Non-ST-segment elevation acute coronary syndrome, 27 therapeutic drug usage in 9 categories

Non-ST-elevation acute coronary syndrome (NSTE-ACS) is divided into non-ST-elevation myocardial infarction (NSTEMI) and unstable angina (UA), and treatment strategies include conservative drug therapy and revascularization therapy. The Guidelines for rational use of drugs at the grass-roots level for non-ST-segment elevation acute coronary syndrome provide assistance for primary general practitioners to quickly and efficiently grasp the corresponding drug principles, dosage of drugs, contraindications, adverse reactions and treatment.

Nitrates

➤ Nitroglycerin

(1) Oral: Adults take 0.25 to 0.50 mg sublingually at a time, and 1 tablet can be repeated every 5 minutes until the pain is relieved. If the pain persists after a total of 3 times in 15 minutes, you should seek medical attention immediately. Prophylactic use 5 to 10 minutes before activity or stool can avoid inducing angina.

(2) Intravenous administration: intravenous infusion, the initial dose of 5 ~ 10 μg / min, every 3 ~ 5 minutes can increase 5 ~ 10 μg / min, the upper limit of the dose is generally not more than 200 μg / min. Individual differences in patients with this drug are very large, and there is no fixed suitable dose for intravenous infusion.

➤ Isosorbide nitrate

(1) Oral: prevention of angina, 5 ~ 10 mg / time, 2 ~ 3 times / day, a total of 10 ~ 30 mg a day, due to different individual reactions, the dose needs to be individualized. Sublingual administration, 5 mg/dose for relief of symptoms.

(2) Intravenous infusion: the initial dose can start from 1 to 2 mg/h, and then adjust according to the individual needs of the patient, and the maximum dose is usually not more than 8 to 10 mg/h. However, when patients have heart failure, the dose may need to be increased to 10 mg/h, and in individual cases as high as 50 mg/h.

➤ Isosorbide mononitrate

(1) Oral: tablets, 10 to 20 mg / time, 2 to 3 times / day; sustained-release preparations, 40 ~ 50 mg / time, 1 time / day.

(2) Intravenous administration: start intravenous infusion with 1 to 2 mg/h, adjust the dose according to the response, and the maximum dose is 8~10 mg/h. Dose needs to be individualized.

Potassium channel opener

➤ Nicoldil

(1) Oral: adults 5 mg / time, 3 times / day, according to the severity of symptoms can be appropriately increased or decreased.

(2) Intravenous infusion: Nicotil is dissolved in 0.9% sodium chloride injection or 5% glucose injection to make 0.01% to 0.03% solution. Starting at 2 mg/h, the dose may be increased or decreased according to symptoms, and the maximum dose should not exceed 6 mg/h.

β receptor blockers

➤ Metoprolol

Acute myocardial infarction and UA, in the absence of contraindications, are advocated for use in the early stages, i.e., within the first few hours. Metoprolol 2.5 to 5.0 mg (within 2 min) may be given intravenously every 5 minutes for a total of 3 doses, with a total dose of 10 to 15 mg. After that, 25 to 50 mg was started every 6 to 12 hours for 24 to 48 h, followed by 50 to 100 mg/dose twice daily. If there is no contraindication to the occurrence of atrial fibrillation in acute myocardial infarction, metoprolol can be used intravenously as above.

➤ Bisoprolol

take orally. Usually 5 mg/dose, 1 dose/day, adjusted as needed, up to a maximum of 10 mg a day.

➤ Atenolol

take orally. Common dosage for adults: 6.25 to 12.5 mg/day, 2 times/day, gradually increase to 50 to 200 mg/day according to need and tolerance. In the case of renal impairment, the creatinine clearance < 15 ml·min-1·(1.73m2)-1, 25 mg/day, and the creatinine clearance is 15-35 ml·min-1·(1.73m2)-1, up to 50 mg/day.

