Acute Coronary Syndromes w/out Persistent ST-Segment Elevation Drug Summary

Last updated: 26 September 2025

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Antiplatelet Agents

Content on this page:

Antiplatelet Agents

Antiplatelet Agents


Drug Dosage Remarks
Aspirin1 Loading dose: Chew 150-325 mg non-enteric-coated x 1 dose followed by: 
Maintenance dose: 75-100 mg PO 24 hourly
Maintenance dose if combined with Clopidogrel/Ticagrelor:
75-100 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 (increased bleeding time, decreased platelet adhesiveness, hemorrhage); Hypersensitivity reactions
Special Instructions
  • Contraindicated in patients with active pathological bleeding (eg peptic ulcer, intracranial hemorrhage), known allergy, hemophilia, hemorrhagic disorders, severe renal or hepatic impairment
  • Ensure that benefit outweighs the risk prior to use in combination with Warfarin, Heparin, thrombolytics, NSAIDs and other drugs that increase the risk of bleeding
Cangrelor 30 mcg/kg IV bolus prior to PCI followed by 4 mcg/kg/minute 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 pathological bleeding
  • An oral P2Y12 platelet inhibitor must be administered after Cangrelor infusion to maintain platelet inhibition
Clopidogrel Co-administered with Aspirin:
Loading dose: 300 mg PO followed by 75 mg PO 24 hourly 
PCI for ACS patients:
300-600 mg PO loading dose prior to or at the time of PCI, followed by 75 mg PO 24 hourly		 Adverse Reactions
  • Hematologic effects (hemorrhage, purpura, epistaxis; blood dyscrasias, including neutropenia, thrombotic thrombocytopenic purpura have occurred); Dermatologic effects (rash, pruritus); GI effects (abdominal pain, nausea/vomiting, dyspepsia, constipation)
Special Instructions
  • Contraindicated in patients with active bleeding or severe liver impairment
  • 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 
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 bleeding, hemorrhagic diatheses, history of leukopenia, thrombocytopenia or agranulocytosis, history of stroke or TIA, severe hepatic impairment
  • Use with caution in patients with hepatic impairment
  • Use with caution when combining with Warfarin, Heparin, thrombolytics, 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); Respiratory effect (dyspnea); CNS effects (headache, dizziness); ENT effects (epistaxis, vertigo); GI effects (abdominal pain, nausea/vomiting, constipation, diarrhea); Metabolic effect (hyperuricemia); Dermatologic effects (rash, pruritus); Other effect (post-procedural 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
  • Avoid abrupt discontinuation of therapy or therapy lapses
Ticlopidine  250 mg PO 12-24 hourly   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 bleeding, hemorrhagic diatheses, patients with history of leukopenia, thrombocytopenia or agranulocytosis
  • Use with caution in patients with hepatic impairment and when combining with Warfarin, Heparin, thrombolytics, NSAIDs and other drugs that increase the risk of bleeding
  • Consider discontinuation 10 days prior to surgery prior to surgery
  • CBC with differential and platelet counts should be taken at the start of treatment then every 2 weeks for the first 3 months of therapy and within 15 days of discontinuation (if discontinued within the first 3 months of treatment)
Triflusal  600 mg/day PO in single or divided doses or
900 mg/day PO in divided doses  		 Adverse Reactions
  • GI effects (dyspepsia, nausea/vomiting, abdominal pain, constipation, flatulence); Other effects (anorexia, headache)
Special Instructions
  • Contraindicated in patients with hypersensitivity to other salicylates, active, antecedent or complicated peptic ulcer or other active pathological bleeding
  • Use with caution in patients with renal or hepatic impairment, increased risk of bleeding from trauma or other pathological conditions; ASA- or other NSAIDs-induced lesions
  • Discontinue use 7 days prior to surgery
1Combinations of Aspirin/Glycine and Aspirin/Clopidogrel are available. Please see the latest MIMS for specific formulations and prescribing information.

