Myocardial Infarction w/ ST-Segment Elevation Drug Summary

Last updated: 02 June 2026
Reviewed by

ACE Inhibitors

 
Drug Dosage Remarks
Captopril Post-MI
Initial dose: 6.25-12.5 mg PO 8 hourly
Adjust dose gradually according to response
Maintenance dose: 25-50 mg PO 8-12 hourly
Max dose: 150 mg/day 		Adverse Reactions
  • CV effects (hypotension, angioedema); CNS effects (fatigue, headache); GI effects (taste disturbances, nausea/vomiting); Respiratory effects (persistent dry cough, upper respiratory tract symptoms); Dermatologic effects (skin rashes, erythema multiforme, toxic epidermal necrolysis); Hypersensitivity reactions; Renal effect (renal impairment); Electrolyte disturbances (hyperkalemia, hyponatremia); Blood disorders
Special Instructions
  • Start with low-dose oral administration and increase steadily to full dose within 24-48 hours (as tolerated)
  • Contraindicated in patients with SBP <100 mmHg, in patients with aortic stenosis or outflow tract obstruction and should generally be avoided in suspected or actual renovascular disease
  • Use with caution in patients with history of hereditary or idiopathic angioedema
  • Renal function should be assessed prior to administration of ACE inhibitors and should be monitored during therapy
    • Patient with renal disease or taking high doses should be monitored regularly for proteinuria
Enalapril Post-MI
Initial dose: 2.5 mg PO 12 hourly
Increase gradually to 10 mg PO 12 hourly
or
Initial dose: 2.5 mg PO 24 hourly or divided 12 hourly
Maintenance dose: 20 mg PO 24 hourly or divided 12 hourly
Max dose: 40 mg/day
Lisinopril Acute MI
Initial dose: 5 mg PO within 24 hours of infarct
Repeat 5 mg PO after 24 hours, then 10 mg after 48 hours
Maintenance dose: 5-40 mg PO 24 hourly
Patients with SBP ≤120 mmHg: 2.5 mg PO initially
Perindopril1 MI prophylaxis in stable CAD
Initial dose: 4-5 mg PO 24 hourly x 2 weeks
Maintenance dose: 8-10 mg PO 24 hourly
Ramipril Post-MI
Initial dose: 2.5 mg PO 12 hourly
May start at 1.25 mg PO 12 hourly for 2 days if with hypotension or
patient cannot tolerate higher dose
Dose may be doubled at 1- to 3-day intervals to
Maintenance dose: 2.5-5 mg PO 12 hourly
Max dose: 10 mg/day
Trandolapril Post-MI
Initial dose: 0.5 mg PO 24 hourly 3 days after infarction
May titrate up to
Max dose: 4 mg/day
Zofenopril Acute MI
Begin 24 hours after onset of acute MI symptoms and continue dose for 6 weeks
Initial dose: 7.5 mg PO 12 hourly for 2 days,
then 15 mg PO 12 hourly for 2 days,
then 30 mg PO 12 hourly onwards
1Combination with Bisoprolol is available. Please see the latest MIMS for specific formulations and prescribing information.

Angiotensin II Antagonists

Drug Dosage Remarks
Candesartan Initial dose:
4 mg PO 24 hourly
Increase by doubling the dose ≥2 week intervals to the highest dose tolerated by the patient
Target dose:
32 mg PO 24 hourly 		Adverse Reactions
  • Usually mild and transient: CNS effect (dizziness); CV effects (dose-related orthostatic hypotension which may occur particularly in patients with volume depletion, bradycardia); renal impairment; Other rare effects: Rash, angioedema, elevated LFTs, myalgia
Special Instructions
  • Patients with volume depletion (eg high-dose diuretic therapy) may experience hypotension and should be started on low dose
  • Use with caution in patients with renal artery stenosis, renal impairment or hepatic impairment
  • Check BP, renal function and electrolytes 1-2 weeks after each dose increment, at 3 months then every 6 months
    • More frequent monitoring is necessary in patients with past or present renal dysfunction
  • The triple combination of ACE inhibitor, beta-blocker and angiotensin II antagonists should be avoided
Losartan 50 mg PO 24 hourly
Telmisartan 80 mg PO 24 hourly
Valsartan Start ≥12 hours after MI:
Initial dose:
20 mg PO 12 hourly
Increase dose up to max of 160 mg PO 12 hourly as tolerated by patient

