Angiotensin-converting enzyme (ACE) inhibitors

Benazepril

Captopril

Enalapril

Fosinopril

Lisinopril

Moexipril

Perindopril

Quinapril

Ramipril

Trandolapril

Variable

All patients with CAD, especially those with large infarctions, renal insufficiency, heart failure, hypertension, or diabetes

Contraindications include hypotension, hyperkalemia, bilateral renal artery stenosis, pregnancy, and known allergy

Angiotensin II receptor blockers (ARBs)

Candesartan

Eprosartan

Irbesartan

Losartan

Olmesartan

Telmisartan

Valsartan

Variable

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

350 mcg/kg (IV bolus) followed by 25 mcg/kg/minute (IV infusion)

As an alternative to heparin in patients with ACS and a known or suspected history of heparin-induced thrombocytopenia

Bivalirudin

Variable

Fondaparinux

2.5 mg subcutaneously every 24 hours

Apixaban

5 mg orally twice a day

May be useful long-term in patients with non-valvular atrial fibrillation

Dabigatran

150 mg orally twice a day (or 110–150 mg orally twice a day for patients also taking P2Y12 inhibitors)

Rivaroxaban

20 mg orally once a day (or 15 mg orally once a day for patients also taking P2Y12 inhibitors)

Low molecular weight heparins:

• Dalteparin

• Enoxaparin‡

• Tinzaparin

Variable

Patients with unstable angina or NSTEMI

Patients < 75 years receiving tenecteplase

Almost all patients with STEMI 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

60–70 units/kg IV (maximum, 5000 units; bolus), followed by 12–15 units/kg/hour (maximum, 1000 units/hour) for 48 hours or until PCI is complete

Patients with unstable angina or NSTEMI as an alternative to enoxaparin

60 units/kg IV (maximum, 4000 units; bolus) given when alteplase, reteplase, or tenecteplase is started, then followed by 12 units/kg/hour (maximum, 1000 units/hour) for 48 hours or until PCI is complete

Patients who have STEMI and undergo urgent angiography and PCI or patients > 75 years receiving tenecteplase

Warfarin

Oral dose adjusted to maintain INR of 2.5–3.5

Recommended for primary prevention in patients at high risk of systemic emboli (ie, with atrial fibrillation, mechanical heart valves, venous thromboembolism, hypercoagulable disorders, or LV thrombus)

Reasonable for patients with asymptomatic mural thrombus

Antiplatelet drugs

Aspirin

For stable angina†: 75 or 81 mg orally once a day (enteric-coated)

All patients with CAD or at high risk of developing CAD, unless aspirin is not tolerated or is contraindicated; used long-term

For ACS: 160–325 mg orally chewed (not enteric-coated) on arrival at emergency department and once a day thereafter during hospitalization and 81 mg† orally once a day long-term after discharge

—

Clopidogrel

75 mg orally once a day

Used with aspirin or, in patients who cannot tolerate aspirin, alone

For patients undergoing PCI: 300–600 mg orally once, then 75 mg orally once a day for 1–12 months

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

60 mg orally once, followed by 10 mg orally once a day for 1–12 months

Only for patients with ACS undergoing PCI

Not used in combination with fibrinolytic therapy

Ticagrelor

For patients undergoing PCI: 180 mg orally once before the procedure, followed by 90 mg orally twice a day for 1–12 months

—

Ticlopidine

250 mg orally twice a day for 1–12 months

Rarely used routinely because neutropenia is a risk and white blood cell count must be monitored regularly

Glycoprotein IIb/IIIa inhibitors

Abciximab

Variable

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

Variable

Tirofiban

Variable

Beta-blockers

Atenolol

50 mg orally every 12 hours acutely; 50–100 mg orally twice a day long-term

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 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

2.5–5 mg orally once a day, increasing to 10–15 mg once a day depending on heart rate and BP response

Carvedilol

25 mg orally twice a day (in patients with heart failure or other hemodynamic instability, the starting dose should be as low as 1.625–3.125 mg twice a day and increased very slowly as tolerated)

Metoprolol

25–50 mg orally every 6 hours continued for 48 hours; then 100 mg twice a day or 200 mg once a day given long term

Calcium channel blockers

Amlodipine

5–10 mg orally once a day

Patients with stable angina if symptoms persist despite nitrates use or if nitrates are not tolerated

Diltiazem (extended-release)

180–360 orally once a day

Felodipine

2.5–10 mg orally once a day

Nifedipine (extended-release)

30–90 mg orally once a day

Verapamil (extended-release)

120–360 mg orally once a day

Statins

Atorvastatin

Fluvastatin

Lovastatin

Pravastatin

Rosuvastatin

Simvastatin

Variable

Patients with CAD should be given maximally tolerated statin dose

Nitrates: Short acting

Sublingual nitroglycerin (tablet or spray)

0.3–0.6 mg every 4–5 minutes up to 3 doses

All patients for immediate relief of chest pain; used as needed

Nitroglycerin as continuous IV drip

Started at 5 mcg/minute and increased 2.5–5.0 mcg every few minutes until required response occurs

Selected patients with ACS:

During the first 24 to 48 hours, those with heart failure (unless hypotension is present), large anterior myocardial infarction, 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

10–20 mg orally 3 times a day; can be increased to 40 mg 3 times a day

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 require different durations of nitrate-free period)

Isosorbide dinitrate (sustained-release)

40–80 mg orally twice a day (typically given at 8 AM and 2 PM)

Isosorbide mononitrate

20 mg orally twice a day, with 7 hours between 1st and 2nd doses

Isosorbide mononitrate (sustained-release)

30 or 60 mg once a day, increased to 120 mg or, rarely, 240 mg

Nitroglycerin patches

0.2–0.8 mg/hour applied between 6:00 and 9:00 AM and removed 12–14 hours later to avoid tolerance

Nitroglycerin ointment 2% preparation (15 mg/2.5 cm)

1.25 cm spread evenly over upper torso or arms every 6 to 8 hours and covered with plastic, increased to 7.5 cm as tolerated, and removed for 8–12 hours each day to avoid tolerance

Opioids

Morphine

2–4 mg IV, repeated as needed

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

Initial dose: 75 mg subcutaneously, once every 2 weeks or 300 mg subcutaneously once every 4 weeks

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

Initial dose for primary hyperlipidemia: 140 mg subcutaneously every 2 weeks or 420 mg subcutaneously once monthly

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

Variable

Patients with CAD should be given maximally tolerated statin dose

Other drugs

Ivabradine

5 mg orally twice a day, increased to 7.5 mg orally twice a day if needed

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

500 mg orally twice a day, increased to 1000 mg orally twice a day as needed

Patients in whom anginal symptoms continue despite treatment with other antianginal drugs