Beta-blockers


Drug Dosage Remarks
Acebutolol Initial dose: 200 mg PO 12 hourly or 400 mg PO 24 hourly or 300 mg PO 8 hourly 
Max dose: 1,200 mg/day		 Adverse Reactions
  • CNS effects (fatigue, depression, dizziness, confusion, sleep disturbances); CV effects (heart failure, 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
  • Contraindicated in severe bradycardia, pre-existing high degree of AV block, sick sinus syndrome and severe, unstable LV failure
  • Use with caution in patients with bronchospasm, asthma or obstructive airway diseases, 1st-degree block, depression, PVD, and patients on insulin
  • Beta-blockers may mask the symptoms of hyperthyroidism and hypoglycemia and may aggravate psoriasis
  • Patients on long-term treatment should not discontinue abruptly; should discontinue gradually over 1-2 weeks
Alprenolol 200-400 mg/day PO in divided doses
Atenolol1 50-100 mg PO 24 hourly or 50 mg PO 12 hourly 
Max dose: 200 mg/day
Bisoprolol Initial dose: 5 mg PO 24 hourly 
May increase to 10 mg PO 24 hourly
Max dose: 20 mg/day
Bopindolol  0.5-2 mg PO 24 hourly 
Carvedilol Initial dose: 12.5 mg PO 12 hourly x 2 days 
Then increase to 25 mg PO 12 hourly 
May increase dose every 2 weeks thereafter, if required up to: 
Max dose: 100 mg/day
Celiprolol
 200-400 mg PO 24 hourly 
Labetalol  Initial dose: 100 mg PO 12 hourly 
May increase dose after 2 weeks to 200-400 mg/day PO 
Max dose: 2,400 mg/day
Metoprolol Regular-release: 50-100 mg PO 8-12 hourly 
Max dose: 400 mg/day 
Extended-release: 25-100 mg PO 24 hourly 
Max dose: 400 mg/day
Nadolol Initial dose: 40 mg PO 24 hourly 
May increase dose weekly up to 160 mg/day until adequate response is achieved 
Max dose: 240 mg/day
Oxprenolol
 80-160 mg/day PO in 2-3 divided doses
May increase dose every 1-2 weeks until adequate response is achieved
Max dose: 320 mg/day
Pindolol 2.5-5 mg PO 8 hourly 
May increase up to 10 mg PO 8 hourly
Max dose: 40 mg/day
Propranolol  Regular-release: 
Initial dose: 20-40 mg PO 8-12 hourly 
May increase at weekly interval according to patient response 
Max dose: 240 mg/day 
Extended-release: 
Initial dose: 80 mg PO 24 hourly 
Max dose: 320 mg/day 
Sotalol Initial dose: 80-160 mg PO 24 hourly or divided 12 hourly
May increase dose gradually at 2-3 day intervals to 80-160 mg PO 12 hourly
1Atenolol is available in combination with Nifedipine. Please see the latest MIMS for specific formulations and prescribing information.

Calcium Antagonists


Drug Dosage Remarks
Benzothiazepine
Diltiazem Regular-release:
Initial dose: 30-60 mg PO 6-8 hourly 
May gradually increase to 360 mg/day PO in divided doses or up to 480 mg/day, if needed 
Extended-release:
120-480 mg PO 24 hourly 
or 
1-5 mcg/kg/min IV drip infusion 
Dose should be started low and may be adjusted depending on symptoms
Max dose: 5 mcg/kg/minute		 Adverse Reactions
  • CV effects (depression of cardiac function, hypotension, worsening heart failure, edema, flushing, bradycardia); GI effect (constipation); CNS effects (headache, dizziness)
  • HR-modulating calcium antagonists (eg Diltiazem, Gallopamil and Verapamil): AV dissociation, AV block, bradycardia and sinus node dysfunction
  • Short-acting dihydropyridine agents should be avoided because they have the potential to enhance risk of adverse cardiac events
Special Instructions
  • Contraindicated in patients with overt decompensated heart failure, though vasoselective dihydropyridines (eg Amlodipine, Felodipine) are tolerated in patients with decreased LVEF
  • HR-modulating calcium antagonists are contraindicated in patients with bradycardia, sinus node dysfunction and AV nodal block
Dihydropyridines
Amlodipine Initial dose: 2.5-5 mg PO 24 hourly 
May increase to 10 mg PO 24 hourly if needed
Max dose: 10 mg/day 

