Download Guidance for prescribing Beta Blocker and ACE

Guidance for prescribing Beta Blocker and ACE (Angiotensin converting enzyme) inhibitor as secondary
prevention after acute Myocardial Infarction (MI)
Background:
Beta blocker and ACE inhibitor should be started early as secondary prevention after presenting with acute MI, in line with NICE guidelines
CG48 (May 2007). The dose for Beta blocker and ACE inhibitor should be titrated upwards to the maximum tolerated dose post event.
In the absence of local guidelines, recent in-house audit has shown that Beta blocker and ACE inhibitor were often started at a lower dose and
not titrated upwards during hospital stay as recommended by different trials. Also, GPs were not given specific instructions on up-titrating the
dose of beta-blocker and ACE inhibitor on discharge.
Selection of patients:
Beta blocker and ACE inhibitor should be initiated for patients after acute MI with preserved left ventricular function or with left ventricular
systolic dysfunction provided there are no contra-indications.
Contra-indications:
Beta blocker:
Hypersensitivity
Severe bronchial asthma or caution in severe chronic obstructive pulmonary disease
Uncontrolled heart failure
Marked bradycardia, sick sinus syndrome, second or third degree AV block, sinoatrial block
Cardiogenic shock, metabolic acidosis
Severe peripheral arterial disease
Untreated phaeochromocytoma
ACE inhibitor:
Hypersensitivity including angioedema
Significant bilateral renal artery stenosis or renal artery stenosis in a single functioning kidney
Pregnancy
Doses:
Beta blocker:
Bisoprolol : initially 2.5mg daily ( unless frail or resting heart rate < 60bpm, systolic blood pressure <100mmHg on admission where 1.25mg
daily may be more appropriate) and titrate up at weekly intervals to a target dose of 10mg daily if tolerated.
**Aim to discharge on 5mg daily or higher (Depending on the length of stay. Unless frail, resting heart rate <50bpm, systolic BP <95mmHg then
2.5mg daily or maximum tolerated dose).
Metoprolol : initially 50mg twice daily (unless frail or resting heart rate < 60bpm, systolic blood pressure <100mmHg on admission where
25mg twice daily may be more appropriate) titrate up at weekly intervals to a target dose of 100mg twice daily if tolerated.
**Aim to discharge on 75mg twice daily or higher (Depending on the length of stay. Unless frail, resting heart rate <50bpm, systolic BP
<95mmHg then 50mg twice daily or maximum tolerated dose)
Carvedilol: initially 6.25mg twice daily (unless frail or resting heart rate < 60bpm, systolic blood pressure <100mmHg on admission where
3.125mg twice daily may be more appropriate) titrate up at weekly intervals to a target dose of 25mg twice daily if tolerated.
**Aim to discharge on 12.5mg twice daily or higher (Depending on the length of stay. Unless frail, resting heart rate <50bpm, systolic BP
<95mmHg then 6.25mg twice daily or maximum tolerated dose)
ACE inhibitor:
Ramipril: initially 2.5mg twice daily (unless frail or systolic blood pressure <100mmHg or renal function CrCl< 30ml/min on admission where
1.25mg twice daily may be more appropriate) titrate up at 3 to 5 days intervals to a target dose of 5mg twice daily if tolerated. (AIRE)
**Aim to discharge on 2.5mg twice daily or higher (Depending on the length of stay. Unless frail, systolic BP <95mmHg, CrCl <30ml/min then
1.25mg twice daily or maximum tolerated dose)
Perindopril (Erbumine): initially 4mg daily (unless frail or systolic blood pressure <100mmHg or renal function CrCl<30ml/min on admission
where 2mg daily may be more appropriate) titrate up at 3 to 5 days intervals to a target dose of 8mg daily if tolerated.
**Aim to discharge on 4mg daily or higher (Depending on the length of stay. unless frail, systolic BP <95mmHg, CrCl <30ml/min then 2mg daily
or maximum tolerated dose)
If ACE inhibitor if not tolerated, Angiotensin-II Receptor blocker (ARB) can be used instead
Candesartan: initially 4mg daily (unless frail or systolic blood pressure <100mmHg or renal function CrCl<30ml/min on admission where 2mg
daily may be more appropriate) titrate up at 3 to 5 days intervals to a target dose of 32mg daily if tolerated.
**Aim to discharge on 6mg daily or higher (Depending on the length of stay. Unless frail, systolic BP <95mmHg then 4mg daily or maximum
tolerated dose)
Losartan: initially 50mg daily (unless frail or systolic blood pressure <100mmHg or renal function CrCl<30ml/min on admission where 25mg
daily may be more appropriate) titrate up at 3 to 5 days intervals to a target dose of 100mg daily if tolerated.
**Aim to discharge on 75mg daily or higher (Depending on the length of stay. Unless frail, systolic BP <95mmHg then 37.5mg daily or maximum
tolerated dose)
On discharge:
Please ensure GPs are given specific instructions on eDAN where both Beta-blocker and ACE inhibitor should be titrated to maximum tolerated
doses at appropriate intervals as stated above with appropriate monitoring (e.g. U+Es & renal function).
Prepared by: Miss Chiat ee Choong, Specialist Pharmacist. Mr Chris Jones, Specialist Pharmacist. Dr Saud Khawaja, Cardiology SHO on 21st Oct 2013.
Checked & Reviewed by: Dr. Muzahir Tayebjee, Consultant Cardiologist and Dr Rani Khatib, Senior Cardiology Pharmacist.