Medications for Coronary Artery Disease*

Angiotensin-converting enzyme (ACE) inhibitors

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)

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: Direct-acting oral anticoagulants‡

5 mg orally twice a day

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

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

60 mg orally once a day

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

Anticoagulants: Direct thrombin inhibitors

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

Variable†

Anticoagulants: Factor Xa inhibitor

2.5 mg subcutaneously every 24 hours

Anticoagulants: Low molecular weight heparins

Tinzaparin

Variable†

Patients with unstable angina or NSTEMI

Patients <

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

Anticoagulants: Unfractionated heparin

Patients with unstable angina or NSTEMI: 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 STEMI

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

Anticoagulants: Vitamin K inhibitor

Oral dose adjusted to maintain INR of 2–3

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)

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

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

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

All patients with CAD unless aspirin is not tolerated or is contraindicated; used long-term

75 mg orally once a day

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

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)

60 mg orally once before PCI, 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

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

Beta-blockers

Variable†

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.

Variable†

Variable†

Variable†

Calcium channel blockers

Variable†

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

Variable†

Variable†

Variable†

Variable†

Glycoprotein IIb/IIIa inhibitors

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

Variable†

Variable†

Nitrates: Short acting

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

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

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, patients with recurrent angina or persistent pulmonary congestion

Nitrates: Long acting

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 recommend different durations of nitrate-free period)

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

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

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

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

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

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

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

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 (HMG-CoA reductase inhibitors)

Variable† (see Dyslipidemia)

Patients with CAD should be given maximally tolerated statin dose

Other medications

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

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