Calcium channel blocker

➤ Nifedipine

Orally, the initial dose is 10 mg/time, 3 times/day, and the usual maintenance dose is 10 to 20 mg/time, 3 times/day. The maximum dose should not exceed 120 mg/day. Extended-release formulations 20 to 40 mg/dose twice daily. Controlled-release formulations 30 to 60 mg/dose once daily.

➤ Amlodipine

The initial dose for the treatment of angina is 5 to 10 mg/dose and 1 dose/day. Treatment at lower doses is recommended in elderly and patients with hepatic insufficiency.

➤ L-amlodipine

Orally, the initial dose is 2.5 mg/dose, 1 time/day, and the dose can be increased to up to 5 mg/dose and 1 dose/day depending on the patient's clinical response.

➤ Felodipine

take orally. The starting dose is 2.5 mg/dose and 2 doses/day, and the maintenance dose is 5 or 10 mg/dose once/day. Extended-release formulations are started at 5 mg/time, 1 dose/day, and maintenance doses are 5 or 10 mg/dose once/day.

➤ Diltiazem

Orally, starting at 30 to 60 mg/dose, 3 to 4 times/day, before meals and at bedtime, if the dose is increased, the daily dose does not exceed 360 mg/day. Extended-release formulations are 90 to 180 mg/dose and 1 dose/day.

➤ Verapamil

Orally, 80 to 120 mg/dose, 3 times daily. Extended-release formulations, starting at 120 or 180 mg/dose and once daily, can be gradually increased to 120 or 180 mg/time, 2 times/day, or 240 mg/time, 1 time/day, as needed and tolerated. The total amount does not exceed 480 mg/day.

Antiplatelet drugs

➤ Aspirin

Oral, enteric-coated tablets should be taken with an appropriate amount of water before meals. Use small doses of 75 to 150 mg/dose once daily. To reduce the risk of acute myocardial infarction in patients with suspected disease, it is recommended that the first dose of 300 mg be taken after chewing for rapid absorption, and then 100 to 200 mg/day.

➤ Clopidogrel

take orally. Recent myocardial infarction, 75 mg/dose, 1 dose/day, non-ST-segment elevation myocardial infarction, loading dose 300 mg, followed by 75 mg/time, 1 time/day, recommended for 12 months (with long-term aspirin).

➤ Tigrelo

May be taken before or after meals. The initial dose is 180 mg per load, followed by 90 mg/dose and 2 doses/day thereafter. Unless there is a clear contraindication, ticagrelor should be used in combination with aspirin. After the first dose of loading aspirin, the maintenance dose of aspirin is 75 to 100 mg/dose and 1 dose/day. Patients with ACS who have received an overloaded dose of clopidogrel can begin to use ticagrelor.

Anticoagulants

➤ Heparin

(1) Deep subcutaneous injection: the first 5 000 ~ 10 000 U, after every 8 hours 8 000 ~ 10 000 U or every 12 hours 15 000 ~ 20 000 U; the total amount of 30 000 ~ 40 000 U every 24 hours, generally can achieve satisfactory results.

(2) Intravenous injection: the first 5 000 ~ 10 000 U, after which according to body weight every 4 hours 100 U / kg, diluted with sodium chloride injection after application.

(3) Intravenous infusion: 20 000 ~ 40 000 U/ day, added to sodium chloride injection 1 000 ml continuous instillation. Intravenous 5 000 U can be given as an initial dose prior to instillation.

➤ Low molecular weight heparin

Injected subcutaneously, the usual injection site is the anterolateral side of the abdominal wall, alternating left and right. Treatment of thromboembolic disease: subcutaneously twice daily, usually for 7 to 10 days. Due to the different processes of low molecular weight heparin sodium preparations of different manufacturers, the average molecular weight and anti-X.a:anti-II.a ratio are different, and the dosage should be administered according to the instructions of each drug (adjust the drug dose according to body weight and kidney function). Intramuscular injection of this product is strictly prohibited.

Lipid-regulating and anti-atherosclerotic drugs

➤ Simvastatin

(1) Patients with hypercholesterolemia: the initial dose is 10 to 20 mg/time, and it is taken at night.

