Sandbox Rim

FIRE: Focused Initial Rapid Evaluation

A Focused Initial Rapid Evaluation (FIRE) should be performed to identify patients in need of immediate intervention.

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

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Low risk
Initial conservative strategy

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 aspirin ❑ 162 to 325 mg of non enteric aspirin,orally, crushed or chewed, THEN ❑ 75 to 325 mg/day ❑ 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

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

YES

NO

Does the patient have negative ECG findings AND negative biomarkers?

Yes

No

Repeat ECG and biomarkers within next 6 hours and 12 hours

Both negative

At least one positive

Calculate the risk of patients: ❑ Thrombolysis in Myocardial Infarction (TIMI) risk score, OR ❑ GRACE score

Proceed to angiography

High risk Initial invasive strategy

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Administer ONE of the following antiplatelet agents (before or at the time of PCI): ❑ P2Y12 receptor inhibitors ❑ Clopidogrel 600 mg ❑ Ticagrelor 180 mg ❑ Prasugrel 60 mg 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 ❑ IV GP IIb/IIIa inhibitors ❑ Abciximab ❑ Loading dose 0.25 mg/kg IV bolus ❑ Maintenance dose 0.125 mg/kg/min ❑ Eptifibatide ❑ Loading dose 180 mcg/kg IV bolus ❑ Another 180 mcg/kg IV bolus after 10 minutes ❑ Maintenance dose 2 mcg/kg/min ❑ Decrease infusion by 50% if creatinine clearance <50 mL/min ❑ Avoid in hemodialysis patients ❑ Tirofiban ❑ Loading dose 25 mcg/kg ❑ Maintenance dose 0.15 mcg/kg/min ❑ Decrease infusion by 50% if creatinine clearance <30 mL/min Administer ONE of the following anticoagulant therapy: ❑ 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 ❑ Bivalirudin ❑ 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

Administer one of the following antiplatelet agents: Before PCI ❑ P2Y12 receptor inhibitors ❑ Clopidogrel (600 mg), or ❑ Ticagrelor (180 mg), 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 At the time of PCI ❑ P2Y12 receptor inhibitors ❑ Clopidogrel (600 mg), or ❑ Ticagrelor (180 mg), or ❑ Prasugrel (60 mg) ❑ 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

Administer one of the following antiplatelet agents: ❑ Clopidogrel ❑ Loading dose (300 mg) ❑ Maintenance dose for up to 12 months (75 mg) ❑ Ticagrelor ❑ Loading dose (180 mg) ❑ Maintenance dose for up to 12 months (90 mg twice daily)

Consider urgent CABG if the coronary anatomy is not amenable to PCI and one of the following: ❑ Patients with left main or left main equivalent disease ❑ Patients with three or two vessel disease involving the left anterior descending artery with left ventricular dysfunction ❑ Diabetic patients

❑ Perform an angiography

Continue with the complete diagnostic approach below