Adverse Reactions

  • CV effects (depression of cardiac function, hypotension, worsening heart failure, edema, flushing, bradycardia); GI effect (constipation); CNS effects (headache, dizziness)
  • HR-modulating calcium antagonists (eg Diltiazem, Gallopamil and Verapamil): AV dissociation, AV block, bradycardia and sinus node dysfunction
  • Short-acting dihydropyridine should be avoided because they have the potential to enhance risk of adverse cardiac events

Special Instructions

  • Contraindicated in patients with overt decompensated heart failure, though vasoselective dihydropyridines (eg Amlodipine, Felodipine) are tolerated in patients with decreased LVEF
  • HR-modulating calcium antagonists are contraindicated in patients with bradycardia, sinus node dysfunction and AV nodal block
Benidipine 4 mg PO 12 hourly
Felodipine Initial dose: 2.5-5 mg PO 24 hourly 
Max dose: 10 mg/day
Nicardipine
 Regular-release: 
Initial dose: 10-20 mg PO 8 hourly 
May increase to 20-40 mg PO 8 hourly 
Extended-release: 40 mg PO 12 hourly
Nifedipine1  Regular-release: 
Initial dose: 5-10 mg PO 8 hourly 
May increase to 20 mg PO 8 hourly
Extended-release:
Initial dose: 40 mg PO 24 hourly or 10-40 mg PO 12 hourly  
Phenylalkylamines 
Gallopamil 
 Regular-release: 25-50 mg PO 6-12 hourly 
Max dose: 200 mg/day 
Verapamil  Regular-release:
Initial dose: 40-80 mg PO 6-8 hourly 
Max dose: 480 mg/day 
Extended-release: 120-480 mg PO 24 hourly 
Combination Product
Amlodipine/Perindopril/Atorvastatin  Amlodipine 5 mg/Perindopril 5 mg/Atorvastatin 10 mg 
Amlodipine 5 mg/Perindopril 5 mg/Atorvastatin 20 mg
Amlodipine 5 mg/Perindopril 10 mg/Atorvastatin 20 mg
Amlodipine 10 mg/Perindopril 10 mg/Atorvastatin 20 mg
Amlodipine 10 mg/Perindopril 10 mg/Atorvastatin 40 mg
1 tab PO 24 hourly

Adverse Reactions

  • GI effects (constipation, dyspepsia, nausea/vomiting, diarrhea); CNS effects (headache, dizziness, paresthesia, asthenia); Musculoskeletal effects (myalgia, arthralgia, back pain, joint and ankle swelling); Metabolic effects (hyperglycemia, abnormal LFT, increased blood creatine); CV effects (palpitations, hypotension); Other effects (nasopharyngitis, hypersensitivity, epistaxis, flushing, edema, visual impairment, tinnitus, cough, dyspnea, rash, pruritus)

Special Instructions

  • Use with caution in patients with collagen vascular disease, on immunosuppressant therapy, Allopurinol or Procainamide
  • Increased risk of hypotension, hyperkalemia, decreased renal function; interstitial lung disease on long-term therapy
  • Monitor glycemic control and LFTs periodically
  • Avoid in patients with hypersensitivity, liver disease, severe hypotension, hemodynamically unstable heart failure, history of angioedema, significant bilateral renal artery stenosis; on Sacubitril/Valsartan
1Nifedipine is available in combination with Atenolol. Please see the latest MIMS for specific formulations and prescribing information.

Direct Thrombin Inhibitors


Drug Dosage Remarks
Argatroban Heparin-induced thrombocytopenia:
2 mcg/kg/minute via continuous IV infusion Adjusted to maintain the aPTT at 1.5-3 times the initial baseline value		 Adverse Reactions
  • CV effects (chest pain, hypotension); GU effects (GU tract hemorrhage including hematuria) 
Special Instructions
  • ACT should be checked 5-10 minutes after bolus infusion
  • Contraindicated in patients with active bleeding
  • Use with caution in patients with hepatic dysfunction 
Bivalirudin 0.1 mg/kg IV bolus followed by 0.25 mg/kg/hr IV infusion
PCI: Administer an additional 0.5 mg/kg IV bolus before PCI then increase the infusion to 1.75 mg/kg/hr during PCI
CABG: Stop infusion 1 hour pre-op and treat with UFH		 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
  • Medically managed patients may continue infusion for up to 72 hours
  • 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


