Drug reference
Prophylaxis and treatment of stable angina (second-line) ▶BY MOUTH ▶Adult: Initially 5–10 mg twice daily, then increased if tolerated to 40 mg twice daily; usual dose 10–20 mg twice daily, use lower initial dose regimen if patient susceptible to headache
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Acute pulmonary oedema. hypovolaemia. left ventricular dysfunction with low filling pressure or cardiac decompensation. severe hypotension. shock (including cardiogenic shock)
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Diverticular disease (risk of fistula formation or bowel perforation). G6PD deficiency. heart failure (class III–IV). hyperkalaemia
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→Appendix 1: nicorandil Cardiovascular system
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▶Common or very common Asthenia. dizziness. haemorrhage. headache (more common on initiation, usually transitory). nausea. vasodilation. vomiting ▶Rare or very rare Abdominal pain. angioedema. conjunctivitis. eye disorders. gastrointestinal disorders. genital ulceration. hepatic disorders. hyperkalaemia. mucosal ulceration. myalgia. oral disorders. skin reactions. skin ulcer ▶Frequency not known Diplopia SIDE-EFFECTS, FURTHER INFORMATION Nicorandil can cause serious skin, mucosal, and eye ulceration; including gastrointestinal ulcers, which may progress to perforation, haemorrhage, fistula or abscess. Stop treatment if ulceration occurs and consider an alternative.
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Manufacturer advises use only if potential benefit outweighs risk—no information available.
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No information available—manufacturer advises avoid.
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There can be variation in the licensing of different medicines containing the same drug. Tablet ▶Nicorandil (Non-proprietary) Nicorandil 10 mg Nicorandil 10mg tablets | 60 tablet P £7.71 DT = £3.03 Nicorandil 20 mg Nicorandil 20mg tablets | 60 tablet P £14.64 DT = £3.72 ▶Ikorel (Sanofi) Nicorandil 10 mg Ikorel 10mg tablets | 60 tablet P £7.71 DT = £3.03 Nicorandil 20 mg Ikorel 20mg tablets | 60 tablet P £14.64 DT = £3.72 8.1 Acute coronary syndromes Acute coronary syndromes Overview Acute coronary syndromes encompass a spectrum of conditions which include unstable angina, and myocardial infarction with or without ST-segment elevation. Patients with different acute coronary syndromes may present similarly; definitive diagnosis is made on the basis of clinical presentation, ECG changes, and measurement of biochemical cardiac markers. For recommendations on the management of acute myocardial injury and its cardiac complications in adults with known or suspected COVID-19 but without known pre- existing cardiovascular disease, see NICE rapid guidelines: Acute myocardial injury (available at: www.nice.org.uk/ guidance/ng171). For further information on COVID-19, see COVID-19 p. 656. Unstable angina and non-ST-segment elevation myocardial infarction (NSTEMI) These are related acute coronary syndromes that fall between the classifications of stable angina and ST-segment elevation myocardial infarction (STEMI). They usually occur as a result of atheromatous plaque rupture, and are often characterised by stable angina that suddenly worsens, recurring or prolonged angina at rest, or new onset of severe angina. Patients with unstable angina have no evidence of myocardial necrosis, whereas in NSTEMI, myocardial necrosis (less significant than with STEMI) will be evident. There is a risk of progression to STEMI or sudden death, particularly in patients who experience pain at rest. Management of unstable angina and non-ST-segment elevation myocardial infarction (NSTEMI) These conditions are managed similarly; the aims of management are to provide supportive care and pain relief during the acute attack and to prevent further cardiac events and death. For advice on the management of patients with acute ST-segment elevation myocardial infarction (STEMI), see below. Initial management Oxygen should be administered if there is evidence of hypoxia, pulmonary oedema, or continuing myocardial ischaemia; hyperoxia should be avoided and particular care is required in patients with chronic obstructive airways disease. Nitrates are used to relieve ischaemic pain. If sublingual glyceryl trinitrate p. 232 is not effective, intravenous or buccal glyceryl trinitrate or intravenous isosorbide dinitrate p. 233 is given. If pain continues, diamorphine hydrochloride p. 477 or morphine p. 484 can be given by slow intravenous injection; an antiemetic such as metoclopramide hydrochloride p. 452 should also be given. Aspirin p. 130 (chewed or dispersed in water) is given for its antiplatelet effect. If aspirin is given before arrival at hospital, a note saying that it has been given should be sent with the patient. Clopidogrel p. 131 should also be given. Prasugrel p. 228 is an alternative to clopidogrel in certain patients undergoing percutaneous coronary intervention (see NICE guidance). Ticagrelor p. 228 is also an alternative to clopidogrel (see NICE guidance). Patients should also receive either heparin (unfractionated) p. 143, a low molecular weight heparin, or fondaparinux sodium p. 136. Patients without contra-indications should receive