Acute coronary syndrome
SIGN 148: Acute coronary syndrome NICE NG185: Acute coronary syndromes
DAPT for STEMI/NSTEMI post PCI would be initiated on specialist advice.
As per local and tertiary guidelines.
Prescribing Notes:
- If treated at an interventional centre, the duration of DAPT should be advised by interventional cardiologist.
- The duration of DAPT should be clearly communicated on any discharge summary.
- For patients aged ≥75 years or less than 60kg prasugrel 5mg daily may be used at consultant cardiologist discretion.
History Notes
27/05/2026
Regional formulary chapter launched.
History Notes
27/05/2026
Regional formulary chapter launched.
For those intolerant to atorvastatin – rosuvastatin tablets. See prescribing notes.
For those with swallowing difficulties only – rosuvastatin capsules can be opened and the contents sprinkled on soft food.
Prescribing Notes:
- See SIGN Guideline 149 and NICE Clinical Guideline 238 for guidance on risk estimation and the prevention of cardiovascular disease.
- If someone reports adverse effects when taking statins discuss:
- stopping the statin and trying again when the symptoms have resolved to check if the symptoms are related to the statin;
- changing to a different statin in the same intensity group (rosuvastatin if already receiving atorvastatin);
- reducing the dose; or
- changing to a lower-intensity statin.
- For those with swallowing difficulties rosuvastatin capsules can be opened and the contents sprinkled on soft food. See SmPC for further information.
- Ezetimibe may be considered in combination with a statin for patients who have failed to reach target cholesterol levels despite treatment with titrated/optimised statins alone.
History Notes
27/05/2026
Regional formulary chapter launched.
Statins are more effective than any other lipid lowering option. See prescribing notes.
Ezetimibe may be considered as monotherapy where statins are contraindicated or poorly tolerated.
Prescribing Notes:
- If someone reports adverse effects when taking statins discuss:
- stopping the statin and trying again when the symptoms have resolved to check if the symptoms are related to the statin;
- changing to a different statin in the same intensity group (rosuvastatin if already receiving atorvastatin);
- reducing the dose; or
- changing to a lower-intensity statin.
- There may be a role for ezetimibe in secondary prevention in patients who are statin intolerant or those who fail to achieve target LDL on maximum tolerated dose of statin. Refer to local guidelines for further information.
History Notes
27/05/2026
Regional formulary chapter launched.
For secondary prevention post MI, the medicines in this pathway should be considered in conjunction with antiplatelets and alongside the secondary prevention with statins pathways.
Ramipril or candesartan. Ramipril is the Angiotensin Converting Enzyme Inhibitor of choice. Use candesartan (Angiotensin-II receptor antagonist) if intolerant to ramipril.
If intolerant to betablocker or inappropriate consider diltiazem or verapamil. Modified release diltiazem should be prescribed by brand name for strengths over 60mg due to differences in bioavailability.
Ramipril or candesartan. Ramipril is the Angiotensin Converting Enzyme Inhibitor of choice. Use candesartan (Angiotensin-II receptor antagonist) if intolerant to ramipril.
Prescribing Notes:
- Beta-blockers may cause bronchospasm; use with caution and under specialist supervision in patients with a history of asthma.
- Modified release diltiazem should be prescribed by brand name for strengths over 60mg due to differences in bioavailability. The most cost-effective brand for the formulation required should be prescribed.
History Notes
27/05/2026
Regional formulary chapter launched.
History Notes
27/05/2026
Regional formulary chapter launched.