Drug Dosage Remarks
Fondaparinux UA/NSTEMI:
2.5 mg SC 24 hourly up to 8 days or until hospital discharge		 Adverse Reactions
  • Hematologic effects (bleeding, anemia); GI effects (nausea/vomiting, constipation, diarrhea); CV effects (edema, hypotension, chest pain, PCI guiding-catheter thrombosis); CNS effects (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
Rivaroxaban
Prevention of atherothrombotic events after ACS with elevated cardiac biomarkers:
2.5 mg PO 12 hourly 
Taken with daily dose of Aspirin 75-100 mg, or daily dose of Aspirin 75-100 mg plus daily dose of Clopidogrel 75 mg or standard daily dose of Ticlopidine		 Adverse Reactions
  • Hematologic effects (hemorrhage, anemia, hematoma); Hepatic effect (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 (fever, peripheral edema, postprocedural hemorrhage)
Special Instructions
  • Contraindicated in patients with clinically significant active bleeding, hepatic disease associated with coagulopathy that can lead to relevant risk of bleeding
  • Use with caution in patients with hemorrhagic risk, severe HTN, bronchiectasis, lactose or galactose intolerance, and moderate-severe renal impairment

Glycoprotein IIB/IIIA Inhibitors


Drug Dosage Remarks
Abciximab 250 mcg/kg as IV bolus injection (over 1 minute) 
Followed by 0.125 mcg/kg/minute as a continuous IV infusion 
Max dose: 10 mcg/min
For stabilization of UA:
Bolus dose followed by IV infusion should be started up to 24 hours prior to the possible intervention and then stopped 12 hours after intervention 
For the prevention of ischemic cardiac complications related to PCI: Start the bolus dose 10-60 minutes prior to the intervention followed by the infusion for 12 hours 		 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 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, are >65 years old, history of GI disease and those receiving thrombolytics
  • Monitor platelet counts prior to therapy, 2-4 hours after bolus and at 24 hours
Eptifibatide UA/NSTEMI: 180 mcg/kg IV bolus over 1-2 minutes
Followed by 2 mcg/kg/min continuous IV x 72 hours or until discharge
If PCI is performed during therapy: Continue for 18-24 hours post-PCI or until discharge 
If CABG is to be performed:
Discontinue prior to procedure 
Max duration: 96 hours
PCI without prior treatment for UA/NSTEMI: 180 mcg/kg IV bolus x 2 doses 10 min apart
Start continuous IV infusion after first bolus: 2 mcg/kg/min IV x 18-24 hours or until discharge 		 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
UA/NSTEMI: 0.4 mcg/kg/min IV x 30 minutes
Followed by 0.1 mcg/kg/min IV infusion x at least 48 hours
Infusion can be continued through angiography and continued x 12-24 hours post-angioplasty/atherectomy
Max duration: 108 hours
Angioplasty/atherectomy without prior treatment for UA/NSTEMI: 
In combination with Heparin, as an initial bolus of 10 mcg/kg IV administered over 3 minutes immediately prior to procedure
Followed by 0.15 mcg/kg/min IV infusion x 36 hours  
 Adverse Reactions
  • Hematologic effects (bleeding, thrombocytopenia); GI effect (nausea); Other effects (headache, dizziness, fever and chills) 
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)
  • Monitor platelet count, hemoglobin, hematocrit prior to treatment, within 6 hours following bolus or loading dose and daily until completed

Low-Molecular-Weight-Heparins (LMWH)


Drug Dosage Remarks
Dalteparin UA: 120 IU/kg SC 12 hourly x 5-8 days with low-dose Aspirin  Adverse Reactions
  • Hematologic effects (hemorrhage, thrombocytopenia); rarely hypersensitivity reactions (anaphylaxis)
Special Instructions
  • Contraindicated in patients with active major bleeding, patients with positive in vitro test for antiplatelet Ab to the specific Heparin, prosthetic heart valves, acute bacterial endocarditis and drug-induced thrombocytopenia
  • 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 ophthalmologic 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
Enoxaparin UA/non-Q-wave MI: 1 mg/kg (100 IU/kg) SC 12 hourly x 2-8 days with low-dose Aspirin 
Nadroparin UA/non-Q-wave MI: In combination with Aspirin:
Initial dose: 86 IU/kg IV bolus injection
Subsequent doses are given SC 12 hourly x 6 days

