BNF 2.1-2.

12 Cardiovascular System

2 CARDIOVASCULAR SYSTEM

2.01 THIAZIDE, OSMOTIC & LOOP DIURETICS

- THIAZIDES [TD], POTASSIUM SPARING [PSD], LOOP DIURETICS [LD]

GENERIC (TRADE) NAME CAT. INDICATION/DOSE

Frusemide Inj 10mg/ml, 2ml MSL Acute pulmonary oedema: slow IV

(Lasix) [Furosemide] initially 20-50mg, if needed increase
[LD] by 20mg steps every 2 hours; child
0.5-1.5mg/kg/DAY, max 20mg daily.

IV inj: if single effective dose is <

50mg inject undiluted slowly over 1-2
min at max rate 0.5mg/kg/min; if >
50mg dilute 20mg in 20-100ml of
WFI/NS, infuse 30-60 min at max
rate of 4mg/min.
EDL
Frusemide Tab 40mg (Lasix) MSL Oedema initially 40mg in the
[Furosemide] morning; maintenance 20mg daily,
[LD] resistant oedema up to 80mg daily;
child 1-3mg/kg/DAY (max 40mg/day).
EDL
Hydrochlorothiazide Tab 25mg Oedema 25-50mg daily in the
(Esidrex) morning; max 100mg daily, elderly
[TD] initially 12.5mg daily.
Hypertension 12.5-25mg daily in the
morning; elderly initially 12.5mg daily.
EDL
Mannitol Inj 10% (10g/100ml) IV infusion 0.25-1g/kg of a 5-25% (5-
& 25% (25g/100ml) 500ml 25g/100ml) solution adjusted to
response. Test dose: IV 200mg/kg of
a 15-25% solution over 3-5 min to
give a urine flow of 1ml/kg/HOUR at
least, over the next 2-3 hours.
EDL
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BNF 2.1-2.12 Cardiovascular System

GENERIC (TRADE) NAME CAT. INDICATION/DOSE

*Spironolactone Tab 25mg Oedema, 100-200mg daily, increased

(Aldactone) if needed to 400mg daily in resistant
[PSD] oedema; usual maintenance dose
75-200mg daily; child initially
3mg/kg/DAY in divided doses.
EDL

COMMENT/CAUTIONS:
• Thiazides [TD] have a fast onset (1-2 hrs) and prolonged action duration
(12-24 hrs). Administer in the morning. May cause postural hypotension
especially in the elderly.
• High doses of thiazides [TD] and loop diuretics [LD] can cause
hypokalaemia. IV frusemide in large bolus doses may cause ototoxicity,
so doses > 50mg should be diluted in 100ml of NS and given at a rate not
exceeding 4mg/min.
• Potassium-sparing diuretics [PSD] such as spironolactone should be
used cautiously in patients on ACE inhibitors as they may cause severe
hyperkalaemia. Do not give concurrently with potassium supplements.

2.02 ANTIANGINAL DRUGS, NITRATES

GENERIC (TRADE) NAME CAT. INDICATION/DOSE

Atenolol Tab 50mg (Tenormin) MSL Angina: 50-100mg in 1 or 2 divided

dose.
EDL
Isosorbide Dinitrate Tab 20mg Prophylaxis of angina: 20-40mg
SR (Isordil) every 12 hours; left ventricular failure
40-160mg daily in divided doses.
EDL
Nitroglycerin Sublingual Spray MSL When needed: spray 1-2 doses
0.4mg/dose, 200 doses (Glytrin) under tongue and then close mouth.
[Nitroglycerin=Glyceryl
trinitrate (GTN)]

Nitroglycerin Inj 1mg/ml MI or severe ischaemia, by IV

[Nitroglycerin=Glyceryl infusion, give 5-200ug/min titrated to
trinitrate (GTN)] patient response, diluted in D5/NS,
max conc 400ug/ml.

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BNF 2.1-2.12 Cardiovascular System

2.03 ANTIHYPERTENSIVE DRUGS

2.03a CENTRALLY-ACTING & VASODILATOR ANTIHYPERTENSIVES

GENERIC (TRADE) NAME CAT. INDICATION/DOSE

*Nitroprusside, Sodium Inj Hypertensive crisis; IV infusion dilute

50mg/5ml 50mg in 500-1000mls of D5 to give
[Vasodilator] conc of 50-100ug/ml, and infuse at
an initial rate of 0.3ug/kg/min, titrate
(Protect from light.) slowly according to response; max
10ug/kg/min. Note: use IV pump and
monitor BP closely.
EDL

COMMENT/CAUTIONS:
• Nitroprusside: Avoid using for > 72 hrs as accumulation of cyanide
metabolites occurs (cause tachycardia, sweating, hyperventilation,
arrhythmias). Tail infusion off slowly over 10-30 min to avoid rebound
effect. Stop if no marked response with max dose in 10 min. Protect the
solution completely from light in storage and when in use.
• Most serious peripheral vascular disorders may be due to occlusion of
vessels, either by spasm/sclerotic plaque. Advise patients on lifestyle
changes including smoking cessation and exercise training, and consider
low-dose aspirin to prevent cardiovascular events.