(2) People at high risk of cardiovascular events: the recommended initial dose is 20 to 40 mg/time, and it is taken overnight. Dose adjustments should be made at intervals of more than 4 weeks.

(3) Patients with homozygous familial hypercholesterolemia: it is recommended to take 40 mg/time at night; or 80 mg/day, divided into 20 mg in the morning, 20 mg at noon and 40 mg in the evening.

(4) Patients with renal insufficiency: chronic kidney disease stage 1 to 3 do not need to adjust the dose, chronic kidney disease stage 4 patients reduce the dose, use with caution.

➤ Atorvastatin

(1) Primary hypercholesterolemia and mixed hyperlipidemia: the initial dose is 10 mg/time, 1 time/day.

(2) Heterozygous familial hypercholesterolemia: the initial dose is 10 mg/time, 1 time/day. Gradual increase (at intervals of 4 weeks) to 40 mg, if still not satisfied, the dose can be increased to 80 mg/time, 1 time/day, or with the addition of a choleic acid chelating agent.

(3) Homozygous familial hypercholesterolemia: 10 to 80 mg/time, 1 time/day.

(4) Prophylactic for patients with risk factors for coronary heart disease: 10 mg/time, 1 time/day.

(5) The elderly do not need to adjust the dose. Patients with renal insufficiency do not need to adjust the dose.

➤ Rosuvastatin

(1) For patients who need to reduce LDL⁃C more effectively, the starting dose can be considered 10 mg/time, 1 time/day. If necessary, the dose can be adjusted after 4 weeks of treatment. The maximum daily dose is 20 mg.

(2) The elderly ≥ 65 years old and patients with hypothyroidism should pay attention to the elevation of muscle enzymes, reduce the starting dose, and be cautious when adjusting the dose.

(3) Patients with renal insufficiency: patients with chronic kidney disease stage 1 to 3 do not need to adjust the dose, and patients with chronic kidney disease stage 4 are disabled.

➤ Fenofibrate

Oral, 0.1 g/time, 3 times/day, maintenance amount 0.1 g/time, 1 to 3 times/day, take with meals. The pros and cons should be weighed when applying to pregnant women. Elderly people with renal insufficiency need to reduce the dose appropriately.

➤ Folding wheat cloth

(1) Adults: 10 mg/time, 1 time/day. May be taken alone or in combination with statins, at any time of the day, on an empty stomach or with food.

(2) There is no clinical drug data for pregnant and lactating women, so use with caution.

(3) Elderly patients do not need to adjust the dose.

(4) The dose should be reduced when renal function is reduced.

ACEI class

➤ Captopril

It depends on the condition or individual differences. The dose of administration must follow the principle of individualization and be adjusted according to the efficacy. The oral starting dose of 12.5 mg/time, 2 to 3 times/day, should be increased to 50 mg/time and 2 to 3 times/day within 1 to 2 weeks as needed, and it is appropriate to take the drug 1 hour before meals.

➤ Enalapril

Orally, the initial dose is 5 to 10 mg/day, divided into 1 to 2 divided doses, the maximum daily dose is 40 mg. Patients with renal impairment can adjust the dose according to creatinine clearance, starting at 5 mg/day at 30 to 80 ml/min and 30 ml/min < with an initial dose of 2.5 mg/day.

➤ Reinopril

Orally, 10 to 20 mg/dose, once/day, the maximum dose per day is 80 mg.

ARB class

➤ Valsartan

80 or 160 mg/time, 1 dose/day. May be taken with meals or on an empty stomach. The maximum dose is 320 mg/day.

The above content is excerpted from: Chinese Medical Association, Chinese Medical Association Clinical Pharmacy Branch, Chinese Medical Association Journal, et al. Guidelines for rational use of non-ST-segment elevated acute coronary syndrome at the grass-roots level [J] . Chinese Journal of General Practitioners, 2021, 20(4): 410-422.