Anticoagulants

Drug Dosage Remarks
Direct Thrombin Inhibitor
Bivalirudin For patients who will undergo PCI:
0.75 mg/kg IV bolus followed by an IV
infusion of 1.75 mg/kg/hr during the procedure and
up to 4 hours post-procedure
If needed, may continue infusion at 0.25 mg/kg/hr x 4-12 hours		 Adverse Reactions
  • Hematologic effect (bleeding); Dermatologic effects (hypersensitivity reactions, pain on the injection site, severe anaphylaxis); CV effects (hypertension, hypotension, bradycardia); GI effects (nausea/vomiting, dyspepsia); Renal effect (urinary retention); Musculoskeletal effect (back pain); CNS effects (headache, anxiety)
Special Instructions
  • Contraindicated in patients with active major bleeding, severe renal impairment including dialysis-dependent patients
  • Use with caution in patients at high risk for bleeding, recent major surgery, puncture of large blood vessels or organ biopsy, hepatic dysfunction and moderate renal impairment
Factor Xa Inhibitors
Fondaparinux Fibrinolytic therapy:
2.5 mg IV infusion or injection single dose followed by
2.5 mg SC 24 hourly on subsequent doses x
8 days or until hospital discharge 		Adverse Reactions
  • Hematologic effects (bleeding, anemia); GI effects (nausea/vomiting, constipation, diarrhea); CV effects (edema, hypotension, hypertension, chest pain, PCI guiding-catheter thrombosis); CNS effects (insomnia, headache, dizziness, confusion); Dermatologic effects (rash, purpura)
Special Instructions
  • Do not administer via IM route
  • Contraindicated in patients with significant bleeding, acute bacterial endocarditis, hypersensitivity to the drug, severe renal impairment and body weight <50 kg
  • Use with caution in the elderly and in moderate renal impairment
  • Avoid administration 24 hours before and 48 hours after CABG surgery
  • Periodic monitoring of CBC and creatinine, and occult blood testing of stools are recommended
Rivaroxaban Prevention of atherothrombotic events after ACS: 2.5 mg PO 12 hourly
Taken with an Aspirin dose of 75-100 mg PO 24 hourly 		Adverse Reactions
  • Hematologic effects (hemorrhage, thrombocytopenia, hematoma); Hepatic effects (increased ALT and AST, cholestasis); CNS effects (dizziness, headache, fatigue), CV effect (hypotension); GI effects (nausea/vomiting, abdominal pain); Dermatologic effects (pruritus, rashes); Other effects (angioedema, postprocedural hemorrhage)
Special Instructions
  • Contraindicated in patients with active pathologic bleeding or significant risk of major bleeding, moderate to severe hepatic impairment
  • Use with caution in patients with hemorrhagic risk, severe HTN, bronchiectasis, hepatic and renal impairment
Heparin Group
Enoxaparin Fibrinolytic therapy
<75 years old:
30 mg IV bolus initially with 1 mg/kg SC
given at the same time, follow with 1 mg/kg
SC 12 hourly x 8 days or until hospital discharge
Max dose: 100 mg for each of the first 2 SC doses
Administer an additional 0.3 mg/kg IV bolus at the time of PCI if SC Enoxaparin is given >8 hours before balloon inflation
If administered with a fibrinolytic, administer Enoxaparin between 15 minutes before and 30 minutes after the initiation of fibrinolytic therapy