2.03b BETA-BLOCKERS – ANGINA, HYPERTENSION, CARDIAC ARRHYTHMIAS

GENERIC (TRADE) NAME CAT. INDICATION/DOSE

Atenolol Tab 50mg (Tenormin) MSL Hypertension & angina, 50-100mg

daily.
EDL
*Labetalol HCl Inj 100mg/20ml IV Inj 50mg, repeat after 5 min prn;
(Trandate) IV infusion at a max rate of 2mg/min,
titrate to response; max 200mg both
routes.

Inject slow IV undiluted over 1-2 min,

for IV infusion further dilute 100mg
with 100-200mls of D5/NS and
infuse over 50-60min.

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BNF 2.1-2.12 Cardiovascular System

GENERIC (TRADE) NAME CAT. INDICATION/DOSE

Metoprolol Tab 100mg 50-100mg twice daily, max 300mg

(Betaloc/Lopressor) daily.

Propranolol HCl Inj 1mg/ml Arrhythmias & thyrotoxic crisis: IV Inj

(Inderal/Avlocardyl) 1mg (undiluted over 1 min); repeat
every 2-4 minutes according to
response; max 5mg.

Propranolol Tab 40mg Hypertension, 80mg twice daily, max

(Inderal/Avlocardyl) 320mg daily (half dose for portal
hypertension). Angina, 40mg 2-3
times daily to 240mg/day.
Arrhythmia & thyrotoxic crisis, 10-
40mg 3-4 times daily.
Child: 1-5mg/kg/DAY in divided
doses every 6-12 hours. Max:
8mg/kg/DAY.
EDL

COMMENT/CAUTIONS:
• Beta-blockers: NOT if asthma or history of obstructive airways disease.
• Labetolol: Severe hepatocellular damage reported, monitor liver function.
• Beta-blockers may mask signs/symptoms of hypoglycaemia and affect
glucose tolerance. Avoid in patients with frequent hypoglycaemic episodes
or in those with poor blood glucose control.
• Risk of precipitating heart failure when beta-blockers used in conjunction
with verapamil.

2.03c CALCIUM CHANNEL ANTAGONISTS

GENERIC (TRADE) NAME CAT. INDICATION/DOSE

Diltiazem HCl Cap 90mg SR, NF Angina and mild to moderate

120mg SR & 180mg SR hypertension: initially 90-120mg
(Tildiem Retard) twice daily, max 360mg daily in
divided doses.
Non-modified release/non-SR
formulations: initially 30mg 3 times
daily (elderly patient 30mg twice
daily); max 360mg daily in divided
doses.

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BNF 2.1-2.12 Cardiovascular System

GENERIC (TRADE) NAME CAT. INDICATION/DOSE

Nifedipine Tab 20mg SR Initially 20mg-100mg daily with food

(Adalat) in 1-2 divided doses, according to
manufacturer’s directions (different
for each SR formulation)
EDL
Verapamil HCl Inj 5mg/2ml Arrhythmias: slow IV 5-10mg (over
(Isoptin) 2-4 min) of max conc 2.5mg/ml in
NS/D5 with ECG monitoring;
paroxysmal tachyarrhythmias:
further 5mg after 5-10 min if needed.
DO NOT administer to patients
recently given beta-blockers
(hypotension/asystole risk).
EDL
Verapamil HCl Tab 40mg or Arrhythmias: 40-120mg 3 times a
80mg (Isoptin) day. Hypertension: 240-480mg daily
in 2-3 divided doses.
EDL
Verapamil HCl Tab 240mg SR Angina or hypertension: 240mg
(Securon SR) daily, max 240mg twice daily.
Prophylaxis after MI where beta-
blockers are inappropriate: 240mg
the morning & 120mg in the evening.

