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FIRE: Focused Initial Rapid Evaluation

A Focused Initial Rapid Evaluation (FIRE) should be performed to identify patients in need of immediate intervention based on the 2012 ACCF/AHA focused update of the guideline for the management of patients with unstable angina/non-ST-elevation myocardial infarction. An invasive strategy is defined as diagnostic angiography with the intention of revascularization.

Boxes in the red color signify that an urgent management is needed.

Identify cardinal findings of unstable angina/ NSTEMI : ❑ Chest pain or chest discomfort ❑ Sudden onset ❑ Sensation of heaviness, tightness, pressure, or squeezing ❑ Duration> 20 minutes (but usually less than half an hour) ❑ Radiation to the left arm, jaw, neck, right arm, back or epigastrium ❑ No relief with medications ❑ No relief with rest ❑ Worse with time ❑ Worse with exertion ❑ Associated symptoms of palpitations, nausea, vomiting, sweating, dyspnea, and lightheadedness ❑ Characteristic ECG changes consistent with unstable angina/ NSTEMI ❑ No changes ❑ Non specific ST / T wave changes ❑ Flipped or inverted T waves ❑ ST depression (carries the poorest prognosis) ❑ Increase in >99th percentile of upper limit of normal of troponin and / or CK MB, which is consistent with NSTEMI

Rule out life threatening alternative diagnoses: ❑ Aortic dissection (suggestive findings: back pain, interscapular pain, aortic regurgitation, pulsus paradoxus, blood pressure discrepancy between the arms) ❑ Pulmonary embolism (suggestive findings: acute onset of dyspnea, tachypnea, hemoptysis, previous DVT) ❑ Cardiac tamponade (suggestive findings: hypotension, jugular venous distention, muffled heart sounds, pulsus paradoxus) ❑ Tension pneumothorax (suggestive findings: sudden dyspnea, tachycardia, chest trauma, unilateral absence of breath sound) ❑ Esophageal rupture (suggestive findings: vomiting, subcutaneous emphysema)

Begin initial treatment: ❑ Administer 162 to 325 mg of non enteric aspirin,orally, crushed or chewed (I-A) Among patients with either GI intolerance or hypersensitivity to aspirin, administer a loading dose followed by maintenance dose of either clopidogrel (I-B), or prasugrel in PCI patients (I-C), or ticagrelor (I-C) ❑ Administer 2-4 L/min oxygen via nasal cannula when saturation <90% ❑ Caution in COPD patients: maintain an oxygen saturation between 88% and 92% ❑ Administer beta-blockers (unless contraindicated) and titrate to the heart rate and blood pressure Contraindicated in heart failure, prolonged or high degree AV block, reactive airway disease, high risk of cardiogenic shock and low cardiac output state ❑ Metoprolol IV, 5 mg every 5 min, up to 3 doses, then 25 to 50 mg orally every 6 hours ❑ Carvedilol IV, 25 mg, two times a day ❑ Administer sublingual nitroglycerin 0.4 mg every 5 minutes for a total of 3 doses Contraindicated in suspected right ventricular MI, recent use of phosphodiesterase inhibitors, decreased blood pressure 30 mmHg below baseline ❑ Administer IV morphine if persistent symptoms or pulmonary edema ❑ Initial dose 4-8 mg ❑ 2-8 mg every 5 to 15 minutes, as needed ❑ Administer 80 mg atorvastatin ❑ Monitor with a 12-lead ECG all the time

TRIAGE FOR IMMEDIATE INTERVENTION Does the patient have ANY of the following indications that require immediate angiography and revascularization ? ❑ Hemodynamic instability or cardiogenic shock, OR ❑ Severe left ventricular dysfunction or heart failure, OR ❑ Recurrent or persistent rest angina despite intensive medical therapy, OR ❑ New or worsening mitral regurgitation or new VSD, OR ❑ Sustained VT or VF, OR ❑ Prior PCI within past 6 months or CABG

YES

NO

Does the patient have no ECG changes AND no rise in cardiac biomarkers?

Yes. The patient has no ECG changes AND no rise in cardiac biomarkers.

No. The patient has either positive ECG changes, OR rise in cardiac biomarkers, OR both.