Nitrates (IV)


Drug Dosage Remarks
Glyceryl trinitrate
(Nitroglycerin, GTN, NTG)		 Initial dose: 5-10 mcg/min IV infusion after dilution 
Increase by 5 mcg/min every 3-5 minutes until some response is noted 
If there is still no response at 20 mcg/min:
May increase at increments of 10 mcg/min and later if required, 20 mcg/min increments can be used 
Usual dose: 5-100 mcg/min
Max dose: 200 mcg/min or
Initial dose: 10 mcg/min slow IV infusion 
May increase in increments of 5-10 mcg/min at
30-minutes intervals according to patient response  		 Adverse Reactions
  • IV administration (especially if given too rapidly): May cause CV effects (severe hypotension, retrosternal discomfort, flushing, tachycardia); GI effects (nausea and retching, abdominal pain); CNS effects (headache, dizziness, 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, heart failure due to obstruction or raised intracranial pressure due to head trauma or hemorrhage
  • Use with caution when there is a fall of SBP <110 mmHg in normotensive patients, and fall of mean arterial pressure >25% in hypertensive patients
  • Use with caution in patients with severe renal or hepatic dysfunction, hypothyroidism, malnutrition or hypothermia
  • Close monitoring of HR and BP is necessary during IV infusion
  • Do not administer to patients who have taken phosphodiesterase inhibitors within the past 24 hours 
  • The plastic equipment used for administration may absorb GTN and dosing may need to be adjusted for this
  • Nitrate tolerance usually develops with long-term use and dosing with adequate nitrate-free interval is recommended
Isosorbide dinitrate 2-12 mg/hr IV infusion after dilution 
Max dose: 20 mg/hr IV  

Nitrates (Oral - Long-Acting)


Drug Dosage Remarks
Glyceryl trinitrate 
(Nitroglycerin, GTN, NTG)		 Extended-release cap: 2.5 mg PO 8-12 hourly or
5 mg PO 8-12 hourly in severe cases 
Extended-release tab:
Initial dose: 2.6 mg PO 12 hourly
May increase to 6.4 mg PO 8-12 hourly 
(Dose will depend on formulation) 		 Adverse Reactions
  • CNS effects (headache which usually decreases with long-term administration, lightheadedness, dizziness, syncope); rarely CV effects (bradycardia, hypotension); GI effects (nausea/vomiting, bowel incontinence, xerostomia)
  • Nitrate tolerance usually develops with long-term use and dosing with adequate nitrate-free interval is recommended
Special Instructions
  • Dosing to overcome nitrate tolerance: Recommend giving last dose of short-acting agents at 7 PM; administer 2x/day rather than 4x/day; administer extended-release preparations once in the morning
  • Avoid in patients with severe hypotension, hypovolemia, marked anemia, heart failure 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 inhibitors (eg Sildenafil) are contraindicated
Isosorbide dinitrate 20-120 mg/day PO in divided doses 
May increase according to patient response
Max dose: 240 mg/day 
Extended-release: 20 mg PO 12 hourly or
40 mg PO 24 hourly
Isosorbide 5-mononitrate
(Isosorbide mononitrate)
 Regular-release:
Initial dose: 10 mg PO 12 hourly 
May increase to 20-40 mg PO 8-12 hourly depending on formulation
Max dose: 120 mg/day
Extended-release: 30-120 mg PO 24 hourly depending on formulation  

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, heart failure 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 inhibitors (eg Sildenafil) is contraindicated within 24 hour interval after taking a Nitrate preparation
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 tablet 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 or 5-10 mg PO 2-3 hourly 
1.25 mg/dose or spray
 Acute anginal attack: 
1-3 sprays (1.25-3.75 mg) SL at 30 seconds interval between sprays. Do not inhale medication 
Prophylaxis: 1-3 sprays (1.25-3.75 mg) SL prior to activity at 30 seconds interval between sprays. Do not inhale medication 

Nitrates (Topical - Long-Acting)


Drug Available Strength Dosage Remarks
Glyceryl trinitrate
(Nitroglycerin, GTN, NTG)		 5 mg/24 hr patch 
(0.2 mg/hr)
10 mg/24 hr patch (0.4 mg/hr)

