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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.[1] 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.
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
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
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
IMMEDIATE initial invasive strategy
 
Initial invasive strategy (4 to 48 hours)
 
Initial conservative strategy
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
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), OR


Administer ONE of the following antiplatelet agents (before OR at the time of PCI) (I-A)
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


OR
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)

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)

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
Heart failure
❑ Serious arrhythmia

❑ Subsequent ischemia
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Yes
 
No
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
❑ 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
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
❑ 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
Ticagrelor 180 mg
Prasugrel 60 mg
❑ 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 (5 days prior to CABG) (I-B)
❑ Discontinue ticagrelor (5 days prior to CABG) (I-C)
❑ Discontinue prasugrel (7 days prior to CABG) (I-C)

❑ Manage the anticoagulation therapy

❑ Continue UFH (I-B)
❑ Discontinue enoxaparin (12-24 hours prior to CABG) and dose with UFH (I-B)
❑ Discontinue fondaparinux (24 hours prior to CABG) and dose with UFH (I-B)
❑ Discontinue bivalirudin (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 (I-B)
❑ Manage antithrombotic therapy if started before angiography:

❑ Continue IV UFH for at least 48 hours or until discharge (I-A)
❑ Continue enoxaparin for entire hospital stay, up to 8 days (I-A)
❑ Continue fondaparinux for entire hospital stay, up to 8 days (I-B)
❑ Discontinue bivalirudin or continue at 0.25 mg/kg/hour for up to 72 hours (I-B)
 
  1. Jneid H, Anderson JL, Wright RS, Adams CD, Bridges CR, Casey DE; et al. (2012). "2012 ACCF/AHA focused update of the guideline for the management of patients with unstable angina/non-ST-elevation myocardial infarction (updating the 2007 guideline and replacing the 2011 focused update): a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines". J Am Coll Cardiol. 60 (7): 645–81. doi:10.1016/j.jacc.2012.06.004. PMID 22809746.