Repeat ECG and biomarkers within next 6 hours and 12 hours Does the patient still have no ECG changes AND no rise in cardiac biomarkers?

Yes. The patient has no ECG changes AND no rise in cardiac biomarkers.

No. The patient has either positive ECG changes, OR rise in cardiac biomarkers, OR both.

Proceed to complete diagnostic approach of chest pain to rule out differential diagnoses

TRIAGE FOR INITIAL CONSERVATIVE OR INVASIVE THERAPY Calculate the risk of future adverse clinical outcomes: ❑ Thrombolysis in Myocardial Infarction (TIMI) risk score, OR ❑ GRACE score

Intermediate or high risk

Low risk

INITIAL INVASIVE THERAPY (IMMEDIATELY)

INITIAL INVASIVE THERAPY (4 to 48 hours)

INITIAL CONSERVATIVE THERAPY

Initiate ONE of the following anticoagulant therapy (I-A) ❑ Enoxaparin (I-A) OR ❑ Unfractionated heparin ♦ If GP IIb/IIIa receptor antagonist is planned ❑ 50- to 70-U/kg IV bolus ♦ If no GP IIb/IIIa receptor antagonist is planned ❑ 70- to 100-U/kg bolus OR ❑ Bivalirudin (I-B) ❑ 0.75-mg/kg IV bolus, then 1.75–mg/kg/h infusion ❑ Additional bolus of 0.3 mg/kg if needed ❑ Decrease infusion to 1 mg/kg/h when creatinine clearance <30 mL/min OR ❑ Fondaparinux (I-B) PLUS Administer ONE of the following antiplatelet agents (before OR at the time of PCI) (I-A) If before PCI: ❑ Loading dose of P2Y12 receptor inhibitors ❑ Clopidogrel (600 mg) (I-B) OR ❑ Ticagrelor(180 mg) (I-B) OR ❑ IV GP IIb/IIIa inhibitors (I-A) ❑ Eptifibatide ❑ Loading dose 180 mcg/kg IV bolus followed by another bolus after 10 minutes ❑ Maintenance dose 2 mcg/kg/min OR ❑ Tirofiban ❑ Loading dose 25 mcg/kg ❑ Maintenance dose 0.15 mcg/kg/min If at the time of PCI ❑ Loading dose of P2Y12 receptor inhibitors ❑ Clopidogrel (600 mg) (I-A) OR ❑ Ticagrelor (180 mg) (I-B) OR ❑ Prasugrel (60 mg) (I-B) Prasugrel is contraindicated in case of prior history of strokes or TIAs, active pathological bleeding, age ≥75 years, when urgent coronary artery bypass graft surgery (CABG) is likely, body weight <60 kg, propensity to bleed, concomitant use of medications that increase the risk of bleeding OR ❑ IV GP IIb/IIIa inhibitors (I-A) ❑ Eptifibatide ❑ Loading dose 180 mcg/kg IV bolus followed by another bolus after 10 minutes ❑ Maintenance dose 2 mcg/kg/min OR ❑ Tirofiban ❑ Loading dose 25 mcg/kg ❑ Maintenance dose 0.15 mcg/kg/min

Initiate ONE of the following anticoagulant therapy (I-A) ❑ Enoxaparin (I-A) OR ❑ UFH (I-A) OR ❑ Fondaparinux (I-B) OR Enoxaparin or fondaparinux preferred over UFH (II-B) PLUS Administer ONE of the following antiplatelet agents (I-B): ❑ Clopidogrel (I-B) ❑ Loading dose (300 mg) ❑ Maintenance dose for up to 12 months (75 mg) OR ❑ Ticagrelor (I-B) ❑ Loading dose (180 mg) ❑ Maintenance dose for up to 12 months (90 mg twice daily)

TRIAGE FOR NEED OF INVASIVE THERAPY Does the patient experience ANY of the following? ❑ Recurrence of symptoms, OR ❑ Heart failure, OR ❑ Serious arrhythmia, OR ❑ Subsequent ischemia

