2: Cardiovascular System

2.5mg daily produces a near maximal blood pressure lowering effect, with very little biochemical disturbance.

when furosemide not tolerated or ineffective

Intolerance / adverse effects with spironolactone (heart failure patients only)

• Benign intracranial hypertension

For use of acetazolamide in:

• ophthalmology see section 11.6
• epilepsy see section 4.8.1

4th line adjunct

4th line adjunct

4th line adjunct

• 4th line adjunct
  
• 2nd line antihypertensive in pregnancy
  

4th line adjunct

tablets

tablets (for patients unable to tolerate standard doses)

• stable angina in patients with intolerance or contraindications to beta blockers and where diltiazem / verapamil is not appropriate
  
• chronic heart failure as per NICE TA267
  
• MHRA Safety Warning: Risk of cardiac side effects
  

Peripheral arterial disease as per NICE TA223

Prophylaxis and Treatment of Venous Thromboembolism (VTE) in Patients with Renal Impairment

Warfarin intolerance where other oral anticoagulants are unsuitable (e.g. mechanical heart valve)

Rosuvastatin should only be considered in the following circumstances:

1. Patients taking potent CYP3A4 inhibitors (see page 6) for whom pravastatin is not a clinically appropriate alternative (when total cholesterol >7.5mmol/L; LDL >4.5mmol/L).
   
2. Patients who require a high-intensity statin who:
   

• are intolerant to atorvastatin, or
  
• have demonstrated an inadequate response to the maximum tolerated dose of atorvastatin, or
  
• have undesirably low HDL (<1mmol/L in men; <1.2mmol/L in women); If HDL< 0.5mmol/L please refer to Lipid Clinic).
  

Ezetimibe should only be considered in the following circumstances:

1. Monotherapy in patients who have demonstrated intolerance to at least 3 different statins (including pravastatin & rosuvastatin); or because of contraindications to all initial statins.

2. In combination with an initial statin only when an inadequate response to maximum tolerated doses of statin monotherapy (avoid simvastatin 80mg) has been demonstrated.

When decision has been made to treat with ezetimibe co-administered with a statin, ezetimibe should be prescribed on the basis of lowest acquisition cost (i.e. avoid proprietary combination preparations).

NICE TA385

In combination with ezetimibe where statins are contraindicated or not tolerated and ezetimibe monotherapy is inadequate: NICE TA694

For reducing the risk of cardiovascular events in people with raised triglycerides, as per NICE TA805

Primary hypercholesterolaemia (heterozygous familial and non-familial) or mixed dyslipidaemia if:

• History of cardiovascular disease, and
• LDL-C persistently 2.6 mmol/l or more, despite maximum tolerated lipid-lowering therapy

As per NICE TA733

Inclisiran information