5-20 mg/24 hr (1-2 patches) applied 24 hourly usually in the morning 
To prevent tolerance: Patch-free period of 8-12 hours, usually at night every 24 hours is recommended 

Adverse Reactions

  • CNS effects (headache which usually decreases with long-term administration, lightheadedness, dizziness, syncope); rarely CV effects (bradycardia, hypotension); GI effects (nausea/vomiting, bowel incontinence, xerostomia)
  • Nitrate tolerance usually develops with long-term use and dosing with adequate nitrate-free interval is recommended
  • Topical preparations: Contact dermatitis, local irritation and erythema
Special Instructions
  • Dosing to overcome nitrate tolerance: Recommend giving last dose of short-acting agents at 7 PM; administer 2x/day rather than 4x/day; administer extended-release preparations once in the morning
  • Avoid in patients w/ severe hypotension, hypovolemia, marked anemia, heart failure 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 inhibitors (eg Sildenafil) are contraindicated 

Opioid (IV)


Drug Dosage Remarks
Morphine MI: 10 mg IV at a rate of
2 mg/min followed by a further dose of 5-10 mg IV, if necessary
Use half dose in elderly
UA: 2-5 mg IV at a rate of 2 mg/min
May repeat every 5-30 minutes as needed for symptom relief 
 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 than Morphine
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 airway 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

Other Anti-anginal Drugs


Drug Dosage Remarks
3-Ketoacyl-CoA Thiolase Inhibitor
Trimetazidine 40-60 mg/day PO in divided doses or 35 mg PO 12 hourly or 60-80 mg PO 24 hourly Adverse Reactions
  • GI effects (nausea/vomiting, abdominal pain, diarrhea); CNS effects have been reported (parkinsonism, gait disorders, tremors)
Special Instructions
  • Should be taken with food
  • Contraindicated in patients with known hypersensitivity, pregnancy and lactation
Potassium Channel Activator
Nicorandil
 10-20 mg PO 12 hourly
Max dose: 30 mg 12 hourly

Adverse Reactions

  • CNS effects (headache which is usually transitory, weakness); CV effects (vasodilation, flushing, hypotension, increased HR); GI effects (nausea/vomiting, oral ulcerations)

Special Instructions

  • Avoid in patients with cardiogenic shock, LV failure with low filling pressures and hypotension
  • Use with caution in patients with low SBP, hypovolemia or acute pulmonary edema
Sodium Channel Inhibitor
Ranolazine 500 mg PO 12 hourly 
Max dose: 2 g/day

Adverse Reactions

  • CNS effects (dizziness, headache, vertigo); GI effects (constipation, nausea/vomiting, abdominal pain, dry mouth); CV effects (syncope, bradycardia, palpitations, hypotension, peripheral edema); Other effects (tinnitus, dyspnea, hematuria)

Special Instructions

  • Use with caution in patients with renal disease, in patients with history of malignant neoplasms and adenomatous polyps
  • Contraindicated in patients with significant hepatic impairment
  • Avoid co-administration with azoles, macrolides, Nefazodone, Nelfinavir, Rifampicin, Phenytoin, Phenobarbital, Carbamazepine, St John’s wort

Unfractionated Heparin (UFH)


Drug Dosage Remarks
Heparin 60 units/kg IV bolus (max dose: 4,000 units), then 12 units/kg/hr continuous IV infusion (max dose: 1,000 units/hr)
Adjust dose to maintain target anti-factor Xa concentration or aPTT
Continue infusion for 48 hours or until PCI		 Adverse Reactions
  • Hematologic effects (hemorrhage, thrombocytopenia); Rare hypersensitivity reactions (urticaria, angioedema, anaphylaxis); Other effects that may occur with long-term use (osteoporosis, alopecia)
Special Instructions
  • aPTT should be measured 6 hours after any dosage change
  • Avoid in patients with active major bleeding, patients with history of Heparin-induced thrombocytopenia
  • Use with caution in patients with hemophilia or other hemorrhagic disorders, peptic ulcer, recent cerebral hemorrhage, severe hypertension, severe liver disease, post-major trauma or recent surgery to brain, spinal or ophthalmic, 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

Disclaimer

All dosage recommendations are for 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.  

Related MIMS Drugs