Objectives To directly compare the diagnostic accuracy of four decision aids (Troponin-only Manchester Acute Coronary Syndromes (T-MACS), History, ECG, Age, Risk factors and Troponin (HEART), Thrombolysis in Myocardial Infarction (TIMI) and Emergency Department Assessment of Chest Pain (EDACS)) used to expedite the early diagnosis of acute coronary syndromes (ACS) in the ED.
Methods We prospectively included patients who presented to 14 EDs in England (February 2015 to June 2017) with suspected ACS within 12 hours of symptom onset. Data to enable evaluation of the T-MACS, HEART, TIMI and EDACS decision aids (without recalibration) were prospectively collected, blinded to patient outcome. We tested admission blood samples for high-sensitivity cardiac troponin I (hs-cTnI; Siemens ADVIA Centaur). Patients also underwent serial cardiac troponin testing over 3–12 hours. The target condition was an adjudicated diagnosis of acute myocardial infarction (AMI). We also evaluated the incidence of major adverse cardiac events (including death, AMI or coronary revascularisation) at 30 days. Diagnostic accuracy of each decision aid and hs-cTnI alone (using the limit of quantification cut-off, 3 ng/L) was evaluated by calculating sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV).
Results Of 999 included patients, 132 (13.2%) had AMI. C-statistics were 0.96 for T-MACS, 0.78 for HEART and 0.69 for TIMI. The sensitivities of T-MACS, HEART, TIMI, EDACS and hs-cTnI <3 ng/L for AMI were 99.2% (95% CI 95.7% to 100.0%), 91.8% (85.0% to 96.2%), 97.5% (92.9% to 99.5%), 96.2% (92.2% to 99.4%) and 99.2% (95.9% to 100.0%), respectively. The respective strategies would have ruled out 46.5%, 34.9%, 19.4%, 48.3% and 28.8% patients. PPVs for the decision aids that identify ‘high-risk’ patients were 80.4% (T-MACS), 51.9% (TIMI) and 37.2% (HEART).
Conclusions In this study, T-MACS could rule out AMI in 46.5% patients with 99.2% sensitivity. EDACS could rule out AMI in 48.3% patients with lower sensitivity, although the difference was not statistically significant. The HEART and TIMI scores had lower diagnostic accuracy.
- acute coronary syndrome
- cardiac care, diagnosis
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Presented at European Society for Emergency Medicine (EUSEM) Annual Congress, 2018 (Glasgow)
Contributors All authors meet authorship criteria as specified by the ICMJE.
Funding Siemens provided reagents without charge for the purpose of this study. The study was sponsored by Manchester University NHS Foundation Trust.
Competing interests RB: Speaker fees from Singulex, Roche, Abbott, Siemens, Beckman, Ortho, ET Healthcare, Alere; Research grants from Roche, Abbott Point of Care and Singulex; donation of reagents for research from Roche, Siemens, Singulex, Abbott, Alere, FABPulous BV, Beckman, Abbott Point of Care.
Patient and public involvement statement We thank the Manchester Heart Centre Service User Group for their input into the design of this study.
Patient consent for publication Not required.
Ethics approval The study was registered on the National Institute for Health Research Clinical Research Network portfolio (reference UK CRN 18000) and ethical approval was obtained from the National Research Ethics Service (reference 14/NW/1344).
Provenance and peer review Not commissioned; externally peer reviewed.
Data availability statement Data are available upon reasonable request.