Administer in combination with Aspirin
≥75 years old:
No initial IV bolus; 0.75 mg/kg SC 12 hourly x 8 days or until hospital discharge
Max dose: 75 mg for each of the first 2 SC doses, followed by 0.75 mg/kg SC for the remaining doses
If administered with a fibrinolytic, administer Enoxaparin between 15 minutes before and 30 minutes after initiation of fibrinolytic therapy
Administer in combination with Aspirin
Regardless of age, if CrCl <30 mL/min:
1 mg/kg SC 24 hourly 		Adverse Reactions
  • Hematologic effects (hemorrhage, thrombocytopenia); Rare hypersensitivity reactions (anaphylaxis)
Special Instructions
  • Avoid in patients with active major bleeding, patients with positive in vitro test for antiplatelet antibody to the specific Heparin
  • UFH should not be given for >48 hours in the absence of current indication for anticoagulation
  • Use with caution in patients with hemophilia or other hemorrhagic disorders (including history of Heparin-induced thrombocytopenia), peptic ulcer, recent cerebral hemorrhage, severe hypertension, severe liver disease, post-major trauma or recent surgery to brain, spinal or ophthalmic surgery, hypersensitivity to Heparin
  • Consider risk versus benefit before neuraxial intervention is employed in patients anticoagulated or to be anticoagulated for thromboprophylaxis
  • Monitoring of platelets is recommended at baseline and periodically during treatment
Heparin
(Unfractionated
Heparin)		 STEMI with fibrinolytic therapy:
Patients receiving Alteplase, Tenecteplase, Reteplase, Streptokinase:
Initial dose: 60 units/kg IV bolus (max dose: 4,000 units), followed by 12 units/kg/hr IV infusion (max dose: 1,000 units/hr)
Then, adjust dose to maintain aPTT at 1.5-2.0 x control
Continue for at least 48 hours or until revascularization
STEMI with primary PCI:
Patients receiving glycoprotein IIb/IIIa inhibitor: 50-70 units/kg IV bolus (target activated clotting time [ACT]: 200-250 sec)
Patients not receiving glycoprotein IIb/IIIa inhibitor: 70-100 units/kg IV bolus (target ACT: 250-350 sec)
Sulodexide 600 LSU IM/IV injection 24 hourly x 15-20 days
then continue with 250-500 LSU PO 12 hourly x 30-40 days
Repeat the treatment cycle at least twice yearly
Vitamin K Antagonist
Warfarin Adjunct in prophylaxis of systemic embolism after MI:
Individualized dosage and duration of treatment
Initial dose: 2-5 mg PO 24 hourly
Maintenance dose: 2-10 mg PO 24 hourly 		Adverse Reactions
  • Hematologic effects (hemorrhage, decreased Hb and hematocrit); Hepatic effects (hepatic dysfunction, jaundice); GI effects (nausea/vomiting, abdominal pain); Dermatologic effects (dermatitis, rashes); Other effects (acute kidney injury, skin necrosis or gangrene)
Special Instructions
  • Contraindicated in patients with active pathologic bleeding or significant risk of major bleeding, concomitant use with fibrinolytic drugs
  • Use with caution in patients with Heparin-induced thrombocytopenia and DVT, thyroid disease, acute infection, active TB, disruption of normal GI flora, protein C or protein S deficiency, vitamin K deficiency, surgical patients, hepatic and renal impairment