beta- blockers which should be continued indefinitely. In patients without left ventricular dysfunction and in whom beta- blockers are inappropriate, diltiazem hydrochloride p. 169 or verapamil hydrochloride p. 175 can be given. The glycoprotein IIb/IIIa inhibitors eptifibatide p. 223 (in combination with heparin (unfractionated) and aspirin) and tirofiban p. 223 (in combination with heparin (unfractionated), aspirin, and clopidogrel) can be used for unstable angina or for NSTEMI in patients at a high risk of either myocardial infarction or death. In intermediate- and high-risk patients, abciximab or eptifibatide (in combination with heparin (unfractionated) and aspirin), or tirofiban (in combination with heparin (unfractionated), aspirin, and clopidogrel) can also be used in patients undergoing percutaneous coronary intervention, to reduce the immediate risk of vascular occlusion. In intermediate- and high-risk patients in whom early intervention is planned, bivalirudin p. 145 can be considered as an alternative to the combination of a glyocprotein IIb/IIIa inhibitor plus a heparin. Revascularisation procedures are often appropriate for patients with unstable angina or NSTEMI; see Antiplatelet drugs p. 129 for the use of antiplatelet drugs in patients undergoing coronary stenting. Long-term management The need for long-term angina treatment or for coronary angiography should be assessed. Most patients will require standard angina treatment to prevent recurrence of symptoms. ST-segment elevation myocardial infarction (STEMI) This is an acute coronary syndrome where atheromatous plaque rupture leads to thrombosis and myocardial ischaemia, with irreversible necrosis of the heart muscle, often leading to long-term complications. STEMI can also occasionally occur as a result of coronary spasm or embolism, arteritis, spontaneous thrombosis, or sudden severe elevation in blood pressure. Management of ST-segment elevation myocardial infarction (STEMI) These notes give an overview of the initial and long-term management of myocardial infarction with ST segment elevation (STEMI). For advice on the management of non- ST-segment elevation myocardial infarction (NSTEMI) and unstable angina, see above. The aims of management of STEMI are to provide supportive care and pain relief, to promote reperfusion and to reduce mortality. Oxygen, nitrates, and diamorphine hydrochloride or morphine can provide initial support and pain relief; aspirin and percutaneous coronary intervention or thrombolytics promote reperfusion; anticoagulants help to reduce re- occlusion and systemic embolisation; long-term use of aspirin, beta-blockers, ACE inhibitors, and statins help to reduce mortality further. Local guidelines for the management of myocardial infarction should be followed where they exist. Initial management Oxygen should be administered if there is evidence of hypoxia, pulmonary oedema, or continuing myocardial ischaemia; hyperoxia should be avoided and particular care is required in patients with chronic obstructive airways disease. The pain (and anxiety) of myocardial infarction is managed with slow intravenous injection of diamorphine hydrochloride or morphine; an antiemetic such as metoclopramide hydrochloride (or, if left ventricular function is not compromised, cyclizine p. 449) by intravenous injection should also be given. Aspirin (chewed or dispersed in water) is given for its antiplatelet effect. If aspirin is given before arrival at hospital, a note saying that it has been given should be sent with the patient. Clopidogrel, should also be given. Prasugrel, is an alternative to clopidogrel in certain patients undergoing percutaneous coronary intervention (see NICE guidance). Ticagrelor, is also an alternative to clopidogrel (see NICE guidance). Patency of the occluded artery can be restored by percutaneous coronary intervention or by giving a thrombolytic drug, unless contra-indicated. Percutaneous coronary intervention is the preferred method; a glycoprotein IIb/IIIa inhibitor can be used to reduce the risk of immediate vascular occlusion in intermediate- and high-risk patients. Patients undergoing percutaneous coronary intervention should also receive either heparin (unfractionated) or a low molecular weight heparin (e.g. enoxaparin sodium p. 142); bivalirudin is an alternative to the combination of a glycoprotein IIb/IIIa inhibitor plus a heparin (see also NICE guidance). In patients who cannot be offered percutaneous coronary intervention within 90 minutes of diagnosis, a thrombolytic drug should be administered along with either heparin (unfractionated) (for maximum 2 days), a low molecular weight heparin (e.g. enoxaparin sodium p. 142), or fondaparinux sodium p. 136. See use of antiplatelet drugs in patients undergoing coronary stenting in Antiplatelet drugs p. 129. Patients who do not receive reperfusion therapy (with percutaneous coronary intervention or a thrombolytic) should be treated with either fondaparinux sodium, enoxaparin sodium, or heparin (unfractionated) p. 143. Prescribers should consult product literature and local protocols (where they exist) for details of anticoagulant dose and duration. Nitrates are used to relieve ischaemic pain. If sublingual glyceryl trinitrate p. 232 is not effective, intravenous glyceryl trinitrate or isosorbide dinitrate p. 233 is given. Early