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Enhanced triage for patients with suspected cardiac chest pain

the History and Electrocardiogram-only Manchester Acute Coronary Syndromes (HE-MACS) decision aid

Alghamdi, Abdulrhmana,e; Howard, Laurab; Reynard, Charlesc; Moss, Philipd; Jarman, Heatherd; Mackway-Jones, Kevinb,c; Carley, Simonb,c; Body, Richarda,b,c

doi: 10.1097/MEJ.0000000000000575
Original article: PDF Only

Objectives Several decision aids can ‘rule in’ and ‘rule out’ acute coronary syndromes (ACS) in the Emergency Department (ED) but all require measurement of blood biomarkers. A decision aid that does not require biomarker measurement could enhance risk stratification at triage and could be used in the prehospital environment. We aimed to derive and validate the History and ECG-only Manchester ACS (HE-MACS) decision aid using only the history, physical examination and ECG.

Methods We undertook secondary analyses in three prospective diagnostic accuracy studies that included patients presenting to the ED with suspected cardiac chest pain. Clinicians recorded clinical features at the time of arrival using a bespoke form. Patients underwent serial troponin sampling and 30-day follow-up for the primary outcome of ACS. The model was derived by logistic regression in one cohort and validated in two similar prospective studies.

Results The HE-MACS model was derived in 796 patients and validated in cohorts of 474 and 659 patients. HE-MACS incorporated age, sex, systolic blood pressure plus five historical variables to stratify patients into four risk groups. On validation, 5.5 and 12.1% (pooled total 9.4%) patients were identified as ‘very low risk’ (potential immediate rule out) with a pooled sensitivity of 99.5% (95% confidence interval: 97.1–100.0%).

Conclusion Using only the patient’s history and ECG, HE-MACS could ‘rule out’ ACS in 9.4% of patients while effectively risk stratifying remaining patients. This is a very promising tool for triage in both the prehospital environment and ED. Its impact should be prospectively evaluated in those settings.

This is an open-access article distributed under the terms of the Creative Commons Attribution-Non Commercial-No Derivatives License 4.0 (CCBY-NC-ND), where it is permissible to download and share the work provided it is properly cited. The work cannot be changed in any way or used commercially without permission from the journal.

aCardioavascular Science Research Group, Division of Cardiovascular Sciences The University of Manchester

bPostgraduate Medical School, Manchester Metropolitan University

cEmergency Department, Manchester University NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester

dEmergency Department, St George’s University Hospitals NHS Foundation Trust, London, UK

eEmergency Medical Services Department, College of Applied Medical Sciences, King Saud Bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia

Correspondence to Abdulrhman Alghamdi, Msc, Cardioavascular Science Research Group, The University of Manchester, Grafton Street, Manchester M13 9PL, UK Tel: +44 7491 942 853; e-mail:

Received March 20, 2018

Accepted August 22, 2018

Copyright © 2019 Wolters Kluwer Health, Inc. All rights reserved.