Antiplatelet Agents

Drug Dosage Remarks
Aspirin1 Loading dose:
Chew 150-325 mg non-enteric-coated x 1 dose
followed by
Maintenance dose:
75-325 mg PO 24 hourly 		Adverse Reactions
  • GI effects (GI upset which may be minimized by administering with food and with use of enteric-coated formulation, also GI irritation including erosion, ulceration, etc); Hematologic effects (increase in bleeding time, decrease in platelet adhesiveness, hemorrhage); hypersensitivity reactions
Special Instructions
  • Contraindicated in patients with peptic ulcer or known allergy
  • Ensure that benefit outweighs the risk prior to use in combination with Warfarin, Heparin, fibrinolytics, NSAIDs and other drugs that increase the risk of bleeding
Cangrelor 30 mcg/kg IV bolus prior to PCI followed by 4 mcg/kg/min continuous IV infusion over at least 2 hours or for the duration of the PCI, whichever is longer Adverse Reactions
  • Hematologic effect (hemorrhage/bleeding); Other effects (renal impairment, dyspnea, hypersensitivity reaction)
Special Instructions
  • Contraindicated in patients with active bleeding
  • An oral P2Y12 platelet inhibitor must be administered after Cangrelor infusion to maintain platelet inhibition
Clopidogrel2 Secondary prevention:
75 mg PO 24 hourly
Co-administered with Aspirin:
With PCI:
Loading dose: 300-600 mg PO followed by
Maintenance dose: 75 mg PO 24 hourly x 12 months
With fibrinolytic therapy:
Loading dose ≤75 years old: 300 mg PO followed by
Maintenance dose: 75 mg PO 24 hourly x 12 months
No loading dose for >75 years old		 Adverse Reactions
  • GI effects (abdominal pain, vomiting, dyspepsia, constipation); CV effects (chest pain, edema, hypertension); Hematologic effects (purpura, epistaxis, hemorrhage); Dermatologic effects (rash, pruritus); Neuromuscular effects (arthralgia, back pain); Hepatic effects (LFT abnormalities)
Special Instructions
  • Contraindicated in patients with active bleeding
  • Concurrent use of drugs known to inhibit CYP2C19 (eg Omeprazole, Esomeprazole, Cimetidine, Fluconazole, Ketoconazole, Voriconazole, Etravirine, Felbamate, Fluoxetine, Fluvoxamine and Ticlopidine) should be avoided
    • Separating the time of administration between the drugs does not reduce the chance of interaction
  • Use with caution in patients with liver impairment
Prasugrel Co-administered with Aspirin:
Loading dose: 60 mg PO followed by
Maintenance dose:
<60 kg: 5 mg PO 24 hourly x 12 months
≥60 kg: 10 mg PO 24 hourly x 12 months		 Adverse Reactions
  • GI effects (nausea/vomiting, diarrhea); Dermatologic effect (rash); Hepatic effects (elevated LFT, rarely hepatitis and cholestatic jaundice); Hematologic effects (neutropenia, thrombotic thrombocytopenic purpura, agranulocytosis, hemorrhage)
Special Instructions
  • Contraindicated in patients with active pathologic bleeding and hemorrhagic diathesis, patients with history of stroke or TIA and in severe hepatic impairment
  • Use with caution in patients with renal and moderate hepatic impairment or when combining with Warfarin, Heparin, fibrinolytics, NSAIDs and other drugs that increase the risk of bleeding
Ticagrelor Co-administered with Aspirin:
Loading dose: 180 mg PO followed by
Maintenance dose: 90 mg PO 12 hourly x 12 months
When an extended treatment is required for patients with a history of MI of at least 1 year and a high risk of an atherothrombotic event:
60 mg PO 12 hourly 		Adverse Reactions
  • Hematologic effect (bleeding, epistaxis); Respiratory effect (dyspnea); CNS effects (headache, dizziness, vertigo); GI effects (abdominal pain, nausea/vomiting, constipation, diarrhea); Metabolic effect (hyperuricemia); Dermatologic effects (rash, pruritus); Other effect (postprocedural hemorrhage)
Special Instructions
  • Contraindicated in patients with active pathological bleeding, intracranial hemorrhage history, known allergy, or severe hepatic impairment
  • Use with caution in patients with increased risk for bradycardia, moderate hepatic impairment
  • Avoid abrupt discontinuation of therapy or therapy lapses
Triflusal 600-900 mg/day PO in single or divided doses Adverse Reactions
  • GI effects (dyspepsia, abdominal pain, nausea/vomiting, flatulence, constipation); Other effects (headache, anorexia)
Special Instructions
  • Contraindicated in patients with active bleeding or peptic ulcer and those with salicylate hypersensitivity
  • Use with caution in patients with renal or hepatic impairment, increased risk of bleeding from trauma or other pathologic conditions, or ASA- or other NSAID-induced lesions
1Combinations of Aspirin/Glycine and Aspirin/Clopidogrel are available. Please see the latest MIMS for specific formulations and prescribing information.
2Combination with Rosuvastatin is available. Please see the latest MIMS for specific formulations and prescribing information.