COMMENT/CAUTIONS:
• Calcium Channel Antagonists can cause dizziness, headache,
peripheral oedema (worse than with verapamil and diltiazem). Most
common: flushing, rash, and gingival hyperplasia. Constipation is more
common with verapamil. Disturbances of cardiac conduction and
disruption of left ventricular failure are more likely with either verapamil or
diltiazem. Avoid abrupt withdrawal, may induce hypertensive
crisis/rebound.
• Contraindication (C/I): concurrent intravenous beta-blocker therapy,
CHF, hypersensitivity, hypotension.

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BNF 2.1-2.12 Cardiovascular System

2.03d ANGIOTENSIN CONVERTING ENZYME INHIBITORS

GENERIC (TRADE) NAME CAT. INDICATION/DOSE

Enalapril Maleate Tab 5mg Initially 2.5-5mg in the morning (1st

(Renitec) dose at night), usual maintenance
10-20mg in the morning, max 40mg
daily.

COMMENT/CAUTIONS:
• ACE Inhibitors (ACE/I) can cause very rapid falls of BP in volume-
depleted patients, so discontinue diuretics or reduce dose 2-3 days before
ACE/I initiation. Give first ACE/I dose at bedtime. Resume diuretics if
needed after a few weeks. If diuretics cannot be stopped, supervise
medically for 2 hrs after first ACE/I dose, or until stable BP.
• Monitor renal function (baseline creatinine) and assess within 1 week of
initiating therapy. If >10% increase in creatinine levels review therapy.
Reassess regularly (3-4 times/yr).
• Drug interaction – caution if used with calcium channel antagonists, see
product leaflets.

2.04 OTHER DRUGS FOR ARRHYTHMIAS

GENERIC (TRADE) NAME CAT. INDICATION/DOSE

*Amiodarone Inj 50mg/ml Advanced cardiac life support

(Cordarone) (ACLS): 300mg IV by rapid infusion;
if necessary, supplementary doses
of 150mg IV by rapid infusion may
be considered; max 1.2g/DAY.
Max IV rate 30 mg/min, usually at 1-
6mg/ml; conc > 2 mg/ml via central
line. Dilute 300mg in 300ml of D5 to
give 1mg/ml conc.

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BNF 2.1-2.12 Cardiovascular System

GENERIC (TRADE) NAME CAT. INDICATION/DOSE

Lidocaine HCl Inj 1% 10mg/ml MSL Arrhythmia: Adult IV bolus load 50-
20ml or 50ml vials, 10ml Minijet; 100mg over 2-3min, repeated after 5
2% 20mg/ml 20ml or 50ml vials, min if needed up to 300mg in first
10ml Minijet; & 20% 200mg/ml hour; followed by IV infusion at 1-
(Xylocard/Xylocaine) 4mg/min, dose 20-50ug/kg with ECG
monitoring, max 4.5mg/kg or 300mg
[Lidocaine = Lignocaine] in any one-hour period. Child,
1mg/kg/DOSE IV bolus every 5-10
minutes to max 5mg/kg,
maintenance 10-50ug/kg/min.
Ventricular arrhythmias: may be
given IM 300mg into the deltoid or
quadriceps muscle.

Give IM as a 10% solution (dilute

1.5ml of 20% solution in 1.5ml WFI).
Inject IV undiluted over 2-3 min. For
IV infusion, dilute 1g (5ml of 20%
solution or 50ml of 2% solution) with
D5/NS to make up to 500-1000ml to
give 1-2mg/ml (0.1-0.2%).
EDL
Magnesium Sulphate Inj 50% Ventricular tachycardia + low
5g/10ml magnesium: IV bolus 1-2g (4-8mmol
[Mg = 500mg/10ml = Mg or 2-4ml) slowly over 1-2min,
20mmoles/10ml] repeat prn, or IV infusion 2.5g
(10mmol or 5ml) in 100ml D5/NS,
over 1 hr.

Hypomagnesaemia, emergency: 1-
2g (4-8mmol Mg or 2-4ml) in 100ml
D5 infused over 1-2 min. Severe
deficiency: IV infusion 5g (20mmol
Mg or 10ml) diluted in 1000ml D5/NS
given over 3 hrs. Mild deficiency:
adult IM undiluted 1g (5mmol Mg or
2ml) q6h for four doses per 24hrs.

An IV calcium solution (e.g.10%

calcium gluconate) should be readily
available when magnesium sulphate
injection is administered.
EDL
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BNF 2.1-2.12 Cardiovascular System

GENERIC (TRADE) NAME CAT. INDICATION/DOSE

Procainamide Inj 100mg/ml Antiarrhythmia: adult, IV initial

(Pronestyl) 100mg diluted, given at max rate
50mg/min, repeat every 5 min until
arrhythmia is controlled or up to max
total dose of 1g; maintenance
infusion diluted and given at rate 2-
6mg/min. Alternatively, adult IM
50mg/kg/DAY in divided doses given
every 3-6 hours.
Child, IV slow 10-15mg/kg over
15min then 20-80ug/kg/min OR 50-
100mg/kg/DAY in divided doses
given q4h, max 2g/24h.

