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Enhanced triage for patients with suspected cardiac chest pain: the History and Electrocardiogram-only Manchester Acute Coronary Syndromes decision aid.

Alghamdi, A; Howard, L; Reynard, C; Moss, P; Jarman, H; Mackway-Jones, K; Carley, S; Body, R (2019) Enhanced triage for patients with suspected cardiac chest pain: the History and Electrocardiogram-only Manchester Acute Coronary Syndromes decision aid. Eur J Emerg Med, 26 (5). pp. 356-361. ISSN 1473-5695 https://doi.org/10.1097/MEJ.0000000000000575
SGUL Authors: Moss, Philip Simon

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Abstract

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.

Item Type: Article
Additional Information: Copyright © 2018 The Author(s). Published by Wolters Kluwer Health, Inc. This is an open-access article distributed under the terms of the Creative Commons Attribution-Non Commercial-No Derivatives License 4.0 (CC BY-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.
Keywords: Acute Coronary Syndrome, Aged, Chest Pain, Databases, Factual, Decision Support Techniques, Diagnosis, Differential, Electrocardiography, Emergency Service, Hospital, Female, Hospital Mortality, Humans, Incidence, Male, Middle Aged, Myocardial Infarction, ROC Curve, Reproducibility of Results, Retrospective Studies, Risk Assessment, Survival Analysis, Triage, Troponin T, United Kingdom, Humans, Myocardial Infarction, Chest Pain, Troponin T, Diagnosis, Differential, Electrocardiography, Incidence, Hospital Mortality, Risk Assessment, Survival Analysis, Retrospective Studies, Reproducibility of Results, ROC Curve, Decision Support Techniques, Databases, Factual, Aged, Middle Aged, Emergency Service, Hospital, Triage, Female, Male, Acute Coronary Syndrome, United Kingdom, acute coronary syndromes, acute myocardial infarction, cardiac troponin, clinical decision rules, sensitivity, specificity, 1103 Clinical Sciences, Emergency & Critical Care Medicine
SGUL Research Institute / Research Centre: Academic Structure > Institute of Medical & Biomedical Education (IMBE)
Academic Structure > Institute of Medical & Biomedical Education (IMBE) > Centre for Clinical Education (INMECE )
Journal or Publication Title: Eur J Emerg Med
ISSN: 1473-5695
Language: eng
Dates:
DateEvent
October 2019Published
16 October 2018Accepted
Publisher License: Creative Commons: Attribution-Noncommercial-No Derivative Works 4.0
Projects:
Project IDFunderFunder ID
PDF-2012-05-193Department of Healthhttp://dx.doi.org/10.13039/501100000276
PubMed ID: 30289775
Web of Science ID: WOS:000509327500010
Go to PubMed abstract
URI: https://openaccess.sgul.ac.uk/id/eprint/112506
Publisher's version: https://doi.org/10.1097/MEJ.0000000000000575

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