Beta-Blockers

Drug Dosage Remarks
Atenolol Start within 12 hours of onset of chest pain:
First dose: 5-10 mg slow IV injection at 1 mg/min
Second dose: If tolerated, may give 50 mg PO after 15 minutes
Subsequent dose: 50 mg PO after 12 hours after IV injection followed by:
Maintenance dose (12 hours after IV Atenolol injection): 100 mg PO 24 hourly or divided 12 hourly 		Adverse Reactions
  • CNS effects (fatigue, depression, dizziness, confusion, sleep disturbances); CV effects (HF, heart block, coldness of extremities, male impotence); Respiratory effects (bronchospasm in susceptible patients and drugs with beta1 selectivity should be used with caution in these patients); GI effects (nausea/vomiting, diarrhea, constipation); Metabolic effects (can produce hyper- or hypoglycemia, changes in serum cholesterol and triglycerides)
Special Instructions
  • Monitor HR, BP and ECG during IV administration of Atenolol and Metoprolol
  • Contraindicated in severe bradycardia, SBP <100 mmHg, pre-existing high degree of AV block, sick sinus syndrome and severe, unstable LV failure, pulmonary congestion with crackles beyond the bases, signs of peripheral hypoperfusion
  • Use with caution in patients with bronchospasm, asthma or obstructive airway diseases, 1st-degree block, depression, peripheral vascular disease and patients on Insulin
  • Beta-blockers may mask the symptoms of hyperthyroidism and of hypoglycemia and may aggravate psoriasis
  • Patients on long-term treatment should not discontinue abruptly; should discontinue gradually over 1-2 weeks
Bisoprolol1 1.25 mg PO 24 hourly
May increase to 2.5 mg after a week if tolerated then increase gradually at 1–4-week intervals
Max dose: 10 mg/day
Carvedilol LV dysfunction after MI:
Immediate-release:
Initial dose: 6.25 mg PO 12 hourly, may be increased after 3-10 days, if tolerated, to 12.5 mg PO 12 hourly
Max dose: 25 mg PO 12 hourly
Extended-release:
Initial dose: 20 mg PO 24 hourly, may be increased after 3-10 days, if tolerated, to 40 mg PO 24 hourly 
Max dose: 80 mg PO 24 hourly
Labetalol Hypertensive episodes following MI:
IV infusion started at 15 mg/hr and gradually increased to max of 120 mg/hr, depending on control of BP
Metoprolol Start within 12 hours of onset of chest pain:
5 mg IV over 2 minutes
May repeat giving up to total of 15 mg IV at 2-minute intervals
If full IV dose is tolerated, initiate 15 minutes after the last IV dose: 50 mg PO 6 hourly x 48 hours
Maintenance dose: 100 mg PO 12 hourly
If full IV dose is not tolerated, initiate 15 minutes after the last IV dose: 25-50 mg PO 6 hourly
Late treatment (>12 hours after onset of chest pain): 
100 mg PO 12 hourly x at least 3 months             
Propranolol Late treatment (starting 5-21 days after MI):
40 mg PO 6 hourly x 2-3 days followed by 80 mg PO 12 hourly or 180-240 mg/day PO in divided doses
1Combination with Perindopril is available. Please see the latest MIMS for specific formulations and prescribing information.

Calcium Antagonists

Drug Dosage Remarks
Benzothiazepine 
Diltiazem Regular-release: 
30-80 mg PO 6 hourly or
30-120 mg PO 8 hourly
Extended-release
120-480 mg PO 24 hourly 		 Adverse Reactions
  • CV effects (AV block, hypotension, peripheral edema, flushing, bradycardia); GI effects (constipation, nausea); CNS effects (headache, dizziness)
Special Instructions
  • Contraindicated in patients with overt decompensated heart failure, cardiogenic shock, severe bradycardia, sick sinus syndrome, hypotension 2nd- or 3rd-degree AV block (without a functioning pacemaker)
  • Use with caution in patients with bradycardia, 1st-degree AV block, renal or hepatic impairment
 Phenylalkylamine
 Verapamil Regular-release: 
80-160 mg PO 8 hourly
Extended-release:
120-480 mg PO 24 hourly 