YES

NO

INVASIVE THERAPY ❑ Perform diagnostic angiography (I-A) Administer upstream antiplatelet agent: ❑ P2Y12 receptor inhibitors ❑ Clopidogrel ❑ Loading dose (600 mg) ❑ Maintenance dose (75 mg) OR ❑ Ticagrelor ❑ Loading dose (180 mg) ❑ Maintenance dose (90 mg twice daily) OR ❑ IV GP IIb/IIIa inhibitors ❑ Eptifibatide ❑ Loading dose 180 mcg/kg IV bolus followed by another bolus after 10 minutes ❑ Maintenance dose 2 mcg/kg/min OR ❑ Tirofiban ❑ Loading dose 25 mcg/kg ❑ Maintenance dose 0.15 mcg/kg/min

TRIAGE PATIENTS BY RISK ON STRESS TEST ❑ Perform a stress test (I-B)

High risk on stress test

Low risk on stress test OR did not undergo stress test

INVASIVE THERAPY ❑ Perform diagnostic angiography (I-A)

❑ Continue aspirin for life (I-A) ❑ Continue P2Y12 receptor inhibitors up to 12 months (I-B) ❑ Clopidogrel (75 mg once a day) OR ❑ Ticagrelor (90 mg twice a day) ❑ Discontinue GP IIb/IIIa inhibitors (I-A) ❑ Continue antithrombotic therapy: ❑ UFH for 48 hours (I-A) OR ❑ Enoxaparin for duration of hospitalization (up to 8 days) (I-A) OR ❑ Fondaparinux for duration of hospitalization (up to 8 days) (I-B) ❑ Measure LVEF (I-B)

TRIAGE FOR SUBSEQUENT THERAPY PLAN FOLLOWING ANGIOGRAPHY Does the angiography show coronary vessel obstruction ?

No

Yes

❑ 1 or 2 vessel disease CABG or medical therapy might also be considered

❑ Left main coronary artery disease ❑ 3 vessel disease ❑ 2 vessel disease with proximal left anterior descending artery affection ❑ Left ventricular dysfunction ❑Patient treated from diabetes

Medical treatment

PCI

CABG

Medical treatment

❑ Administer aspirin indefinitely ❑ Administer additional antiplatelet therapy at the discretion of the physician (I-C) ❑ Administer anticoagulant therapy at the discretion of the physician (I-C)

❑ Administer aspirin for life ❑ Administer a loading dose of P2Y12 receptor inhibitor (if not initially started) ❑ Clopidogrel 600 mg OR ❑ Ticagrelor 180 mg OR ❑ Prasugrel 60 mg OR ❑ Discontinue anticoagulant therapy following PCI in uncomplicated cases (I-B)

❑ Continue aspirin (I-A) ❑ Discontinue IV GP IIb/IIIa inhibitors (4 hours before CABG) (I-B) ❑ Manage the P2Y12 receptor inhibitor therapy as follows if CABG can be delayed (depending on whether benefits of CABG outweigh the risk of bleeding) (I-B): ❑ Discontinue clopidogrel if started before angiography (5 days prior to CABG) (I-B) ❑ Discontinue ticagrelor if started before angiography (5 days prior to CABG) (I-C) ❑ Discontinue prasugrel if started before angiography (7 days prior to CABG) (I-C) ❑ Manage the anticoagulation therapy ❑ Continue UFH (I-B) ❑ Discontinue enoxaparin if started before angiography (12-24 hours prior to CABG) and dose with UFH (I-B) ❑ Discontinue fondaparinux if started before angiography (24 hours prior to CABG) and dose with UFH (I-B) ❑ Discontinue bivalirudin if started before angiography (3 hours prior to CABG) and dose with UFH (I-B)

❑ Continue aspirin (I-A) ❑ Administer a loading dose of P2Y12 receptor inhibitors if not given before angiography (I-B) ❑ Clopidogrel (600 mg) OR ❑ Prasugrel (60 mg) ❑ Discontinue IV GP IIb/IIIa inhibitors if started before angiography (I-B) ❑ Manage antithrombotic therapy: ❑ Continue IV UFH for at least 48 hours or until discharge if started before angiography before angiography(I-A) OR ❑ Continue enoxaparin for entire hospital stay, up to 8 days if started before angiography before angiography(I-A) OR ❑ Continue fondaparinux for entire hospital stay, up to 8 days if started before angiography before angiography(I-B) AND ❑ Discontinue bivalirudin or continue at 0.25 mg/kg/hour for up to 72 hours (I-B)