Inject IM undiluted deep into a

muscle mass. For IV injection further
dilute 100mg with 25-50ml of D5,
inject slowly over 2-5 min. For IV
infusion, dilute 200mg with 50-
100mls of D5, give over 30-100 min.
EDL

COMMENT/CAUTIONS:
• All anti-arrhythmics are potentially pro-arrhythmic. If using more than one
antiarrhythmic care is needed as fatal interactions can occur. Avoid rapid
changes and combinations.
• Amiodarone is intended for use only in patients with life-threatening
arrhythmias because of substantial toxicity.

2.05 CARDIAC GLYCOSIDES, INOTROPIC & VASOCONSTRICTOR

SYMPATHOMIMETICS

GENERIC (TRADE) NAME CAT. INDICATION/DOSE

*Digoxin Tab 250ug (Lanoxin) Rapid digitalisation, 0.75-1.5mg in

divided doses over 24 hrs; less
urgent digitalisation/ maintenance
125-250ug daily; elderly half dose.
EDL
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BNF 2.1-2.12 Cardiovascular System

GENERIC (TRADE) NAME CAT. INDICATION/DOSE

*Digoxin Inj 500ug/2ml Loading dose for IV urgent cases

(Lanoxin) (check patient has not received
cardiac glycosides within 2 weeks
before): 0.5-1mg in divided doses
q4-8h, then 125-500ug daily orally.

May be injected slow IV undiluted, or

infused by further diluting 500ug with
500ml of D5/NS/WFI over 10-20min.
EDL
Dopamine HCl Inj 200mg/5ml Cardiogenic shock: slow IV infusion
via large vein 2-5ug/kg/min, increase
in 5-10ug/kg/min increments
adjusted according to response, max
50ug/kg/min.

Dilute 200mg with 50-100mls of

D5/NS/LR, max conc 6mg/ml, range
0.8-3.2mg/ml.
EDL
Ephedrine HCl Inj 30mg/ml Hypotension prevention in epidural/
spinal anaesthesia: slow IV Inj 3-
6mg (max 9mg) repeated every 3-4
minutes, max cumulative dose 30mg

Slow IV inj: further dilute 30mg with

10-20ml WFI, max conc 3mg/ml.
EDL
Epinephrine Inj 1mg/ml MSL Anaphylaxis: undiluted SC/IM, adult
[Adrenaline 1:1000] 500ug (0.5ml), 6-12 yo 250ug
(0.25ml), 6 mth-6 yo 120ug (0.12ml),
< 6 mth 50ug (0.05ml).
EDL
Epinephrine Inj 100ug/ml MSL Cardiac Arrest: slow IV bolus inj 1mg
(0.1mg/ml), pre-filled syringe (undiluted) q3-5min, max 100ug/kg
10mls (1mg/10mls) every 3-5 minutes; IM/SC 100-500ug
[Adrenaline 1:10 000] (undiluted 1-5mls) every 10-15
minutes; or IV cont infusion in NS
(max concentration 64ug/ml), at a
rate of 1-10ug/kg/min. IV infusion:
dilute 1mg with 50-100mls of NS.
EDL
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BNF 2.1-2.12 Cardiovascular System

GENERIC (TRADE) NAME CAT. INDICATION/DOSE

Phenylephrine Inj 1% (10mg/ml) Acute mild-moderate hypotension:

(Neosynephrine) SC/IM undiluted 2-5mg, repeat dose
at 10-15 min intervals, max total
dose 10mg; slow IV 0.2-0.5mg (200-
500ug), repeat dose at 10-15 min
intervals, injected slow IV diluted in
D5/NS as 1mg/ml solution, over 3
minutes.

COMMENT/CAUTIONS:
• Digoxin: hypokalaemia predisposes to digoxin toxicity. Use with caution in
pregnancy, elderly and renal impairment, avoid rapid IV administration.
Excessive dosage may cause nausea & vomiting, GI & visual
disturbances, CNS & heart symptoms.