Glycoprotein IIB/IIIA Inhibitors

Drug Dosage Remarks
Abciximab For the prevention of acute ischemic complications related to PCI:
In conjunction with Heparin and Aspirin
250 mcg/kg as IV bolus injection (over 1 minute) to be given 10-60 minutes prior to PCI
Followed by 0.125 mcg/kg/min as a continuous IV infusion x 12 hours
Max dose: 10 mcg/min
 Adverse Reactions
  • Hematologic effects (bleeding, thrombocytopenia); GI effects (nausea/vomiting); CV effects (hypotension, bradycardia, etc); CNS effects (headache, confusion, dizziness, abnormal vision, dysphonia, fever); Other effects (pain in the extremities, peripheral edema, hypersensitivity reactions)
Special Instructions
  • Contraindicated in patients with active bleeding, recent (<6 weeks) GI or GU bleeding of clinical significance, history of CVA within the past 2 years or CVA with neurologic deficit, bleeding diathesis, thrombocytopenia, anticoagulant use within past 7 days unless prothrombin time (PT) ≤1.2, recent (<6 weeks) recent surgery or trauma, intracranial neoplasm, arteriovenous malformation, aneurysm, severe hypertension, history of vasculitis, use of IV Dextran before percutaneous transluminal coronary angioplasty (PTCA) or intent to use IV Dextran, severe renal or hepatic impairment
  • Use with caution in patients <75 kg, age >65 years old with history of GI disease and those receiving fibrinolytics
  • Monitor platelet counts prior to therapy, 2-4 hours after bolus and at 24 hours
Eptifibatide STEMI patients who will undergo primary PCI:
180 mcg/kg (max dose: 22.6 mg) IV bolus over 1-2 minutes followed by 2 mcg/kg/min (max dose: 15 mg/hr) continuous IV infusion 18-24 hours after PCI or until hospital discharge, whichever is earlier
Give second IV bolus of 180 mcg/kg 10 minutes after first IV bolus
A minimum of 12 hours of infusion is recommended
If CABG is to be performed:
Discontinue at least 2-4 hours prior to procedure 		Adverse Reactions
  • Hematologic effects (bleeding, thrombocytopenia); CV effect (hypotension); Hypersensitivity reactions (anaphylaxis, rash, urticaria)
Special Instructions
  • Contraindicated in patients with active bleeding (except menstrual bleeding), or active abnormal bleeding within the last 30 days, history of stroke within last 30 days, history of hemorrhagic stroke, major surgery within last 6 weeks, history of bleeding diathesis, thrombocytopenia, PT >1.2 or international normalized ratio (INR) ≥2, severe hypertension, major trauma, severe renal impairment
  • Use with caution in patients with moderate renal impairment, hepatic dysfunction
Tirofiban Undergoing primary PCI:
Loading dose:
25 mcg/kg IV bolus over 3-5 minutes
Followed by 0.15 mcg/kg/min continuous IV infusion
Initiate treatment at the time of PCI or at the time of STEMI diagnosis, and continue x 12-24 hours
Max duration: 48 hours		 Adverse Reactions
  • Hematologic effects (bleeding, thrombocytopenia); GI effect (nausea); Dermatologic effect (rash); Other effects (headache, dizziness, fever and chills, bradycardia, pelvic pain)
Special Instructions
  • Contraindicated in patients with active bleeding, history of intracranial hemorrhage, intracranial neoplasm, arteriovenous malformation or aneurysm, major surgery or trauma within the last month, history of aortic dissection, severe uncontrolled hypertension, acute pericarditis, hemorrhagic retinopathy, anemia, serious hepatic impairment
  • Use with caution in patients with recent bleeding (<1 year), known coagulopathy, platelet disorder or history of thrombocytopenia, low platelet count, history of cerebrovascular disease (<1 year), recent epidural procedure, severe CHF, cardiogenic shock
  • Use with caution in patients with severe renal impairment (Cr clearance <30 mL/min)
    • Patients with CrCl <30 mL/min: Reduce infusion by 50%
  • Monitor platelet count, hemoglobin, hematocrit prior to treatment, within 6 hours following bolus or loading dose and daily until completed

Nitrates (IV)

Drug Dosage Remarks
Glyceryl trinitrate
(Nitroglycerin,
GTN, NTG) 		Initial dose: 5 mcg/min IV infusion
Increase by 5 mcg/min every 3-5 minutes up to
20 mcg/min until some response is noted
If there is still no response at 20 mcg/min:
May increase at increments of 10-20 mcg/min every 3-5 minutes
Usual dose: 5-100 mcg/min
Max dose: 200 mcg/min 		Adverse Reactions
  • IV administration (especially if given too rapidly): May cause CV effects (severe hypotension, retrosternal discomfort, palpitations); GI effects (nausea and retching, abdominal pain); CNS effects (apprehension, restlessness, muscle twitching, syncope); Other effect (diaphoresis); Prolonged administration has been associated with methemoglobinemia
Special Instructions
  • Avoid in patients with severe hypotension, hypovolemia, marked anemia, HF due to obstruction or raised ICP due to head trauma or hemorrhage
  • Use with caution in patients with severe renal or hepatic dysfunction, hypothyroidism, malnutrition or hypothermia
  • Use caution when there is a fall of SBP <110 mmHg in normotensive patients and fall of MAP >25% in hypertensive patients
    • Close monitoring of BP and HR is necessary during IV infusion
  • Do not administer to patients who have taken phosphodiesterase type 5 inhibitors within the past 24 hours
  • The plastic equipment used for administration may absorb GTN and dosing may need to be adjusted for this
Isosorbide
dinitrate		 2-12 mg/hr IV infusion after dilution
Max dose: 20 mg/hr IV
Percutaneous transluminal coronary angioplasty: 1 mg IV bolus before balloon inflation
Max dose: 5 mg within 30 minutes
Only those approved for intracoronary use should be given