administration of some beta-blockers has been shown to be of benefit and should be given to patients without contra-indications. ACE inhibitors, and angiotensin-II receptor antagonists if Cardiovascular system an ACE inhibitor cannot be used, are also of benefit to patients who have no contra-indications; in hypertensive and normotensive patients treatment with an ACE inhibitor, or an angiotensin-II receptor antagonist, can be started within 24 hours of the myocardial infarction and continued for at least 5–6 weeks (see below for long-term treatment). All patients should be closely monitored for hyperglycaemia; those with diabetes or raised blood-glucose concentration should receive insulin p. 751. Long-term management Long-term management following STEMI involves the use of several drugs which should ideally be started before the patient is discharged from hospital. Aspirin p. 130 should be given to all patients, unless contra-indicated. The addition of clopidogrel p. 131 has been shown to reduce morbidity and mortality. Prasugrel p. 228 or ticagrelor p. 228 are alternatives to clopidogrel in certain patients. For those intolerant of clopidogrel, and who are at low risk of bleeding, the combination of warfarin sodium p. 150 and aspirin should be considered. In those intolerant of both aspirin and clopidogrel, warfarin sodium alone can be used. Warfarin sodium should be continued for those who are already being treated for another indication, such as atrial fibrillation, with the addition of aspirin if there is a low risk of bleeding. The combination of aspirin with clopidogrel or warfarin sodium increases the risk of bleeding. Low-dose rivaroxaban p. 137, in combination with aspirin alone or aspirin and clopidogrel, is licensed for the prevention of atherothrombotic events following STEMI—see Prevention of cardiovascular events. For details of antiplatelet drug duration following coronary stenting—see also Antiplatelet drugs and coronary stents in Antiplatelet drugs p. 129. Beta-blockers should be given to all patients in whom they are not contra-indicated. Acebutolol p. 163, metoprolol tartrate p. 166, propranolol hydrochloride p. 162 and timolol maleate p. 163 are suitable; for patients with left ventricular dysfunction, carvedilol p. 160, bisoprolol fumarate p. 165, or long-acting metoprolol tartrate may be appropriate Diltiazem hydrochloride p. 169 [unlicensed] or verapamil hydrochloride p. 175 can be considered if a beta-blocker cannot be used; however, they are contra-indicated in those with left ventricular dysfunction. Other calcium-channel blockers have no place in routine long-term management after a myocardial infarction. An ACE inhibitor should be considered for all patients, especially those with evidence of left ventricular dysfunction. If an ACE inhibitor cannot be used, an angiotensin-II receptor antagonist may be used for patients with heart failure. A relatively high dose of either the ACE inhibitor or angiotensin-II receptor antagonist may be required to produce benefit. Nitrates are used for patients with angina. Eplerenone p. 205 is licensed for use following a myocardial infarction in those with left ventricular dysfunction and evidence of heart failure. See also the role of statins in preventing recurrent cardiovascular events in Dyslipidaemias p. 208. Prevention of cardiovascular events Patients with stable angina, unstable angina, or NSTEMI should be given advice and treatments to reduce their cardiovascular risk. The importance of life-style changes, especially stopping smoking, should be emphasised. Aspirin should be given indefinitely. Antihypertensive treatment should be initiated if appropriate, and a statin should also be given. In patients with stable angina, addition of an ACE inhibitor should be considered for patients with diabetes (and should be continued if indicated for a co-morbidity). In patients with unstable angina or NSTEMI, clopidogrel is Cardiovascular system given, in combination with aspirin, for up to 12 months— most benefit occurs during the first 3 months. Prasugrel or ticagrelor are alternatives to clopidogrel in certain patients. An ACE inhibitor should also be given. Low-dose rivaroxaban, in combination with aspirin alone or aspirin and clopidogrel, is licensed for the prevention of atherothrombotic events following an acute coronary syndrome with elevated cardiac biomarkers. Advanced Pharmacy Services Patients with a history of acute coronary syndrome may be eligible for the New Medicines Service / Medicines Use Review service provided by a community pharmacist. For further information, see Advanced Pharmacy Services in Medicines optimisation p. 18. Other drugs used for Acute coronary syndromes Captopril, p. 179. Dalteparin sodium, p. 140. Lisinopril, p. 181. Perindopril arginine, p. 182. Perindopril erbumine, p. 183. Ramipril, p. 184. Trandolapril, p. 185. Valsartan, p. 190 ANTITHROMBOTIC DRUGS › ANTIPLATELET DRUGS
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Driving and skilled tasks Patients should be warned not to drive or operate machinery until it is established that their performance is unimpaired.
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Initially 5–10 mg twice daily, then increased if
First-line fragment. Read the complete Indications and Dose section above.
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