2.06 ANTICOAGULANTS & HAEMOSTATICS

GENERIC (TRADE) NAME CAT. INDICATION/DOSE

*Acetylsalicylic Acid (Aspirin) 75-300mg daily dissolved in a glass

Tab Soluble 100mg of water
EDL
Heparin Sodium Inj 5,000 DVT/PE treatment: adult, IV loading
units/ml, 5ml dose 5000 units, then cont infuse
1000-2000unit/hr (15-25unit/kg/hr) or
[NOT FOR IM INJECTION] 5000-10000units IV Inj q4h or 15000
units SC q12h [Determine dose for
maintenance by APTT time of 2-2.5
[NB: These doses do not apply times of normal.]
to LMWH.] DVT/PE prophylaxis, SC 5000 units
q8-12h post-surgery until patient is
ambulant; in pregnancy, 10000 units
given every 12 hours.

The IV dose may be administered

undiluted or diluted with 50-1000ml
NS over 24 hours.
EDL
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BNF 2.1-2.12 Cardiovascular System

GENERIC (TRADE) NAME CAT. INDICATION/DOSE

Heparin Sodium Inj 1,000 SMALL ADULT/CHILD, IV infusion

units/ml in 5ml loading dose 50 units/kg, then 10-25
units/kg/HOUR, or SC 250units/kg
[NOT FOR IM INJECTION] q12h. Give IV undiluted or diluted
with 50-1000ml NS over 24 hours.

Heparin Sodium 100units/ml NF 50-200 units administer as a flush

units in NaCl Injection through catheters or IV cannula, q4h
(Heparin Saline) or prn.
EDL
Low Molecular Weight Heparin NF SC Inj. Surgical prophylaxis, for 10
(LMWH) – Nadroparin days: General 0.3ml daily, 1st Inj 2-4
7500AxaICU/0.3ml, 10 000 hrs pre-surgery; orthopaedic 100
AxaICU/0.4ml, & 15,000 AxaICU/kg/DAY for 3 days, given 12
AxaICU/0.6ml (Fraxiparine) hrs pre- & post-surgery, then
150AxaICU/kg/DAY from 4th post-op
day onwards.
Treatment 0.1ml/10kg q12h.

Phytomenadione (Vitamin K1) MSL Hypoprothrombinaemia or

Inj 10mg/ml haemorrhage due to anticoagulant
therapy: IM 10-20mg. Slow IV inj
[ADULT USE ONLY] ONLY for potentially fatal
haemorrhage from warfarin
overdose, 2.5-25mg, max 50mg (not
> 1mg/min).
CHECK: Some commercial preps
unsuitable for IV use.
EDL
Protamine Sulphate Inj Slow IV Inj (undiluted or dilute in
10mg/ml, 5ml D5/NS) over 10 min, 1mg neutralises
80-100 units heparin when given
within 15 min; if longer, less
protamine needed (heparin excretion
rapid), max 50mg total dose.
EDL
Streptokinase Inj MI: infuse IV 1 500 000 units over 60
1 500 000 units vial min. Reconstitute vial with 5mls of
D5/NS and further dilute in 45mls of
D5/NS. Use reconstituted solution
within 8 hours.

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BNF 2.1-2.12 Cardiovascular System

GENERIC (TRADE) NAME CAT. INDICATION/DOSE

Tranexamic Acid Inj 100mg/ml, Haemorrhage from excessive

5ml fibrinolysis: Slow IV undiluted 1g q8h
(Transamin/Exacyl) or 10-15mg/kg q8h, max rate 100mg
(1ml) per minute.

Warfarin Sodium Tab Loading dose: 10mg on day 1, 5mg

2mg, 3mg & 5mg on days 2 and 3. Subsequent
dosages determined by INR values.
For rapid effect consider heparin
IV/SC for first 2-3 days.
NOTE: See current guidelines for
warfarin dosing details.
EDL

COMMENT/CAUTIONS:
• Aspirin C/I: active peptic ulceration, haemophilia/bleeding disorders.
• Treatment using full dose unfractionated heparin should be controlled by
monitoring of coagulation parameters. Monitor platelet counts if patient on
for more than 5 days. Heparin may cause haemorrhage; effects are
reversible by protamine sulphate.

2.07 ANTIHYPERLIPIDAEMIC AGENTS

GENERIC (TRADE) NAME CAT. INDICATION/DOSE

Simvastatin Tab 20mg (Zocor) NF 10mg at night, adjusted at intervals

of not less than 4 weeks; max
80mg/day.

COMMENT/CAUTIONS:
• Rhabdomyolysis associated with lipid-regulating drugs may be increased
in patients with renal impairment, hypothyroidism, and patients on
concomitant ciclosporin treatment. Concomitant treatment with a fibrate
and a statin may also increase risk of serious muscle toxicity. Advice
patients to report promptly unexplained muscle pain, tenderness, and
weakness.

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