Nitrates (Oral - Short-Acting)

Drug Available Strength Dosage Remarks
Glyceryl trinitrate
(Nitroglycerin, GTN, NTG) 		400, 500 mcg sublingual (SL) tab Acute anginal attack:
300-600 mcg SL every 3-5 minutes until cessation of pain or side effects occur
Max dose: 3 doses within 15 minutes
Prophylaxis: 300-600 mcg SL 5-10 minutes prior to activity 		Adverse Reactions
  • CNS effects (headache, lightheadedness, dizziness, syncope); rarely CV effects (bradycardia, hypotension); GI effects (nausea/vomiting, bowel incontinence, xerostomia)
Special Instructions
  • Avoid in patients with severe hypotension, hypovolemia, marked anemia, HF due to obstruction or raised intracranial pressure due to head trauma or hemorrhage
  • Use with caution in patients with severe renal or hepatic dysfunction, hypothyroidism, malnutrition or hypothermia
  • Co-administration with phosphodiesterase type 5 inhibitors (eg Sildenafil, Vardenafil, Tadalafil) is contraindicated
Acute attacks:
  • Instruct patient to sit down and use medication at first sign of angina attack
  • Patient should be made aware that dose may be repeated in 5-10 minutes with max of 3 doses given
  • Patient should seek emergency medical treatment if pain does not subside
400 mcg/dose SL spray Acute anginal attack:
1-2 sprays (400-800 mcg) SL every 5 minutes until cessation of pain or side effects occur
Max dose: 3 doses within 15 minutes
Prophylaxis: 1-2 sprays SL 5-10 minutes prior to activity
500 mcg buccal tab Acute anginal attack:
2-5 mg 8 hourly, placed between gum and upper lip
If accidentally swallowed, place another tab in buccal cavity
Isosorbide dinitrate 5, 10 mg SL tab Acute anginal attack:
2.5-10 mg SL every 5-10 minutes until cessation of pain or side effects occur
Max dose: 3 doses within 15-30 minutes
Prophylaxis: 2.5-10 mg SL prior to activity
1.25 mg/dose SL spray Acute anginal attack:
1-3 sprays (1.25-3.75 mg) SL at 30-second interval between sprays; do not inhale medication
Prophylaxis: 1-3 sprays (1.25-3.75 mg) SL prior to activity at 30-second interval between sprays; do not inhale medication

Opioid (IV)

Drug Dosage Remarks
Morphine Initial dose: 2-4 mg IV followed by 2-8 mg IV every 5-30 minutes, if needed
or
Initial dose: 1-5 mg IV followed by 1-5 mg IV every 5-30 minutes, if needed 		Adverse Reactions
  • GI effects (nausea/vomiting, constipation); CV effects (hypotension, bradycardia); Respiratory effect (respiratory depression); CNS effects (drowsiness, confusion, changes in mood)
  • Diamorphine may cause less nausea and hypotension
Special Instructions
  • Avoid IM injection
  • Antiemetics may be administered concurrently with opioids
  • If Morphine-induced respiratory depression occurs, Naloxone IV can be administered
  • Contraindicated in respiratory depression, obstructive airways disease
  • Use with caution in acute alcoholism, convulsive disorders, head injuries and if intracranial pressure is raised, patients with hypothyroidism, adrenocortical insufficiency, asthma, renal or hepatic impairment, prostatic hyperplasia, hypotension, shock, inflammatory or obstructive bowel disorders or myasthenia gravis

Thrombolytic Agents (IV)

