intravenous beta-blockers may be used in patients with ongoing chest pain Chest Pain Chest pain is a very common complaint. Many patients are well aware that it is a warning of potential life-threatening disorders and seek evaluation for minimal symptoms. Other patients, including... read more despite usual measures, or persistent tachycardia, or hypertension in patients with unstable angina and myocardial infarction. Caution is necessary in patients with hypotension or other evidence of hemodynamic instability. | |
Bisoprolol | ||
Carvedilol | ||
Metoprolol | ||
Calcium channel blockers | ||
Amlodipine | Patients with stable angina Angina Pectoris Angina pectoris is a clinical syndrome of precordial discomfort or pressure due to transient myocardial ischemia without infarction. It is typically precipitated by exertion or psychologic stress... read more if symptoms persist despite nitrates use or if nitrates are not tolerated | |
Diltiazem (extended-release) | ||
Felodipine | ||
Nifedipine (extended-release) | ||
Verapamil (extended-release) | ||
Nitrates: Short acting | ||
Sublingual nitroglycerin (tablet or spray) | ||
Nitroglycerin as continuous IV drip | Selected patients with ACS: During the first 24 to 48 hours, those with heart failure Heart Failure (HF) Heart failure (HF) is a syndrome of ventricular dysfunction. Left ventricular (LV) failure causes shortness of breath and fatigue, and right ventricular (RV) failure causes peripheral and abdominal... read more (unless hypotension is present), large anterior myocardial infarction Acute Myocardial Infarction (MI) Acute myocardial infarction is myocardial necrosis resulting from acute obstruction of a coronary artery. Symptoms include chest discomfort with or without dyspnea, nausea, and/or diaphoresis... read more , persistent angina, or hypertension (BP is reduced by 10–20 mm Hg but not to < 80–90 mm Hg systolic) For longer use, those with recurrent angina or persistent pulmonary congestion | |
Nitrates: Long acting | ||
Isosorbide dinitrate | Patients who have unstable angina or persistent severe angina and continue to have anginal symptoms after the beta-blocker dose is maximized A nitrate-free period of about 8–10 hours (typically at night) recommended to avoid tolerance (specific drugs recommend different durations of nitrate-free period) | |
Isosorbide dinitrate (sustained-release) | ||
Isosorbide mononitrate | ||
Isosorbide mononitrate (sustained-release) | ||
Nitroglycerin patches | ||
Nitroglycerin ointment 2% preparation (15 mg/2.5 cm) | ||
Opioids | ||
Morphine | Morphine should be used judiciously (eg, if nitroglycerin is contraindicated or if patient has symptoms despite maximal doses of nitroglycerin) given a possible increase in mortality as well as attenuation of P2Y12 receptor inhibitor activity | |
PCSK-9 inhibitors | ||
Alirocumab | For patients not at target LDL-C levels, used alone or in combination with other lipid-lowering therapies (eg, statins, ezetimibe) for the treatment of adults with primary hyperlipidemia (including familial hypercholesterolemia) | |
Evolocumab | For patients not at target LDL-C levels, used alone or in combination with other lipid-lowering therapies (eg, statins, ezetimibe) for the treatment of adults with primary hyperlipidemia (including familial hypercholesterolemia) | |
Statins | ||
Atorvastatin Fluvastatin Lovastatin Pravastatin Rosuvastatin Simvastatin | Patients with CAD should be given maximally tolerated statin dose | |
Other medications | ||
Ivabradine | Inhibits sinus node For symptomatic treatment of chronic stable angina pectoris in patients with normal sinus rhythm who cannot take beta-blockers In combination with beta-blockers in patients inadequately controlled by beta-blocker alone and whose heart rate > 60 beats/minute | |
Ranolazine | Patients in whom anginal symptoms continue despite treatment with other antianginal agents | |
* Clinicians may use different combinations of drugs depending on the type of coronary artery disease that is present. | ||
† Higher doses of aspirin do not provide greater protection and increase risk of adverse effects. | ||
‡ Of low molecular weight heparins (LMWHs), enoxaparin is preferred. | ||
ACS = acute coronary syndromes; BP = blood pressure; CABG = coronary artery bypass grafting; CAD = coronary artery disease; INR = international normalized ratio; LV = left ventricular; MI = myocardial infarction; NSTEMI = non–ST-segment elevation MI; PCI = percutaneous intervention; STEMI = ST-segment elevation MI. |