Drug Dosage Remarks
Fibrin-Specific Agents
Alteplase
(rt-PA)		 Initiated within 6 hours of symptom onset:
<65 kg: 15 mg IV bolus
Followed by: 0.75 mg/kg IV infusion over 30 minutes (not exceeding 50 mg) then 0.5 mg/kg IV infusion over 60 minutes (not exceeding 35 mg)
≥65 kg: 15 mg IV bolus
Followed by: 50 mg IV infusion over 30 minutes then 35 mg IV infusion over 60
minutes (total 100 mg over 90 min)
Initiated 6-12 hours after symptom onset:
<65 kg: 10 mg IV bolus
Followed by: IV infusion up to a total dose of 1.5 mg/kg
over 3 hours
≥65 kg: 10 mg IV bolus
Followed by: 50 mg IV infusion over 60 minutes then 4 infusions each of 10 mg IV over 30 minutes (total 100 mg over 3 hours)
Max dose: 1.5 mg/kg in patients <65 kg (100 mg)
Administer UFH as ancillary to fibrinolytic therapy:
60 u/kg IV bolus (max dose: 4,000 u) followed by: 12 u/kg/hr IV infusion (max dose: 1,000 u/hr) x 48 hours
Adjust to maintain target PTT: 50-70 seconds		 Adverse Reactions
  • Hematologic effects (hemorrhage especially from puncture sites, severe internal bleeding, intracranial hemorrhage); Allergic reactions (rashes, flushing, urticaria and rarely anaphylactic and serum sickness-like symptoms); GI effects (nausea/vomiting); Other effects (fever, chills with back and abdominal pain)
  • Infusion may be associated with hypotension (both direct and as a result of reperfusion), bradycardia and arrhythmias may occur because of reperfusion
  • Break-up of clots may occasionally cause emboli elsewhere hence the need for Heparin prophylaxis
Special Instructions
  • See Evaluation section for specific inclusion, warnings and contraindications
Reteplase
(r-PA)		 10 u IV injection bolus over 2 minutes x 2 doses given 30 minutes apart within 12 hours of symptom onset
Administer UFH as ancillary to fibrinolytic therapy:
60 u/kg IV bolus (max dose: 4,000 u) followed by: 12 u/kg/hr IV infusion (max dose: 1,000 u/hr) x 48 hours
Adjust to maintain target PTT: 50-70 seconds
Tenecteplase
(TNK-tPA)		 Give as single IV bolus injection over 5-10 seconds as follows:
<60 kg: 30 mg (6,000 u)
60 to <70 kg: 35 mg (7,000 u)
70 to <80 kg: 40 mg (8,000 u)
80 to <90 kg: 45 mg (9,000 u)
≥90 kg: 50 mg (10,000 u)
Max dose: 50 mg (10,000 u)
Administer UFH as ancillary to fibrinolytic therapy:
60 u/kg IV bolus (max dose: 4,000 u) followed by: 12 u/kg/hr IV infusion (max dose: 1,000 u/hr) x 48 hours
Adjust to maintain target PTT: 50-70 seconds
 Non-fibrin-specific Agent
 Streptokinase Short term: 1.5 MU in 100 mL of 5% dextrose or 0.9% saline given by IV infusion over 30-60 minutes
or
10,000-30,000 IU intracoronary bolus over 15 seconds to 2 minutes
Maintenance dose: 2,000-4,000 IU/min over 30-60 minutes
Administer UFH as ancillary to fibrinolytic therapy:
UFH: 60 units/kg IV bolus (max dose: 4,000 units), followed by 12 units/kg/hr IV infusion

Adverse Effects

  • Hematologic effects (hemorrhage especially from puncture sites, severe internal bleeding, intracranial hemorrhage); Allergic reactions (rashes, flushing, urticaria and rarely anaphylactic and serum sickness-like symptoms); GI effects (nausea/vomiting); Other effects (fever, chills with back and abdominal pain)

Special Instructions

  • See Evaluation section for specific inclusion, warnings and contraindications
  • Anti-streptokinase antibodies are formed after about 5 days after Streptokinase use
    • These antibodies may cause resistance or hypersensitivity to subsequent doses of Streptokinase
    • Recommend not to administer Streptokinase 5 days-12 months after first administration (alternative fibrinolytic may be used)

Disclaimer

All dosage recommendations are for non-pregnant and non-breastfeeding women, and non-elderly adults with normal renal and hepatic function unless otherwise stated.  
Not all products are available or approved for above use in all countries.  
Products listed in the Drug Summary are based on indications stated in the locally approved product monographs.   
Please refer to local product monographs in Related MIMS Drugs for country-specific prescribing information.